Simultaneous coronary and cerebral embolization from late watchman device-related thrombosis six years after implantation: A case report

Background Device-Related Thrombosis (DRT) following Left Atrial Appendage Closure (LAAC) is an uncommon yet concerning complication that carries an increased risk of morbidity and mortality. We present a case of Watchman DRT that occurred six years after implantation, leading to simultaneous coronary and cerebral embolization, resulting in acute myocardial infarction and embolic stroke. Case presentation A 76-year-old female who had undergone left atrial appendage closure with a Watchman legacy device six years prior, and who had been off all antithrombotic therapy for a year, presented with acute chest pain and an EKG suspicious for an acute anterolateral myocardial infarction. Coronary angiography revealed acute embolic occlusion of the first diagonal artery, treated with successful percutaneous coronary intervention, and of the distal left anterior descending artery, which was managed medically. Two days later she developed diplopia, and imaging confirmed an acute embolic cerebellar infarct. Transesophageal echocardiography revealed a sizable thrombus on the Watchman device. She was managed with anticoagulation and discharged on triple therapy. Discussion This case highlights the importance of extended antithrombotic therapy after LAAC, even years after implantation, and the need for a high index of suspicion for DRT in patients presenting with embolic events. Treatment centers on oral anticoagulation (OAC) with serial imaging to confirm resolution; OAC may be discontinued once the thrombus resolves, though the risk of recurrence supports continued surveillance. Conclusions DRT, although rare, presents significant clinical challenges with potentially devastating consequences. Future research should focus on improving device design and developing optimal treatment strategies, and on defining long-term antithrombotic protocols for LAAC recipients.