2.3. Procedure of ACP implantation

In Group A, ACP implantation procedure is performed on conscious condition with local anesthesia of bilateral inguinal area. A 5‐F marked pigtail catheter is inserted into the sinus of Valsava through left femoral artery puncture. A transseptal puncture is performed using BRK Transseptal Needle (St. Jude Medical) delivered inside the SL‐0 Schwartz long sheath through right femoral vein. The pigtail catheter is used as a marker of safe septal puncture. Following angiographic LAA sizing, an appropriate ACP size is delivered using 13‐F Torqvue‐45 sheath into the LAA. The ACP is step by step released in LAA. Of note, that device release should be started at distal part LAA with slowly unsheath the device till the ball shape is formed, then keep unsheath but hold the proximal part of delivery system softly to let the device move slightly proximal inside LAA when the strawberry shape formed. Then hold the delivery system tightly while continue unsheath and keep the device in the landing zone when the lobe completely opens. Once the lobe is positioned at landing zone, release the disk by means of simultaneous unsheath and light push of the device.

In Group B, ACP implantation is performed using standard protocol.12 Procedure is performed under general anesthesia. In brief, the procedure comprised of (a) TEE‐guided transseptal puncture which targets more inferior part of the fossa ovalis, (b) LAA angiography in order to measure landing zone and ostial diameter which is then confirmed by TEE, (c) Step‐by‐step ACP placement, and (d) Finally appropriate position of ACP and absence of residual flow jet is confirmed by TEE before the device is unscrewed from the delivery system.

Appropriate ACP position determined by five criteria including (a) tire shape of the lobe, (b) the lobe position is distal to left circumflex artery, (c) present of distance between lobe and disk, (d) concave shape of the disk, and (e) stable device position during tug test (Figure 2).

Amplatzer Cardiac Plug (ACP) placement at the appropriate position. Lobe position is distal to left circumflex (red arrow), and the disk is nicely covering the whole ostial of LAA without protrusion to pulmonary vein nor mitral valve. Left panel shows contrast injection confirm complete LAA closure. The figure is taken from the same patient as Figure 1