Author + information
- Received December 1, 2016
- Revision received December 19, 2016
- Accepted December 19, 2016
- Published online March 20, 2017.
- Fabian Stimpfle, MDa,
- Karin Müller, MDa,
- Tobias Geisler, MDa,
- Jürgen Schreieck, MDa,
- Dennis Schlak, MDb,
- Ulf Ziemann, MDb,
- Meinrad Gawaz, MDa and
- Peter Seizer, MDa,∗ ()
- aDepartment of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
- bDepartment of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- ↵∗Address for correspondence:
Dr. Peter Seizer, Eberhard-Karls-Universität Tübingen, Ottfried-Muellerstraße 10, Tuebingen 72076, Germany.
We report the case of a 73-year-old male patient who first presented for cardiology consultation after transient ischemic attack. No pre-existing conditions, other than hypertension, were known. Long-term electrocardiography did not reveal atrial fibrillation. Transesophageal echocardiography (TEE) showed a hyperechogenic structure in the left atrial (LA) appendage suspicious for an older thrombus. Thus, phenprocoumon therapy was initiated (target international normalized ratio: 2 to 3). However, 9 months later, the patient presented again after retinal embolism. Despite sufficient phenprocoumon therapy, TEE revealed a big thrombus in the LA adherent to the anterior wall. Therapeutic heparinization (activated partial thromboplastin time ratio: 1.5 to 2.5) was initiated to await spontaneous international normalized ratio drop to 1.7 before intended thrombolysis or surgery (1). Unfortunately, a cerebral infarction in the right medial cerebral artery territory (National Institutes of Health Stroke Scale score 18) occurred instantly, and systemic thrombolysis (recombinant tissue plasminogen activator 0.9 mg/kg) was performed after administration of protamine. However, TEE showed an unaltered thrombus (Figure 1A, Online Video 1). Because on-pump surgery or a repeated thrombolysis was impossible due to increased intracerebral bleeding risk, interventional thrombus aspiration was planned as a bailout strategy to reduce thrombus burden and systemic thromboembolic risk. Thus, Sentinel Cerebral Protection System (Claret Medical, Santa Rosa, California) was placed to protect the patient from further embolism (Figure 2). After TEE guided transseptal puncture, a 12-F FlexCath Advance Steerable Sheath (Medtronic, Minneapolis, Minnesota) was advanced into the LA (Figure 1B, Online Video 1). Guided by TEE, the thrombotic material could be almost completely aspirated using a 50 ml syringe (Figures 1C and 1D, Online Video 1). Only a minimal residue, adhesive to the anterior wall remained in the LA (Figure 1D, Online Video 1). Histological investigation of the aspirated clot confirmed thrombotic origin.
Our case reports for the first time that interventional thrombus aspiration can be an alternative strategy to remove LA thrombotic material if surgery or thrombolysis is impossible.
For a supplemental video and its legend, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 1, 2016.
- Revision received December 19, 2016.
- Accepted December 19, 2016.
- 2017 American College of Cardiology Foundation