# Late Hybrid Retrieval of an Embolized Left Atrial Appendage Occlusion Device: A Case and Literature Review

## TL;DR

A rare case of a left atrial appendage occlusion device embolizing and being retrieved after 2 years is described, highlighting challenges and a hybrid surgical solution.

## Contribution

This case is the first to report successful retrieval of an embolized LAAO device after 2 years and demonstrates the need for hybrid strategies due to tissue ingrowth.

## Key findings

- Device embolization occurred 2 years post-implantation, with the device lodged in the aortic arch.
- Chronic tissue ingrowth made percutaneous resheathing impossible, requiring surgical extraction via aortotomy.
- Hybrid retrieval strategies are effective when percutaneous methods fail in long-term embolized device cases.

## Abstract

Device embolization after left atrial appendage occlusion (LAAO) is rare (∼0.1%) but may be life-threatening.

A 72-year-old man presented with a left frontal stroke 2 years after Amplatzer Amulet LAAO device implantation. Computed tomography angiography showed the occluder lodged across the left subclavian artery ostium in the transverse aortic arch. After heart team review and Health Products Regulatory Authority compassionate-use approval, an ONO basket retrieval system (Onocor) was used to capture the device under fluoroscopic and transesophageal echocardiography guidance. Repeated attempts to resheath it into a 26-F DrySeal sheath failed because the device could not be adequately compressed. The device was withdrawn to the right common iliac artery, where evolving limb ischemia prompted surgical device extraction via an infrarenal aortotomy. Extensive tissue ingrowth was evident on device retrieval.

Review of 18 published reports describing 20 cases of late LAAO device embolization showed retrieval intervals up to 18 months, almost all successfully managed percutaneously. This case extends that experience to 2 years and highlights how chronic tissue incorporation can hinder resheathing, emphasizing the role of hybrid retrieval strategies when percutaneous extraction fails.

Embolized LAAO devices that remain in situ for prolonged periods may develop tissue ingrowth, making percutaneous removal technically challenging. When full percutaneous extraction is not achievable, hybrid percutaneous-surgical retrieval via an infrarenal aortotomy offers a safe bailout that avoids sternotomy.