Abstract
WEB SITE FEATURE
A 50-year-old woman presented with palpitations and dyspnea. On examination, she was in sinus rhythm. Transesophageal echocardiography (TEE) showed a 26-mm secundum atrial septal defect with rims that were adequate for percutaneous transcatheter closure. The procedure was performed under TEE guidance. At the start of the procedure, the patient was given heparin (100 IU/kg) for anticoagulation. As a 28-mm Amplatzer® Septal Occluder (AGA Medical Corporation; Plymouth, Minn) was being advanced into the left atrium, TEE revealed a 20 × 8-mm mobile thrombus at the tip of the delivery sheath (Figs. 1 and 2). A 50-cc injector was used to create negative pressure, so that the thrombus was sucked into the lumen of the delivery sheath. The delivery system was then removed from the circulation (Fig. 3). The patient was given an additional 5,000 IU of heparin, after which the procedure was continued. The atrial septal defect was closed successfully with a 28-mm Amplatzer Septal Occluder. No thromboembolic events occurred. A follow-up TEE performed the next day showed no thrombus formation on the device. No indications of a hypercoagulable state—such as anticardiolipin antibodies, factor V Leiden, prothrombin gene mutation, or protein C or protein S deficiency—were found. The patient was discharged from the hospital on a regimen of clopidogrel and aspirin.
Fig. 1. Transesophageal echocardiogram recorded at a 31° probe rotation shows thrombus (arrow) at the tip of the delivery sheath in the left atrium.
Fig. 2. Another transesophageal echocardiogram recorded at a 31° probe rotation shows thrombus (arrow) at the tip of the delivery sheath in the left atrium.
Real-time motion image is available at www.texasheart.org/journal.
Fig. 3. Macroscopic image of the thrombus after removal from the circulation.
Comment
Transcatheter closure of atrial septal defect has become an alternative to surgical closure. Periprocedural or postprocedural thrombus formation on the device, which can lead to systemic embolization, is a rare but important complication.1–6 To our knowledge, in all of the previously reported cases, thrombus formed on the occluder device. In our patient, despite appropriate anticoagulation and a short procedural time, a thrombus attached to the tip of the delivery sheath. The thrombus probably formed inside the sheath, and manipulation of the occluder pushed it out to the tip of the sheath. Although monitoring of activated clotting time is not routinely recommended during transcatheter closure procedures, we believe that it could help to ensure effective anticoagulation and to avoid thromboembolic events. In addition, oral antiaggregation therapy should be started 1 day before the procedure. This case also highlights the importance of echocardiographic guidance (TEE or intracardiac echocardiography) not only for properly deploying the device, but also for detecting potential thromboembolic complications and enabling immediate preventive measures to be taken.
Supplementary Material
Footnotes
Address for reprints: Nihan Kahya Eren, MD, Izmir Ataturk Egitim ve Arastirma Hastenesi, Kardiyoloji Bolumu, Yesilyurt, 35360 Izmir, Turkey
E-mail: nkahya77@yahoo.com
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