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A 77-year-old male with a history of persistent atrial fibrillation on warfarin developed an abdominal hematoma when his INR was supratherapeutic, so he was evaluated for WATCHMAN (Boston Scientific Corporation, Marlborough, MA) left atrial appendage occlusion. Transesophageal echocardiography (TEE) showed an adequately sized left atrial appendage so a 27mm WATCHMAN device was deployed. Angiogram showed the device in good position and TEE showed no peri-device leak or pericardial effusion. He was placed on a continuous heparin infusion which was maintained in the therapeutic range based on anti-Xa assay. The following morning, he was confused, clammy, and short of breath. Shortly thereafter the patient went into cardiac arrest. During arrest it was noted that the patient had a 4g drop in hemoglobin and intraarrest bedside ultrasound revealed a complex left pleural effusion, so he was transfused with protamine sulfate, vitamin K, fresh frozen plasma, packed red blood cells, and incompatible platelets. Return of spontaneous circulation was achieved after 16 minutes. Post-arrest a CT angiogram of the chest revealed a large left pleural effusion without evidence of perforation of any large arteries. Transthoracic echocardiogram showed no evidence of pericardial effusion. A left chest tube was placed with drainage of 2200 cc of frank blood in the first 12 hours. Endoscopy showed a superficial ulcer of the mid-esophagus but no evidence of esophageal perforation or tear. The patient was stabilized but ultimately had poor neurologic recovery due to anoxic brain injury and palliatively extubated and discharged home to family on comfort measures.DISCUSSION: Left atrial appendage closure with a WATCHMAN device has similar bleeding rates compared to warfarin alone, with a majority of major bleeding events occurring in the periprocedural period [2]. Although periprocedural bleeding after device implantation is not uncommon, hemothorax is a very rare complication occurring in only 0.1% of cases [1]. In this case rupture of the left atrial appendage or other perforation of cardiac structures was ruled out by the absence of a pericardial effusion, as well as bleeding from esophageal rupture after TEE. It is unclear whether dissections or perforations of smaller arterial or venous structures lead to the hemothorax or whether it was a spontaneous event related to heparin infusion. CONCLUSIONS:Hemothorax is a rare bleeding complication of WATCHMAN device implantation but needs to be considered as a potential major bleeding event after device deployment.

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