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Late Organized Left Atrial Thrombus on a Left Atrial Appendage Closure Device DAGMARA DILLING-BOER, M.D.,∗ EDOUARD BENIT, M.D.,∗ LIEVEN HERBOTS, M.D., Ph.D.,∗ and MARC HENDRIKX, M.D., Ph.D.∗ ,† From the ∗ Departments of Cardiology and Cardiac Surgery, Hartcentrum Hasselt, Jessa Hospital, Belgium; and †Faculty of Medicine, Hasselt University, Hasselt, Belgium

atrial fibrillation, closure device, left atrial appendage, thrombus An 84-year-old woman with permanent atrial fibrillation, congestive heart failure with mitral regurgitation and an implanted biventricular pacemaker experienced an ischemic cerebrovascular accident 4 years after discontinuation of oral anticoagulation after prior intracerebral bleeding. Because of a CHAD2DS2-VASc score of 7 and a contraindication for oral anticoagulation therapy she was referred for percutaneous closure of left atrial appendage in February 2012 (Amplatzer Cardiac Plug, 30 mm). There were no periprocedural complications and the patient was discharged on a regimen of 80 mg aspirin and 75 mg of clopidogrel daily. Clopidogrel was discontinued 1 month after

J Cardiovasc Electrophysiol, Vol. 25, pp. 445-446, April 2014. No disclosures. Address for correspondence: Dagmara Dilling-Boer, M.D., Jessa Ziekenhuis, Department of Cardiology, Stadsomvaart 11, 3500 Hasselt, Belgium. Fax: +32 11 307839; E-mail: [email protected] doi: 10.1111/jce.12363

the procedure. The patient was followed up with a transthoracic echocardiography every 6 months. During routine transthoracic echocardiography 14 months after the procedure the presence of a left atrial thrombus was suspected. The transoesophageal echocardiography confirmed the presence of a large left atrial mass 87 mm × 47 mm adjacent to the atrial appendage occluder (Fig.1). The left atrium was severely enlarged with a diameter of 95 mm and spontaneous contrast was present. Because of the size of the atrial mass and the fact that the patient refused oral anticoagulation out of fear for recurrence of intracerebral bleeding, she was referred for cardiac surgery. The anatomopathologic analysis revealed an epithelialized Amplatzer Cardiac Plug device with adjacent, partially organized, large thrombus (133 g, 9 × 5 cm). Our patient fulfilled the indication criteria for the implantation of a left atrial closure device. However, the presence of severely dilated left atrium with spontaneous contrast, moderate mitral regurgitation and heart failure NYHA class III with severely impaired systolic left ventricular function might have predisposed her to thrombus formation even after complete endothelialization of the device.


Journal of Cardiovascular Electrophysiology

Vol. 25, No. 4, April 2014

Figure 1. (A) Transesophageal echocardiography (TEE) view of left atrial thrombus (white arrow). (B) Intraoperative view of left atrium: black arrows: lobe and disc of left atrial occluder; asterisk: organized thrombus. (C) Intraoperative view of left atrium: black arrow: lobe of the occluder; white arrow: thrombus; asterisk: pacemaker leads. (D) Organized left atrial thrombus attached to the left atrial appendage occluder: white arrow: thrombus.

Late organized left atrial thrombus on a left atrial appendage closure device.

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