Abstract Body (Do not enter title and authors here): Case:
An 82-year-old male with a history of paroxysmal atrial fibrillation, coronary artery disease, heart failure with preserved ejection fraction, and end-stage renal disease on hemodialysis underwent a concomitant pulmonary vein isolation with pulsed field ablation and left atrial appendage (LAA) closure with a watchman device as he was a poor candidate for long-term anticoagulation. A 27 mm Watchman device was successfully deployed into the LAA with all PASS criteria (position, anchor, size, seal) being met. However, a transthoracic echocardiogram 24 hours later revealed that the device had dislodged from the LAA, and lodged in the left ventricular outflow tract (LVOT).

The device was retrieved percutaneously via right femoral artery access under fluoroscopy and transesophageal echocardiogram (TEE) guidance. An 8.5F Agilis NXT steerable sheath (Abbott Vascular, Santa Clara, CA) was introduced through the femoral artery into the ascending aorta. A Rescue Combo 8mm forceps (Boston Scientific, Marlborough, MA) was advanced across the aortic valve. The Watchman was grasped to orient the anchors away from the valve and was retracted into the descending aorta with gentle traction. The device was released in the infrarenal aorta. After preclosure with two Proglides the Agilis was exchanged for an 18F Gore Dryseal (WL Gore, Flagstaff, AZ) sheath. The forceps was reintroduced and the device was grasped and collapsed into the large sheath. It was then removed intact from the body.

Post-procedure TEE showed no valvular or ascending aortic trauma from the retrieval. The patient was monitored overnight in the cardiac intensive care unit and discharged in stable condition on apixaban.



Discussion:
LAA occlusion with the Watchman device is an effective strategy for stroke prevention in patients with atrial fibrillation at high stroke risk, with contraindications to long-term anticoagulation. Although device dislodgement is rare, as seen in the PROTECT-AF (0.6%) and EWOLUTION (0.2%) trials, some cases have been documented in the literature. Most dislodged devices migrate into the left atrium, left ventricle, or aorta, and are typically removed percutaneously or surgically. Our case highlights a rare instance of LVOT migration of a Watchman device, emphasizing the importance of early post-procedural imaging and structural cardiology evaluation before considering surgery. It also provides valuable insights into removing a dislodged Watchman device via the aortic approach.