Pulmonary artery perforation and coronary air embolism—two fatal outcomes in percutaneous left atrial appendage occlusion

Abstract

Percutaneous left atrial appendage (LAA) closure is a routinely performed method to reduce the risk of stroke in patients suffering from atrial fibrillation, when an oral anticoagulation is no longer indicated due to relevant bleeding complications. Currently, the Amplatzer Amulet and the Watchman system are two equally used systems. While there is an acute success rate of more than 95 per cent for this intervention, several minor and major complications such as pericardial effusions, air embolism, vascular lesions in proximity to the heart or even death can occur. Here, we report two cases of very rare fatal outcomes in percutaneous LAA occlusion. Eight hours after deployment of an Amplatzer Amulet a patient died, after the pulmonary trunk was perforated by a hook of the occluder device causing pericardial tamponade. In the second case during final radiological position control of the deployed Watchman occluder air was injected accidentally. The patient immediately died due to coronary air embolism. Forensic autopsies are necessary to solve the cause and manner of death, to evaluate and develop medical devices and to rule out medical malpractice. Thus, a close collaboration of legal medicine and the various cardiologic departments is proposed.

Systematic Review of Contiguous Vessel and Valve Injury Associated with Endocardial Left Atrial Appendage Occlusion Devices

“…Comprehensive search revealed 12 publications from Asia, Europe, and Australia with description of 13 cases of contiguous vessels and mitral valve injury after LAAO [6][7][8][9][10][11][12][13][14][15][16][17] . The average age of the patients was 71.4 ± 8.2 years; 92% were Caucasians.…”

Pulmonary artery perforation caused by a left atrial appendage closure device

“…Unfortunately, pericardial tamponade occurred, which was caused by the barbs of the device eroding into the adjacent PA. PA perforation is a dreaded complication, and previous cases reported similar complications caused by an Amplatzer Amulet or Amplatzer Cardiac Plug. 3,4 Unstable hemodynamics suddenly occurred several hours after the procedures. Although emergency resuscitation was performed, the two patients still died, which may be due to a greater penetration depth (1.5 mm for the Amulet hooks, 0.5 mm for the WATCHMAN barbs) from the Amplatzer Amulet or Amplatzer Cardiac Plug than from the WATCHMAN device.…”

“…1,2 However, transcatheter LAAC has been associated with potentially serious complications, such as pericardial effusions, air embolizations, embolizations of the device, and ischemic strokes. 2,3 Here, we report a case of pulmonary artery (PA) perforation caused by the barbs of the WATCHMAN device that required surgical intervention for cardiac tamponade.…”

Epicardial appendage ooze causing pericardial tamponade after left atrial appendage device implantation

“…The commonly accepted and well-documented cause of pericardial tamponade during LAA device occlusion is cardiac perforation from instrumentation of the left atrium or LAA (related to transseptal puncture or manipulation of device or delivery equipment in the left atrium or LAA). 3 Other reported causes include delayed cardiac or vascular perforation 5 , 6 due to penetration of device strut or fixation hooks. The tissue of the LAA is well-known for being fragile and extremely thin in parts.…”