Successful percutaneous closure for complex left atrial appendage using three-dimensional curved sheath re-shaped by heat gun

A man in his eighties with long-standing atrial fibrillation was referred to our hospital for percutaneous left atrial appendage (LAA) closure (LAAC) because of high risks of stroke and bleeding. Pre-procedural multidetector computed tomography (CT) revealed reverse chicken-wing morphology of the LAA, with a maximum orifice size of 23.7 mm at 0° and minimum depth of 15.9 mm at 135° CT views (Panels A1 and A2). LAAC was performed using a WATCHMAN FLX 27 mm device via the femoral vein using a standard double-curved WATCHMAN TRUSEL ACCESS SYSTEM sheath (Boston Scientific, Inc., Marlborough, MA, USA). It was difficult to maintain suitable sheath alignment due to the complex LAA morphology (Panel B1). Despite several attempts, the LAAC device could not be implanted properly. More than half of the device protruded from the LAA in the 135° transoesophageal echocardiographic view (Panel B2). We re-shaped the double-curved sheath three-dimensionally using a heat gun (Makita HG6031VKⓇ, Makita Corporation, Aichi, Japan). We heated the sheath to deform and then cooled it in water to restore it (Panels C1 and C2). The first curve of the sheath rose steeply (Panel D1), and the second curve extended gently towards the anterior side (Panel D2). This handmade three-dimensional sheath enabled us to advance adequate co-axiality and gain depth (Panel E1). Finally, a WATCHMAN FLX 27 mm device was successfully deployed in the proper position without protrusion (Panel E2). Intentional sheath re-shaping using a heat gun is a possible solution to adjust sheath alignment and implant the device efficiently during the LAAC. Multidetector computed tomography findings identify the existence of the reverse chicken-wing morphology of left atrial appendage (Panel A1), wherein 135° computed tomography view shows a minimum left atrial appendage depth of 15.9 mm (Panel A2). A standard double-curved WATCHMAN TRUSEL ACCESS SYSTEM sheath was inserted via the femoral vein, but it was difficult to maintain proper alignment for the left atrial appendage (Panel B1). The WATCHMAN FLX 27 mm device protruded from the ostium of the left atrial appendage, as shown in the 135° transoesophageal echocardiographic view (Panel B2). The standard double-curved sheath was deformed by heating it using a heat gun (Panel C1). Subsequently, the sheath was dipped in water to fix the three-dimensional curve (Panel C2). The first curve of the re-shaped three-dimensional sheath is steep (Panel D1), whereas the second curve is long and gentle (Panel D2). The re-shaped three-dimensional sheath enabled us to maintain proper alignment for the left atrial appendage (Panel E1). A WATCHMAN FLX 27 mm was implanted in the proper position without device protrusion in the 135° transoesophageal echocardiographic view (Panel E2). The authors thank everyone who participated in percutaneous left atrial appendage closure at the Gifu Heart Center. Consent: Informed consent was obtained from the patient in accordance with COPE guidelines. Funding: None declared.