\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Left Atrial Appendage Perforation by the Watchman Device: Considerations
for Emergency Repair}



\author[1]{Saqib Masroor}%
\author[1]{Qiong Qiu}%
\author[2]{Mohamad Alghothani}%
\author[2]{rajesh Gupta}%
\author[1]{george moukarbel}%
\affil[1]{University of Toledo Medical Center}%
\affil[2]{University of Toledo - Health Science Campus}%


\vspace{-1em}



  
  \date{March 14, 2025}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Percutaneous occlusion of the left atrial appendage is increasingly
being used for stroke prevention in patients with non-valvular atrial
fibrillation (AF) at high risk of complications from long term
anticoagulation. We describe a case of left atrial appendage perforation
after Watchman device deployment requiring emergency repair of the left
atrium using sternotomy and cardiopulmonary bypass. Technical
considerations for surgical decision making are discussed, in
hemodynamically unstable patients as well as those at high risk for
embolization.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Left atrial appendage (LAA) occlusion with the Watchman device (Boston
Scientific, Marlborough, MA) is increasingly being used as an
alternative for stroke prevention in patients with non-valvular atrial
fibrillation (AF) at high risk of complications from long term
anticoagulation (1). Although the procedure has an overall favorable
safety profile, it does carry a small risk of serious complications.
Compared to the initial PROTECT AF trial, the subsequent PREVAIL trial
demonstrated a reduction in the incidence of procedural complications
from 8.7\% to 4.2\%. In particular, post-procedural pericardial
effusions requiring pericardiocentesis or surgery were significantly
reduced, with only one reported case of cardiac perforation among 269
patients in the device group (1). Here we report a case of left atrial
appendage perforation resulting from Watchman device deployment
requiring emergency repair of the left atrium using sternotomy and
cardiopulmonary bypass and discuss options for surgical management of
this complication. Informed consent was waived by Institutional Review
Board.

\textbf{Case Report}

The patient is an 82-year-old male with a past medical history of
coronary artery disease (post stenting), seizure disorder,
gastrointestinal (GI) bleeding, paroxysmal AF, CHA2DS2-VASc score of 3,
and HAS-BLED score of 3. Due to his history of GI bleed and fall risk,
he underwent LAA occlusion with Watchman device with moderate sedation.
Under intracardiac echocardiography (ICE) and fluoroscopic guidance, a
21mm Watchman device was deployed. Post-deployment angiography revealed
brisk contrast extravasation in the pericardial space. The device was
retracted and redeployed at a more proximal position in the ostium of
the LAA, and the delivery system was disconnected. The patient developed
cardiac tamponade which was confirmed by transthoracic echocardiogram.
Emergency pericardiocentesis was performed with the evacuation of 800 mL
of blood. Protamine was administered. Cardiothoracic surgery was
emergently consulted. Since the patient continued to require pressor
support, he was transferred to the operating room for emergency repair
of presumed LAA perforation.

Due to the high risk of embolization of the device and the resulting
clot, the plan was to not manipulate LAA until cardiopulmonary bypass
was established. Following median sternotomy, the patient's systolic
blood pressure was 80 mm Hg, and there was persistent slow bleeding. The
patient was immediately heparinized, and cardiopulmonary bypass was
initiated after standard cannulation. With the heart empty and beating,
we exposed the LAA and identified a large clot adherent to the LAA. Once
the clot was removed, the device anchors were seen protruding through
the LAA (Figure 1, Video 1) with active bleeding in between the anchors.

Next, antegrade cardioplegic arrest was achieved, and the left atrium
was explored through the interatrial groove. The 8-9 mm septal defect
created by the transseptal puncture was repaired with 3-0 monofilament
suture. However, the Watchman device was not visible at the ostium It
had been pushed into the LAA. The device was delicately pulled out
through the left atrium (Figure 2), taking care to unentangle the
anchors embedded in the wall of the LAA (Video 2). Upon close
examination, there were clots adherent to both the anchors and the
nitinol stent cover of the device (Fig 3). Left atrial Cryomaze
procedure was then performed using 2-minute ablations encircling the
four pulmonary veins as an island. Another lesion was created connecting
the left inferior pulmonary vein to the P3 region of the mitral annulus.
The LAA was then excluded externally at the base with an epicardial
Atriclip (Atricure Inc, Cincinnati, OH). The atriotomy was closed with
3-0 monofilament and cross-clamp removed. After the heart was de-aired,
the patient was successfully weaned off of cardiopulmonary bypass. The
rest of the procedure and his postoperative course were uneventful. He
was discharged on postoperative day 5 in normal sinus rhythm on
beta-blockers without antiarrhythmics drugs or anticoagulants.

\textbf{Comment}

Despite the low reported incidence of post-procedure pericardial
effusion and device dislodgement in the randomized trials (1.5\% and
0.74\%, respectively in PREVAIL), the real-life complication rate proved
to be even better than that seen in trials (2). While surgical repairs
of perforation have been reported in the registry, there is no data on
what surgical repair was performed. This is the first report of Watchman
device associated LAA perforation requiring emergent open surgical
repair and discusses the choice of surgical options.

