Journal of Vascular Medicine & Surgery

Management Strategy of Left Atrial Appendage Closure Device Embolization

Anggia Chairuddin Lubis and Dian Andina Munawar ¹Department of Cardiology, Binawaluya Cardiac Center, Jakarta, Indonesia
²Department of Medicine, University of Sumatera Utara, Sumatera Utara, Indonesia
³Department of Cardiology and Vascular Medicine, University of Indonesia, Jakarta, Indonesia
^*Correspondence: Muhamad Munawar, Department of Cardiology, Binawaluya Cardiac Center, Jakarta, Indonesia, Email:

Received: 07-Apr-2022, Manuscript No. JVMS-22-16066; Editor assigned: 13-Apr-2022, Pre QC No. JVMS-22-16066(PQ); Reviewed: 26-Apr-2022, QC No. JVMS-22-16066; Revised: 28-Apr-2022, Manuscript No. JVMS-22-16066(R); Published: 07-May-2022, DOI: 10.35841/2329-6925.22.10.449

Description

Device embolization is a well-known complication of Left Atrial Appendage Closure (LAAC) procedures, with incidence rate of less than 2% reported in the real-world registry. Most cases of the embolization occur acutely after the procedure: during the procedure, the same day or the day after procedure [1-4]. We have previously reported a case of acute dislodgement of LAAC device and managed with a contemporary approach in the retrieval strategy [4]. Either percutaneous or surgical retrieval strategy offers its own advantages and disadvantages. Percutaneous retrieval strategy is more favorable in most LAAC embolization, and yields high successful rate. Device embolization had a 94% chance of being snared percutaneously. However, what is clear that irrespective of these techniques that if a LAAC device becomes entangled in the mitral valve, surgical removal is the safest way to proceed. The endocardium and pliable leaflets are at high risk of perforation and damaged by the fixation anchors [5]. A better understanding of the mechanism and the key of percutaneous retrieval strategy is essential for prevention and management of LAAC device embolization.

Mechanisms of device embolization

Several mechanisms of device embolization have been identified and categorized based on timing: pre-procedure, during implantation or after procedure. Pre-procedure evaluation underlines the importance of anatomical assessment prior to procedure, including shallow LAA landing zone. In this case, the use of thinner LAAC devices are potentially more suitable, otherwise percutaneous LAA ligation should be considered. During implantation procedure, device sizing and positioning are very important to analyze, including device apposition assessment and vigorous wiggle test. Undersize or oversize device also increase the risk of embolization. Finally, the risk for embolization remains increased after implantation. Conversion from Atrial Fibrillation (AF) to sinus rhythm escalates the risk of embolization. In addition, although simultaneous AF ablation and LAAC in a single procedure has been proven safe in some reports, however it may also bring additional risk [4,6-10].

Location of LAAC device embolization

The anatomical locations for LAAC device embolization can be in the Left Atrium (LA), Left Ventricle (LV) and Aorta (Ao). The first two were more common; however the retrieval strategy is somehow different. Retrieval from the LV chamber is the most complex approach, mostly due to the presence of mitral apparatus and surrounding critical structures. Extraction by percutaneous approach is considered high risk of damaging mitral or aortic valves.

Stepwise approach of percutaneous retrieval of embolized LAAC device:

1. Device stabilization

Acute valvular damages and acute heart failure has been reported due to migrating LAAC devices. Irrespective to the retrieval strategy, stabilizing the dislodged device is an important first step. The use of snare and steerable-sheath has been reported to wrap and stabilize the dislodged device [6,7].

2. Is the LAAC device in the LV?

The complexities of LV structures made percutaneous retrieval strategy very difficult and put surgical strategy as first option. However percutaneous approach considered as first option in other embolization locations.

3. Percutaneous extraction tools

Regular snare is the most popular tool to capture the LAAC device. However several modifications have been used; modified snare or grasping device has been proven effective in several scenarios. Each tools has their own advantages and disadvantages [4,11].

4. Safe escape route

The best way to do the extraction safely is to pull the whole device into the sheath, and take all assemblies out as a unit. However, in most situations it can be difficult after the device has been fully deployed. The second option is to shrink the device, pull most part of the device into the sheath and leave some other part outside during the pull back. Finally, venous access can be handled with regular care, however care for arterial access and large sheath should be managed gently. Arterial access can be managed with multiple vascular closure devices or by surgical closure.

Conclusion

In conclusion, prevention of LAAC embolization can be optimized with better understanding of identified mechanisms. Moreover, step-by-step details in percutaneous retrieval strategy are important in preventing further complication and improving success rate.

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