Pseudo-Migration After Left Atrial Appendage Occlusion

BACKGROUND: Left atrial appendage occlusion (LAAO) is a validated strategy for stroke prevention in patients with atrial fibrillation who have contraindications to anticoagulation or who are at risk of high bleeding. LAAO device embolization is a rare but serious complication that typically occurs within the first 24 hours postprocedure. CASE SUMMARY: We report 2 cases of apparent device migration on transthoracic echocardiography (TTE) after LAAO that were ultimately determined to represent pseudo-migration. In both cases, routine postprocedural TTE raised concern for device dislodgement. However, confirmatory transesophageal echocardiography and cardiac computed tomography demonstrated stable device position with no peridevice leak or embolization. Both patients remained clinically stable without adverse outcomes. DISCUSSION: These cases highlight the limitations of TTE in patients with an anteriorly oriented left atrial appendage and emphasize the importance of confirmatory imaging before assuming true embolization. To our knowledge, pseudo-migration has not been previously described in the literature, and it may be an under-recognized phenomenon. Recognition of this imaging pitfall could prevent unnecessary interventions. Future directions include systematic evaluation of imaging artifacts after LAAO and establishing standardized protocols for confirming device position. TAKE-HOME MESSAGES: Pseudo-migration after LAAO is a newly described phenomenon caused by TTE limitations in specific appendage anatomies. Awareness of this pitfall and reliance on confirmatory imaging may prevent misdiagnosis and unnecessary interventions.