Case Report Herzschr Elektrophys 2015 · 26:54–55 DOI 10.1007/s00399-015-0357-7 Received: 27 January 2015 Accepted: 29 January 2015 Published online: 3 March 2015 © Springer-Verlag Berlin Heidelberg 2015
Electronic supplementary material The online version of this article (doi: 10.1007/s00399-015-0357-7) contains supplementary material, which is available to authorized users.
Introduction Pulmonary vein (PV) isolation is one of the treatments of choice for symptomatic paroxysmal atrial fibrillation (AF) [1]. However, thromboembolic complications are an important limitation of this approach, occurring in up to 1 % of patients [2]. Most cases are due to disruption of the endothelial surface during energy delivery with radiofrequency ablation [3, 4]. However, there are other reasons of thromboembolic complications, not due to radiofrequency energy delivery.
Fig. 1 8 Angiography of the left PV: after the contrast wash-out, a contrasted longitudinal thrombus is shown within the left atrium (arrow)
Mauro Toniolo1,2 · Alejandro Estrada1 · David Filgueiras-Rama1 · Josè L. Merino1 1 Arrhythmia and Robotic Cardiac Electrophysiology Unit, IdiPaz, Hospital Universitario “La Paz”, Madrid, Spain 2 Division of Cardiology, University Hospital “S.Maria della Misericordia”, Udine, Italy
Revolving thrombus within the left atrium at atrial fibrillation ablation Case report
Discussion
A 68-year-old man with no structural heart disease and daily episodes of paroxysmal atrial fibrillation was referred for PV isolation. The patient was in sinus rhythm at the beginning of the procedure. He was on warfarin therapy, with an international normalized ratio of 1.7. Transoesophageal echocardiogram achieved 2 h before procedure showed no thrombus in the atria. Access to the left atrium was obtained via a single transseptal puncture. An 8000-unit heparin bolus was given immediately after puncture, and the transseptal sheath (Bard Channel Fx, length: 61 cm, size: 8F) was continuously flushed with a heparinized saline solution. Angiography of the left PV was performed. After the contrast washout, a contrasted longitudinal thrombus was shown revolving within the left atrium for several seconds before being expelled through the mitral and aortic valves (Fig. 1 and electronic supplementary video showing fluoroscopy of the left atrium in the left oblique projection). The thrombus was probably formed on the transseptal sheath. The patient had no symptoms or signs of neurological damage, and, after 10 min of observation, the ablation procedure was continued. The following day, the patient was asymptomatic and had no signs of neurological complications. Cerebral magnetic resonance imaging showed normal results, and there were no analytical abnormalities except for a mild increase of creatine phosphokinases and aspartate aminotransferase serum levels. The patient was discharged with no complications at follow-up.
Thrombus formation on the transseptal sheath during PV isolation has been described in the past [5, 6]. Some of these cases have been resolved by systemic thrombolysis [5] or by thrombus aspiration with a strong suction produced by a large syringe via the sheath’s sidearm [6]. In most cases, this complication resulted in no major injury to the patient. It is common practice in these procedures to administer an intravenous bolus of unfractioned heparin immediately after the transseptal puncture or event after an initial observational period. However, heparin has latency to become effective, and this varies between patients. Bruce et al. [6] demonstrated that an early administration of intravenous heparin, specifically before transseptal puncture, decreases the incidence of left atrial thrombi.
54 | Herzschrittmachertherapie + Elektrophysiologie 1 · 2015
Conclusion The use of left atrial angiography or intracardiac echocardiography in PV isolation procedures is not considered mandatory for AF ablation and is not commonly performed in some countries. Therefore, thrombus formation incidence may be underestimated but still contributes to the pathogenesis of relevant events such as subclinical stroke.
