Thanks for including me here today. This is a patient who has a complicated appendage. You see here that there's this large chicken wing with this very large funnel-shaped opening. Here in a 90 degree, we measured an osteodameter of only 15 millimeters. But as we come around to 135, we're measuring, and I somehow cut off my measurement here, but I think like 28 millimeters. So it's a very elliptical, 33 millimeters we measured. So it's very elliptical. Here in 2018, I tried to close this with a Watchman 2.5 device. And you see that my angles and trajectory were not good. I had a really hard time coming up into the chicken wing. I did two transeptals, tried to stay as low as possible. And here is the type of position I was able to achieve with a 2.5, which I felt like was not stable. So this was a patient who truly could not take anticoagulants and brought this patient back with Flex. And in some of our views, it looked pretty good. So I thought that looked pretty good. Here, 90 degrees, it looks pretty good. Here, 48 degrees, it looks pretty good. Here is what it looks like by angio, where it's tucked behind the chicken wing. And here it is in 135 with a pretty big shoulder. So everyone knows the topic of my presentation here. My compression is a 27-millimeter device. I had 23 to 24-millimeter measurements. And this device embolized and was retrieved. I think this 3D is telling for why it embolized, where we see that nearly 180 degrees of this was sticking out posteriorly and how the appendage falls away from the posterior wall posteriorly. This is a second case that was sent to me from an outside hospital that, once again, was a chicken wing without a lot of depth into this proximal lobe here. And you see some of our measurements, 22, 19. And on six-week TE, this is what the device looked like, which is amazing that it was still there in the appendage. And we went in and snared this device here using the Raptor catheter. And you see that we were able to use a Gillis-like or direct sheath here, grab it with the Raptor, and retrieve this device. So I think I'd be interested in maybe in the discussion. We can come and see what others think about this. But my take home is that the complications occur in difficult anatomies. And sometimes we just have to walk away. That large shoulders are a problem. Stock the Raptor for retrieval. But I think embolization is the number one complication. In my mind, that is the most dangerous. Perforation is close behind as second. Here is a patient who, this is an angiogram where we see contrast extravasation into the pericardial effusion. This is not my case, but it was a very recent case. And here you see a flex ball that is up against the back wall. And as I show this case briefly, what you'll see here, on fluoroscopy, is that there is a shallow appendage and not a lot of depth. And we see the same thing on transesophageal echo, where there's only 0.8 centimeters between the ostium and the back wall. And what happened in this case is that as they were trying to deploy this appendage or this device here with the flex ball, and I'll show you how they ended up with a big shoulder and they kept trying to make this flex ball smaller to clock it into this inferior lobe to get a little more depth. Without doing that, you see how this was just too proximal. There just wasn't enough depth. And so as they kept using the small flex ball and trying to get it very distally, perforation occurred. So perforations are usually related to a constrained device against the back wall. There are certainly other complications that can occur. Stroke is one that comes to mind. Important, paying good attention to air management and thrombus management, anticoagulation is important. But those are the most important to my mind. And I'm going to keep that very brief. Thank you.

complicated appendages

Watchman 2.5 device

Flex device

embolization

perforation