Left Atrial Appendage Occlusion Device Infection: A Rare Case Report and Literature Review

An 84-year-old male patient with a history of paroxysmal atrial fibrillation, status post dual-chamber permanent pacemaker and Watchman device implantation two weeks prior to presentation, came to the hospital with an acute onset of fevers, chills, and rigors. Blood cultures were positive for coagulase-negative Staphylococcus in two out of two bottles. Transthoracic echocardiography (TTE) was negative, and TEE showed a mobile echodensity measuring 1.4 × 1.2 cm attached to the Watchman device, consistent with a vegetation due to infective endocarditis (IE). He underwent surgical removal of the Watchman device along with explantation of the right atrial and ventricular pacemaker leads. He was discharged on oral cefuroxime and intravenous vancomycin for a total of six weeks. We conducted a literature search of PubMed, Embase, Cochrane, Scopus, Web of Science, and Google Scholar. We found 14 cases of infected Left Atrial Appendage Occlusion (LAAO) devices. The Watchman device was the most commonly used, in 10 of 14 patients; the Amulet device was used in three patients, and one patient had an AtriClip. The diagnostic modality of choice was transesophageal echocardiography, which was performed in all cases. FDG PET/CT was performed in one case to determine FDG uptake and infection of the LAAO device. The most common organisms identified from blood cultures were gram-positive organisms, reported in 12 patients (85.7%). The predominant organism was Staphylococcus aureus, with six patients having methicillin-sensitive Staphylococcus aureus (MSSA) and three patients having methicillin-resistant Staphylococcus aureus (MRSA). Three patients had coagulase-negative Staphylococcus, including one patient in whom the organism was specifically identified as Staphylococcus epidermidis. Patients with MRSA infection were treated with vancomycin in one patient and ceftaroline with daptomycin in the other two patients. Patients with MSSA were treated with nafcillin, cefazolin with or without oral rifampicin, or flucloxacillin. Pseudomonas infection was treated with amikacin, cefotaxime, and ciprofloxacin. Mortality was noted in 4 of 14 patients (28.57%), and three patients died during hospitalization.