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\begin{document}

\title{A 14F Flexible Sheath and Forceps for Safe Retrieval of a Dislodged Left
Atrial Appendage Occluder}



\author[1]{Libin Qiu}%
\author[1]{Bing Rong}%
\author[1]{Kai Zhang}%
\author[1]{Jingquan Zhong}%
\affil[1]{Shandong University Qilu Hospital}%


\vspace{-1em}



  
  \date{March 15, 2025}


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\selectlanguage{english}
\begin{abstract}
Introduction:LAmbre occluder (Lifetech Scientific, Shenzhen, China), a
new device for left atrial appendage (LAA) occlusion, is increasingly
used, but the procedure for retrieval after dislodgement has rarely
reported in human. Methods and Results:An 80-year-old male patient with
permanent atrial fibrillation underwent the implantation of LAA
occlusion device. The occluder dislodged to left atrium (LA) at the end
of procedure. We failed to retrieve device in LA with a LASSO catheter
and forceps with the 8.5F sheath. After it suddenly flowing into aortic
arch, we successfully retrieved with a 14F flexible sheath and forceps.
We also discussed reasons for the device dislodgment and reported
experiences for device retrieval. Conclusion: Combination of the 14F
flexible sheath and forceps could be used to retrieve the dislocation of
LAA occlusion device.%
\end{abstract}%



\sloppy


\textbf{Introduction}

LAmbre (Lifetech Scientific, Shenzhen, China), a new self-expanding left
atrial appendage (LAA) occluder, is specifically designed for LAA
occlusion (LAAO)\textsuperscript{1}. So far, only one case about LAmbre
device migration has been published by Mohamed Sanhoury et al in
2017\textsuperscript{2}. We herein describe a case of acute dislodgment
of LAmbre and the complex procedure for percutaneous retrieval.

\textbf{Case presentation}

An 80-year-old male patient, had history of coronary atherosclerotic
heart disease, hypertension, and implantation of permanent double
chamber cardiac pacemaker, AF,
CHA\textsubscript{2}DS\textsubscript{2}-VASc score of 4, HAS-BLED score
of 3. The patient was referred to transcatheter LAAO because of
reluctant long-term oral anticoagulants. Transesophageal
echocardiography (TEE) excluded the thrombus formation and measured the
diameter of inlet and waist of LAA. The patient refused to use
intracardiac echocardiography due to financial constraint. Implantation
of LAA device was guided by X-ray fluoroscopy and angiography without
general anesthesia with only perioperative use of
TEE\textsuperscript{3}. During LAAO procedure, the shape and size of LAA
was determined by angiogram. We chose the occluder with diameter of 26mm
lobe/38mm disc (LAmbre 2638, Lifetech Scientific, China). Under
continuous fluoroscopy monitoring, the occluder was in position with no
obvious residual flow in a correct tug test, and then it was fully
released. The method referred the COST principle (umbrella deployed
beyond Circumflex artery; umbrella fully Open; peri-device optimal
Sealing; device stability confirmed by Tug test)\textsuperscript{2}. The
occluder, however, unexpectedly dislodged to left atrium (LA) at the end
of procedure. Instantly, a LASSO catheter (Nav, Biosense Webster,
America) was introduced to entrap the tumbling device to prevent it from
falling into left ventricle (Figure 1A, online Video 1). And the
department of cardiovascular surgery was ready for unexpected needs. The
normal head foreign body removal forceps (Mousetooth alligator forceps,
Alton Medical Limited, China) was sent to LA through another 8.5F
transseptal sheath (L1, Synaptic Medical, China). We tried many times,
but still failed to grasp the device. After that, we adjusted LASSO to
access the center of occluder, while it suddenly migrated to left
ventricle, and instantly flowed into aorta arch (Figure 1B). The patient
was asymptomatic and with stable heart rhythm and blood pressure. A 14F
flexible sheath (FlexCath, Medtronic, America) was delivered via right
femoral artery approach to adjust and access the center of sealing disc,
thereafter the aforementioned forceps were sent out, and finally after
several attempts the sealed disc center was caught (Figure 1C-D, online
Video 2); the LAA occluder was smoothly retrieved into the sheath
(Figure 1E, online Video 3). The device was completely destroyed due to
the pulling and squeezing inside the sheath (Figure 1F). Repeat aorta
arch angiography showed no vascular complications. The patient refuted
further implantation of other devices, and returned to ward with stable
hemodynamic parameters, without pericardial effusion and injury of
valves.

