Objective:

To study peri-procedural complications of Watchman device placement.

Background:

Left atrial appendage therapy with a Watchman device is a non-inferior ischemic stroke prevention strategy for patients with paroxysmal atrial fibrillation (pAF) deemed to be unsuitable for conventional anticoagulation. Peri-procedural air embolism is a known complication and can present with systemic emboli provoking ischemic strokes, coronary ischemia, or cardiac arrest. The PROTECT AF trial specifically documented 5 peri-procedural strokes out of 542 total procedures due to air embolism. We present two cases of periprocedural cerebral emboli resulting in potentially fatal complications.

Design/Methods:

Retrospective review of electronic medical records.

Results:

81year old gentleman was noted to have acute change of decreased generalized responsiveness, and concomitant electrocardiographic change during Watchman deployment. Rapid reversal of anesthetic agents did not result in clinical improvement. Neurological exam showed asymmetric pupils, L>R, and initially withdrew on all four extremities with rapid progression to flexor posturing to noxious stimulus. CT stroke protocol demonstrated an area of acute infarction in the right middle cerebral artery territory, associated with air in sulci. He required transfer to another facility for hyperbaric oxygen treatment. Follow up CT scan of head demonstrated complete resolution of air emboli, however his neurologic exam remained poor, and patient expired during hospital admission. 
Case 2: 61year old gentleman presented with periprocedural acute onset of right gaze deviation, left facial droop, left sided paralysis, sustained clonus, and left sensory deficit. CT stroke protocol showed hypodensity in the right MCA territory with air in sulci. He was transferred for hyperbaric oxygen therapy. After protracted rehabilitation, he lives independently with residual left sided weakness.

Conclusions:

Air embolism remains an under-recognized potentially fatal complication of Watchman device placement. These cases indicate the need to recognize air emboli as an etiology of periprocedural stroke requiring a unique treatment strategy including a framework for expedited hyperbaric access.