Clin Res Cardiol 108, Suppl 2, October 2019

How to retrieve dislodged left atrial appendage occlusion devices

S. Kany1, S. Bordignon2, M. Piorkowski2, S. Chen2, K. R. J. Chun2, B. Schmidt2

1Universitäres Herz- und Gefäßzentrum Hamburg, Hamburg; 2Medizinische Klinik III, CCB am AGAPLESION BETHANIEN KRANKENHAUS, Frankfurt am Main;

Background: To minimize atrial fibrillation related stroke risk oral anticoagulation (OAC) has been established as the mainstay of therapy. A subset of patients being unsuitable for long-term OAC may benefit from percutaneous left atrial appendage closure (LAAC). However, major complications such as LAAC device embolization may occur in approximately 1% of procedures. Therefore, we aimed to describe all clinical details regarding LAAC device embolization such as device type, time course and retrieval management. Patients and Methods: All patients undergoing a LAAC device implantation between July 2010 and June 2019 were enrolled in this retrospective observational study. Relevant patient characteristics have been prospectively noted and CHA2DS2-VASc and HAS-BLED score calculated. LAAC implantation have been performed by three experienced EP physicians guided by TEE and fluoroscopy. Device position was documented immediately after the procedure, day 1 and day 42 with Xray or TEE, respectively. Results: Device dislodgment was observed in 11 cases, including Amplatzer Cardiac Plug (4), Amplatzer Amulet (1), Coherex (3), Watchman (1). Total LAAC device retrieval encompassed 11 patients including two referred external patients (Watchman & Amulet). Embolization was detected intraprocedurally (5/11) or within 24 h (5/11). One device dislocation was discovered after 47 d. The embolized devices were retrieved from the left atrium (LA), left ventricle (LV) and the aorta (Ao) in 5, 2 and 4 cases, respectively. Percutaneous retrieval was successful in eight cases (LA & Ao). Sufficient oversizing was achieved in all cases during initial implantation (mean Device ⌀26 mm, mean LAA ⌀21,3 mm). Devices dislocated to the LA were retrieved transseptally via a custom 12 F steerable sheath. The devices were captured by gooseneck snares (15-30 mm) and retraction into the sheath was attempted. Complete retraction was achieved with the ACP/Amulet only while the other occluders were partially retracted into the sheath and then removed from the LA by pulling the sheath into the venous system and ultimately removed from the patient's body. No relevant atrio-septal defect was detected after the procedure. LAAC embolization to the aorta was approached via arterial puncture of the groin and subsequent retrieval through either 30 mm gooseneck or myocard biopsy forceps using a 16 F sheath. One occluder dislodged to the LV was approached via transseptal access but could not be retrieved. During the procedure damage to the mitral valve occurred with subsequent urgent cardiac surgery. The second occluder in the LV was directly referred for surgical retrieval with an uneventful outcome. Conclusion: Percutaneous retrieval of dislodged LAAC devices can be attempted successfully and feasible in most cases, especially if dislodgment occurs into the left atrium or aorta. However, dislocation to the LV carries a risk of structural damage to valves and should prompt early surgical intervention.

https://www.abstractserver.com/dgk2019/ht/abstracts//PP155.htm