Left atrial appendage closure device complicated by late-onset pericardial effusion and tamponade: a case report

Abstract Background Late-onset complications of left atrial appendage occlusion (LAAO) device procedure are anecdotal and there are no such complications reported in literature using Cardia Ultraseal (Cardia, Inc., Eagan, MN, USA). Case summary We report the case of a 74-year-old Caucasian man affected by paroxysmal atrial fibrillation with significant bleeding risk (familiar thrombocytopenia, macroscopic haematuria episodes during therapy with direct oral anticoagulants, HAS-BLED risk score: 4) and ischaemic risk as well (CHADSVASC score: 3). The patient was treated with LAAO device implantation for high bleeding risk. Subsequently, after 26 days from LAAO procedure, he was admitted to the emergency department for haematic cardiac tamponade. The patient was successfully treated with subxyphoidal pericardiocentesis in the acute phase, unfortunately cardiac arrest occurred during the transfer to the referral hospital for urgent cardiac surgery. Permanent neurological damage was reported and the patient died on day 28. Discussion LAAO late-onset complications are very rare and the case presented is the first case described of late-onset pericardial effusion and tamponade secondary to the Cardia Ultraseal LAAO device implantation. We present a revision of the literature regarding the occurrence of similar adverse events and discuss the hypothetical mechanism of this major complication.

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Pulmonary artery injury in left atrial appendage closure device implantation: a systematic review of a potentially fatal complication

European Heart Journal ◽

10.1093/ehjci/ehaa946.0667 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

B Hanna ◽

R Desai ◽

S Sachdeva ◽

S Singh ◽

K Gangani ◽

...

Keyword(s):

Mortality Rate ◽

Pulmonary Artery ◽

Left Atrial ◽

Left Atrial Appendage ◽

Case Reports ◽

Bleeding Risk ◽

Atrial Appendage ◽

Closure Device ◽

Left Atrial Appendage Closure ◽

Device Implantation

Abstract Background Pulmonary artery (PA) injury is a rarely reported complication following percutaneous left atrial appendage closure (LAAC). This study aims to systematically review all reported cases of PA injury associated with LAAC. Methods PubMed/Medline, SCOPUS, EMBASE, Google Scholar and the MAUDE databases were searched to find studies reporting PA injury during or after LAAC with the Amplatzer Amulet (AA), Amplatzer Cardiac Plug (ACP) or Watchman device through October 2019. Categorical data were reported in terms of numbers and/or percentages (%). Results We found 13 cases (mean age 71.4 yrs) with reported PA injury associated with LAAC. Of these, 9 were case reports, 3 were reported in observational studies, and 1 was in the MAUDE database. Most cases (n=8) were reported in Europe followed by Australia (n=2) and Asia (n=2). The indication for device implantation in all patients was a high bleeding risk with anticoagulation for atrial fibrillation. Five cases were reported with the ACP (1/5 patients died), 5 with AA (2/5 patients died), and 3 with the Watchman (1/2 patients died). Acute and late presentations following implantation were reported for all three devices. 69.2% of cases (9/13) occurred acutely (during or within 24 hours of intervention). Of these, 3/9 occurred during device implantation. 2/4 of the delayed cases occurred >2 weeks following implantation. The mortality rate for acute and delayed cases was 22% (2/9 patients) and 50% (2/4 patients), respectively. A majority of the cases were attributable to barb/strut/hook injury of the PA. PA injury was associated with a mortality rate of approximately 31%. All surviving patients were managed with surgical intervention. Conclusion PA injury is an infrequently reported complication following LAAC and is associated with high mortality. Cases can present acutely (intra-procedurally or within 24 hours) or delayed (>24 hours post-implantation). A majority of cases are due to direct injury of the PA by the struts/hooks/barbs of the device. Practitioners should be cognizant of this life-threatening complication, which requires a high index of suspicion for diagnosis and can occur weeks after device implantation. Funding Acknowledgement Type of funding source: None

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Cardiac CT Prior to Left Atrial Appendage Closure Device Implantation and Percutaneous Mitral Valve Interventions

Current Cardiovascular Imaging Reports ◽

10.1007/s12410-014-9295-8 ◽

2014 ◽

Vol 7 (11) ◽

Author(s):

Swaminatha V. Gurudevan ◽

Reza Arsanjani

Keyword(s):

Mitral Valve ◽

Left Atrial ◽

Cardiac Ct ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Closure Device ◽

Left Atrial Appendage Closure ◽

Device Implantation

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Left atrial appendage closure device implantation in patients at very high risk for stroke

Heart Rhythm ◽

10.1016/j.hrthm.2019.07.011 ◽

2020 ◽

Vol 17 (1) ◽

pp. 27-32 ◽

Cited By ~ 3

Author(s):

Erika Hutt ◽

Oussama M. Wazni ◽

Simrat Kaur ◽

Walid I. Saliba ◽

Khaldoun G. Tarakji ◽

...

