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.