Case report 959
Intracardiac echocardiography for immediate detection of intracardiac thrombus formation Jakub Baran, Agnieszka Sikorska, Roman Piotrowski and Tomasz Kryn´ski An 85-year-old man with persistent atrial flutter (AFL) with slow ventricular rate of 44/min, causing fatigue and presyncope, was referred for urgent treatment. In spite of thromboembolic risk scale value 4, he had not been treated with anticoagulants because of high risk of bleeding. The decision was made to perform urgent catheter ablation to interrupt and cure AFL. Intracardiac echocardiography probe was placed in the pulmonary artery and visualized left atrial appendage free from thrombus with its proper function. Heparin was administered and AFL stopped during energy application. Intracardiac echocardiography showed immediate thrombus formation in left atrial appendage owing to complete atrial standstill and no retrograde conduction during hemodynamically effective escape nodal rhythm. This case report shows that in patients with sinus node disease effective ablation of AFL with escape rhythm without retrograde conduction to the atria may
An 85-year-old man with persistent atrial flutter (AFL) with slow ventricular rate of 44/min, causing fatigue and presyncope, was referred for urgent treatment. In spite of thromboembolic risk scale value (CHA2DS2-VASc) 4 he had not been treated with anticoagulation agents [international normalized ratio (INR) 1.15, platelet count 125 K/ml, D-dimer 200 mg/ml]. The decision was made to perform urgent catheter ablation to interrupt and cure AFL with a possibility of subsequent pacemaker implantation.
result in complete ‘electrically induced’ atrial standstill and immediate thrombus formation. Blood Coagul Fibrinolysis 26:959–960 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
Blood Coagulation and Fibrinolysis 2015, 26:959–960 Keywords: intracardiac echocardiography, thrombus, transoesophageal echocardiography Division of Clinical Electrophysiology, Department of Cardiology, Grochowski Hospital, Postgraduate Medical School, Warsaw, Poland Correspondence to Jakub Baran, Division of Clinical Electrophysiology, Department of Cardiology, Grochowski Hospital, Postgraduate Medical School, Warsaw, Poland E-mail: [email protected] Received 24 January 2015 Revised 1 May 2015 Accepted 14 May 2015
Fig. 1
LAA LSPV
LA
Because of inability to perform transoesophageal echocardiography, an intracardiac echocardiography probe was also introduced and placed in the pulmonary artery to visualize left atrial appendage (LAA) and its function [1]. Before ablation, the left atrial cavity and LAA were free from thrombus with sufficient LAA function – empting velocity was 0.5–0.7 m/s (Fig. 1, upper panel, see supplementary video 1, http://links.lww.com/BCF/ A15). Heparin in a standard dose of 5000 U was administered and subsequent radiofrequency ablation terminated AFL. However, because of sinus node disease and no retrograde conduction during hemodynamically effective escape nodal rhythm, there was complete atrial standstill and immediate formation of thrombus in the LAA was observed (Fig. 1, lower panel, see supplementary video 2, http://links.lww.com/BCF/A16). An additional 5000 U of heparin were administered and pacing from coronary sinus catheter to preserve atrial contractions was started.
Thrombus
LSPV LAA
LA
The LAA free from thrombus LAA (upper panel). The LAA filled with thrombus (lower panel).
0957-5235 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI:10.1097/MBC.0000000000000340 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.bloodcoagulation.com).
