# Less Is More: Management of Left Atrial Appendage Perforation With Impending Cardiac Tamponade Following Watchman Device Placement

## TL;DR

A rare case of heart perforation during a device implantation was managed successfully without major surgery.

## Contribution

Presents a novel management approach for a rare complication during Watchman device implantation.

## Key findings

- Left atrial appendage perforation was managed by leaving the device in place to seal the leak.
- A pericardial window with temporary drain avoided sternotomy and led to a good patient outcome.

## Abstract

By 2030, the United States will have over 12 million people with atrial fibrillation, which carries a five-fold increase in risk of stroke. Watchman device is an alternative in patients who are poor candidates for anticoagulation. Here, we present a rare case of Watchman device implantation related to left atrial appendage (LAA) perforation noted intraoperatively with portion of the device in the pericardial space. A 93-year-old female with high fall risk and on Coumadin presented for Watchman device placement. During implantation, LAA perforation was noted with exudation of contract in the pericardium during deployment, and decision to deploy the device was made, hoping it would help seal the leak. Retrieving the device was thought to put the patient at risk of bigger perforation. Following which successful pericardial window with temporary drain placement avoided sternotomy and overall had a good outcome. A Watchman device with self-expanding frame covering the left atrial facing surface was deployed, after which a rare but potential complication of perforation was noted during delivery. The device left in place sealed the leak and prevented potential worsening incase device was retrieved. Eventually, this decision improved the outcome of the patient.