Table 3.
Major procedural complications of percutaneous left atrial appendage closure devices
| Complication | Cause | Preventative Strategy |
|---|---|---|
| Pericardial effusion | Initial transseptal puncture | TEE guidance (eg, X-plane) |
| Avoid severe tenting of IAS (increases the risk of free-wall puncture) - alternative strategies eg application of radiofrequency energy | ||
| Puncturing at the fossa ovalis | ||
| Guidewire or catheter into LAA after initial transseptal puncture | Advance dilator into LAA under fluoroscopy over 0.32-in wire with distal curve or coronary wire | |
| Manipulation of delivery sheath/system into and within LAA | Advance delivery sheath into LAA over pigtail catheter rather than guidewire | |
| Posterior-inferior puncture to optimize coaxial approach to LAA; avoid using PFO which guides entry superiorly and suboptimaally to work within LAA | ||
| LARIAT endocardial wire pulls epicardial wire into the LAA | Recognize tension on LARIAT endocardial wire when connected to epicardial wire including when balloon being placed at ostium | |
| Device deployment and retrieval | Maintain delivery sheath position; minimize retrievals and reimplantations if possible | |
| Procedural stroke | Preexisting thrombus in LAA | Careful baseline TEE |
| Insufficient anticoagulation | Monitor anticoagulation, if possible; consider anticoagulation before transseptal puncture | |
| Air embolus from delivery sheath/system | Flush sheath only after entering LAA, and after device exchange, if performed | |
| Device embolization | Inappropriate size | Tug-test; confirm device compression (Watchman should be 8–20% compressed) or appropriate fluoroscopic appearance |
| Inappropriate position | Confirm device position and seal by TEE and fluoroscopy | |
| Vascular (hematoma, arteriovenous fistula, pseudoaneurysm, bleeding) | Venous access | Careful technique; consider ultrasound guidance as needed |
| Pericardial pain | Common after LARIAT closure - ?pericardial inflammation / LAA necrosis | Anecdotal: prophylactic NSAIDS, oral colchicine course, intrapericardial therapy eg local anesthetic flushes |
Modified from Price, Intervent Cardiol Clin 3 (2014) 301–311