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Erschienen in: BMC Cardiovascular Disorders 1/2020

Open Access 01.12.2020 | Case report

Late discovery of left atrial appendage occluder device embolization: a case report

verfasst von: Mohamad Jihad Mansour, Clément Bénic, Romain Didier, Antoine Noel, Martine Gilard, Jacques Mansourati

Erschienen in: BMC Cardiovascular Disorders | Ausgabe 1/2020

Abstract

Background

Left atrial appendage (LAA) closure has been well evaluated in the prevention of stroke in patients with atrial fibrillation. Device embolization remains one of the most common complications. To the best of our knowledge, there have been no reports of late discovery of LAA occluder device embolization at 1.5 years after implantation.

Case presentation

We describe the case of a 77-year-old man who underwent uneventful LAA closure. Echocardiography performed the next day showed the device in place. The patient was discharged but was then lost to follow-up. 1.5 years later, he was admitted for ischemic stroke. Transesophageal echocardiography showed the absence of the occluder device in the LAA. Computed tomography scan of the abdomen showed the device in the abdominal aorta. Due to the high cardiovascular risk, the device was kept in place and the patient was treated medically.

Conclusions

Per-procedural and late device embolization are not uncommon. Review of the literature however showed no report of late discovery of device embolization at 1.5 years. Follow-up echocardiography is mandatory for the detection of endothelialization or embolization.
Hinweise

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Abkürzungen
AF
Atrial fibrillation
CT
Computed tomography
LAA
Left atrial appendage
TEE
Transesophageal echocardiography
TTE
Transthoracic echocardiography

Background

Several studies have evaluated different left atrial appendage (LAA) occluder devices and demonstrated non-inferiority in stroke prevention compared to warfarin in patients with atrial fibrillation (AF) [1, 2]. Early device embolization remains one of the most common complications, which requires urgent extraction. We herein describe a case of late discovery of an occluder device embolization that was not extracted but rather medically managed.

Case presentation

A 77-year-old male patient with a medical history significant for permanent AF with a CHA2DS2-VASC score of 6, ischemic stroke with residual seizure and two hemorrhagic strokes, was referred for LAA closure using a Watchman device (Boston Scientific, Inc., Natick, Massachusetts). LAA morphology and measurements were obtained from cardiac computed tomography (CT) angiography and transesophageal echocardiography (TEE). LAA was bilobed. The maximum width of the ostium was measured at 20 mm. Hence, a 24 mm device was successfully implanted. The device was well aligned with the axis of the LAA. A gentle tug test did not change the device position. The patient remained stable and there were no complications noted during or after the procedure. Transthoracic echocardiography (TTE) performed the next day showed the device in place. The patient was discharged with a scheduled TEE six weeks after the procedure but was lost to follow-up.
1.5 years later, he presented with two new ischemic strokes and unexplained left foot pain. Repeat TTE/TEE showed the absence of the occluder device in the LAA. CT scan of the chest and abdomen showed the device in the abdominal aorta between the ostium of the celiac trunk and the superior mesenteric artery (Fig. 1, Panels A-C). Mild thrombosis was seen in the device at the level of the fabric membrane (Panels B and D). The abdominal aorta was severely calcified (Panels A and C). Due to the high cardiovascular risk, surgical or percutaneous extraction were not done and the device was kept in place. Low dose aspirin was added to his medical treatment. The patient died 3 months later from seizure.

