Tools and Techniques Clinical: Transcatheter closure of left atrial appendage using the Amplatzer™ Cardiac Plug

Background Since chronic oral anticoagulation cannot be administered in a substantial proportion of patients with atrial fibrillation, the endovascular exclusion of the left atrial appendage (LAA), which represents the source of atrial-derived emboli in the majority of cases, has been proposed as a valuable alternative in selected patients. In this article we briefly summarise the basic steps to perform an effective and safe implantation procedure using the AmplatzerTM Cardiac Plug (ACP; St. Jude Medical, Plymouth, MN, USA). Methods First, both cardiac computed tomography and transoesophageal echocardiography should be complementarily performed to study LAA anatomy and size accurately (Figure 1). LAA dimensions must be validated and confirmed during the procedure either by TEE or intracardiac echo (ICE) and angiographic measurements. It is recommended that the AmplatzerTM Cardiac Plug be oversized by about 2 to 3 mm with respect to the LAA measurements. Second, a transseptal puncture, using either the Mullins sheath (Medtronic AVE, Galway, Ireland) or the SL1 sheath (St. Jude Medical, Plymouth, MN, USA), should be performed in the lower part of the fossa ovalis. Third, after the advancement of a marker pigtail catheter (5 Fr, 100 cm long) through the transseptal sheath and the localisation of the pigtail catheter inside the LAA, perform an LAA angiogram to size the LAA ostium and “neck” angiographically. Fourth, prepare the LAA device accurately in