Feasibility of steerable sheath-guided left atrial appendage closure in challenging anatomy

Percutaneous left atrial appendage closure (LAAC) is an established treatment option for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) who are unsuitable for long-term oral anticoagulation. However, an anatomically challenging left atrial appendage (LAA) can limit optimal device positioning and complete occlusion with conventional fixed-curve sheaths.Two elderly men with NVAF and high bleeding risk underwent LAAC using Watchman FLX Pro devices (Boston Scientific, Marlborough, MA, USA). Pre-procedural imaging revealed anatomically challenging LAAs. With a standard double-curve sheath, one case showed unacceptable posterior protrusion of a large 40-mm device. In another case, tilting of the device led to incomplete coverage of the posterior lobe, resulting in a residual peri-device leak. After switching to the TruSteer™ Access System (Boston Scientific), a bidirectional steerable sheath, improved coaxial alignment, enabled acceptable device protrusion, complete sealing with no residual leak, and stable device release in both cases. These cases suggest that a steerable sheath can overcome the limitations of fixed-curve sheaths in anatomically challenging LAAs by enabling coaxial alignment and optimized posterior wall apposition during LAAC.

In wide-neck, shallow, or multilobed left atrial appendages (LAAs), failure to meet PASS criteria with a conventional fixed-curve sheath may reflect non-coaxial deployment and, with very large devices, sheath instability due to kick-back at release, leading to device tilt. A bidirectional steerable sheath provides real-time control of the delivery axis and may prevent kick-back at release, enabling reproducible optimal device positioning in anatomically challenging LAAs where fixed-curve sheaths are inadequate.