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\begin{document}

\title{Hyperdynamic Left Atrial Appendage May Increase the Risk of Perforation
During Left Atrial Appendage Closure-- A Case Series}



\author[1]{Steven Filby}%
\author[2]{Salvatore  Savona }%
\author[1]{Luis Augusto Palma Dallan}%
\author[2]{Zachary Garrett}%
\author[3]{Mahmoud Houmsse}%
\affil[1]{University Hospitals}%
\affil[2]{The Ohio State University }%
\affil[3]{The Ohio State university}%


\vspace{-1em}



  
  \date{June 07, 2024}


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\begin{abstract}
Introduction: Delayed pericardial effusion following WATCHMAN FLX
implantation is not well understood. We present a case series of two
patients with hyperdynamic left atrial appendages (LAA) who developed
delayed pericardial effusions following WATCHMAN FLX implantation.
Methods: Successful left atrial appendage closure was performed in 2
patients with paroxysmal atrial fibrillation using the WATCHMAN FLX
device. Both patients had hyperdynamic left atrial appendages noted
during their procedures. Intra-procedure course was uncomplicated.
Results: Delayed pericardial effusion occurred necessitating drainage in
both cases. Conclusion: While exact mechanisms remain unclear, sinus
rhythm and the presence of a hyperdynamic LAA may play a role.
Understanding the interaction of the appendage and the delivery system
may help to reduce the likelihood of this rare, but serious,
complication. Keywords: Atrial fibrillation; Left Atrial Appendage
Closure; Pericardial Effusion; Pericardiocentesis.%
\end{abstract}%



\sloppy


\textbf{Title: Hyperdynamic Left Atrial Appendage May Increase the Risk
of Perforation During Left Atrial Appendage Closure-- A Case Series}

\textbf{Authors:} Steven J Filby, MD;\textsuperscript{1} Salvatore
Savona, MD; \textsuperscript{2} Luis Augusto Palma Dallan, MD,
PhD;\textsuperscript{1} Zachary Garrett, MD; \textsuperscript{2} Mahmoud
Houmsse, MD.\textsuperscript{2}

\textbf{Affiliation:}

\textsuperscript{1}Harrington Heart \& Vascular Institute, University
Hospitals Cleveland Medical Center, Cleveland, OH, United States

\textsuperscript{2}The Ohio State University Wexner Medical Center,
Columbus, OH, United States

\textbf{Running title: Delayed Pericardial Effusion Following LAAC}

\textbf{Word count:} 1396 words

\textbf{Correspondence to:}

Steven J. Filby, MD

University Hospitals, Cleveland Medical Center

11100 Euclid Avenue

Lakeside 3rd floor

Cleveland, OH 44106

Phone: 216-844-8242 / Fax: 216-844-7116

E-mail: Steven.Filby@UHhospitals.org

\textbf{Disclosures:}

Steven J. Filby, M.D.: Consultant, Boston Scientific Corp.

Salvatore Savona, MD: None

Luis Augusto Palma Dallan, MD, PhD: None

Zachary Garrett, MD: None

Mahmoud Houmsse, MD: None

\textbf{Funding:} none

\textbf{Introduction}

Left atrial appendage closure (LAAC) is increasingly utilized to
mitigate stroke risk in patients unable to tolerate anticoagulation.
Serious complications from LAAC with the WATCHMAN device are rare.
According to the NCDR registry, major in-hospital adverse events occur
in only 2.16\% of cases and 1.39\% of these events were due to
pericardial effusion requiring intervention (1). To date, there have
been no reported risk factors for pericardial effusion development
following LAAC. In the PINNACLE FLX trial, there were no acute
pericardial effusions requiring drainage within the first 7 days from
WATCHMAN FLX device implant; however, 3 patients required
pericardiocentesis between 7 and 45 days (2). We present a case series
of two patients with hyperdynamic left atrial appendages who developed
pericardial effusions following WATCHMAN FLX implantation.

\textbf{Case Series}

\textbf{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
CHA\textsubscript{2}DS\textsubscript{2}-VASc score was 4. Cardiac CTA
indicated LAA ostial dimensions of 2.0 x 2.4 cm with an ostial area of
3.88 cm\textsuperscript{2}. 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.

\textbf{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
CHA\textsubscript{2}DS\textsubscript{2}-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
cm\textsuperscript{2}. 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.

