PMC9871351_01
Midesophageal TEE Images from case 1: (A) 2D x-plane view at 45  showing the acute angle of deployment catheter positioned into the LAA; (B) 2D x-plane view at 45  showing LAAO device buckle immediately after deployment; (C) 3D view at 25  showing collapse of device shoulder immediately after deployment; (D) 2D view with color Doppler at 44  showing the buckle at 45 days postimplantation; (E) 2D x-plane view at 115  showing device buckling and color Doppler evidence of peridevice leak at 1-year postimplantation; (F) 3D view at 45  showing device the buckle at 1-year postimplantation. AV, aortic valve; LA, left atrium; PA, pulmonary artery.
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fig1
Immediately following implantation, the 30-mm device was well seated and showed no evidence of periprocedural leak (Figure 1A-C, Videos 1-3). TEE (Figure 1D and E). The patient's anticoagulation was stopped and:per protocol:was switched to aspirin and clopidogrel and then aspirin monotherapy at 6 months. One-year follow-up TEE again confirmed device stability, but a buckle was recognized during this study (Figure 1F, Videos 4 and 5). Comparing the buckle to the imaging from implant and 45-day TEE, the buckling appeared to worsen in the interim period between implantation and 1-year follow-up and was well visualized on 3D TEE (Figure 1F, Video 5).
TEE MPR image from case 1. (A) Orthogonal postacquisition MPR images showing noncoaxial orientation of the catheter relative to the axis of the LAA. (B) The deployment catheter is coaxial to the LAA ostium. (C) Lack of coaxial orientation, which is noted in panel A, led to an asymmetric shape of the device face. (D) Three-dimensional view showing noncoaxial deployment catheter orientation.
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fig2
Device buckling was confirmed on postacquisition multiplanar reconstruction (MPR) imaging (Figure 2A-D).
TEE MPR image from case 2. (A) Postacquisition MPR images showing noncoaxial orientation of the deployment catheter to the LAA ostium. (B) Note that the deployment catheter appears more coaxial following a proximal tug. (C) Asymmetric device face noted due to buckle on initial deployment before proximal tug. (D) Three-dimensional image showing buckled device face before proximal tug maneuver.
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Device buckling before correction was confirmed on postacquisition MPR imaging (Figure 4A-D).
Midesophageal TEE images from case 3: (A) 2D x-plane view at 40  showing acute angle of deployment catheter into LAA; (B) 2D view at 120  showing LAAO device buckle immediately after deployment; (C) 3D view at 120  showing buckling immediately after deployment; (D) 2D x-plane view at 110  showing less acute deployment catheter angle and well-seated device after initial device recapture; (E) 3D view at 140  showing well-seated device. LA, Left atrium; LCx, left circumflex coronary artery.
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fig5
During initial device implantation using a 31-mm device (Watchman FLX), a large buckle was noted in which almost 50% of the face of the device collapsed in on itself potentially under the downward (toward the left circumflex) pressure of the deployment catheter (Figure 5A-C, Videos 9-11). The device was well seated in the LAA, and no peridevice leak was noted (Figure 5D and E, Videos 12 and 13).
PMC9871351_02
Midesophageal TEE images from case 2: (A) 2D x-plane view at 60  showing acute angle of deployment catheter into LAA; (B) 2D x-plane view at 60  showing LAAO device buckling immediately after deployment; (C) 3D view at 45  showing buckling immediately after deployment; (D) 2D x-plane view at 60  showing proximal tug to relieve collapsed portion of the device face; (E) 2D x-plane view at 60  showing relieved buckle; (F) 3D view at 60  showing well-seated device. AV, aortic valve; LA, left atrium; LCx, left circumflex coronary artery; PA, pulmonary artery.
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fig3
After initial device (Watchman FLX) deployment, the mitral shoulder of the device at 60  appeared to buckle, appearing to collapse in on itself under the forward and possibly downward (toward the left circumflex) pressure of the deployment catheter attached to the device at a relatively acute angle (Figure 3A-C, Videos 6 and 7). After recognition of the buckle, using a combination of 2D and 3D TEE, the catheter was relocated more proximally and posteriorly to make the sheath more coaxial with the device and the device was tugged proximally while fully expanded, a move akin to the "tug test." With continued gentle proximal traction, the device expanded into a normal circular shape (Figure 3D and E, Video 8). The device was noted to be well seated with no peridevice leak (Figure 3E and F, Video 8).
TEE MPR image from case 2. (A) Postacquisition MPR images showing noncoaxial orientation of the deployment catheter to the LAA ostium. (B) Note that the deployment catheter appears more coaxial following a proximal tug. (C) Asymmetric device face noted due to buckle on initial deployment before proximal tug. (D) Three-dimensional image showing buckled device face before proximal tug maneuver.
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fig4
Device buckling before correction was confirmed on postacquisition MPR imaging (Figure 4A-D).
