CASE REPORT
A Simple Percutaneous Retrieval Technique for an Embolized Watchman Left Atrial Appendage Closure Device in the Thoracic
Aorta Using a Homemade Snare
A Case Report
Anggia Chairuddin Lubis,
1,2MD, Mohammad Iqbal,
1MD, Dian Andina Munawar,
1,3MD, Beny Hartono,
1MD and Muhammad Munawar,
1,3MD
Summary
A 60-year old male with paroxysmal atrial fibrillation underwent a combined procedure of left atrial ap- pendage occlusion and pulmonary vein isolation. However, an acute intraprocedural 24-mm Watchman device dislodgement occurred, and thus a decision for urgent surgery was made. However, it was noted during the sur- gery that the device had migrated further to the descending aorta, just distal to the left subclavian artery. Since a right sternotomy access for retrieval was not feasible, a percutaneous approach was justified. A homemade snare was created using a combination of a long sheath, J-wire, and a regular snare, and the device was suc- cessfully retrieved without significant difficulty.
(Int Heart J 2021; 62: 1153-1155) Key words:Atrial fibrillation, Left atrial appendage occlusion, Complication
D
evice embolization is a well-known complication of percutaneous left atrial appendage closure (LAAC) procedures, and both surgical and percu- taneous retrieval strategies have their own advantages and disadvantages. We report a case of device embolization during a combined procedure of LAAC and atrial fibrilla- tion (AF) ablation. Successful retrieval was ultimately achieved using a percutaneous homemade snare technique following a failed surgical strategy.Case Report
A 60-year-old male with paroxysmal AF and CHA2
DS2VaSc of 3 was scheduled for LAAC and pulmonary vein ablation (PVI)/AF ablation concomitantly. A trans- septal puncture was performed slightly posterior and infe- rior to the fossa ovalis, as confirmed by trans-oesophageal echocardiography (TOE), to accommodate both proce- dures. A standard LAAC implantation procedure was per- formed under general anesthesia (GA). TOE revealed the maximum left atrial appendage (LAA) ostium and depth were 21 mm and 27 mm, respectively. After successful implantation of a 24 mm Watchman (WM) device (Boston Scientific Corp., Marlborough, MA, USA), it was noticed that the device was acutely dislodged into the left atrium during left atrial geometry mapping (Figure A). Thus, ur- gent surgery was necessary.
The left atrium was approached through a right ster- notomy, but the device migrated further to the thoracic aorta, just distal to the subclavian artery as identified by TOE, and no further structural damage was seen. While surgical AF ablation and LAA ligation were successfully performed, device retrieval remained unsolved; right ster- notomy access for WM device retrieval in the thoracic aorta made a surgical approach unfeasible, therefore, per- cutaneous intervention was justified.
Bilateral femoral arteries were accessed using 6F and 14F WM device delivery sheaths, and the WM device was manipulated using a deflectable ablation catheter to pre- vent direct exposure of the tines to the aorta. The initial strategy using a regular snare was ineffective, so a home- made snare using a combination of a long sheath, a 0.038” J wire, and a snare was created. This homemade snare was used to grasp and retrieve the device into the long sheath, followed by removing all assemblies without any resistance. A schematic diagram of this strategy can be seen in clockwise rotation in Figure B. Vascular access was repaired surgically and no further mechanical or vas- cular complications occurred during follow-up. Anticoagu- lation was discontinued afterwards.
Discussion
Dislocation of a WM device has occurred in < 1% in
From the1Binawaluya Cardiac Center, Jakarta, Indonesia,2Faculty of Medicine, Universitas Sumatera Utara, Sumatera Utara, Indonesia and3Department of Cardiology and Vascular Medicine, Medical Faculty, Universitas Indonesia, Jakarta, Indonesia.
Address for correspondence: Muhammad Munawar, MD, Binawaluya Cardiac Center, Jalan TB Simatupang 71, Jakarta 13650, Indonesia. E-mail: muna@cb n.net.id, [email protected]
Received for publication December 11, 2020. Revised and accepted March 24, 2021.
Released in advance online on J-STAGE September 17, 2021.
doi: 10.1536/ihj.20-790
All rights reserved by the International Heart Journal Association.
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Int Heart J September 2021
1154 LUBIS, ET AL
Figure. A: Fluoroscopic imaging during atrial fibrillation ablation. Multiple catheters positioned inside cardiac chambers shown by fluoroscopic imaging, and the white arrow shows an LAA occluder device float- ing inside of the left atrium. B: Step by step homemade snare illustration. The use of a deflectable ablation catheter to change the direction of the device, followed by step by step illustration of our homemade snare that consisted of a 14 Fr Watchman delivery sheath, 0.038” J wire, and snare. Final image showing success- ful device retrieval.
real world clinical settings.1) Most of the dislodgements are asymptomatic. On the other hand, some serious ad- verse events and one unexplained death have been re- ported. Combination of LAAC and AF ablation in a single procedure appears to be safe in most cases.2-5)Prior to this case, we have some limited experience in performing si- multaneous procedures, and the safety issue was in line with these cohorts.
Intraprocedural device embolization has been noted since the early introduction of the LAAC procedure, and most embolization can be recognized within 24 hours af- ter the procedure.6)Identified potential causal mechanisms are device undersizing, excessive oversizing, device appo- sition, a shallow landing zone, a vigorous wiggle test, and conversion from AF to sinus rhythm. In our case, device sizing and stability seemed to be appropriate with 20%
device compression and a stable tug test as observed with the fluoroscopy as well as the TOE. We presumed that the dislodgement was caused by catheter manipulation.
The use of flexible deflectable ablation and a loop snare in the percutaneous retrieval technique has been de- scribed previously.7) The ablation catheter is useful for
preventing iatrogenic dissection by changing the device’s anchor direction. In general, the location of the emboliza- tion determines the retrieval strategy. A percutaneous snar- ing strategy remains favorable for most embolic complica- tions, however, it is imperfect. Several maneuvers have been attempted to improve this limitation, including the use of a double snare technique, grasping forceps, and an endoscopic grasping tool.8,9) Our simple technique pro- vides several advantages: (1) a flexible loop diameter that is useful in narrow lumen spaces; (2) a strong and firm capture provided by the J wire; and (3) better gripping ability which also improves forceful traction.
In conclusion, even though some reports have sug- gested that LAAC and AF ablation can be combined safely in a single procedure, combining both procedures also bring additional risks. The risk of device emboliza- tion is < 4% among patients undergoing a single LAAC procedure and potentially more in a simultaneous proce- dure, however, larger cohorts are needed to verify this.4,6,10) In a simultaneous procedure, LAAC as the first step pro- vides an additional risk of catheter entrapment or device displacement. On the contrary, performing PVI first is not
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free of risk either, since acute and sub-acute radiofre- quency tissue injury and edema in this region increase the probability of erroneous measurement of the LAA, caus- ing peri-device leak.10,11) Careful evaluation must be made before deciding upon a simultaneous procedure. A percu- taneous strategy is still more favorable in most embolic complications, and this homemade snare optimize its effi- cacy.
Disclosure Conflicts of interest:None.
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