Left Atrial Appendage Occlusion Complicated by Appendage Perforation Rescued by Device Deployment

Abstract

The Watchman device is a transcatheter left atrial appendage (LAA) occluding device used in patients with nonvalvular atrial fibrillation (NVAF) and a high CHADS2-VA2SC score who are poor long-term anticoagulation candidates. Pericardial effusion related to device deployment and perforation can be a life-threatening complication. While not common in hands of experienced operators, management may require surgical intervention. Here we present a rare case of LAA perforation, which was corrected by successful repositioning of the device foregoing the need for surgical management.

Keywords: Watchman; left atrial appendage occlusion; pericardial effusion.

Figure 1.

Transesophageal echocardiography images showing the Watchman device located in the patient’s transverse sinus. (A) Crown of the Watchman device (blue arrow) can be seen in the transverse sinus beyond the wall of the left atrial appendage (LAA; red arrow). (B) The sheath (yellow arrow) was not in the plane of view in image “A” but can be seen passing through the LAA into the transverse sinus in image “B.” The Watchman device (blue arrow) remains connected to the delivery system. Transverse sinus is showing evidence of fluid accumulation relative to preprocedure images (not shown).

Figure 2.

Transesophageal echocardiography images with color Doppler 2 days after device placement shows Watchman deep in the left atrial appendage, without significant peri-device leak. Fluid is no longer apparent in the transverse sinus.

Figure 3.

Computed tomography chest 1-month postprocedure showing adequate device positioning (blue arrow) with a small residual pericardial effusion (red arrow).