Attending Cooper University Health Care, United States
Introduction: In atrial fibrillation, anticoagulation prevents cardioembolic cerebrovascular events from the left atrial appendage. For patients intolerant of anticoagulation, percutaneous closure is an alternative. This case describes a unique hemorrhage source during this procedure.
Description: A 62-year-old female with atrial fibrillation underwent elective percutaneous left atrial appendage closure via two femoral venous access sites with fluoroscopic and transesophageal echocardiographic guidance. No intra-procedure complications were noted. The patient was heparinized to an ACT of >300 seconds and reversed with protamine sulfate at the end.
Post-procedure, she had a blood pressure of 80/40 mmHg, refractory to crystalloid bolus. Her condition worsened with increasing pallor and shortness of breath. Norepinephrine was required and rapidly up-titrated to maintain perfusion. Lab analysis was remarkable for a hemoglobin of 4.5g/dl (8.5g/dl pre-procedure). A massive transfusion protocol was initiated. Her ACT was 140 seconds and she was not given additional protamine.
Point of care ultrasound revealed a new massive left pleural effusion and absence of pericardial effusion. A chest tube drained 2,000ccs of frank blood, and proceeded to continue bleeding 200-400ccs/hr. CTA showed acute hemorrhagic blush in the left hemithorax, source unclear. Angioembolization identified the Superior Phrenic Artery as the source. Unsuccessful bleeding control was followed by thoracotomy and direct ligation. The procedure was successful, and she was extubated and discharged a few days later.
Discussion: While bleeding is a known complication, this unique site highlights the need for vigilance in patients with bleeding predispositions during percutaneous left atrial appendage ligation, where significant heparinization occurs. Bedside ultrasound can rapidly help determine the cause of a patient's decompensation and expedite necessary procedures and definitive management.