\textbf{Discussion}

Acute pericardial effusion and tamponade during deployment is a
recognized though uncommon complication of LAAC. The incidence of
pericardial effusion in both the EWOLUTION registry and the Boston
Scientific manufacturer-compiled registry is less than 1\%,
significantly lower than reported in the original trials (3,4). Delayed
pericardial effusion after LAAC is even less common (5). Regardless of
timing, such effusions can lead to cardiac tamponade and even death.
Avoidance and recognition of procedurally-related pericardial effusion
are imperative to the LAAC operator.

As far as we know, this is the first case series to report delayed
pericardial effusion following LAAC with WATCHMAN FLX. The mechanism in
both of these cases was likely microperforation during implantation. One
plausible explanation would be that the J-shaped fixation anchors of the
WATCHMAN FLX device caused appendage microperforations during the
procedure, an etiology that has been theorized in the PINNACLE FLX trial
(2). In both cases presented, the patient was in sinus rhythm at the
time of the procedure and noted to have a hyperdynamic left atrial
appendage on contrast injection. We hypothesize that this hyperdynamic
state may have caused increased anchor tissue engagement leading to
appendage microperforation.

The appearance of ``auto-tug''---where the core wire moves automatically
back and forth within a loosened hemostatic valve---is not an uncommon
finding noted prior to WATCHMAN release. Tightening the hemostatic
valve on the core wire in this situation may put strain upon the
appendage, especially in the setting of a hypermobile or hyperdynamic
appendage, causing the anchors to repeatedly pull upon appendage tissue.
Therefore, we recommend loosening the hemostatic valve from the core
wire, allowing the core wire to move freely in these situations until
device release. When the ``tug test'' is performed, it should be
performed very gently. Though the exact mechanism of microperforation is
not well understood, attention to the interaction of the WATCHMAN
device, delivery system, and the appendage may help to reduce the chance
of inadvertent appendage perforation.

\textbf{Conclusion}

We report a small case series of delayed pericardial effusion following
LAAC. While mechanisms are still unclear, sinus rhythm and in particular
the presence of a hyperdynamic LAA may play a role. Understanding the
interaction of the appendage and the delivery system may help to reduce
the likelihood of this rare, but serious, complication.

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
\item
  Freeman, J. V., Varosy, P., Price, M. J., Slotwiner, D., Kusumoto, F.
  M., Rammohan, C and Masoudi, F. A. The NCDR left atrial appendage
  occlusion registry.~Journal of the American College of Cardiology
  2020~75(13), 1503-1518.
\item
  Kar, S., Doshi, S. K., Sadhu, A., Horton, R., Osorio, J., Ellis, C.
  and PINNACLE FLX Investigators. Primary Outcome Evaluation of a
  Next-Generation Left Atrial Appendage Closure Device: Results From the
  PINNACLE FLX Trial.~Circulation. 2021~143(18), 1754-1762.
\item
  Schmidt B, Betts TR, Sievert H, et al. Incidence of pericardial
  effusion after left atrial appendage closure: the impact of underlying
  heart rhythm--- data from the EWOLUTION study. J Cardiovasc
  Electrophysiol 2018;29:973--8.
\item
  Reddy VY, Gibson DN, Kar S, et al. Post-FDA approval, initial U.S.
  clinical experience with Watchman left atrial appendage closure for
  stroke prevention in atrial fibrillation. J Am Coll Cardiol
  2017;69:253--61.
\item
  Nandkeolyar S, Parwani P, Contractor T. A Case of Delayed Hemorrhagic
  Effusive-Constrictive Pericarditis After Left Atrial Appendage
  Occlusion Device Placement. JACC: ase Reports. 2019;1(1):27-31.
\end{enumerate}

\textbf{FIGURE LEGEND}

\textbf{Figure 1:} \textbf{Panels A and B.} Left atrial appendage
angiography demonstrating hyperdynamic appendage contractility.

\textbf{Figure 2:} \textbf{Panel A.} Transthoracic echocardiogram (TTE)
prior to the procedure displaying small pericardial
effusion.\textbf{Panel B.} Transthoracic echocardiogram (TTE) after the
procedure displaying the effusion unchanged. \textbf{Panel C.}
Transthoracic echocardiogram (TTE) 1 day after the procedure displaying
moderate-sized effusion. \textbf{Panel D.} Transthoracic echocardiogram
(TTE) 7 days after the procedure displaying large posterior pericardial
effusion.

\textbf{Figure 3:} Left atrial appendage emptying velocity

\textbf{Hosted file}

\verb`Figures_JEC.docx`  available at \url{https://authorea.com/users/736486/articles/712116-hyperdynamic-left-atrial-appendage-may-increase-the-risk-of-perforation-during-left-atrial-appendage-closure-a-case-series}

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