Late Infection of a Left Atrial Appendage Occlusion Device Detected by Transesophageal Echocardiography

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BACKGROUND: Left atrial appendage occlusion devices are used for stroke prevention in patients with atrial fibrillation who cannot tolerate long-term anticoagulation. Device-related infection is a rare complication and typically occurs early after implantation. CASE SUMMARY: A 73-year-old woman with paroxysmal atrial fibrillation who underwent Watchman implantation 6 years earlier presented with persistent methicillin-resistant Staphylococcus aureus bacteremia following debridement of infected right humeral hardware. Transthoracic echocardiography demonstrated preserved left ventricular systolic function without valvular abnormalities. Because of ongoing bacteremia, transesophageal echocardiography was performed that revealed a large mobile echodensity attached to the Watchman device, consistent with device infection. Surgical removal was not pursued because of prohibitive operative risk. DISCUSSION: This case illustrates a rare instance of Watchman infection from hematogenous seeding and highlights the critical diagnostic role of transesophageal echocardiography. TAKE-HOME MESSAGE: Persistent bacteremia in patients with left atrial appendage occlusion devices should prompt evaluation with transesophageal echocardiography for exclusion of device infection as demonstrated in this case.

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