PMC9498062_01
(A) Left atrial appendage angiography before device selection (Supplementary Video 1). (B) Post-deployment angiography shows brisk contrast extravasation (white arrow) into the pericardial space (Supplementary Video 2). (C) The device is redeployed at a more proximal position to seal the appendage and distal perforation (Supplementary Video 3). (D) The device is released after confirmation of device stability and the absence of residual peri-device leakage (Supplementary Video 4).
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F1
Left atrial appendage (LAA) angiography (Figure 1A and Supplementary Video 1) at the right anterior oblique 30  and caudal 20  view revealed ostial width of 19.5 mm and depth of 21.8 mm. Post-deployment angiography revealed brisk contrast extravasation into the pericardial space (Figure 1B and Supplementary Video 2). The device was retracted and redeployed at a more proximal position to effectively seal the LAA and distal perforation (Figure 1C and Supplementary Video 3). After confirmation of device stability and absence of residual peri-device leakage, the Watchman device was released (Figure 1D and Supplementary Video 4).
(A) Fluoroscopic image showing a near-normal sized cardiac silhouette (Supplementary Video 5), although the patient's blood pressure decreased to 90/62 mmHg. (B,C) Images showing the use of a thrombus aspiration catheter (white arrows) for thrombus aspiration from multiple pericardial sites with cautious manipulation of the guiding catheter and guidewire (Supplementary Videos 6, 7). (D) Image showing a sludge-like appearance of blood (as opposed to a formed thrombus) drained by the aspiration catheter. TS, thrombus aspiration.
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F2
Post-deployment angiography revealed brisk contrast extravasation into the pericardial space (Figure 1B and Supplementary Video 2). Fluoroscopy revealed a near-normal-sized cardiac silhouette (Figure 2A and Supplementary Video 5), and minimal pericardial blood was drained after the insertion of a new pigtail catheter. Supplementary Videos 6, 7). Sludge-like blood (instead of a thrombus) was drained using the aspiration catheter (Figure 2D).
(A) Echocardiography showing hypoechoic (rather than anechoic) areas in the pericardial space. (B) Echocardiography shows mild effusions with a round hyperechoic thrombus in the vicinity of the right ventricular apex after intrapericardial thrombus aspiration. (C) Image showing shrinkage of the round thrombus, which appears as a strip in the vicinity of the right ventricular apex on the second postoperative day (Supplementary Video 8). (D) Echocardiography was obtained 2 weeks after discharge and showed no thrombus or pericardial effusion (Supplementary Video 9).
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F3
The device was retracted and redeployed at a more proximal position to effectively seal the LAA and distal perforation (Figure 1C and Supplementary Video 3). Emergency echocardiography revealed a hypoechoic (rather than anechoic) effusion in the pericardial space (Figure 3A), suggestive of early pericardial thrombosis. Echocardiography revealed mild effusion and a round hyperechoic thrombus (2.5 cm x 1.7 cm) in the vicinity of the right ventricular apex (Figure 3B). We observed shrinkage of the round thrombus, which appeared as a strip that measured 1.8 cm x 0.7 cm in size near the right ventricular apex (Figure 3C and Supplementary Video 8). Echocardiography performed 2 weeks after discharge revealed no thrombus or pericardial effusion (Figure 3D and Supplementary Video 9), and the patient had no thromboembolic event or pericardial effusion during 1-year follow-up.