Corresponding address Dr. M. Toniolo M.D. Arrhythmia and Robotic Cardiac Electrophysiology Unit, IdiPaz Hospital Universitario “La Paz”, Madrid [email protected]
Abstract · Zusammenfassung
Video legend Angiography of the left PV: after the contrast washout, a contrasted longitudinal thrombus is shown within the left atrium
Compliance with ethical guidelines Conflict of interest. Dr. J.L. Merino is consultant to Magnetecs, Inc. and receives honoraria payment for providing medical and technical training for St. Jude Medical. All other authors have no conflicts of interest to declare. The accompanying manuscript does not include studies on humans or animals.
References 1. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti JB, Ellinor PT, Ezekovitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CV (2014) AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 64(21):e1–e76 2. Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Natale A, Packer D, Skanes A, Ambrogi F, Biganzoli E (2010) Update worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 3(1):32–38 3. Demolin JM, Eick OJ, Munch K, Koullick E, Nakagawa H, Wittkampf FHM (2002) Soft thrombus formation in radiofrequency catheter ablation. Pacing Clin Electrophysiol 25:1219–1222 4. Wazni O, Rossillo A, Marrouche NF, Saad EB, Martin DO, Bhargava M, Bash D, Beheiry S, Wexman M, Potenza D, Pisano E, Faneli F, Bonso A, Themistoclakis S, Erciyes D, Saliba WI, Schweikert RA, Brachmann J, Raviele A, Natale A (2005) Embolic events and char formation during pulmonary vein isolation in patients with atrial fibrillation: impact of different anticoagulation regimens and importance of intracardiac echo imaging. J Cardiovasc Electrophysiol 16:576–581 5. Okuyama Y, Kashiwase K, Mizuno H, Oka T, Takeda Y, Komatsu S, Hirayama A, Kodama K (2006) Development of thrombus on a transseptal sheath in the left atrium during attempted electrical pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation. Europace 8:191–192 6. Bruce CJ, Friedman PA, Narayan O, Munger TM, Hammill SC, Packer DL, Asirvatham SJ (2008) Early heparinization decreases the incidence of left atrial thrombi detected by intracardiac echocardiography during radiofrequency ablation for atrial fibrillation. J Interv Card Electrophysiol 22:211–219
Herzschr Elektrophys 2015 · 26:54–55 DOI 10.1007/s00399-015-0357-7 © Springer-Verlag Berlin Heidelberg 2015 M. Toniolo · A. Estrada · D. Filgueiras-Rama · J.L. Merino
Revolving thrombus within the left atrium at atrial fibrillation ablation Abstract A 68-year-old man was referred for pulmonary vein (PV) isolation. Access to the left atrium was obtained via a single transseptal puncture. A heparin bolus was given immediately after puncture. Angiography of the left PV was performed. After the contrast wash-out, a contrasted longitudinal thrombus was shown revolving within the left atrium for several seconds before being expelled through the mitral and aortic valves. It is common practice in these procedures to
administer an intravenous bolus of heparin immediately after the transseptal puncture. However, heparin has latency to become effective, and this can result in thromboembolic events. Keywords Pulmonary vein isolation · Transseptal puncture · Thrombus · Heparin · Thromboembolic events
Flottierender Thrombus im linken Vorhof während Pulmonalvenenisolation Zusammenfassung Ein 68-jähriger Mann wurde zur Pulmonalvenenisolation überwiesen. Es erfolgte eine einfache transseptale Punktion mit unmittelbar darauffolgender i. v. Heparingabe. Die linken Pulmonalvenen wurden angiographisch dargestellt. Im Laufe des Kontrastmittel-wash outs wurde ein Thrombus festgestellt, der zunächst für einige Sekunden im linken Vorhof flottierte und dann durch Mitral- und Aortenklappe in den Systemkreislauf gelangte. Bei linksatrialen Prozeduren ist es üblich, einen
Heparinbolus unmittelbar nach transseptaler Punktion zu verabreichen. Allerdings weist Heparin eine gewisse Wirkungslatenz auf, was zu thrombembolischen Ereignissen führen kann. Schlüsselwörter Pulmonalvenenisolation · Transseptale Punktion · Thrombus · Heparin · Thrombembolischen
Herzschrittmachertherapie + Elektrophysiologie 1 · 2015
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Electronic supplementary material The online version of this article (doi: 10.1007/s00399-015-0357-7) contains supplementary material, which is available to authorized users.
