Case Report
The patient is an 82-year-old male with a past medical history of
coronary artery disease (post stenting), seizure disorder,
gastrointestinal (GI) bleeding, paroxysmal AF, CHA2DS2-VASc score of 3,
and HAS-BLED score of 3. Due to his history of GI bleed and fall risk,
he underwent LAA occlusion with Watchman device with moderate sedation.
Under intracardiac echocardiography (ICE) and fluoroscopic guidance, a
21mm Watchman device was deployed. Post-deployment angiography revealed
brisk contrast extravasation in the pericardial space. The device was
retracted and redeployed at a more proximal position in the ostium of
the LAA, and the delivery system was disconnected. The patient developed
cardiac tamponade which was confirmed by transthoracic echocardiogram.
Emergency pericardiocentesis was performed with the evacuation of 800 mL
of blood. Protamine was administered. Cardiothoracic surgery was
emergently consulted. Since the patient continued to require pressor
support, he was transferred to the operating room for emergency repair
of presumed LAA perforation.
Due to the high risk of embolization of the device and the resulting
clot, the plan was to not manipulate LAA until cardiopulmonary bypass
was established. Following median sternotomy, the patient’s systolic
blood pressure was 80 mm Hg, and there was persistent slow bleeding. The
patient was immediately heparinized, and cardiopulmonary bypass was
initiated after standard cannulation. With the heart empty and beating,
we exposed the LAA and identified a large clot adherent to the LAA. Once
the clot was removed, the device anchors were seen protruding through
the LAA (Figure 1, Video 1) with active bleeding in between the anchors.
Next, antegrade cardioplegic arrest was achieved, and the left atrium
was explored through the interatrial groove. The 8-9 mm septal defect
created by the transseptal puncture was repaired with 3-0 monofilament
suture. However, the Watchman device was not visible at the ostium It
had been pushed into the LAA. The device was delicately pulled out
through the left atrium (Figure 2), taking care to unentangle the
anchors embedded in the wall of the LAA (Video 2). Upon close
examination, there were clots adherent to both the anchors and the
nitinol stent cover of the device (Fig 3). Left atrial Cryomaze
procedure was then performed using 2-minute ablations encircling the
four pulmonary veins as an island. Another lesion was created connecting
the left inferior pulmonary vein to the P3 region of the mitral annulus.
The LAA was then excluded externally at the base with an epicardial
Atriclip (Atricure Inc, Cincinnati, OH). The atriotomy was closed with
3-0 monofilament and cross-clamp removed. After the heart was de-aired,
the patient was successfully weaned off of cardiopulmonary bypass. The
rest of the procedure and his postoperative course were uneventful. He
was discharged on postoperative day 5 in normal sinus rhythm on
beta-blockers without antiarrhythmics drugs or anticoagulants.