Comment
Despite the low reported incidence of post-procedure pericardial effusion and device dislodgement in the randomized trials (1.5% and 0.74%, respectively in PREVAIL), the real-life complication rate proved to be even better than that seen in trials (2). While surgical repairs of perforation have been reported in the registry, there is no data on what surgical repair was performed. This is the first report of Watchman device associated LAA perforation requiring emergent open surgical repair and discusses the choice of surgical options.
One reported case of LAA perforation was successfully treated with thoracoscopic stapling of the left atrial appendage (3). In this case, the entire device extruded into the pericardium before deployment; therefore, retraction of the delivery system controlled frank hemorrhage by compressing the LAA allowing the surgeons to use a thoracoscopic approach to staple the base of the LAA. The device delivery system was disconnected and withdrawn just as the stapler was fired, thus sealing the two edges of the LAA.
Despite our experience with the thoracoscopic epicardial exclusion of LAA, we chose an open surgical approach for this case for several reasons (4). First, because the watchman device had already been deployed, it could have embolized during the procedure during an off-pump repair. Secondly, the patient was given protamine in the catheterization laboratory in an effort to stop the bleeding, and therefore had an increased likelihood of thrombus formation on and around the device, which could also embolize. Third, a previous study demonstrated that the stapling of the LAA could leave a large stump of LAA, which can be a nidus for future thrombi (5). In contrast, the epicardial clip application results in the complete exclusion of the LAA without leaving any residual stump (6). Finally, because the treatment of AF is important for reducing stroke risk, the Cryomaze procedure was performed at the time of initial surgical repair. The Cyromaze procedure can be performed with a relatively short pump and cross-clamp time and has been reported to have 100% success in treating paroxysmal AF in contemporary literature (7).
In conclusion, LAA appendage perforation by the Watchman device is an uncommon but serious complication that can be managed with either endovascular, thoracoscopic, or open surgical approach. An individualized approach is needed for each situation based on factors such as the technique of device deployment and the patient’s hemodynamic and overall health status.