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A3488 - Left Atrium Wall Rupture Following Watchman Device Placement
Author Block: B. Batson1, H. Edriss2; 1Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, United States, 2Pulmonary and Critical Care, Texas Tech University Health Science Center, Lubbock, TX, United States.
Introduction: The WATCHMAN device is a left atrial appendage (LAA) occlusion device that was approved in 2015 for prevention of LAA blood clots in patients with nonvalvular atrial fibrillation. It is indicated to reduce the risk of thromboembolism. These patients must be deemed suitable for anticoagulation with warfarin and must also have an appropriate rationale to seek a non-pharmacologic alternative to warfarin.
Case: An 81-year-old man with a history of chronic hypoxic respiratory failure on home oxygen and pacemaker for tachycardia-bradycardia syndrome developed a large pericardial effusion and required surgical repair of ruptured LAA following a placement of WATCHMAN device. Patient received WATCHMAN device since he failed radiofrequency ablation three times and refused long term anticoagulation. Prior to the device placement, transesophageal echocardiography (TEE) was performed to measure LAA dimensions and rule out presence of clot. A 24 mm WATCHMAN device was placed. After the device placement, post-procedure TEE revealed a large pericardial effusion with no tamponade. Pericardiocentesis was performed and 500 cc of blood was aspirated. Then patient was taken for exploratory thoracotomy due to persistent pericardial bleeding. He was found to have a LAA tear which required ligation due to inability to surgically close the tear and the WATCHMAN device was removed. He remained intubated for 3 days and then was extubated to high flow nasal cannula. He required a prolonged weaning from oxygen supplementation. Additionally, he developed acute on chronic kidney failure which required hemodialysis. Patient was discharged to an inpatient rehabilitation facility after a 22 day hospital stay. However, he was readmitted within 24 hours with worsening shortness of breath and pulmonary edema. He was hospitalized for 10 additional days and then discharged to a skilled nursing facility to continue hemodialysis. Discussion: The WATCHMAN device is the only FDA approved LAA occlusion device in the U.S. Device complication is reported to occur in 2-3% of cases. This patient suffered a serious life threatening complications, including LAA tear resulted in bleeding, required pericardiocentesis, thoracotomy and repair of the LAA tear. The success rate of this procedure is about 97%, but the severity of major complications needs to be evaluated and addressed before proceeding with the procedure. Clinicians should have a high clinical suspicious for left atrium rupture and bleeding in these patients after placement. Additional literature review revealed other complications, such as device embolization and device anchors puncturing pulmonary vasculature leading to pericardial effusion.