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
960 Blood Coagulation and Fibrinolysis 2015, Vol 26 No 8
Next, dual-chamber pacemaker was implanted. The LAA thrombus was still visible at the end of procedure. The patient received low molecular weight heparin 2 mg/kg s.c. with subsequent warfarin therapy initiation. Transoesophageal echocardiography performed 3 days later showed normal LAA without thrombus. The subsequent 1-month follow-up was uneventful. This observation shows that in patients with sinus node disease effective ablation of AFL with escape rhythm without retrograde conduction to the atria may result in complete ‘electrically induced’ atrial standstill and immediate thrombus formation. This complication may
by effectively detected and monitored by intracardiac echocardiography located in the pulmonary artery.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
Reference 1
Ren JF, Marchlinski FE, Supple GE, Hutchinson MD, Garcia FC, Riley MP, et al. Intracardiac echocardiographic diagnosis of thrombus formation in the left atrial appendage: a complementary role to transesophageal echocardiography. Echocardiography 2013; 30:72–80.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Intracardiac echocardiography for immediate detection of intracardiac thrombus formation Jakub Baran, Agnieszka Sikorska, Roman Piotrowski and Tomasz Kryn´ski An 85-year-old man with persistent atrial flutter (AFL) with slow ventricular rate of 44/min, causing fatigue and presyncope, was referred for urgent treatment. In spite of thromboembolic risk scale value 4, he had not been treated with anticoagulants because of high risk of bleeding. The decision was made to perform urgent catheter ablation to interrupt and cure AFL. Intracardiac echocardiography probe was placed in the pulmonary artery and visualized left atrial appendage free from thrombus with its proper function. Heparin was administered and AFL stopped during energy application. Intracardiac echocardiography showed immediate thrombus formation in left atrial appendage owing to complete atrial standstill and no retrograde conduction during hemodynamically effective escape nodal rhythm. This case report shows that in patients with sinus node disease effective ablation of AFL with escape rhythm without retrograde conduction to the atria may
An 85-year-old man with persistent atrial flutter (AFL) with slow ventricular rate of 44/min, causing fatigue and presyncope, was referred for urgent treatment. In spite of thromboembolic risk scale value (CHA2DS2-VASc) 4 he had not been treated with anticoagulation agents [international normalized ratio (INR) 1.15, platelet count 125 K/ml, D-dimer 200 mg/ml]. The decision was made to perform urgent catheter ablation to interrupt and cure AFL with a possibility of subsequent pacemaker implantation.
result in complete ‘electrically induced’ atrial standstill and immediate thrombus formation. Blood Coagul Fibrinolysis 26:959–960 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
Blood Coagulation and Fibrinolysis 2015, 26:959–960 Keywords: intracardiac echocardiography, thrombus, transoesophageal echocardiography Division of Clinical Electrophysiology, Department of Cardiology, Grochowski Hospital, Postgraduate Medical School, Warsaw, Poland Correspondence to Jakub Baran, Division of Clinical Electrophysiology, Department of Cardiology, Grochowski Hospital, Postgraduate Medical School, Warsaw, Poland E-mail: [email protected] Received 24 January 2015 Revised 1 May 2015 Accepted 14 May 2015
Fig. 1
LAA LSPV
LA
Because of inability to perform transoesophageal echocardiography, an intracardiac echocardiography probe was also introduced and placed in the pulmonary artery to visualize left atrial appendage (LAA) and its function [1]. Before ablation, the left atrial cavity and LAA were free from thrombus with sufficient LAA function – empting velocity was 0.5–0.7 m/s (Fig. 1, upper panel, see supplementary video 1, http://links.lww.com/BCF/ A15). Heparin in a standard dose of 5000 U was administered and subsequent radiofrequency ablation terminated AFL. However, because of sinus node disease and no retrograde conduction during hemodynamically effective escape nodal rhythm, there was complete atrial standstill and immediate formation of thrombus in the LAA was observed (Fig. 1, lower panel, see supplementary video 2, http://links.lww.com/BCF/A16). An additional 5000 U of heparin were administered and pacing from coronary sinus catheter to preserve atrial contractions was started.
Thrombus
LSPV LAA
LA
The LAA free from thrombus LAA (upper panel). The LAA filled with thrombus (lower panel).
0957-5235 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI:10.1097/MBC.0000000000000340 Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.bloodcoagulation.com).
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
960 Blood Coagulation and Fibrinolysis 2015, Vol 26 No 8
Next, dual-chamber pacemaker was implanted. The LAA thrombus was still visible at the end of procedure. The patient received low molecular weight heparin 2 mg/kg s.c. with subsequent warfarin therapy initiation. Transoesophageal echocardiography performed 3 days later showed normal LAA without thrombus. The subsequent 1-month follow-up was uneventful. This observation shows that in patients with sinus node disease effective ablation of AFL with escape rhythm without retrograde conduction to the atria may result in complete ‘electrically induced’ atrial standstill and immediate thrombus formation. This complication may
by effectively detected and monitored by intracardiac echocardiography located in the pulmonary artery.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
Reference 1
Ren JF, Marchlinski FE, Supple GE, Hutchinson MD, Garcia FC, Riley MP, et al. Intracardiac echocardiographic diagnosis of thrombus formation in the left atrial appendage: a complementary role to transesophageal echocardiography. Echocardiography 2013; 30:72–80.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