Discussion and conclusions

Complications of Watchman device implantation are rare, with device embolization rates of 0.6 and 0.7% [1, 2]. Device extraction can be performed either percutaneously via a snare introduced in the femoral artery sheath (e.g., for Watchman device), or surgically (for larger devices) [3]. Percutaneous removal remains the treatment of choice for vascular embolization, particularly in patients with multiple comorbidities and the elderly population. Device embolization risk depends on the operator’s experience, the choice of device size and the final position. Patient related characteristics such as LAA morphology and length, ostium size or unusual morphologies are also important criteria. Per procedural TEE guidance is mandatory, thereby avoiding vigorous tug testing (usually performed for proof of device stability). Nevertheless, aggressive physical movements are not advised before endothelialization [4].
Published articles retrieved from PubMed database included single center/multicenter registries, randomized controlled trials, observational studies, case reports and a systematic review [324] (Table 1). Device embolization occurred mostly during the procedure and within 7 days in the described cases. Some cases reported embolization at 45 and 48 days [3, 16, 19]. A study published by Swaans et al. [5] described device embolization 3 months following the procedure. Another case described percutaneous retrieval of an AMPLATZER cardiac plug 6 months after embolization [23]. In a systematic review, Aminian et al. [24] concluded that embolization occurred mostly in the periprocedural period but late embolization was not uncommon. Review of the literature however showed no report of late discovery of device embolization at 1.5 years. Since in the majority of cases device embolization is asymptomatic, patient education for short and long term follow-up is extremely important as there is no way to know the exact timing of device embolization. Hence, in our case, embolization could have occurred earlier but was lately picked up due to loss of follow-up.
Table 1
Summary of published data on Watchman device embolization
Reference
Study Design
Number of device embolization
Device size
Device location
Timing
Retrieval Approach
Holmes et al. [2]
Randomized controlled trial (N = 269)
2
27 mm
LV
Post procedure day 1
Surgery
Holmes et al. [3]
Randomized non-inferiority trial (N = 463)
3
30 mm
LV
Thoracic Aorta
AA
Intraprocedural
45 days
45 days
Surgery
Percutaneous (femoral – snare)
Surgery
Sick et al. [4]
Multicenter registry (N = 66)
2
NA
NA
Intraprocedural
Percutaneous (femoral – snare)
Swaans et al. [5]
Single center registry (N = 30)
1
NA
AA
3 months
Surgery
Reddy et al. [6]
Multicenter registry (N = 150)
2
NA
Descending Aorta
Intraprocedural
Percutaneous (femoral – snare)
Matsuo et al. [7]
Single center registry (N = 179)
2
NA
AA
Post procedure within 12 h
Percutaneous (femoral – snare)
Pérez Matos et al. [8]
Case report
1
27 mm
LV
Post procedure day 1
Transapical access and pulling catheter
Chopra et al. [9]
Case report
1
34 mm
LA
Post procedure day 1
Transseptal
Vivek et al. [10]
Registry
(N = 3822)
9
NA
NA
NA
6 surgery
3 Percutaneous
Boersma et al. [11]
Cohort (N = 1025)
2
NA
NA
Within 7 days
1 surgery
1 percutaneous
Vivek et al. [12]
RCT (N = 707)
3
NA
NA
Early
NA
Pillarisseti et al. [13]
Multicenter observational study (N = 478)
1
NA
NA
NA
Surgery
Betts et al. [14]
Multicenter retrospective registry (N = 371)
1
NA
NA
Per procedure
NA
Saw et al. [15]
Multicenter experience
1
NA
NA
Early
Percutaneous –Snared
Fanari et al. [16]
Case report
1
21 mm
AA
48 days
Percutaneous
Gabriels et al. [17]
Case report
1
24 mm
LA
Intraprocedural
Percutaneous – transseptal
Fastner et al. [18]
Case report
1
NA
LA
Intraprocedural
Percutaneous
Hai Deng et al. [19]
Case report
1
30 mm
Aortic arch
45 days
Percutaneous – snared
Stollberger et al. [20]
Case report
1
30 mm
LV
Periprocedural
Surgery
Barth et al. [21]
Case Report
2
24 mm
21 mm
LA
Descending Aorta
Periprocedural
Percutaneous – transseptal
Percutaneous –Snared
Bôsche et al. [22]
Single center prospective study
1
NA
NA
Within 7 days
Percutaneous
Obeid et al. [23]
Case report
1
24 mm
LA
6 months
Percutaneous
Aminian et al. [24]
Systematic Review
21
NA
9 Aorta
9 LV
3 LA
Until 90 days
Surgical
Percutaneous
AA abdominal aorta, LA left atrium, LV left ventricle, NA not applicable
We report a unique case of late discovery of LAA occluder device embolization in the abdominal aorta. Per procedural and follow-up echocardiography is crucial for the detection of device endothelialization or embolization.

Acknowledgments

This article was also published as an abstract in EP Europace [25].
Not applicable.
Patient’s next-of-kin gave written consent for their relatives personal or clinical details along with any identifying images to be published in this manuscript.

