Left atrial appendage closure in patients with reversed chicken-wing morphology: Anatomical features and procedural strategy

Fig. 1. Flow diagram of inclusion criteria and summaries regarding the number of failed LAAC procedures in different LAA morphologies. LAA: left atrial appendage; LAAC, left atrial appendage occlusion.

Fig. 2. The measurement of LAA anatomical features and LAAC procedure from angiography at a right anterior oblique (RAO) of 30° and caudal (CAU) of 20°. 1: ostium width; 2: root depth; 3: root axis; 4: neck length; 5: sheath depth; θ1: axial angle; θ2: bending angle; θ3: angle of the sheath. The height of the sheath indicated its position entering the LAA ostium, classified as high (black), medium (blue) or low (orange), representing the high, middle, or low 1/3 of the ostium, respectively. LAA, left atrial appendage; LAAC, left atrial appendage occlusion. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article.)

Fig. 3. The change in the direction and the depth of the sheath before and after the re-ATP at a more inferior and anterior position of FO during the LAAC procedure from the sagittal section (A) and the coronal section (B), and an example of how the re-ATP helped achieving the LAAC after a failed deployment due to insufficient depth of the sheath (C ∼ H). Before the re-ATP, the sheath (grey) was superior and posterior. After the re-ATP, the sheaths (blue) were shifted to a more inferior and anterior position with a greater available depth of the sheath (A, B). (C) LAA angiography; (D) sheath in the LAA showing insufficient depth of the sheath; (E) device deployment for the first time after which the independent movement was observed during the tug test and the device was recaptured afterward; (F) re-ATP at a more inferior and anterior site compared to the previous one; (G) device deployment for the second time with the sheath presenting a greater angle; (H) angiography after the release showing a perfect closure of the LAA. FO, foramen ovale; LAAC, left atrial appendage closure; Re-ATP, repeated atrial transseptal puncture. (For interpretation of the references to colour in this figure…