LAA closure with the LAmbre device
The LAAC procedure was performed under local anaesthesia. Transseptal puncture was performed via right femoral venous access under fluoroscopic guidance. The sizes of the landing zone and the orifice were measured from LAA angiography at the right anterior oblique and caudal projection. The appropriate LAmbre size was selected on the basis of the intraoperative angiographic and preoperative TEE measurements. The size of the implant was 4 to 8 mm larger than the measured LAA orifice based on the clinical judgement of the operators. The CM was described as previously reported14. In brief, the delivery sheath was placed in the proximal part of the LAA. The distal umbrella was released into the LAA by stepwise pushing out of the device from the delivery sheath. Subsequently, the sheath was withdrawn to expose the proximal cover. The umbrella was adjusted to open as fully as possible. In the MM, the distal umbrella was initially half deployed outside of the LAA (defined as when a radio-opaque marker of the LAmbre device was located between two distal marker bands at the end of the delivery sheath and it was closer to the proximal marker band) and then gently “en-bloc” advanced into the proximal part of the LAA. Complete deployment of the umbrella to the landing zone was subsequently achieved by pushing out the device from the delivery sheath (Figure 2). The manipulation to expose the cover was the same as that for the CM. A fully open umbrella was defined as when the nadir of the U-shaped hooks was at the same level as the radio-opaque marker connecting the umbrella and cover in fluoroscopic imaging (Figure 1B). Stability was confirmed by the tug test. The position of the device and any presence of peri-device leakage were assessed by fluoroscopy and two-dimensional TEE (0°, 45°, 90°, and 135°) and following three-dimensional TEE under local laryngeal anaesthesia with tetracaine. Patients who could not tolerate a TEE examination were sedated with etomidate and fentanyl. Recapture and/or resizing of the device was attempted unless the device was in a satisfactory position and no major peri-device leakage (leakage ≤3 mm) was achieved. The activated clotting time was adjusted to maintain 250 to 350 s during the procedure.