One reported case of LAA perforation was successfully treated with
thoracoscopic stapling of the left atrial appendage (3). In this case,
the entire device extruded into the pericardium before deployment;
therefore, retraction of the delivery system controlled frank hemorrhage
by compressing the LAA allowing the surgeons to use a thoracoscopic
approach to staple the base of the LAA. The device delivery system was
disconnected and withdrawn just as the stapler was fired, thus sealing
the two edges of the LAA.

Despite our experience with the thoracoscopic epicardial exclusion of
LAA, we chose an open surgical approach for this case for several
reasons (4). First, because the watchman device had already been
deployed, it could have embolized during the procedure during an
off-pump repair. Secondly, the patient was given protamine in the
catheterization laboratory in an effort to stop the bleeding, and
therefore had an increased likelihood of thrombus formation on and
around the device, which could also embolize. Third, a previous study
demonstrated that the stapling of the LAA could leave a large stump of
LAA, which can be a nidus for future thrombi (5). In contrast, the
epicardial clip application results in the complete exclusion of the LAA
without leaving any residual stump (6). Finally, because the treatment
of AF is important for reducing stroke risk, the Cryomaze procedure was
performed at the time of initial surgical repair. The Cyromaze procedure
can be performed with a relatively short pump and cross-clamp time and
has been reported to have 100\% success in treating paroxysmal AF in
contemporary literature (7).

In conclusion, LAA appendage perforation by the Watchman device is an
uncommon but serious complication that can be managed with either
endovascular, thoracoscopic, or open surgical approach. An
individualized approach is needed for each situation based on factors
such as the technique of device deployment and the patient's hemodynamic
and overall health status.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Holmes DR, Kar S, Price KJ, et al. Prospective randomized evaluation
  of the Watchman left atrial appendage closure device in patient with
  atrial fibrillation versus long-term warfarin therapy. J Am Coll
  Cardiol 2014;64:1-12Ellis CR, Aznaurov SG, Patel NJ et al.
  Angiographic efficacy of the Atriclip left atrial appendage exclusion
  device placed by minimally invasive thoracoscopic approach. J Am Coll
  Cardiol Electrophysiol 2017;3:1356-65
\item
  Freeman JV, Varosy P, Price MJ, et al. The NCDR Left Atrial Appendage
  Occlusion Registry.~\emph{J Am Coll Cardiol} . 2020;75(13):1503-1518.
  doi:10.1016/j.jacc.2019.12.040
\item
  Liu J, Liu F-Z, Fang X-H, et al. A unique emergency maneuver and
  rescue during left atrial appendage occlusion device-related cardiac
  perforation. J Am Coll Cardiol Electrophysiol 2018:4(5):699-700
\item
  Smith NE, Joseph J, Morgan J and Masroor S. Initial experience with
  minimally invasive surgical exclusion of the left atrial appendage
  with an epicardial clip. Innovations 2017;12(1):28-32
\item
  Kanderian AS, Gillinov AM, Pettersson CB, Blackstone E and Klein AL.
  Success of surgical left atrial appendage closure: Assessment by
  transesophageal echocardiography. J Am Coll Cardiol 2008:52(11):924-9
\item
  Emmert MY, Puippe G, Baumuller S, et al. Safe, effective and durable
  epicardial left atrial appendage clip occlusion in patients with
  atrial fibrillation undergoing cardiac surgery: first long-term
  results from a prospective device trial. Eur J Cardiothorac Surg
  2014;45:126-31
\item
  Kakuta T, Fukushima S, Minami K, et al. Contemporary outcomes of the
  concomitant CryoMaze procedure. Interactive Cardiovasc and Thorac Surg
  2019:29:28-34
\end{enumerate}

\par\null

\textbf{Figure Legends}

\textbf{Figure 1: The entire Watchman device with anchors (arrows)
protruding through the LAA.}

\textbf{Figure 2:The Watchman device delicately pulled out through the
left atrium}

\textbf{Figure 3: Extracted Watchman device with visible adherent clot
around the anchors (arrow)}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/WatchmanFig1/WatchmanFig1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/WatchmanFig2/WatchmanFig2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/REMOVED-WATCHMAN/REMOVED-WATCHMAN}

\end{center}
\end{figure}

\textbf{Hosted file}

\verb`WatchmanInLAA.mp4`  available at \url{https://authorea.com/users/316008/articles/476801-left-atrial-appendage-perforation-by-the-watchman-device-considerations-for-emergency-repair}

\textbf{Hosted file}

\verb`Watchman Removal.mp4`  available at \url{https://authorea.com/users/316008/articles/476801-left-atrial-appendage-perforation-by-the-watchman-device-considerations-for-emergency-repair}

\selectlanguage{english}
\FloatBarrier
\end{document}