Competing interests

Professor Jacques Mansourati is consultant and receives research fees from Boston Scientific and Abbott Laboratories. All other authors declare that they have no competing interests.
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Literatur
1.
Zurück zum Zitat Fountain RB, Holmes DR, Chandrasekaran K, Packer D, Asirvatham S, Van Tassel R, et al. The PROTECT AF (WATCHMAN left atrial appendage system for embolic PROTECTion in patients with atrial fibrillation) trial. Am Heart J. 2006 May;151(5):956–61.CrossRef Fountain RB, Holmes DR, Chandrasekaran K, Packer D, Asirvatham S, Van Tassel R, et al. The PROTECT AF (WATCHMAN left atrial appendage system for embolic PROTECTion in patients with atrial fibrillation) trial. Am Heart J. 2006 May;151(5):956–61.CrossRef
2.
Zurück zum Zitat Holmes DR, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, et al. Prospective randomized evaluation of the watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64(1):1–12.CrossRef Holmes DR, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, et al. Prospective randomized evaluation of the watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64(1):1–12.CrossRef
3.
Zurück zum Zitat Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet Lond Engl. 2009;374(9689):534–42.CrossRef Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet Lond Engl. 2009;374(9689):534–42.CrossRef
4.
Zurück zum Zitat Sick PB, Schuler G, Hauptmann KE, Grube E, Yakubov S, Turi ZG, et al. Initial worldwide experience with the WATCHMAN left atrial appendage system for stroke prevention in atrial fibrillation. J Am Coll Cardiol. 2007 Apr 3;49(13):1490–5.CrossRef Sick PB, Schuler G, Hauptmann KE, Grube E, Yakubov S, Turi ZG, et al. Initial worldwide experience with the WATCHMAN left atrial appendage system for stroke prevention in atrial fibrillation. J Am Coll Cardiol. 2007 Apr 3;49(13):1490–5.CrossRef
5.
Zurück zum Zitat Swaans MJ, Post MC, Rensing BJWM, Boersma LVA. Ablation for atrial fibrillation in combination with left atrial appendage closure: first results of a feasibility study. J Am Heart Assoc. 2012 Oct;1(5):e002212.CrossRef Swaans MJ, Post MC, Rensing BJWM, Boersma LVA. Ablation for atrial fibrillation in combination with left atrial appendage closure: first results of a feasibility study. J Am Heart Assoc. 2012 Oct;1(5):e002212.CrossRef
6.
Zurück zum Zitat Reddy VY, Möbius-Winkler S, Miller MA, Neuzil P, Schuler G, Wiebe J, et al. Left atrial appendage closure with the watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix feasibility study with watchman left atrial appendage closure technology). J Am Coll Cardiol. 2013 Jun 25;61(25):2551–6.CrossRef Reddy VY, Möbius-Winkler S, Miller MA, Neuzil P, Schuler G, Wiebe J, et al. Left atrial appendage closure with the watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix feasibility study with watchman left atrial appendage closure technology). J Am Coll Cardiol. 2013 Jun 25;61(25):2551–6.CrossRef
7.
Zurück zum Zitat Matsuo Y, Sandri M, Mangner N, Majunke N, Dähnert I, Schuler G, et al. Interventional closure of the left atrial appendage for stroke prevention. Circ J. 2014;78(3):619–24.CrossRef Matsuo Y, Sandri M, Mangner N, Majunke N, Dähnert I, Schuler G, et al. Interventional closure of the left atrial appendage for stroke prevention. Circ J. 2014;78(3):619–24.CrossRef
8.
Zurück zum Zitat Pérez Matos AJ, Swaans MJ, Rensing BJWM, Heijmen RH, Mast EG, Boersma LVA, et al. Embolization of a left atrial appendage closure device unmasked by intermittent left bundle branch block. JACC Cardiovasc Interv. 2014;7(9):e115–7.CrossRef Pérez Matos AJ, Swaans MJ, Rensing BJWM, Heijmen RH, Mast EG, Boersma LVA, et al. Embolization of a left atrial appendage closure device unmasked by intermittent left bundle branch block. JACC Cardiovasc Interv. 2014;7(9):e115–7.CrossRef
