Case report
An 82-year-old woman with a history of hypertension,third-degree
atrioventricular block and artery embolization was admitted to hospital
because of chest distress and palpitations.She was found to have atrial
fibrillation(AF) on an ECG recorder.She didn’t get pacemaker planted in
her heart and never took oral
anticoagulants(OAC) in the past.Due
to the patient’s desire to prevent the embolization and in view of the
risk of hemorrhage to take OAC,she was referred for
left atrial appendage
occlusion(LAAO) with a CHA2DS2-VASc score of 5 and a HAS-BLED score of
3.The left atrial appendage(LAA) ostial
diameter was 26mm measured by the
pre-procedure cardiac computed tomography.No thrombus was found in the
patient’s left atrial(LA) or LAA
by CT.The diameter of the landing
zone was29.1±2.1mm measured by fluoroscopy and a 34-38mm LAmbre device
was deployed ed to close the patient’s LAA.After placing the implant in
LAA, left atrial angiogram and TEE were performed to check device
positioning,LAA sealing and impingement on surrounding cardiac
structures.The fluoroscopy and TEE
demonstrated that the device was placed in proper position with no
residual leakage and then a tug test by exerting tension to the delivery
cable was performed to ensure device stability.The COST(C-the umbrella
must be flowered at the distal end of the origin of circumflex
artery;O-open fully;S-sealing,peri-device leak≤3 mm;T-tug test)criteria
were confirmed before releasing the device completely.The LAAO was
procedural successful.However,the patient’s blood pressure suddenly
dropped to 60/35mmHg while the
operators withdrew the delivery sheath.We tried to elevated patient’s
blood pressure by speeding up fluid replacement and using noradrenaline
promptly.The fluoroscopy and TEE
showed that the device was detached from the landing zone and closed to
the mitral
valve.We decided to
retrieve
the device by using forceps(Mousetooth alligator forceps, Alton Medical
Limited, China)through a 14F adjustable curved
sheath(FlexCath,
Medtronic, USA)via femoral access immediately but it didn’t work.The
device was trapped in the mitral valve.At once,we contacted the surgeons
and the surgical retrieval was been performed subsequently to remove the
implant in the heart.The patient’s
hemodynamic parameters ultimately
got steady after the cardiovascular surgery.