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.