Syncope Secondary to Amplatzer Cardiac Plug

SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Percutaneous left atrial appendage closure device (LAAD) is indicated for patients at risk of bleeding on oral anticoagulation for non-valvular atrial fibrillation. A rare complication of LAAD is embolization and dislocation of the device. Herein, we present a very interesting case of an older gentleman following a syncopal episode and recent AMPLATZER implantation. CASE PRESENTATION: A 72-year-old man with chronic atrial fibrillation was referred for an AMPLATZER cardiac plug implantation due to high risk of anticoagulant associated bleeding (HAS-BLED score = 4) and high risk of embolism (CHA2DS2-VASc score = 5).The AMPLATZER cardiac plug was successfully deployed without complications and the patient was discharged home the next day. One week later, the patient presented to the emergency room with exercise intolerance and syncope. Blood pressure was 93/67 mmHg, and heart rate was 41 beats per minute. Cardiopulmonary exam was otherwise unremarkable. ECG showed complete heart block with ventricular escape rhythm. On transthoracic echocardiography, the AMPLATZER plug had dislodged from the LAA and was moving freely in the left ventricle cavity. The patient was transferred emergently to the cardiac catheterization laboratory and device was snared in the left ventricle and removed via the left common femoral artery, with immediate resolution of the complete heart block. DISCUSSION: Percutaneous LAA closure device insertion is increasingly performed for patients at high risk of bleeding secondary to oral anticoagulation for atrial fibrillation. In the Protect-AF trial using the Watchman device, dislocation was discovered in 0.65% of implants. In a recent study of 52 patients using the AMPLATAZER cardiac plug, no embolization or dislocation of the device occurred. To our knowledge, our patient is the first case of complete heart block secondary to AMPLATAZER cardiac plug dislodgement. Percutaneous removal of the device is indicated and results in the resolution of heart block. CONCLUSIONS: Dislocation of LAA closure devices is a complication which may cause heart arrhythmias. Echocardiography is imaging of choice when implant location is in question. Immediate percutaneous removal of the device should lead to resolution of symptoms and arrhythmia. Reference #1: Urena M, Rodés-Cabau J, Freixa X, et al. Percutaneous Left Atrial Appendage Closure With the AMPLATZER Cardiac Plug Device in Patients With Nonvalvular Atrial Fibrillation and Contraindications to Anticoagulation Therapy. J Am Coll Cardiol. 2013;62(2):96-102. Reference #2: Fountain R.B., Holmes D.R., Chandrasekaran K.L., et al; The PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with Atrial Fibrillation) trial. Am Heart J. 2006;151:956-961. Reference #3: Pérez Matos AJ, Swaans MJ, Rensing BM, et al. Embolization of a Left Atrial Appendage Closure Device Unmasked by Intermittent Left Bundle Branch Block. J Am Coll Cardiol Intv. 2014;7(9):e115-e117. DISCLOSURE: The following authors have nothing to disclose: Shwan Jalal, Rami Zein, Howard Rosman, Thomas LaLonde, Thomas Davis, Gerald Cohen No Product/Research Disclosure Information