Acute embolisation of Watchman plug onto aortic bioprosthesis followed by successful percutaneous removal

Recent years have brought important advances in percutaneous closures of the left atrial appendage (LAA). With increasing experience of operators, the procedure has become a safe and effective alternative to oral anticoagulation in selected patients. Most of the complications regarding this procedure happen in the periprocedural period, and one of the rarest of them is device embolisation, which, as described in the PROTECT_AF study, happened only in 3 of 546 patients (0.6%) and only in one of them acutely (during the procedure) [1]. In a systematic review, Aminian et al. described 31 cases of device embolisation after percutaneous LAA closure [2]. Most of these complications, however, were acute and almost half of them happened during the procedure. Most of them could also be removed percutaneously, especially if the device embolized into the aorta or left atrial (LA) and not into the LV. Lasek-Bal and Mizia-Stec reported successful closure of the LAA with no significant complications whatsoever [3].
Our patient was an 80-year-old woman who underwent implantation of an aortic bioprosthesis (Shellhigh 27) 8 years earlier due to severe aortic stenosis. She suffered from chronic kidney disease (stage G3a), hypertension and paroxysmal atrial fibrillation, but no coronary artery disease (as it was previously excluded in coronarography). She had a history of multiple severe bleeding from the lower digestive tract during oral anticoagulation with rivaroxaban. After discussing the risks and potential advantages of LAA closure, she was qualified for implantation of the Watchman device.
The procedure initially went with no complications using sedative drugs only and no general anesthesia. Patients’ LAA had “chicken wing” morphology and the maximum width of the ostium was 14.1 mm measured in transesophageal echocardiography (TEE) during the procedure. Initially a Watchman 27 mm was used, but it had to be switched to a Watchman 21 mm because of excessive protrusion. Correct localization of the Watchman device was confirmed in fluoroscopy and TEE, as shown in Figures 1 A and B, respectively, as well as by the tug test with 9% device compression (19/21 mm). Color Doppler showed no significant peri-device flow. A few minutes after the procedure was finished, while the patient was still in the catheterization laboratory, there was a cardiac arrest with pulseless electrical activity. Immediately we began resuscitation and reintroduced the TEE probe. The...


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