Table of Contents
CASE REPORT
Year : 2016  |  Volume : 1  |  Issue : 3  |  Page : 48-50

Percutaneous retrieval of a dislodged watchman left atrial appendage closure device


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 Publication26-Dec-2018

Correspondence Address:
Prof. Jiangtao Yu
Department of Cardiology, Helmut-G.-Walter Klinikum, The Second Hospital, Lichtenfels
Germany
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2470-7511.248357

Get Permissions

  Abstract 


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

How to cite this URL:
Yu J, Guan S, Muenzel M, Duenninger E. Percutaneous retrieval of a dislodged watchman left atrial appendage closure device. Cardiol Plus [serial online] 2016 [cited 2021 Oct 16];1:48-50. Available from: https://www.cardiologyplus.org/text.asp?2016/1/3/48/248357




  Case Report Top


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

Click here to view
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)

Click here to view


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

Click here to view



  Discussion Top


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.[1] Device embolization is a rare complication of LAAC procedures.[2],[3],[4] Most cases of embolization occurred during hospitalization, with majority of embolizations being intraprocedural.[5] 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.[5] 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,[6] 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.[7] 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

Nil.

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.



 
  References Top

1.
John Camm A, Colombo A, Corbucci G, Padeletti L. Left atrial appendage closure: A new technique for clinical practice. Heart Rhythm 2014;11:514-21.  Back to cited text no. 1
    
2.
Reddy VY, Holmes D, Doshi SK, Neuzil P, Kar S. Safety of percutaneous left atrial appendage closure: Results from the watchman left atrial appendage system for embolic protection in patients with AF (PROTECT AF) clinical trial and the continued access registry. Circulation 2011;123:417-24.  Back to cited text no. 2
    
3.
Meerkin D, Butnaru A, Dratva D, Bertrand OF, Tzivoni D. Early safety of the amplatzer cardiac plug™ for left atrial appendage occlusion. Int J Cardiol 2013;168:3920-5.  Back to cited text no. 3
    
4.
Nietlispach F, Gloekler S, Krause R, Shakir S, Schmid M, Khattab AA, et al. Amplatzer left atrial appendage occlusion: Single center 10-year experience. Catheter Cardiovasc Interv 2013;82:283-9.  Back to cited text no. 4
    
5.
Aminian A, Lalmand J, Tzikas A, Budts W, Benit E, Kefer J, et al. Embolization of left atrial appendage closure devices: A systematic review of cases reported with the watchman device and the amplatzer cardiac plug. Catheter Cardiovasc Interv 2015;86:128-35.  Back to cited text no. 5
    
6.
Perrotta L, Bordignon S, Fürnkranz A, Chun JK, Eggebrecht H, Schmidt B, et al. Catch me if you can: Transseptal retrieval of a dislodged left atrial appendage occluder. Circ Arrhythm Electrophysiol 2013;6:e64.  Back to cited text no. 6
    
7.
Chan NY, Choy CC, Lau CL. Successful percutaneous retrieval of a dislodged left atrial appendage occlusion device with double transseptal sheaths and biopsy bioptome. Catheter Cardiovasc Interv 2015;85:328-31.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Case Report
Discussion
References
Article Figures

 Article Access Statistics
    Viewed2506    
    Printed177    
    Emailed0    
    PDF Downloaded160    
    Comments [Add]    

Recommend this journal