Device related thrombosis after left atrial appendage occlusion: does thrombus location always predicts its origin?

Excerpt

This is the case of a 65-year-old male with permanent atrial fibrillation (AF), CHA₂DS₂VASc of 7, and previous history of intracranial hemorrhage (ICH) under oral anticoagulation. The patient underwent left atrial appendage occlusion (LAAO) with the implant of a 25-mm Amulet device without complications. Device implantation was slightly deep, and pulmonary ridge was not covered by the device disc (Fig. 1a). The patient was discharged under dual antiplatelet treatment (DAPT). At 3 months, TEE showed a small thrombus below the pulmonary ridge (Fig. 1b). Considering the small size of the thrombus and previous history of ICH, DAPT was continued. A new TEE after 2 months showed a giant central protruding thrombus (25 × 23 mm) (Fig. 1c). DAPT was therefore substituted by apixaban 2.5 mg/12 h (adjusted for renal function). After 3 months, the size of the thrombus was clearly smaller (11 × 10 mm) (Fig. 1d), and apixaban was continued. Six months later, TEE showed complete DRT resolution (Fig. 1e). Aspirin was therefore started, and an additional TEEs showed no novel thrombus (Fig. 1f). The patient did not experience any symptom that could suggest an embolic event during the clinical follow-up.

…