Case Report 1
The first patient was a 90 year-old female with multiple medical issues
including recent transcatheter aortic valve replacement (TAVR) and
paroxysmal atrial fibrillation (AF) on Warfarin and Aspirin, who had
recent gastrointestinal bleeding and was referred for LAAC. Her
CHA2DS2-VASc score was 4. Cardiac CTA
indicated LAA ostial dimensions of 2.0 x 2.4 cm with an ostial area of
3.88 cm2. With the use of WATCHMAN™ TruPlan™
simulation software (Boston Scientific) a 27 mm WATCHMAN FLX™ device was
chosen with a double curve delivery sheath.
The patient was in sinus rhythm at the time of the procedure and
contrast injection into the appendage was notable for hyperdynamic
contractile function (Figure 1). Intracardiac echocardiography (ICE) was
used for successful deployment of a 27 mm WATCHMAN FLX™ with 20%
compression. No device recapture was performed. Post-procedure TTE
displayed a small pericardial effusion that appeared unchanged from
pre-procedural imaging. Transthoracic echocardiogram (TTE) performed 6
hours post-procedure showed the size of the effusion to be unchanged
(Figure 2). Warfarin was not restarted, but the patient was continued on
Aspirin.
On post-operative day 1, the patient developed AF with rapid ventricular
response and reported severe pleuritic chest pain. Repeat TTE
demonstrated interval increase in the size of the effusion (now
moderate-sized) without tamponade physiology. She was managed with
amiodarone and colchicine. Surveillance echocardiograms performed over
the ensuing days demonstrated slow continued expansion of the
pericardial effusion, and decision was made for drainage. Due to the
posterior location of the effusion, the patient underwent a surgical
approach with removal of 500cc of dark bloody fluid on post-operative
day 7. Follow-up echocardiogram did not demonstrate significant fluid
re-accumulation. The patient was restarted on Warfarin and discharged
three days after her surgical window. Repeat CTA at 45 days post-implant
demonstrated no evidence of device-related thrombus (DRT) and no leak
through the device. The patient was transitioned to aspirin and
clopidogrel and has done well upon clinical follow up.