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

BACKGROUND: Left atrial appendage (LAA) closure (LAAC) in atrial fibrillation (AF) patients with the reversed chicken-wing (RCW) LAA is challenging. AIMS: To elucidate the LAAC strategy of the RCW-LAA. METHODS: A total of 802 AF patients who were enrolled in the LAACablation registry for LAAC procedure were included, 55 of whom presented with the RCW-LAA. The WATCHMAN device was implanted using the standard protocol when the sheath depth was no less than the device depth (the simple group). For those with a sheath depth of less than the device depth (the complex group), device deployment was attempted with acceptable protrusion or after a repeated atrial transseptal puncture (re-ATP) at a more inferior and anterior position. The anatomical and procedural features were compared between groups and before and after the re-ATP. RESULTS: The success rate of LAAC was significantly lower in patients with the RCW-LAA than with the other morphologies (92.7% vs. 98.8%, p = 0.001). Compared with the simple group, the complex group had shorter root depth and shorter neck length, and more LAAs in the complex group were at lower position (all p < 0.05). The sheath depth after the re-ATP was significantly greater than that before the re-ATP (18.8 ± 3.4 mm vs. 14.7 ± 2.6 mm, p < 0.001). For the patients who underwent re-ATP, the sheath went significantly deeper in successful procedures than in aborted procedures (19.7 ± 3.3 mm vs. 15.8 ± 1.8 mm, p = 0.040). CONCLUSIONS: The anatomical features of the RCW-LAA were related to the complexity of the LAAC procedure. The re-ATP at an inferior and anterior location could increase the success rate of LAAC. CLINICALTRIALS.GOV: NCT03788941.