Late Hybrid Retrieval of an Embolized Left Atrial Appendage Occlusion Device

BACKGROUND: Device embolization after left atrial appendage occlusion (LAAO) is rare (∼0.1%) but may be life-threatening. CASE SUMMARY: 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 The device was withdrawn to the right common iliac artery, where evolving limb ischemia prompted surgical device extraction via an infrarenal aortotomy.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. DISCUSSION: 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. TAKE-HOME MESSAGES: 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.