Keyword(s):

High Risk ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Closure Device ◽

Left Atrial Appendage Closure ◽

Device Implantation ◽

Very High

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Contrast Enhanced Transesophageal Echocardiographic Guidance of Left Atrial Appendage Closure Device Implantation

Journal of the American Society of Echocardiography ◽

10.1016/j.echo.2010.02.009 ◽

2010 ◽

Vol 23 (9) ◽

pp. 1007.e3-1007.e4 ◽

Cited By ~ 1

Author(s):

Michael L. Main ◽

George G. Latus ◽

Anthony Magalski ◽

Kenneth C. Huber

Keyword(s):

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Closure Device ◽

Left Atrial Appendage Closure ◽

Device Implantation ◽

Contrast Enhanced

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Percutaneous left atrial appendage closure versus non-vitamin K oral anticoagulants in patients with non-valvular atrial fibrillation and high bleeding risk

EuroIntervention ◽

10.4244/eij-d-19-00507 ◽

2020 ◽

Vol 15 (17) ◽

pp. 1548-1554 ◽

Cited By ~ 4

Author(s):

Cosmo Godino ◽

Francesco Melillo ◽

Barbara Bellini ◽

Mattia Mazzucca ◽

Carlo Andrea Pivato ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Left Atrial ◽

Left Atrial Appendage ◽

Oral Anticoagulants ◽

Bleeding Risk ◽

Atrial Appendage ◽

Left Atrial Appendage Closure ◽

High Bleeding Risk

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Left atrial appendage perforation during appendage angiography treated by percutaneous left atrial appendage closure: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab187 ◽

2021 ◽

Vol 5 (5) ◽

Author(s):

Catherine Champagne ◽

Nicolas Dognin ◽

Josep Rodés-Cabau ◽

Jean Champagne

Keyword(s):

Case Report ◽

Pericardial Effusion ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Closure Device ◽

Left Atrial Appendage Closure ◽

Case Summary ◽

Device Deployment ◽

Laa Closure

Abstract Background Pericardial effusion is a common complication of percutaneous left atrial appendage (LAA) closure. Acute management is the cornerstone of pericardial effusion treatment and interrupting the intervention is often required. Case summary A 65-year-old man presented an acute 10 mm pericardial effusion following pigtail contrast appendage injection. A rapid Watchman Flex 24 mm (Boston Scientific) deployment permitted bleeding interruption. A needle pericardiocentesis was achieved in order to prevent any haemodynamical instability. Discussion This case report describes an atypical cause of pericardial effusion and a technique for bleeding control with LAA closure device deployment.

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Stand-Alone Thoracoscopic Left Atrial Appendage Closure in Nonvalvular Atrial Fibrillation Patients at High Bleeding Risk

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/1556984520960116 ◽

2020 ◽

Vol 15 (6) ◽

pp. 541-546

Author(s):

Marco Franciulli ◽

Giuseppe De Martino ◽

Mariateresa Librera ◽

Ahmed Desoky ◽

Antonio Mariniello ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Oral Anticoagulants ◽

Bleeding Risk ◽

Atrial Appendage ◽

Nonvalvular Atrial Fibrillation ◽

High Bleeding Risk ◽

Laa Closure

Objective In nonvalvular atrial fibrillation (AF) patients at high bleeding risk, oral anticoagulants (OAC) may be contraindicated, and percutaneous left atrial appendage (LAA) closure has been advocated. However, following percutaneous procedure, either OAC or dual antiplatelet treatment is required. In this study, we present our experience in treating nonvalvular AF patients at high bleeding risk with thoracoscopic LAA closure with no subsequent antithrombotic therapy. Methods From April 2019 to January 2020, 20 consecutive AF patients, mean age 75.1 years, 16 (80%) males, underwent thoracoscopic LAA closure as a stand-alone procedure, using an epicardial clip device. OAC and antiplatelet therapy were contraindicated. Mean CHA2DS2-VASc score was 3.61, and the mean HAS-BLED score was 4.42. Successful LAA closure was assessed by transesophageal echocardiography. Primary endpoints were complete LAA closure (no residual LAA flow), operative complications, and all-cause mortality; secondary endpoints were 30-day and 6-month complications (death, ischemic stroke, hemorrhagic stroke, transient ischemic attack, any bleeding). Mean follow-up was 6 ± 4 months. Results Complete LAA closure was achieved in all patients. No operative clip-related complications or deaths occurred. At follow-up, freedom from postoperative complications was 95% and from any cerebrovascular events was 100%. Overall survival rate was 100%. Conclusions In nonvalvular AF patients at high bleeding risk (HAS-BLED score >3), thoracoscopic LAA closure appears to be a valid alternative to percutaneous techniques not requiring dual antiplatelet or OAC treatment. Apparently, external LAA clipping minimizes the risk of thromboembolic events as compared with percutaneous procedures.

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Late left atrial appendage closure device displacement and massive thrombus formation: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa014 ◽

2020 ◽

Vol 4 (2) ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Benjamin Sasko ◽

Oliver Ritter ◽

Peter Bramlage ◽

Fabian Riediger

Keyword(s):

Left Atrial ◽

Left Atrial Appendage ◽

Thrombus Formation ◽

Anticoagulation Therapy ◽

Bleeding Risk ◽

Atrial Appendage ◽

Closure Device ◽

Watchman Device ◽

High Bleeding Risk ◽

Laa Closure

Abstract Background Left atrial appendage (LAA) closure with the WATCHMAN device is an alternative to anticoagulation therapy for the prevention of stroke in selected patients with atrial fibrillation (AF). Infrequently, left atrial (LA) device-related thrombus formation occurs and it is poorly understood. Thrombus formation due to incomplete covering of the LAA is even rarer and may occur within the first few months after device implantation. Case summary Here, we present a case of a 68-year-old male patient with permanent AF, drug- and hepatitis induced liver cirrhosis (CILD Score B), and prior aortic valve replacement. The patient had a history of percutaneous LAA closure using a WATCHMAN device. He developed massive peri-device leak and thrombus arising from the space between the device and appendage cleft 2 years after implantation. Because of the high bleeding risk with a HAS-BLED score of 5 points, surgery was chosen as the therapy of choice instead of long-term anticoagulation. The patient was discharged in good clinical condition and has been scheduled for a yearly follow-up. Discussion This case emphasizes the importance of choosing appropriately sized LAA occluder devices and planning for regular post-interventional follow-ups to minimize the risk of per-device leaks and thrombi.

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