Author + information
- Received June 17, 2015
- Accepted July 2, 2015
- Published online November 1, 2015.
- Paul D. Williams, BM, BCh, MA, MD∗ (, )
- Mark A. de Belder, MA, MD,
- Neil Maredia, MBChB, MD and
- Douglas F. Muir, MBChB
- ↵∗Reprint requests and correspondence:
Dr. Paul D. Williams, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, United Kingdom.
- left atrial appendage thrombus
- transcatheter aortic valve replacement
- transesophageal echocardiography
An 81-year-old man with severe symptomatic aortic stenosis, permanent atrial fibrillation, and a previous stroke underwent transcatheter aortic valve replacement (TAVR). His long-term warfarin therapy was stopped 5 days before admission.
At the beginning of the procedure, transesophageal echocardiography (TEE) identified thrombus within the left atrial appendage (LAA) (Figure 1A, Online Video 1). It initially proved difficult to position a preshaped guidewire within the left ventricle, and there was frequent wire prolapse through the mitral valve into the left atrium. After balloon aortic valvuloplasty, a large mobile filling defect was seen within the left ventricle (Figure 1B, Online Video 2), and the LAA was now empty (Figure 1C, Online Video 3). The activated clotting time was >300 s. Aspiration was performed via an 8-F guide catheter, which caused the filling defect to migrate distally to straddle the aortic valve (Figure 1D, Online Video 4).
A 16-F snare delivery sheath was advanced over the wire to the aortic root, and the wire was withdrawn across the aortic valve and into the sheath during continuous aspiration. A large thrombus with the appearance of an appendage “cast” was retrieved (Figure 1E).
Subsequent implantation of a 29-mm SAPIEN XT valve (Edwards Lifesciences, Inc., Irvine, California) was uncomplicated. The patient made a good recovery with no clinical evidence of an embolic event.
Atrial fibrillation is common in patients undergoing TAVR, and this case demonstrates that LAA thrombus embolization is a potential mechanism of periprocedural stroke. Investigation for LAA thrombus should be performed in all patients with atrial fibrillation as part of their workup for TAVR. This is of particular importance for cases performed under conscious sedation in which intraprocedural TEE is not available. There may be a role for embolic protection devices in patients with persistent LAA thrombus despite adequate anticoagulation.
For supplemental videos and their legends, please see the online version of this article.
Dr. Muir is a proctor for Edwards Lifesciences, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 17, 2015.
- Accepted July 2, 2015.
- American College of Cardiology Foundation