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Image in Cardiology
Thrombus in left atrial appendage – Overcoming percutaneous closure limitations
Trombo no apêndice auricular esquerdo – transpondo limitações do encerramento percutâneo
José Luís Martinsa,
Corresponding author
zeluismartins@gmail.com

Corresponding author.
, Luís Paivab, Marco Costab, Lino Gonçalvesb
a Centro Hospitalar Baixo Vouga, Aveiro, Portugal
b Centro Hospitalar Universitário Coimbra, Hospital Geral, Coimbra, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 70-year-old male patient with a history of rheumatic mitral valve disease&#44; who underwent percutaneous mitral balloon valvuloplasty &#40;2004&#41; and surgical mitral valve repair &#40;2007&#41; was referred for left atrial appendage &#40;LAA&#41; closure due to LAA thrombus persistence&#44; despite adequate anticoagulation&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The LAA thrombus was documented in a transesophageal echocardiography &#40;TEE&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; This thrombus was formed despite long-term oral anticoagulation with warfarin&#46; The first approach was to increase the anticoagulation therapeutic range &#40;INR 3&#46;0-4&#46;0&#41; for 3 months&#44; followed by high-dose enoxaparin &#40;1&#46;5 mg&#47;kg&#44; every 12 h&#41; with limited success&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Due to high cardioembolic risk&#44; the patient underwent successful LAA device implantation &#40;Amulet&#8482; <span class="elsevierStyleItalic">St&#46; Jude Medical</span>&#59; 28 mm&#41; guided by intracardiac echocardiography &#40;ICE&#41;&#44; together with a cerebral protection system &#40;Sentinel&#8482;&#44; <span class="elsevierStyleItalic">Claret Medical</span>&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The patient received five days of unfractionated heparin prior to the procedure to reduce the &#8220;thrombotic burden&#8221;&#44; resulting in partial reduction of the thrombus&#46; Using ICE negated the need for sedation or intubation&#44; thus permitting continuous monitoring and early management of acute neurologic complications&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The procedure was performed without complications and no thrombotic material was retrieved from the cerebral protection system&#46; The patient was discharged the following day on warfarin&#46; The follow-up TEE at four weeks showed the device appropriately implanted &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">It is crucial to take into account strategies to prevent thrombus migration in these circumstances such as not injecting contrast directly into the LAA&#44; performing the cannulation of the delivery system without guide or pigtail and using a cerebral protection system&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Article information
ISSN: 21742049
Original language: English
DOI:10.1016/j.repce.2017.04.011
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