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disconnected and withdrawn just as the stapler was fired, thus sealing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.