|Year : 2016 | Volume
| Issue : 3 | Page : 48-50
Percutaneous retrieval of a dislodged watchman left atrial appendage closure device
Jiangtao Yu1, Shaofeng Guan2, Manuela Muenzel1, Erich Duenninger1
1 Department of Cardiology, Helmut-G.-Walther Klinikum, The Second Hospital, Lichtenfels, Germany
2 Department of Cardiology, Shanghai Chest Hospital, Shanghai, PR China
|Date of Web Publication||26-Dec-2018|
Prof. Jiangtao Yu
Department of Cardiology, Helmut-G.-Walter Klinikum, The Second Hospital, Lichtenfels
Source of Support: None, Conflict of Interest: None
A 46-year-old female underwent left atrial appendage closure (LAAC) with a Watchman LAAC device. During the procedure, the device embolized into the descending aorta. A new device was implanted to the left atrial appendage complete the closure. The displaced device was successfully snared and removed by Amplatz Goose Neck™ Snare Kit. The patient recovered well and suffered from no clinical sequelae.
Keywords: Displacement, embolization, left atrial appendage closure, percutaneous retrieval
|How to cite this article:|
Yu J, Guan S, Muenzel M, Duenninger E. Percutaneous retrieval of a dislodged watchman left atrial appendage closure device. Cardiol Plus 2016;1:48-50
| Case Report|| |
A 46-year-old female with a history of persistent atrial fibrillation (CHA2DS2-VASc score 3) underwent left atrial appendage closure (LAAC) with a Watchman® left atrial appendage (LAA) closure device. Pulmonary vein isolation was performed 4 months prior and atrial fibrillation was still documented. Bleeding and transfusion occurred during warfarin treatment due to chronic gastritis. The patient refused to remain on long-term warfarin therapy (HAS-BLED score 3) and agreed to undergo percutaneous LAAC with the Watchman device.
Transesophageal echocardiography (TEE) revealed an LAA ostial diameter of 21 mm and a length of 26 mm before the procedure. After transseptal puncture, a pigtail catheter was positioned in the LAA. A Double-Curve Watchman Access Sheath was then tracked over the pigtail into the LAA. The LAA anatomy was a “chicken wing” with a wide ostium. After numerous TEE measurements of the LAA were made following the standard protocol, the first LAA closure device (Watchman, 24 mm) was inserted into the anterior-lateral direction and then released. This device was damaged during a recapture and the second (new) LAA closure device (24 mm) was then inserted via a posterior-lateral direction and deployed. A Timed Up and Go (TUG) test was then performed to confirm stability of the device and showed acceptable position with good stability, and the device was released. However, shortly after the release, the device embolized from LAA, traveled through the left atrium and mitral valve and into the descending aorta, coming to rest near the renal artery [Figure 1]. The third new LAA closure device (Watchman, 24 mm) was subsequently inserted in anterior-lateral direction and deployed without recapture. Echocardiography and angiography showed complete occlusion of the LAA with good compression and stability and the device was then released [Figure 2].
|Figure 1: Fluoroscopic image of 24-mm Watchman device displaced from the left atrial appendage (a) after embolized and came to rest in the descending aorta near the renal artery|
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|Figure 2: Retrieval of the dislodged device with Amplatz Goose Neck™ Snare Kit. The proximal end of the device was grabbed (a). The alignment was made easier by rotating the catheter (b). The displaced device was successfully grasped with the snare and then pulled into the sheath on the 3rd or 4th attempts (c and d)|
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A percutaneous retrieval procedure for the second device was performed soon after the final release of the third LAA device. An 18-Fr sheath was introduced via femoral artery puncture. The Amplatz Goose Neck™ Snare Kit, which contains one Amplatz Goose Neck Snare and one Amplatz Goose Neck Snare Catheter, was advanced to the descending aorta. Initially, alignment of the snare catheter and the embolized device was not optimal and was improved by rotating the catheter. The proximal end of the device was then successfully grabbed and looped with the snare; however, the loop of the Amplatzer snare was not strong enough to pull the displaced device into the catheter on the first attempt. After 3–4 attempts, the displaced device was retrieved and successfully pulled into the sheath. Once removed, from the catheter, the retrieved device was examined and was found to be significantly deformed compared to a device of the same size which had not been snared [Figure 3]. The total duration of the procedure was nearly 2 h. The total fluoroscopic time was 19 min. TEE on the second day showed that the deployed LAA device remained in good position. The patient was discharged 5 days after procedure.
|Figure 3: The retrieved device (right white arrow) and original device with same size. The retrieved device was significant deformed|
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| Discussion|| |
Percutaneous closure of the LAAC is a valid alternative to oral anticoagulation in nonvalvular atrial fibrillation patients with contraindications for long-term oral anticoagulants due to previous major bleeding or high-bleeding risk. Device embolization is a rare complication of LAAC procedures.,, Most cases of embolization occurred during hospitalization, with majority of embolizations being intraprocedural. These findings imply that routine TEE should be performed during the procedure. In a review of 21 embolization cases, 9 cases showed embolization into the aorta, 9 cases into the left ventricle (LV), and 3 cases into the left atrium. In ten additional reported cases, no anatomical location was mentioned. In those cases, device embolization into the LV was associated with a higher rate of surgical retrieval (8/9 vs. 2/12; 88% vs. 17%, P = 0.0019) compared to embolization into the aorta or the left atrial cavity. Percutaneous retrieval of embolized devices was usually successful by snare. In some cases, a 30-mm snare with 24-Fr sheath was used for retrieval, while 18-Fr sheath was used in our case. It was time-consuming for us to use a snare to grab the embolized device. Our findings in this case were that the proximal end of the device is the preferred location to grab with the snare and stabilize, rather than attempting to grab the device by the waist. While mechanisms for embolization are rarely reported, device under sizing is one potential cause. All the device release criteria and TUG test were verified in our patient. The reason for embolization remains unknown.
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
Dr. Yu has research donation or travel expense reimbursement of the following companies received in the last 12 months: Abbott, Avidal, BBraun, Biotronic, Boston Sientific, Daiichi-Sankyo, Lifetech, Symetis.
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[Figure 1], [Figure 2], [Figure 3]