Extraction of Watchman device using a double transeptal approach

Abstract Background Left atrial appendage occlusion is a treatment for patients with atrial fibrillation who have a high risk of bleeding and are unable to take oral anticoagulants. The Watchman device is an option and has been shown to be safe and effective in reducing embolic stroke risk. Rare but serious and potentially life-threatening complications, such as dislodgment, can occur. Though there is a designated apparatus available for delivery and implantation of these devices, there are no predefined instructions or required equipment available for extraction of dislodged device. Purpose This multicenter study aimed to describe the Watchman extraction procedure and to assess the success rates and potential complications associated with the procedure. Methods In this observational study, we analyzed prospectively collected data from 9 patients that underwent percutaneous Watchman extraction with an endoscopic gasping tool (Raptor) at two high volume centers for Watchman implant in United States between 2019 and 2023. Procedural success was described as complete extraction of Watchman without procedural complication. Results The Watchman was removed due to dislodgement, a potential risk factor for device embolization. The maximum and the minimum size of the extracted Watchman were 24 and 31 respectively. Mean dwell time was 34±8 days. In all the first attempt of retrieval the watchman was done with only one transeptal access with one bioptome (Raptor) to stabilize the watchman and trying to pull inside a 16 mm sheath. In 7 case a second transeptal was required to use another bioptome to allow entry into the sheath. Thus, in these cases sheath bigger than 16 mm was required to extract the Watchman (Fig.1-2). The device was replaced with a bigger watchman in 6 cases, with an amulet in 1 case and in 2 cases, it was not replaced but oral anticoagulation therapy was continued. Procedural success was obtained in 8 (73%) patients. In one case, the use of a single bioptome during extraction led to the embolization of the Watchman device into the ascending aorta, causing a dissection and the patient's subsequent death within the initial week. Conclusion Watchman extraction is a valuable option when complication, such as dislodgment, occur and should be done using two transeptal access with two bioptomes to improve safety and effectiveness.