Introduction Pulmonary vein (PV) isolation is one of the treatments of choice for symptomatic paroxysmal atrial fibrillation (AF) [1]. However, thromboembolic complications are an important limitation of this approach, occurring in up to 1 % of patients [2]. Most cases are due to disruption of the endothelial surface during energy delivery with radiofrequency ablation [3, 4]. However, there are other reasons of thromboembolic complications, not due to radiofrequency energy delivery.
Fig. 1 8 Angiography of the left PV: after the contrast wash-out, a contrasted longitudinal thrombus is shown within the left atrium (arrow)
Mauro Toniolo1,2 · Alejandro Estrada1 · David Filgueiras-Rama1 · Josè L. Merino1 1 Arrhythmia and Robotic Cardiac Electrophysiology Unit, IdiPaz, Hospital Universitario “La Paz”, Madrid, Spain 2 Division of Cardiology, University Hospital “S.Maria della Misericordia”, Udine, Italy
Revolving thrombus within the left atrium at atrial fibrillation ablation Case report
Discussion
A 68-year-old man with no structural heart disease and daily episodes of paroxysmal atrial fibrillation was referred for PV isolation. The patient was in sinus rhythm at the beginning of the procedure. He was on warfarin therapy, with an international normalized ratio of 1.7. Transoesophageal echocardiogram achieved 2 h before procedure showed no thrombus in the atria. Access to the left atrium was obtained via a single transseptal puncture. An 8000-unit heparin bolus was given immediately after puncture, and the transseptal sheath (Bard Channel Fx, length: 61 cm, size: 8F) was continuously flushed with a heparinized saline solution. Angiography of the left PV was performed. After the contrast washout, a contrasted longitudinal thrombus was shown revolving within the left atrium for several seconds before being expelled through the mitral and aortic valves (Fig. 1 and electronic supplementary video showing fluoroscopy of the left atrium in the left oblique projection). The thrombus was probably formed on the transseptal sheath. The patient had no symptoms or signs of neurological damage, and, after 10 min of observation, the ablation procedure was continued. The following day, the patient was asymptomatic and had no signs of neurological complications. Cerebral magnetic resonance imaging showed normal results, and there were no analytical abnormalities except for a mild increase of creatine phosphokinases and aspartate aminotransferase serum levels. The patient was discharged with no complications at follow-up.
Thrombus formation on the transseptal sheath during PV isolation has been described in the past [5, 6]. Some of these cases have been resolved by systemic thrombolysis [5] or by thrombus aspiration with a strong suction produced by a large syringe via the sheath’s sidearm [6]. In most cases, this complication resulted in no major injury to the patient. It is common practice in these procedures to administer an intravenous bolus of unfractioned heparin immediately after the transseptal puncture or event after an initial observational period. However, heparin has latency to become effective, and this varies between patients. Bruce et al. [6] demonstrated that an early administration of intravenous heparin, specifically before transseptal puncture, decreases the incidence of left atrial thrombi.
54 | Herzschrittmachertherapie + Elektrophysiologie 1 · 2015
Conclusion The use of left atrial angiography or intracardiac echocardiography in PV isolation procedures is not considered mandatory for AF ablation and is not commonly performed in some countries. Therefore, thrombus formation incidence may be underestimated but still contributes to the pathogenesis of relevant events such as subclinical stroke.
Corresponding address Dr. M. Toniolo M.D. Arrhythmia and Robotic Cardiac Electrophysiology Unit, IdiPaz Hospital Universitario “La Paz”, Madrid [email protected]
Abstract · Zusammenfassung
Video legend Angiography of the left PV: after the contrast washout, a contrasted longitudinal thrombus is shown within the left atrium
Compliance with ethical guidelines Conflict of interest. Dr. J.L. Merino is consultant to Magnetecs, Inc. and receives honoraria payment for providing medical and technical training for St. Jude Medical. All other authors have no conflicts of interest to declare. The accompanying manuscript does not include studies on humans or animals.
