open access

Vol 1, No 1 (2016)
Case report
Published online: 2016-08-11
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Device-associated thrombus after percutaneous left atrial appendage closure: a case report and literature review

Iwona Świątkiewicz, Marek Woźnicki, Adam Sukiennik, Jacek Kubica
·
Medical Research Journal 2016;1(1):48-52.

open access

Vol 1, No 1 (2016)
CASE REPORTS
Published online: 2016-08-11

Abstract

Introduction. In the setting of atrial fibrillation (AF), left atrial appendage (LAA) closure using the WatchmanTM device (WD) was proven to effectively prevent stroke, systemic embolism and cardiovascular death when compared with warfarin therapy. However, this procedure is potentially associated with the risk of complications, including device-attached thrombus formation.

Case presentation. We report a case of a 65-year-old woman with permanent non-valvular AF, a history of ischemic stroke on warfarin treatment, hypertension, diabetes mellitus, heart failure with preserved left ventricular ejection fraction, labile values of the international normalized ratio, enlarged left atrium (LA) and spontaneous echo contrast in echocardiography, who was qualified for percutaneous LAA closure using the WD. The pre-procedural patient assessment indicated high thromboembolic (CHA2DS2-Vasc Score = 5) and bleeding risk (HAS-BLED Score = 4), and optimal morphology of LAA in transesophageal echocardiography (TEE). After a successful procedure using a 30 mm-sized WD, and despite appropriate antiplatelet and anticoagulation therapy, 6-month follow-up TEE revealed a mobile thrombus (2.4 cm × 0.6 cm) at the atrial side of the WD. Therapy with intravenous heparin was started. However, a control TEE examination after one week revealed progression of the thrombus size (4.2 cm × 0.7 cm) and its protrusion across the mitral valve orifice into the left ventricle. Although the patient remained asymptomatic, cardiosurgical excision of the thrombus was performed due to high risk of thrombus embolization.

Conclusions. Late device-associated thrombus formation after implantation of the WD remains a rare but severe complication. Formal recommendations regarding prevention and management of device-related thrombosis are still lacking. In this complex clinical setting, we suggest: 1) careful long-term echocardiographic monitoring after percutaneous LAA closure, especially in patients with permanent AF, high thromboembolic risk, large LA and dense spontaneous echo contrast in echocardiography, and 2) an individualized treatment approach.  

Abstract

Introduction. In the setting of atrial fibrillation (AF), left atrial appendage (LAA) closure using the WatchmanTM device (WD) was proven to effectively prevent stroke, systemic embolism and cardiovascular death when compared with warfarin therapy. However, this procedure is potentially associated with the risk of complications, including device-attached thrombus formation.

Case presentation. We report a case of a 65-year-old woman with permanent non-valvular AF, a history of ischemic stroke on warfarin treatment, hypertension, diabetes mellitus, heart failure with preserved left ventricular ejection fraction, labile values of the international normalized ratio, enlarged left atrium (LA) and spontaneous echo contrast in echocardiography, who was qualified for percutaneous LAA closure using the WD. The pre-procedural patient assessment indicated high thromboembolic (CHA2DS2-Vasc Score = 5) and bleeding risk (HAS-BLED Score = 4), and optimal morphology of LAA in transesophageal echocardiography (TEE). After a successful procedure using a 30 mm-sized WD, and despite appropriate antiplatelet and anticoagulation therapy, 6-month follow-up TEE revealed a mobile thrombus (2.4 cm × 0.6 cm) at the atrial side of the WD. Therapy with intravenous heparin was started. However, a control TEE examination after one week revealed progression of the thrombus size (4.2 cm × 0.7 cm) and its protrusion across the mitral valve orifice into the left ventricle. Although the patient remained asymptomatic, cardiosurgical excision of the thrombus was performed due to high risk of thrombus embolization.

Conclusions. Late device-associated thrombus formation after implantation of the WD remains a rare but severe complication. Formal recommendations regarding prevention and management of device-related thrombosis are still lacking. In this complex clinical setting, we suggest: 1) careful long-term echocardiographic monitoring after percutaneous LAA closure, especially in patients with permanent AF, high thromboembolic risk, large LA and dense spontaneous echo contrast in echocardiography, and 2) an individualized treatment approach.  

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Keywords

atrial fibrillation, thromboembolic risk, left atrial appendage closure, WatchmanTM device

About this article
Title

Device-associated thrombus after percutaneous left atrial appendage closure: a case report and literature review

Journal

Medical Research Journal

Issue

Vol 1, No 1 (2016)

Article type

Case report

Pages

48-52

Published online

2016-08-11

Page views

634

Article views/downloads

1162

DOI

10.5603/MRJ.2016.0008

Bibliographic record

Medical Research Journal 2016;1(1):48-52.

Keywords

atrial fibrillation
thromboembolic risk
left atrial appendage closure
WatchmanTM device

Authors

Iwona Świątkiewicz
Marek Woźnicki
Adam Sukiennik
Jacek Kubica

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