Delayed Aortic Embolization of a Left Atrial Appendage Occlusion Device: Implications for Risk-Stratified Postprocedural Management.

BACKGROUND: Left atrial appendage occlusion (LAAO) is an established alternative to long-term anticoagulation for stroke prevention in select patients with atrial fibrillation. Device embolization is rare, most commonly occurring intraprocedurally or within 24 hours. CASE SUMMARY: A 67-year-old man with paroxysmal atrial fibrillation underwent successful implantation of a Watchman FLX device. Eighteen days later, while shoveling snow, he developed sudden-onset chest and back pain followed by bilateral lower extremity paralysis. Computed tomography revealed complete mid-abdominal aortic occlusion from embolization of the LAAO device. Despite emergent endovascular retrieval and restoration of aortic flow, the patient developed fatal distributive shock from severe ischemia-reperfusion injury. DISCUSSION: This case illustrates a rare but clinically significant presentation of delayed device embolization. This patient possessed multiple National Cardiovascular Data Registry-identified risk factors for postdischarge device embolization, indicating that current risk stratification protocols may not be adequate for patients with device embolization risk factors. TAKE-HOME MESSAGES: Risk-stratified protocols with extended activity restrictions and earlier postprocedure surveillance imaging warrant investigation in patients with National Cardiovascular Data Registry-identified risk factors for postdischarge LAAO device embolization.