Case presentation
Case 1
A 59-year-old male with hypertension, diabetes, atrial fibrillation, prior twice stroke history and prior ICD implantation due to cardiac arrest presented for selective percutaneous left atrial appendage occlusion (LAAO). The patient received catheter atrial flutter ablation therapy 6 months ago, but electrocardiogram and 24-h holter showed atrial fibrillation at present (average heart rate 86bpm). The patient’s CHA2DS2-VASc score was 4 and his HASBLED score was 3. He was unwilling to take long term oral anticoagulants because of high risk fo bleeding. Before the procedure, the patient’s coagulation function test was normal.
An 6F sheath was placed in the right femoral vein, intravenous heparin 3,000U was administered. After TEE-guided trans-septal puncture, heparin 4,500U was given. Then a 12F delivery sheath and pigtail catheter were positioned in the LAA. Activated clotting time (ACT) measured 254s. An angiogram and TEE was performed to assess the appendage morphology. TEE revealed a cactus shaped LAA free of thrombus. LAA emptying velocity was 40 cm/sec. Mild spontaneous echocardiographic contrast was in the LAA. The patient then underwent successfully implantation of a 22-mm LACbes device with no para-device leak. After the occlusion device release, TEE showed a 20mm length floating thrombus attached to the delivery sheath tip (Figure 1A, 1B and Video 1). ACT was measured 112s and heparin 3,000U was added immediately. We tried to suck the thrombus through long sheath but failed. ACT measured 124s after 5 min. Heparin was added in divided without any effect on the thrombus resolution. Cerebral embolic protection devices (ev3 SpiderFX) were implanted in the bilateral internal carotid arteries and urokinase 500,000U was administered to achieve ACT >250s until TEE showed thrombus dissolved. After thrombolytic therapy, cerebral and renal artery angiogram were conducted and showed no embolism sign. Thrombus debris was detected in the filter after removal (Figure 2). Rivaroxaban and aspirin were initiated, and the patient was closely monitored post-operation. The neurological function was not impaired and cerebral CT showed old infarcts 1 day after procedure.