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Left atrial thrombus after appendage ligation with LARIAT Matthew S. Baker, MD, J. Paul Mounsey, BM BCh, PhD, MRCP, Anil K. Gehi, MD, FHRS, Eugene H. Chung, MD, MSc, FHRS From the University of North Carolina, Chapel Hill, North Carolina.

Figure 1

A 78-year-old man with intermittently persistent atrial fibrillation (AF) and flutter, hypertension, diabetes mellitus, and a history of spontaneous subarachnoid hemorrhage underwent successful percutaneous left atrial appendage (LAA) ligation using the LARIAT (SentreHeart, Redwood City, CA) suture delivery system. Transesophageal echocardiogram (TEE) at the time of the procedure confirmed complete ligation of the atrial appendage with no evidence of residual communication by color flow Doppler imaging. He was in sinus rhythm on the day of procedure but reverted to AF on postoperative day 2. He was discharged on aspirin. At clinic follow-up 14 days later, he remained in AF but by the day of a subsequently scheduled cardioversion he had returned to sinus rhythm. A follow-up TEE to evaluate obliteration of the LAA was performed on postoperative day 45. This TEE revealed a 1.0  1.2-cm left atrial thrombus, with a stalk arising from the stump of the ligated LAA (Figure 1A; Movie). There was no communication between

the left atrium and the ligated appendage. Anticoagulation with warfarin and Lovenox bridging was initiated. Repeat TEE approximately 45 days later showed complete resolution of the thrombus (Figure 1B) without further complication. We report here a case of successful treatment of a left atrial clot that was a sequela of LAA ligation with the LARIAT. There has been one other report of left atrial thrombus identified by TEE after percutaneous ligation with the LARIAT system.1 Thrombus at the site of closure may represent thrombus extension from an appendage that had slightly opened after the procedure. In addition, pulling of the balloon-tipped catheter and endocardial magnet-tipped wire through a cinched-down LAA neck might traumatize the endothelium and create a prothrombotic surface. Further studies are needed to elucidate the nature of thrombus formation at the site of LAA closure and to investigate the need for routine follow-up imaging and routine administration of anticoagulation postclosure.

Appendix KEYWORDS LARIAT; Left atrial appendage; Thrombus; Percutaneous ligation; Atrial fibrillation ABBREVIATIONS AF ¼ atrial fibrillation; LAA ¼ left atrial appendage; TEE ¼ transesophageal echocardiogram (Heart Rhythm 2014;0:1–1) Address reprint requests and correspondence: Dr Matthew S. Baker, Division of Cardiology, Cardiac electrophysiology, University of North Carolina, Campus Box 7075, 6th Floor Burnett-Womack Building, 160 Dental Circle, Chapel Hill, NC 27599-7075. E-mail address: [email protected]

1547-5271/$-see front matter B 2014 Heart Rhythm Society. All rights reserved.

Supplementary data Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.hrthm. 2013.10.024.

Reference 1. Giedrimas E, Lin AC, Knight BP. Left atrial thrombus after appendage closure using LARIAT. Circ Arrhythm Electrophysiol 2013;6:e52–e53.

http://dx.doi.org/10.1016/j.hrthm.2013.10.024

Left atrial thrombus after appendage ligation with LARIAT.

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