Surgical Extraction of a Watchman Device, Amplatzer Plug, and Failed Transcatheter Mitral Prosthesis

The patient is a seventy-eight-year-old male with a complex cardiac history, including a 3-vessel coronary artery bypass graft surgery (CABG), a Watchman device for atrial fibrillation, and a transcatheter mitral valve replacement for severe mitral regurgitation (MR). He also underwent an Amplatzer occluder replacement for iatrogenic atrial septal defect (ASD) creation. Over the last year, he showed symptoms of progressive heart failure with recurrent pleural effusions. A cardiac catheterization showed patent bypass grafts and a transesophageal echocardiogram showed severe MR secondary to multiple paravalvular leaks, with one lateral leak jet near the Watchman device. Right cardiac catheterization demonstrated an elevated pulmonary capillary wedge pressure (PCWP) and pulmonary hypertension with preserved cardiac output. The procedure was initiated via a redo sternotomy. Following standard aorta bicaval cannulation, a cross-clamp was applied and the surgeons controlled the internal mammary artery to the left anterior descending artery (LIMA-LAD) bypass graft. This was followed by a right atriotomy. Next, a direct retrograde catheter was placed for cardioplegia delivery. Anterograde cardioplegia delivery was also administered and the Amplatzer plug was removed. Next, a transseptal incision was made to expose the mitral valve and remove the Watchman device. A paravalvular leak was discovered near the Watchman device and its removal was required for the appropriate placement of the mitral valve. The Watchman device had scar tissue adhering to the left atrial appendage, but with careful dissection, it was finally extracted. The subvalvular apparatus was then dissected free of the transcatheter mitral valve with a combination of blunt and sharp dissection techniques. The posterior leaflet was successfully preserved during this part of the surgery. The left atrial appendage was dissected and measured in size before being clipped. Mitral valve sizing was done and secured with annular stitches. Subsequently, a bioprosthetic mitral valve was placed, followed by a two-layered closure of the left atrial dome and a transseptal incision. Finally, closure of the right atriotomy was performed. 

This case highlights that even in an era of advancing percutaneous therapies for cardiac procedures, complex and challenging surgical strategies remain vital for achieving optimal patient outcomes. One key insight to emphasize is the importance of not hesitating to remove implanted percutaneous devices when necessary. 

Successful execution of these high-risk cases demands meticulous planning and attention to detail. Specifically, in this instance, where a percutaneous mitral valve was adhered to the subvalvular apparatus, it was crucial to preserve as much of the subvalvular structure and mitral leaflet as possible. 

References

1. Boysan E, Cicek OF, Cicek MC, Hamurcu Z, Gurkahraman S. Surgical Removal of an Atrial Septal Occluder Device Embolized to the Main Pulmonary Artery. Tex Heart Inst J. 2014;41(1):91-93. doi:10.14503/thij-12-3003
2. Palmer ST, Romano MA, Bolling SF, Fukuhara S. Surgical Strategies for a Failed Watchman Device. JTCVS Tech. 2020;4:160-164. doi:10.1016/j.xjtc.2020.08.025
3. Melillo F, Baldetti L, Beneduce A, Agricola E, Margonato A, Godino C. Mitral Valve Surgery After a Failed MitraClip Procedure. Interact Cardiovasc Thorac Surg. 2021;32(3):380-385. doi:10.1093/icvts/ivaa270

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