Clinical Images

Percutaneous Management of Left Atrial Appendage Perforation: Keep Calm and Think Fast

Giovanni Lorenzoni, MD;  Pierluigi Merella, MD;  Paolo Pischedda, MD;  Gavino Casu, MD

Giovanni Lorenzoni, MD;  Pierluigi Merella, MD;  Paolo Pischedda, MD;  Gavino Casu, MD

J INVASIVE CARDIOL 2018;30(11):E126-E127.

Key words: cardiac imaging, cardiac tamponade, heart perforation, left atrial appendage closure

An 83-year-old woman with permanent atrial fibrillation and high thromboembolic and bleeding risk was admitted for elective percutaneous left atrial appendage (LAA) closure. We planned to implant a Watchman closure device (Boston Scientific) under transesophageal echocardiography (TEE) with anesthesiologic back-up.

After right venous femoral access (14 Fr) and transseptal puncture, we advanced the access sheath on an extra-stiff guidewire to engage the LAA. During angiographic study (Figure 1A), the patient suddenly became hypotensive. Heart perforation with leakage of contrast in the pericardial space was evident (Figure 1B) and TEE confirmed cardiac tamponade.

We proceeded as follows: (1) rapid release of 30 mm Watchman closure device in the LAA (Figure 1C); (2) pericardial drainage and aspiration of 1100 mL of blood; (3) autotransfusion with direct reinfusion of 950 mL of blood through right venous femoral access; and (4) infusion of 50 mg intravenous protamine sulfate.

After 50 minutes, we achieved hemodynamic stabilization; angiography (Figure 1D) and TEE showed complete drainage of blood from the pericardial space without contrast leakage and good position of the closure device. The patient was transferred awake to the intensive care unit to continue monitoring.

LAA perforation is a rare but dramatic complication during percutaneous closure that often requires surgical thoracotomy. Perforation is usually linked to device components (struts and hooks) and it can involve structures outside the heart, such as the pulmonary vein. Cardiac tamponade is the worst consequence of this complication and it can occur late after device implantation.

Our case underlines that LAA perforation is a possible complication not only after release of the closure device, but also during the diagnostic phase due to sheath positioning in the LAA. In this case, rapid release of the closure device and pericardial evacuation allowed us to successfully manage the cardiac tamponade and avoid a surgical option.

From the Unità Operativa Complessa di Cardiologia, Ospedale San Francesco, Nuoro, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted May 25, 2018. 

Address for correspondence: Giovanni Lorenzoni, MD, Ospedale San Francesco, Unità Operativa Complessa di Cardiologia, via Mannironi 1, Nuoro, Italy. Email: