Case Report 2
The second patient was a 62 year-old female with persistent AF despite
prior radiofrequency pulmonary vein isolation ablation, hypertension,
thoracic ascending aortic aneurysm, transient ischemic attack, morbid
obesity, hypercholesterolemia, and peptic ulcer disease. Her
CHA2DS2-VASc score was 4. She had
suffered a fall as well as severe uvular bleeding following a
transesophageal echocardiogram (TEE) necessitating discontinuation of
rivaroxaban. She was thus referred for LAAC.
Pre-procedural TEE imaging was notable for a LAA emptying velocity of
approximately 90cm/s (Figure 3). Cardiac CTA indicated LAA ostial
dimensions of 2.9 x 1.5 cm with an ostial area of 3.07
cm2. With the use of WATCHMAN™ TruPlan™ simulation
software, a 20 mm WATCHMAN™ FLX device was chosen with a double curve
delivery sheath. Transseptal puncture was obtained with ICE as well TEE
imaging under general anesthesia. Contrast imaging revealed a
hyperdynamic LAA. The device was implanted with a single deployment and
with 18% compression. No pericardial effusion was noted on post-implant
TEE or ICE. Following the procedure, the patient underwent a bedside
point-of-care TTE, which also did not show a pericardial effusion.
Approximately 12 hours following the procedure, the patient developed
shortness of breath and chest pain and presented to a local emergency
department for further evaluation. She was found to have inferior
ST-segment elevation and a troponin of 0.11 ng/mL. Coronary angiography
was unremarkable but chest CTA demonstrated a large pericardial
effusion. She was started on intravenous fluids and norepinephrine due
to hypotension and transferred to our institution where TTE confirmed
cardiac tamponade (Figure 6). Emergent pericardiocentesis removed 400 mL
of bloody fluid, resulting in improvement in her systolic blood pressure
from 110 mmHg to 150 mmHg. Her pericardial drain was removed after 3
days. The patient was treated with colchicine and restarted on
rivaroxaban which she had not resumed. The pericardial effusion did not
recur, and she has been able to resume her normal baseline activities.