Percutaneous Extraction of a Migrated WATCHMAN™ Device After Seven Months

DOI: 10.19102/icrm.2021.120701

ABHISHEK MAAN, MD, ScM,¹ MOHIT K. TURAGAM, MD, MS,¹ SRINIVAS R. DUKKIPATI, MD,¹ and VIVEK Y. REDDY, MD¹

¹Helmsley Electrophysiology Center, Division of Cardiac Electrophysiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA

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ABSTRACT. Rarely, a left atrial appendage closure device may chronically migrate to an unfavorable position postoperatively, requiring removal. We present the details of a case in which a WATCHMAN™ device (Boston Scientific, Natick, MA, USA) implanted seven months prior was found to have migrated with protrusion 0.91 cm outside the left atrial appendage together with a 90° tilt and peridevice leakage. Adopting a femoral arterial retrograde approach, a 27-mm WATCHMAN™ device was temporarily positioned in the ascending aorta for cerebroembolic protection, never released from the connecting wire. Extraction of the original WATCHMAN™ device was performed using an endoscopic grasping tool, with subsequent device re-implantation of a new device and removal of the temporarily positioned device in the ascending aorta.

KEYWORDS. Atrial fibrillation, endoscopic grasping tool, device extraction, Watchman.

Dr. Maan reports the reception of research grants from Medtronic, Biotronik, and Biosense Webster; research equipment support from QT Medical and Bardy Rx; and equity in Proteostasis Inc. and NovaVax. Dr. Reddy reports the receipt of grant support from and an unpaid consultant role with Boston Scientific. The other authors report no conflicts of interest for the published content.
Manuscript received December 14, 2020. Final version accepted January 29, 2021.
Address correspondence to: Vivek Y. Reddy, MD, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, P. O. Box 1030, New York, NY 10029, USA. E-mail: vivek.reddy@mountsinai.org.

Case presentation

An 84-year-old man with persistent atrial fibrillation (CHA₂DS₂-VASc score of six points) was referred because of the migration of a 24-mm WATCHMAN™ device (Boston Scientific, Natick, MA, USA) implanted seven months prior. His additional medical history was notable for chronic kidney disease and having undergone dual-chamber pacemaker implantation in 2017 for sinus node dysfunction. At the time of the current case, the patient was on a renally adjusted dose of rivaroxaban for thromboprophylaxis. Transesophageal echocardiography (TEE) revealed a loss of device compression with consequent protrusion 0.91 cm outside the left atrial appendage together with a 90° tilt and peridevice leakage (Figure 1 and Videos 1A–1C).

Under general anesthesia, an extraction procedure was performed with TEE, intracardiac echocardiographic, and fluoroscopy guidance. Adopting a femoral arterial retrograde approach, a 27-mm WATCHMAN™ device was temporarily positioned in the ascending aorta for cerebroembolic protection, never released from the connecting wire (ie, “Watchman in Ascending Aorta for Systemic Protection” technique) (Videos 2A and Video 2B).¹ A weight-based heparin intravenous bolus dose was given to achieve an activated clotting time of greater than 250 seconds prior to pursuing transseptal access. A 23-French nondeflectable sheath (Micra™; Medtronic, Minneapolis, MN, USA) was advanced into the right atrium, through which a 12-French deflectable sheath (FlexCath Advance™; Medtronic) was placed transseptally. A 2.4 mm × 20 cm Raptor™ grasping device (US Endoscopy, Mentor, OH, USA) (Figure 1) was advanced through the 12-French sheath to grasp the WATCHMAN™ device. With sustained traction, the device was dislodged from the left atrial appendage into the 23-French sheath (Figure 1 and Video 3). This older WATCHMAN™ device was negative for any surface thrombi or debris. Subsequently, placement of a new 24-mm WATCHMAN™ device was performed with good apposition; the temporary WATCHMAN™ device in the aorta was removed at this point. The procedural steps are summarized in Table 1. Follow-up TEE performed at four months confirmed stable device positioning without significant peridevice leakage.

In unusual instances, a left atrial appendage closure device may be found to have chronically migrated to an unfavorable position, requiring removal. This case demonstrates the safety and feasibility of WATCHMAN™ extraction using an endoscopic grasping tool and subsequent device re-implantation.^2,3 We preferred the use of the Raptor tool given the chronicity of the previously placed WATCHMAN™ device, which may not have been suitable for retrieval using a snare or biopsy bioptome. The decision to place a WATCHMAN™ device temporarily in the ascending aorta was driven by the limitations of currently available embolic protection devices to prevent peripheral embolization.

References

1. Yadav PK, Wang DD, Eng MH, O’Neill WW. Watchman in ascending aorta for systemic protection (WAASP): Novel use of Watchman in ascending aorta for embolic protection—first in man. Catheter Cardiovasc Interv. 2018;92(2):433–436. [CrossRef] [PubMed]
2. Turagam MK, Neuzil P, Dukkipati SR, et al. Percutaneous retrieval of left atrial appendage closure devices with an endoscopic grasping tool. JACC Clin Electrophysiol. 2020;6(4):404–413. [CrossRef] [PubMed]
3. Afzal MR, Ellis CR, Gabriels J, et al. Percutaneous approaches for retrieval of an embolized or malpositioned left atrial appendage closure device: a multicenter experience. Heart Rhythm. 2020;17(9):1545–1553. [CrossRef] [PubMed]