10.
Zurück zum Zitat Reddy VY, Gibson DN, Kar S, O’Neill W, Doshi SK, Horton RP, et al. Post-approval U.S. experience with left atrial appendage closure for stroke prevention in atrial fibrillation. J Am Coll Cardiol. 2017 Jan 24;69(3):253–61.CrossRef Reddy VY, Gibson DN, Kar S, O’Neill W, Doshi SK, Horton RP, et al. Post-approval U.S. experience with left atrial appendage closure for stroke prevention in atrial fibrillation. J Am Coll Cardiol. 2017 Jan 24;69(3):253–61.CrossRef
11.
Zurück zum Zitat Boersma LVA, Schmidt B, Betts TR, Sievert H, Tamburino C, Teiger E, et al. Implant success and safety of left atrial appendage closure with the WATCHMAN device: peri-procedural outcomes from the EWOLUTION registry. Eur Heart J. 2016 Aug;37(31):2465–74.CrossRef Boersma LVA, Schmidt B, Betts TR, Sievert H, Tamburino C, Teiger E, et al. Implant success and safety of left atrial appendage closure with the WATCHMAN device: peri-procedural outcomes from the EWOLUTION registry. Eur Heart J. 2016 Aug;37(31):2465–74.CrossRef
12.
Zurück zum Zitat Reddy VY, Sievert H, Halperin J, Doshi SK, Buchbinder M, Neuzil P, et al. Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: a randomized clinical trial. JAMA. 2014 Nov 19;312(19):1988–98.CrossRef Reddy VY, Sievert H, Halperin J, Doshi SK, Buchbinder M, Neuzil P, et al. Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: a randomized clinical trial. JAMA. 2014 Nov 19;312(19):1988–98.CrossRef
13.
Zurück zum Zitat Pillarisetti J, Reddy YM, Gunda S, Swarup V, Lee R, Rasekh A, et al. Endocardial (watchman) vs epicardial (lariat) left atrial appendage exclusion devices: understanding the differences in the location and type of leaks and their clinical implications. Heart Rhythm. 2015 Jul;12(7):1501–7.CrossRef Pillarisetti J, Reddy YM, Gunda S, Swarup V, Lee R, Rasekh A, et al. Endocardial (watchman) vs epicardial (lariat) left atrial appendage exclusion devices: understanding the differences in the location and type of leaks and their clinical implications. Heart Rhythm. 2015 Jul;12(7):1501–7.CrossRef
14.
Zurück zum Zitat Betts TR, Leo M, Panikker S, Kanagaratnam P, Koa-Wing M, Davies DW, et al. Percutaneous left atrial appendage occlusion using different technologies in the United Kingdom: a multicenter registry. Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 2017;89(3):484–92.CrossRef Betts TR, Leo M, Panikker S, Kanagaratnam P, Koa-Wing M, Davies DW, et al. Percutaneous left atrial appendage occlusion using different technologies in the United Kingdom: a multicenter registry. Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 2017;89(3):484–92.CrossRef
15.
Zurück zum Zitat Saw J, Fahmy P, Azzalini L, Marquis J-F, Hibbert B, Morillo C, et al. Early Canadian multicenter experience with WATCHMAN for percutaneous left atrial appendage closure. J Cardiovasc Electrophysiol. 2017 Apr;28(4):396–401.CrossRef Saw J, Fahmy P, Azzalini L, Marquis J-F, Hibbert B, Morillo C, et al. Early Canadian multicenter experience with WATCHMAN for percutaneous left atrial appendage closure. J Cardiovasc Electrophysiol. 2017 Apr;28(4):396–401.CrossRef
16.
Zurück zum Zitat Fanari Z, Goel S, Goldstein JA. Successful percutaneous retrieval of embolized transcatheter left atrial appendage closure device (watchman) using a modified vascular retrieval forceps. Cardiovasc Revasc Med. 2017;18(8):616-18. Fanari Z, Goel S, Goldstein JA. Successful percutaneous retrieval of embolized transcatheter left atrial appendage closure device (watchman) using a modified vascular retrieval forceps. Cardiovasc Revasc Med. 2017;18(8):616-18.
17.