TEE MPR image from case 3. (A) Postacquisition MPR images showing noncoaxial orientation of the deployment catheter to the LAA ostium. (B) Noncoaxial orientation associated with buckled device. (C) Asymmetric device face before smaller device was exchanged. (D) Three-dimensional image of buckling with defect toward the mitral shoulder of the device.
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fig6
During initial device implantation using a 31-mm device (Watchman FLX), a large buckle was noted in which almost 50% of the face of the device collapsed in on itself potentially under the downward (toward the left circumflex) pressure of the deployment catheter (Figure 5A-C, Videos 9-11). Device buckling was confirmed on postacquisition MPR imaging (Figure 6A-D).
Midesophageal images of transseptal puncture: (A) 2D view at 25  showing the transeptal puncture and associated color Doppler; (B) 2D view at 96  showing the transeptal puncture and associated color Doppler; (C) 2D view at 100  showing the transeptal puncture with needle shadowing present. IAS, interatrial septum.
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fig7
During initial device implantation using a 31-mm device (Watchman FLX), a large buckle was noted in which almost 50% of the face of the device collapsed in on itself potentially under the downward (toward the left circumflex) pressure of the deployment catheter (Figure 5A-C, Videos 9-11).
Buckling graphic. (A) Correct demonstration of LAAO device insertion. Deployment catheter and device face are coaxial to the axis of the LAA and the LAA ostium. The device is well seated. (B) Suboptimal transeptal puncture leads to acute angle between deployment catheter and device face within the LAA. Under torque applied to improve device seating, the device can buckle, resulting in collapse shoulder and an apparent buckle in the face of the device. This could lead to a peridevice leak.
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fig8
During initial device implantation using a 31-mm device (Watchman FLX), a large buckle was noted in which almost 50% of the face of the device collapsed in on itself potentially under the downward (toward the left circumflex) pressure of the deployment catheter (Figure 5A-C, Videos 9-11).
PMC9871351_03
Midesophageal TEE images from case 3: (A) 2D x-plane view at 40  showing acute angle of deployment catheter into LAA; (B) 2D view at 120  showing LAAO device buckle immediately after deployment; (C) 3D view at 120  showing buckling immediately after deployment; (D) 2D x-plane view at 110  showing less acute deployment catheter angle and well-seated device after initial device recapture; (E) 3D view at 140  showing well-seated device. LA, Left atrium; LCx, left circumflex coronary artery.
gr5.jpg
PMC9871351_03_gr5.jpg
fig5
During initial device implantation using a 31-mm device (Watchman FLX), a large buckle was noted in which almost 50% of the face of the device collapsed in on itself potentially under the downward (toward the left circumflex) pressure of the deployment catheter (Figure 5A-C, Videos 9-11). The device was well seated in the LAA, and no peridevice leak was noted (Figure 5D and E, Videos 12 and 13).
TEE MPR image from case 3. (A) Postacquisition MPR images showing noncoaxial orientation of the deployment catheter to the LAA ostium. (B) Noncoaxial orientation associated with buckled device. (C) Asymmetric device face before smaller device was exchanged. (D) Three-dimensional image of buckling with defect toward the mitral shoulder of the device.
gr6.jpg
PMC9871351_03_gr6.jpg
fig6
During initial device implantation using a 31-mm device (Watchman FLX), a large buckle was noted in which almost 50% of the face of the device collapsed in on itself potentially under the downward (toward the left circumflex) pressure of the deployment catheter (Figure 5A-C, Videos 9-11). Device buckling was confirmed on postacquisition MPR imaging (Figure 6A-D).
Midesophageal images of transseptal puncture: (A) 2D view at 25  showing the transeptal puncture and associated color Doppler; (B) 2D view at 96  showing the transeptal puncture and associated color Doppler; (C) 2D view at 100  showing the transeptal puncture with needle shadowing present. IAS, interatrial septum.
gr7.jpg
PMC9871351_03_gr7.jpg
fig7
During initial device implantation using a 31-mm device (Watchman FLX), a large buckle was noted in which almost 50% of the face of the device collapsed in on itself potentially under the downward (toward the left circumflex) pressure of the deployment catheter (Figure 5A-C, Videos 9-11).
Buckling graphic. (A) Correct demonstration of LAAO device insertion. Deployment catheter and device face are coaxial to the axis of the LAA and the LAA ostium. The device is well seated. (B) Suboptimal transeptal puncture leads to acute angle between deployment catheter and device face within the LAA. Under torque applied to improve device seating, the device can buckle, resulting in collapse shoulder and an apparent buckle in the face of the device. This could lead to a peridevice leak.
gr8.jpg
PMC9871351_03_gr8.jpg
fig8
During initial device implantation using a 31-mm device (Watchman FLX), a large buckle was noted in which almost 50% of the face of the device collapsed in on itself potentially under the downward (toward the left circumflex) pressure of the deployment catheter (Figure 5A-C, Videos 9-11).