References 1. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti JB, Ellinor PT, Ezekovitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CV (2014) AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 64(21):e1–e76 2. Cappato R, Calkins H, Chen SA, Davies W, Iesaka Y, Kalman J, Kim YH, Klein G, Natale A, Packer D, Skanes A, Ambrogi F, Biganzoli E (2010) Update worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol 3(1):32–38 3. Demolin JM, Eick OJ, Munch K, Koullick E, Nakagawa H, Wittkampf FHM (2002) Soft thrombus formation in radiofrequency catheter ablation. Pacing Clin Electrophysiol 25:1219–1222 4. Wazni O, Rossillo A, Marrouche NF, Saad EB, Martin DO, Bhargava M, Bash D, Beheiry S, Wexman M, Potenza D, Pisano E, Faneli F, Bonso A, Themistoclakis S, Erciyes D, Saliba WI, Schweikert RA, Brachmann J, Raviele A, Natale A (2005) Embolic events and char formation during pulmonary vein isolation in patients with atrial fibrillation: impact of different anticoagulation regimens and importance of intracardiac echo imaging. J Cardiovasc Electrophysiol 16:576–581 5. Okuyama Y, Kashiwase K, Mizuno H, Oka T, Takeda Y, Komatsu S, Hirayama A, Kodama K (2006) Development of thrombus on a transseptal sheath in the left atrium during attempted electrical pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation. Europace 8:191–192 6. Bruce CJ, Friedman PA, Narayan O, Munger TM, Hammill SC, Packer DL, Asirvatham SJ (2008) Early heparinization decreases the incidence of left atrial thrombi detected by intracardiac echocardiography during radiofrequency ablation for atrial fibrillation. J Interv Card Electrophysiol 22:211–219
Herzschr Elektrophys 2015 · 26:54–55 DOI 10.1007/s00399-015-0357-7 © Springer-Verlag Berlin Heidelberg 2015 M. Toniolo · A. Estrada · D. Filgueiras-Rama · J.L. Merino
Revolving thrombus within the left atrium at atrial fibrillation ablation Abstract A 68-year-old man was referred for pulmonary vein (PV) isolation. Access to the left atrium was obtained via a single transseptal puncture. A heparin bolus was given immediately after puncture. Angiography of the left PV was performed. After the contrast wash-out, a contrasted longitudinal thrombus was shown revolving within the left atrium for several seconds before being expelled through the mitral and aortic valves. It is common practice in these procedures to
administer an intravenous bolus of heparin immediately after the transseptal puncture. However, heparin has latency to become effective, and this can result in thromboembolic events. Keywords Pulmonary vein isolation · Transseptal puncture · Thrombus · Heparin · Thromboembolic events
Flottierender Thrombus im linken Vorhof während Pulmonalvenenisolation Zusammenfassung Ein 68-jähriger Mann wurde zur Pulmonalvenenisolation überwiesen. Es erfolgte eine einfache transseptale Punktion mit unmittelbar darauffolgender i. v. Heparingabe. Die linken Pulmonalvenen wurden angiographisch dargestellt. Im Laufe des Kontrastmittel-wash outs wurde ein Thrombus festgestellt, der zunächst für einige Sekunden im linken Vorhof flottierte und dann durch Mitral- und Aortenklappe in den Systemkreislauf gelangte. Bei linksatrialen Prozeduren ist es üblich, einen
Heparinbolus unmittelbar nach transseptaler Punktion zu verabreichen. Allerdings weist Heparin eine gewisse Wirkungslatenz auf, was zu thrombembolischen Ereignissen führen kann. Schlüsselwörter Pulmonalvenenisolation · Transseptale Punktion · Thrombus · Heparin · Thrombembolischen
Herzschrittmachertherapie + Elektrophysiologie 1 · 2015
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