\textbf{Discussion}

Percutaneous retrieval of the dislodged LAmbre occluder has been
depicted in a canine model with a 14F adjustable curved sheath and
forceps\textsuperscript{4}. We herein reported a human case using this
strategy to safely retrieve the LAmbre device. The reasons for
dislodgement may associate with: improper size, incorrect apposition, a
shallow landing zone, vigorous tug test, passive or active movement
before complete endothelialization\textsuperscript{4}. In the present
case, dislocation may be on account of the complex structure--a
cauliflower shape with a wide ostium and a short distance from each lobe
to the common ostium, and the over sizing of device. We however could
not totally exclude the influence of intraoperative imaging, though
previous study reported the potential feasibility of simplified
procedure using fluoroscopy only\textsuperscript{5}. Unlike the other
two types of devices, i.e. Watchman and Amplatzer Cardiac Plug,
referring to use snare to retrieve, the retrieving tool of LAmbre was
referred to use the disposable grasping forceps (JIUHONG, Changzhou,
China). The fixed disc of LAmbre is too fragile to be caught, but the
sealed disc, woven with nickel titanium alloy wire, could be hauled and
contracted into the sheath integrally by catching the wire of center
area of the metal disc. Therefore, as recently reported in a canine
model\textsuperscript{4}, for successful retrieval, it is important to
get close to the center of disc (using a hard guided wire and a pig tail
duct) and grasp device with the forceps. In present case, when in LA, it
is probable that the used sheath was not as flexible and large as to
access the effective seizing position. We should introduce a 14F
adjustable curved sheath\textsuperscript{4}. Fortunately, after fleeing
from LA, the device was not trapped in left ventricle and quickly
embolized in aorta arch, giving us another chance to retrieve. The 14F
flexible sheath is able to adjust satisfactory angles and get close to
the right position so as to catch the occluder smoothly by forceps.
Therefore, a 14F flexible sheath and forceps can be used to safe
percutaneous retrieval of LAmbre in aorta.

\textbf{Competing interests}

There is no conflict interest to be declared.

\textbf{References}

1. Ali M, Rigopoulos AG, Mammadov M, et al. Systematic review on left
atrial appendage closure with the LAmbre device in patients with
non-valvular atrial fibrillation.\emph{BMC Cardiovasc Disord.}
2020;20(1):78.

2. Sanhoury M, Fassini G, Dello Russo A, Lumia G, Bartorelli A. Early
Dislodgment and Migration of a Left Atrial Appendage Closure Device.
\emph{Am J Cardiol.}2017;120(10):1905-1907.

3. Lam YY, Yan BP, Doshi SK, et al. Preclinical evaluation of a new left
atrial appendage occluder (Lifetech LAmbre device) in a canine model.
\emph{Int J Cardiol.}2013;168(4):3996-4001.

4. Wang G, Kong B, Liu Y, Huang H. Percutaneous retrieval of a
dislocated LAmbre left atrial appendage occluder in a canine model.
\emph{J Cardiovasc Electrophysiol.}2020;31(2):529-535.

5. So CY, Lam YY, Cheung GS, et al. Minimalistic Approach to Left Atrial
Appendage Occlusion Using the LAmbre Device. \emph{JACC Cardiovasc
Interv.} 2018;11(11):1113-1114.

\textbf{Figure Legends}

Figure 1: A: The occluder was entrapped in LA by LASSO; B: The occluder
embolized in aorta arch; C: The sheath was bent to get close to the
center of sealing lobe; D: The forceps caught the wire of center area of
the sealing disc; E: The migrated occluder was smoothly taken back into
the sheath; F: The damaged device in vitro.\selectlanguage{english}
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