Left atrial appendage occlusion device infection: Take it or leave it?

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide, and its prevalence is expanding owing to advanced age and higher rates of chronic heart disease.1 The standard treatment for stroke reduction in patients with nonvalvular AF is anticoagulation. However, alternative therapy may be advisable in a certain subset of patients, owing to either previous failure of oral anticoagulation or presence of contraindications to anticoagulation.1 The left atrial appendage has been identified as the primary site of thrombus formation in more than 90% of patients with AF.2 The PLAATO3 study in 2002 was the first to demonstrate the use of a device to occlude the left atrial appendage for stroke reduction in patients with AF and provided the fundamental ground for future development in that field. Since its publication several percutaneous left atrial appendage occlusion (LAAO) devices have been developed and tested, including the Watchman, Amulet, and LARIAT, among others.4 The Watchman (Boston Scientific, Marlborough, MA) is the most extensively studied and is the only FDA-approved percutaneous LAAO device currently available in the United States.5 More than 100,000 devices have been implanted since it gained its approval in 2015.6 LAAO devices are approved for use in patients with nonvalvular AF who are not candidates for long-term coagulation with comparable outcomes in terms of risk of stroke, bleeding, and cardiovascular complications.7,8 Percutaneous LAAO has also been used in patients with recurrent cardioembolic stroke while on oral anticoagulation.9 Implantation of any intracardiac device carries the risk of device thrombosis and infection. However, risk of LAAO device infection is low owing to complete endothelialization. Currently, there are no guidelines regarding prophylaxis of bacterial endocarditis with Watchman device placement. Similarly, management of LAAO device infections remains uncertain, with no clear guidelines. We report a case of a 74-year-old man with Watchman device infection that was managed conservatively with a long course of antibiotics without the need for surgical extraction. Key Teaching Points • Left atrial appendage occlusion devices, despite endothelialization, can carry a late risk of device-related infective endocarditis. • Review of literature suggests role of transesophageal echocardiogram in the diagnosis of left atrial appendage occlusion device infections. • While surgical extraction has been previously described, we report a case of successful antibiotic suppression at 6-month follow-up.