Zurück zum Zitat Gabriels J, Beldner S, Khan M, Zeitlin J, Jadonath R, Patel A. Embolization of watchman device following a hybrid radiofrequency ablation of atrial fibrillation and watchman implantation procedure. J Cardiovasc Electrophysiol. 2017 Jul;28(7):835–6.CrossRef Gabriels J, Beldner S, Khan M, Zeitlin J, Jadonath R, Patel A. Embolization of watchman device following a hybrid radiofrequency ablation of atrial fibrillation and watchman implantation procedure. J Cardiovasc Electrophysiol. 2017 Jul;28(7):835–6.CrossRef
18.
Zurück zum Zitat Fastner C, Lehmann R, Behnes M, Sartorius B, Borggrefe M, Akin I. Veno-venous double lasso pull-and-push technique for transseptal retrieval of an embolized watchman occluder. Cardiovasc Revascularization Med Mol Interv. 2016;17(3):206–8.CrossRef Fastner C, Lehmann R, Behnes M, Sartorius B, Borggrefe M, Akin I. Veno-venous double lasso pull-and-push technique for transseptal retrieval of an embolized watchman occluder. Cardiovasc Revascularization Med Mol Interv. 2016;17(3):206–8.CrossRef
19.
Zurück zum Zitat Deng H, Liao H, Liu Y, Chen S, Xue Y, Zhan X, et al. Acute heart failure caused by dislocation of a WATCHMAN left atrial appendage Occluder. JACC Cardiovasc Interv. 2016 May 23;9(10):e97–9.CrossRef Deng H, Liao H, Liu Y, Chen S, Xue Y, Zhan X, et al. Acute heart failure caused by dislocation of a WATCHMAN left atrial appendage Occluder. JACC Cardiovasc Interv. 2016 May 23;9(10):e97–9.CrossRef
20.
Zurück zum Zitat Stöllberger C, Schneider B, Finsterer J. Serious complications from dislocation of a watchman left atrial appendage occluder. J Cardiovasc Electrophysiol. 2007 Aug;18(8):880–1.CrossRef Stöllberger C, Schneider B, Finsterer J. Serious complications from dislocation of a watchman left atrial appendage occluder. J Cardiovasc Electrophysiol. 2007 Aug;18(8):880–1.CrossRef
21.
Zurück zum Zitat Barth C, Behnes M, Borgrefe M, Akin I. Peri-interventional embolization of left atrial appendage occlusion devices: two manoeuvers of successful retrieval. Eur Heart J Case Rep. 2018;2(1):yty001.PubMedPubMedCentral Barth C, Behnes M, Borgrefe M, Akin I. Peri-interventional embolization of left atrial appendage occlusion devices: two manoeuvers of successful retrieval. Eur Heart J Case Rep. 2018;2(1):yty001.PubMedPubMedCentral
22.
Zurück zum Zitat Bösche LI, Afshari F, Schöne D, Ewers A, Mügge A, Gotzmann M. Initial experience with novel Oral anticoagulants during the first 45 days after left atrial appendage closure with the watchman device. Clin Cardiol. 2015 Dec;38(12):720–4.CrossRef Bösche LI, Afshari F, Schöne D, Ewers A, Mügge A, Gotzmann M. Initial experience with novel Oral anticoagulants during the first 45 days after left atrial appendage closure with the watchman device. Clin Cardiol. 2015 Dec;38(12):720–4.CrossRef
23.
Zurück zum Zitat Obeid S, Nietlispach F, Luscher TF, Alibegovic J. Percutaneous retrieval of an endothelialized AMPLATZER cardiac plug from the abdominal aorta 6 months after embolization. Eur Heart J. 2014;35(47):3387.CrossRef Obeid S, Nietlispach F, Luscher TF, Alibegovic J. Percutaneous retrieval of an endothelialized AMPLATZER cardiac plug from the abdominal aorta 6 months after embolization. Eur Heart J. 2014;35(47):3387.CrossRef
24.
Zurück zum Zitat Aminian A, Lalmand J, Tzikas A, Budts W, Benit E, Kefer J. 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(1):128–35.CrossRef Aminian A, Lalmand J, Tzikas A, Budts W, Benit E, Kefer J. 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(1):128–35.CrossRef
Metadaten
Titel
Late discovery of left atrial appendage occluder device embolization: a case report
verfasst von
Mohamad Jihad Mansour
Clément Bénic
Romain Didier
Antoine Noel
Martine Gilard
Jacques Mansourati
Publikationsdatum
01.12.2020
Verlag
BioMed Central
Erschienen in
BMC Cardiovascular Disorders / Ausgabe 1/2020
Elektronische ISSN: 1471-2261
DOI
https://doi.org/10.1186/s12872-020-01589-9

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