Bethesda Heart Hospital Baptist South Florida, Florida Atlantic
University, Boynton Beach FL, USA.
This is an original article.
The author has not conflict of interest related to this work.
For Correspondence:
Domenico Calcaterra MD, PhD
Bethesda Heart Hospital
Baptist South Florida
2815 South Seacrest Blvd
Boynton Beach, FL 33435
domenicoc@baptisthealth.net
Ph. 561-374-5720
Word count: 937
I read with interest the manuscript by Masroor and co-authors on the
strategy of surgical repair for left atrial appendage perforation
following implantation of Watchman device. The authors present the
successful management of this complications and they comment on the
preferred therapeutic strategy. This is a particular sensitive subject
nowadays, since the widespread use and the constant growth of a variety
of transcatheter cardiac interventions has inevitably increased the
number of patients who are exposed to this type of complication.
My first comment to the authors is in regards to the choice of the
surgical repair strategy. Cardiac surgeons have learned a lot from the
experience of acute cardiac tamponade1 occurring with
injuries secondary to pace-maker lead insertion or extraction, which
more often involve damage to the right atrial wall2.
This latter scenario is not dissimilar from the one presented in this
manuscript, with the downsize that the rate of bleeding of a left atrial
injury could be even more dangerous because of the higher left atrial
pressure compared to the right atrium. In my experience, the safest way
to approach a life threatening emergency of this type is to proceed with
percutaneous pericardiocentesis in face of hemodynamic instability and
plan for emergency operation if evidence of bleeding persists. The
surgical approach I consider the safest is to establish extracorporeal
circulation with peripheral arterial and venous femoral cannulation,
which can be accomplished expeditiously either with percutaneous
approach or surgical cutdown. The strong benefit offered by this
strategy is allowing to establish cardiopulmonary bypass sooner, also
avoiding to open the chest with ongoing active bleeding. Opening the
chest without establishing peripheral preventive cardiopulmonary bypass
may worsen acute blood loss which could cause cardiac arrest.
Additionally, the presence of uncontrolled active bleeding can make
cannulation maneuvers very cumbersome. Establishing cardiopulmonary
bypass, allows reducing the amount of bleeding by ‘decompressing’ the
heart and allows to facilitate exposure of the area of bleeding when the
pericardium is opened following the sternotomy.
Second, I would discourage any attempt for a thoracoscopic approach to
care for this complication. The author is correct mentioning the report
of a thoracoscopic repair published in the literature. Nonetheless, the
thoracoscopic approach in such a situation should not be recommended. In
fact, choosing this strategy does not ensure safely obtaining control of
the bleeding, since procedural exposure can be challenging. Also, being
able to staple the left atrial appendage on a beating heart with ongoing
bleeding may be unsuccessful or dangerous for causing damage to
surrounding heart structure, the circumflex artery as an example.
Furthermore, trying the thoracoscopic approach could definitely delay
the delivery of the life-saving operation, which is obviously
time-sensitive, and could unnecessarily jeopardize patient’s survival.
If this is a true emergency as it is, the standard of care should be
focused on proceeding with the easiest and fastest approach, which by
definition is a midline sternotomy.
Third, I am not convinced that opening the left atrium through the
Waterston groove is necessarily the best approach3. In
fact, the Watchman has the shape of a mushroom with a stalk and cap.
Retrieving the device from inside the left atrium may be cumbersome and
cause unnecessary damage to the base of the left atrial appendage, which
could ultimately complicate the final repair. Therefore in this
situation, I would favor to attempt removing the device from the outside
of the heart first, after establishing cardioplegic arrest. Under these
conditions, it is relatively safe to oversaw the appendage at its base
with a double layer of 4-0 polypropylene suture.
Lastly, I am not sure I would recommend completing a Maze procedure in
the contest of this emergent operation. According to the literature,
complete exclusion of the left atrial appendage reduces the risk of
stroke up to 90 % in non-valvular atrial fibrillation and approximately
60% in valvular atrial fibrillation4. Therefore, I
would be comfortable with minimizing cross-clamp and cardiopulmonary
bypass time, aiming at saving the patient’s life for the time being.
Exposing the patient to increased risk of bleeding from performing the
Maze procedure and facing the potential risk of causing new conduction
abnormalities which may require permanent pacemaker placement could be,
in my opinion, not justified in this contest. Additionally, is worth to
mention that, as an alternative if needed, transcatheter ablation for
treatment of the atrial fibrillation would also be a valid and suitable
option on an elective base.
With the occasion I would like to thank the editor in Chief of the
Journal of Cardiac Surgery for inviting my comments on this interesting
manuscript.
References:
- Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003 Aug
14;349(7):684-90. doi: 10.1056/NEJMra022643. PMID: 12917306.
- Jacheć W, Polewczyk A, Polewczyk M, Tomasik A, Janion M, Kutarski A.
Risk Factors Predicting Complications of Transvenous Lead Extraction.Biomed Res Int . 2018;2018:8796704. Published 2018 Dec 18.
doi:10.1155/2018/8796704
- Jensen J, Thaler C, Saxena R, Calcaterra D, Sanchez J, Orlandi Q,
Harris KM. Transesophageal Echocardiography to Diagnose Watchman
Device Infection. CASE (Phila). 2020 Feb 18;4(3):189-194. doi:
10.1016/j.case.2020.01.008. PMID: 32577603; PMCID: PMC7303240.
- Chatterjee S, Alexander JC, Pearson PJ, Feldman T. Left atrial
appendage occlusion: lessons learned from surgical and transcatheter
experiences. Ann Thorac Surg. 2011 Dec;92(6):2283-92. doi:
10.1016/j.athoracsur.2011.08.044. Epub 2011 Oct 25. PMID: 22029943.