Removal of Massive Left Atrial Appendage Closure Device-Related Thrombus With Complete Embolic Protection: Step-by-Step Technique.

OBJECTIVE

Device-related thrombus (DRT) is a life-threatening complication of left atrial appendage closure devices. Transcatheter vacuum-assisted thrombectomy has recently been described as a novel strategy for removal of large DRT, but it is associated with increased risk of systemic embolism. We describe a step-by-step technique of a complete embolic protection strategy in patients undergoing vacuum-assisted thrombectomy.

KEY STEPS: First, bilateral cerebral embolic protection devices are deployed. Next, systemic embolic protection is achieved by positioning an ONO retrieval device (Onocor) within the proximal aortic arch. An arterial return cannula is inserted. Then, transseptal crossing is performed with positioning of a suction catheter within the left atrium for aspiration thrombectomy.

POTENTIAL PITFALLS: Aspiration should be performed meticulously, avoiding traumatic dislodgment of thrombotic material. The ONO basket must be assessed for embolic debris before its removal using transesophageal echocardiography. Long-term oral anticoagulation should be considered if tolerated.

TAKE-HOME MESSAGE: Transseptal transcatheter vacuum-assisted thrombectomy with complete embolic protection is a viable and effective strategy to prevent thromboembolic complications for life-threatening DRT.