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.