Abstract 4146286: Embolization of an Amplatzer Amulet Through a MitraClip Causing Torsades and LVOT Obstruction: A Case Report

Introduction: The morphology and blood stasis of the left atrial appendage (LAA) in tandem with disorganized conduction in atrial fibrillation (AF) creates favorable conditions for thrombus formation. Left atrial appendage occlusion (LAAO) devices have become increasingly utilized for stroke prevention in select patients with AF who have contraindications to oral anticoagulation (OAC). We present a unique case of an embolized Amplatzer Amulet LAAO device through a MitraClip into the LV causing polymorphic VT and obstructive shock. Case Presentation: An 80-year-old man with AF and mitral valve prolapse status post MitraClip presented to the hospital for difficulty breathing and palpitations two days after implantation of a 31mm Amplatzer Amulet LAAO device. Notably, he underwent failed attempt at Watchman LAAO implantation due to peridevice leak one year prior. On arrival, he was hypotensive with numerous episodes of polymorphic VT, requiring cardioversion, vasopressors, and mechanical ventilation. TTE located the Amulet within the LV outflow tract (LVOT) creating LVOT obstruction and revealed single-leaflet attachment of the MitraClip. He was evaluated for device retrieval and mechanical support but was deemed not a surgical candidate due to severe thrombocytopenia and guarded prognosis. Despite ongoing resuscitative efforts, the patient became increasingly unstable and died in the cardiac ICU. Discussion: In patients who are unable to tolerate OAC, occlusion of the LAA for stroke prevention has garnered growing interest; however, these devices are not without complication and do not guarantee full occlusion of the LAA. Despite our patient’s history of failing Watchman deployment, he was discharged on the same day after implant of the Amulet device without post-procedure TTE. We postulate that the Amulet device dislodged shortly after deployment and was held within the left atrium by the MitraClip until detachment, allowing for device embolization and severe MR. To our knowledge this is the first documented instance of Amulet device migration into the LV in a patient with a MitraClip. This case highlights the need for heightened post-procedure monitoring, surveillance, and imaging in select patients.