Author + information
- Received January 8, 2014
- Accepted January 16, 2014
- Published online September 1, 2014.
- Ana J. Pérez Matos, MD∗ (, )
- Martin J. Swaans, MD,
- Benno J.W.M. Rensing, MD, PhD,
- Robin H. Heijmen, MD, PhD,
- E. Gijs Mast, MD,
- Lucas V.A. Boersma, MD, PhD and
- Martijn C. Post, MD, PhD
- Department of Cardiology and Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
- ↵∗Reprint requests and correspondence:
Dr. A.J. Pérez Matos, Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands.
An 83-year-old man, with a history of permanent atrial fibrillation, and an ischemic cerebral event, was referred for a percutaneous left atrial appendage (LAA) closure. Because of a high CHA2DS2-VASC (Congestive heart failure [or left ventricular systolic dysfunction], Hypertension: blood pressure consistently >140/90 mm Hg [or treated hypertension on medication], Age ≥75 years, Diabetes mellitus, previous Stroke or TIA or thromboembolism, Vascular disease [e.g., peripheral artery disease, myocardial infarction, aortic plaque], Age 65 to 74 years, Sex category [e.g., female sex]) score (5 points) and a strong contraindication for oral anticoagulants (HAS-BLED [Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs or alcohol] score 4), he was a good candidate for percutaneous LAA occlusion.
The LAA closure procedure has been described elsewhere (1). Briefly, after right femoral vein access a transseptal puncture was performed. A Watchman (Boston Scientific, Natick, Massachusetts) device (27 mm) was positioned in the LAA, and it was released after all release criteria were met.
The next day, the patient was asymptomatic and hemodynamically stable. However, a routine electrocardiogram showed new intermittent left bundle branch block (Figure 1). The transthoracic and transesophageal echocardiograms confirmed the suspected dislocation of the LAA device in the left ventricular outflow tract (Figures 2 and 3⇓, Online Videos 1 and 2). He underwent a successful transapical extraction of the device using a pulling catheter position from the cardiac apex (Figure 4, Online Video 3).
Dislocation of a Watchman device had been described in 0.65% of cases in the PROTECT-AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) trial and is an important procedural complication with possible severe consequences (2). Most dislocations are silent and the device can generally be traced in the abdominal aorta (3). Percutaneous removal via the femoral artery is the treatment of choice. In the present case, the device got attached to the left ventricular outflow tract. The unfolded anchoring barbs were hooked into the interventricular septum and the anterior mitral valve leaflet causing mitral regurgitation. Therefore, a retrograde percutaneous extraction was considered unfeasible because of the risk of damage to the aortic and mitral valves, as described by Stöllberger et al. (4).
This is the first description of Watchman device dislocation unmasked by intermittent left bundle branch block. A Watchman device trapped in the left ventricular outflow tract can be safely extracted by the transapical approach.
For supplemental videos, please see the online version of this article.
The Cardiology Department of the St. Antonius Hospital (Nieuwegein, the Netherlands) receives proctoring fees for training/educational services from Atritech/Boston Scientific.
- Received January 8, 2014.
- Accepted January 16, 2014.
- American College of Cardiology Foundation
- Reddy V.Y.,
- Möbius-Winkler S.,
- Miller M.A.,
- et al.