論文ID: CJ-21-0121
A 65-year-old woman without a history of cardiac surgery underwent a catheter ablation procedure for paroxysmal atrial fibrillation (AF). She was receiving optimal anticoagulant therapy during the course of treatment because she had a CHADS2 score of 1 point and CHA2DS2-VASc score of 3 points. Preprocedural transesophageal echocardiography (TEE) did not show any thrombus, valvular disease or aneurysmal change of the interatrial septum (IAS). Left ventricular function was normal and the diameter of the left atrium (LA) was 36 mm (Figure A). Pulmonary vein isolation (PVI) using a second-generation cryoballoon (CB) catheter was performed with uninterrupted oral anticoagulants. After transseptal puncture using a radiofrequency puncture needle guided by intracardiac echocardiography, a 15Fr steerable sheath (Flexcath Advance, Medtronic) was inserted into the LA. PVI with the CB was performed for each PV with a LA dwell time of 60 min. At 3 months after the procedure, she had a recurrence of persistent AF, and TEE performed 4 months post-procedure revealed irregular mural thrombus formation near the LA site of the transseptal puncture (Figure B), as well as residual shunt flow (Figure C). After 12 months, disappearance of the thrombus was confirmed by echocardiography.
(A) Preprocedural TEE shows no thrombus in the heart. (B) Postprocedural TEE shows irregular mural thrombus formation near the left atrial site of the transseptal puncture (white arrow). (C) Residual shunt flow (white arrowhead). IAS, interatrial septum; LA, left atrium; RA, right atrium; TEE, transesophageal echocardiography.
This case suggests that thrombus can form near the transseptal puncture site several months after an AF ablation procedure despite optimal anticoagulant therapy. Although the mechanism is unknown, the thrombus may have formed as a result of endocardial injury caused by excessive manipulation of the catheter. This case also highlights the need to continue adequate anticoagulant therapy for several months after the procedure, even in patients at relatively low risk of embolic events and no episodes of AF recurrence.
K.K. is a member of Circulation Journal’s Editorial Team.
