Abstract
Intraprocedural device dislodgement of a 24-mm Watchman™ left atrial appendage (LAA) closure device occurred in a 83-year-old female with a wide left atrial appendage ostium (broccoli configuration) and a surgical mitral valve reconstruction. Device rested in the atrial cavity. A second stable 12 French transseptal electrophysiological sheath and two snares were needed to stabilize, elongate and gently guide the device into the second sheath. One of the snares was unclamped at its proximal end and retrogradely pulled through. After successful retrieval, a 27-mm Watchman™ device could easily be implanted in the very same session via the left delivery sheath. Patient was discharged from hospital in good general health after regular turnaround time.
Highlights
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A 83-year-old female suffered from an intraprocedural Watchman™ device dislodgement.
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A prior surgical mitral valve reconstruction may have led to intraatrial device retention.
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Device was retrieved in a veno-venous double lasso pull-and-push approach.
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This technique was successful and a larger device could be implanted.
1
Introduction
For nearly a decade, high-risk patients benefit from interventional occlusion of the left atrial appendage (LAA) as an effective and safe method to prevent embolism in non-valvular atrial fibrillation (AF) . Though being a well established procedure, several peri-interventional and long-term complications are reported . Thereof, device embolization is a rare (< 1,5% of cases with the Watchman™, Boston Scientific, Natick, MA, USA ) but in some circumstances severe complication. In majority of cases, the dislocated device passes the mitral valve and could be found in left ventricular cavity or the aorta . Only for the atrial location of intracardial embolized LAA occlusion device successful transvascular retrieval attempts are described, whereas a ventricular location requires cardiac surgery . Perrotta et al. first described the successful transseptal retrieval of a dislocated AGA Cardiac Plug (ACP, AGA Medical, Plymouth, MN, USA) dancing in the left atrium with a two-snare-one-sheath strategy . Chan et al. retrieved a dislodged ACP with two transseptal sheaths, one snare and a biopsy biotome used to increase the pulling force . In existing literature, we could not find any report of a transseptal attempt to retrieve a Watchman™ LAA closure device – different in shape and structure from the ACP – out of the left atrium. To our knowledge, we therefore report the first case of a transseptal retrieval of a dislocated Watchman™ device floating in the left atrium in veno-venous double lasso pull-and-push technique with two snares and two sheaths.
2
Case series
In our case, a 83-year-old female with a history of paroxysmal atrial fibrillation (CHA 2 DS 2 -VASc score = 5 points, HAS-BLED score = 4 points), traumatic intracerebral and subdural bleeding as well as gastrointestinal bleeding under oral anticoagulation (OAC) was referred to our center for LAA occlusion device implantation. Additionally, she had had a surgical mitral and tricuspid valve reconstruction. Transseptal puncture was performed via a right-sided femoral venous access in a standard fashion and the transseptal sheath was exchanged for the 14 French Watchman™ delivery sheath (Boston Scientific, Natick, MA). Via 5 French pigtail catheter LAA was fluoroscopically illustrated (broccoli configuration) and sized by transesophageal echocardiography (21 × 20 mm) before choosing a 24-mm Watchman™ LAA closure device (Boston Scientific, Natick, MA). Distal section of the device was placed in the major lobe with a shoulder of 0.6 cm and device was not released before having checked stable position by two-time tug test ( Fig. 1 A ).
However, immediately after releasing the device it could be seen free dangling in the left atrium not passing the reconstructed mitral valve cusps ( Fig. 1 B) and it was promptly fixed by a 30-mm snare (ev3 Endovascular, Plymouth, MN). First intention was to retract the device through the inserted delivery sheath, which was seen not to be feasible because of the distal sheath end being too weak to elongate and retrieve the Watchman™ ( Fig. 1 C). While having device still fixed by the first snare, we decided to place a second transseptal sheath in a parallel position. We therefore used a 12 French FlexCath® Advance steerable sheath (Medtronic, Minneapolis, MN) with a more stable distal end than the delivery sheath. A 15-mm snare was inserted through the second sheath and looped around the deformed device, now elongated and gently guided into the steerable sheath ( Fig. 1 D), which was retrieved to the right atrium to avoid microbubble embolization. Unfortunately, it was not possible to loosen the first snare during this process ( Fig. 1 E). The proximal end of the first snare then was unclamped and the now generated lasso – consisting of the two snares with the Watchman™ in their middle – was continuously pulled and pushed, antegradely through the first and retrogradely through the second sheath ( Fig. 1 F) to avoid an iatrogenic slot-shaped cut of the atrial septum. Within a few minutes, the displaced device could be successfully retrieved ( Fig. 2 ) with the second sheath.
