|Year : 2019 | Volume
| Issue : 4 | Page : 125-127
Surgical retrieval of a left atrial appendage closure device (Watchman TM) following embolization into the mitral valve
Kevin P Birmingham1, Nader Moawad1, Ricardo Boix Garibo2, David Rose3
1 Department of Cardiac Surgery, Royal Victoria Hospital, Belfast, UK
2 Department of Cardiac Surgery, St Thomas' Hospital, London, UK
3 Department of Cardiac Surgery, Lancashire Cardiac Centre, Blackpool, UK
|Date of Submission||08-Oct-2019|
|Date of Decision||01-Dec-2019|
|Date of Acceptance||02-Dec-2019|
|Date of Web Publication||31-Dec-2019|
Kevin P Birmingham
Department of Cardiac Surgery, Royal Victoria Hospital, Belfast
Source of Support: None, Conflict of Interest: None
Percutaneous placement of occluding devices in patients with atrial fibrillation (AF) is now a viable alternative to established treatment methods. A favorable advantage is its minimally invasive technique, although it equally poses a risk. Unstable fixation after deployment, while uncommon, can lead to a catastrophic outcome, including damage to intracardiac structures and embolization to the aorta, causing stroke and possibly death. This can quickly become a surgical emergency that requires urgent intervention in the form of open-heart surgery.
Keywords: Atrial fibrillation, embolization, left atrial appendage, watchman
|How to cite this article:|
Birmingham KP, Moawad N, Garibo RB, Rose D. Surgical retrieval of a left atrial appendage closure device (Watchman TM) following embolization into the mitral valve. Cardiol Plus 2019;4:125-7
|How to cite this URL:|
Birmingham KP, Moawad N, Garibo RB, Rose D. Surgical retrieval of a left atrial appendage closure device (Watchman TM) following embolization into the mitral valve. Cardiol Plus [serial online] 2019 [cited 2020 Jan 26];4:125-7. Available from: http://www.cardiologyplus.org/text.asp?2019/4/4/125/274572
| Introduction|| |
Patients with atrial fibrillation (AF) are at a 5-fold higher risk of stroke, with the left atrial appendage (LAA) known to be the main source of thromboembolic events. Embolic management of AF includes medication, surgical ligation, and endovascular closure. The Watchman is a radially expandable device composed of a Nitinol frame contoured to fit the LAA. Fixation anchors along its perimeter provide stability. It is covered with a polyethylene terephthalate, whose pores prevent the passage of microemboli. According to the European Society of Cardiology Guidelines, LAA closure should be considered for the management of nonvalvular AF in patients contraindicated to long-term warfarin administration and with a high stroke risk (Class IIb, level of evidence B).
| Case Report|| |
A 74-year-old lady was admitted electively for a LAA occlusion. Her cardiac history included paroxysmal AF since 2006 following a road traffic accident, severe pneumonitis thought secondary to amiodarone, and moderate mitral and severe tricuspid regurgitation with preserved left ventricular function. Her CHA2 DS2-VASc score was 3 (hypertension, age, and female sex) and her HAS-BLED score was also 3. She had tolerated warfarin for several years until debilitating nose bleeds necessitated cauterization and ligation of the arteries to Kiesselbach's plexus.
An intraoperative preoperative transesophageal echocardiogram (TOE) confirmed a left appendage clear of thrombus and therefore proceeded to closure. Following femoral vein puncture and transseptal access under fluoroscopic guidance, a 27 mm Watchman device was deployed into the LAA. Over the next few minutes, it became apparent that the device was somewhat unstable and it embolized into the atrium and became caught within the apparatus of the mitral valve. A TOE showed the migrated Watchman device causing obstruction at the mitral valve orifice [Figure 1] and [Figure 2].
|Figure 1: (a-d) (From the top, left to right): Transesophageal echocardiogram of device migration in real time showing the mid-esophageal two-chamber views with Watchman dislodged from the left atrial appendage|
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|Figure 2: (a and b) Note the regurgitation jet with continuous wave Doppler as the Watchman device is straddled on its longitudinal axis precariously across the mitral valve|
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Numerous attempts made to retrieve the Watchman device percutaneously were unsuccessful. Immediately following this, there were two episodes of pulseless electric activity resulting in the need for adrenaline (1 ml of 1:10,000), before the return of spontaneous circulation. Consequently, the patient was rushed to the theater for an emergent sternotomy and surgical removal. The procedure was performed with cardiopulmonary bypass using aortic and bicaval cannulation, hypothermia, and cardioplegic arrest. The left atrium was accessed by an extended vertical transatrial septal approach [Figure 3], as described by Guiraudon et al. The mitral valve was carefully examined, and the device was removed [Figure 4]. With no obvious damage, it was felt that the moderate mitral regurgitation that preexisted was not easily amendable to repair and valve replacement would not be in the patient's best interests. The LAA was excluded with an atriclip device, and the transseptal puncture from the primary procedure was repaired. The patient had a protracted postoperative recovery, largely due to significant fluid retention and partly due to a period of acute kidney injury but made a full recovery.
| Discussion|| |
LAA occlusion has now become a viable treatment option as demonstrated by a number of trials – PROTECT AF study and PREVAIL trial being the main ones. The former was a randomized control trial to test noninferiority of Watchman device with short-term warfarin against long-term warfarin for stroke risk reduction in AF. The PREVENT trial was a follow-on study to address the limitations of the PROTECT AF study.
Reflecting on this case study, during the initial deployment, the shear forces when seating the Watchman device caused the unfolding of the anchoring barbs, which attributed to that uncharacteristic shape seen on fluoroscopy. The newly orientated fixation anchors caused it to lodge between the intraventricular septum and the anterior mitral valve leaflet inhibiting leaflet coaptation, thus causing severe mitral regurgitation. Fortunately, in this instance, when inspected intraoperatively, there was no perforation or damage caused to the mitral valve.
There are only a handful of cases in the literature that report LAA device embolization. Aminian et al. (2014) searched the PubMed database to provide a systematic review of reported cases of LAA closure device embolization (focusing on the Watchman device and Amplatzer Cardiac Plug), with 13 cases involving the Watchman identified. Of the anatomical locations for embolization described, 3 of these cases related to the left atrium, all of which were retrieved percutaneously. Therefore, in this instance, our case study appears to be somewhat unique. Comparatively, 8 of the 9 cases that embolized to the left ventricle needed surgical evacuation.
Yu et al. (2016) documented a successful case of percutaneous retrieval from the descending aorta using a snare catheter. Li et al. (2018) managed to retrieve a size 33-mm diameter Watchman device using a double sheath via a double-forceps technique. They used an alligator forceps to secure the device while a second forceps was used to align it coaxially within the sheath. Thereafter, it was removed carefully using fluoroscopy through a double sheath. This is a similar approach to Perrotta et al., who used a steerable sheath and double-snare technique. However, what is clear that irrespective of these techniques that if a Watchman device becomes entangled in the mitral valve, surgical removal is the safest way to proceed. The endocardium and pliable leaflets are at high risk of perforation and damaged by the fixation anchors. There remains a high risk of inadvertently pushing a free-floating occluding device onto the mitral valve apparatus while attempting retrieval from the left atrium. For this reason, consideration should be given to consulting the cardiac surgical team at an early stage if complications should arise. From a clinical safety perspective, these occluding devices should only be inserted in hospitals that have cardiac surgery units on site.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]