Article ID: CR-25-0059
A 79-year-old woman with a prior mitral annuloplasty, left atrial appendage (LAA) closure using a purse-string suture technique, and the maze procedure presented to the outpatient clinic for 1-year follow-up after percutaneous coronary intervention. She was clinically stable in sinus rhythm, and warfarin monotherapy had been continued due to a history of atrial fibrillation and postoperative transient ischemic attack. However, anticoagulation had been interrupted for 1 month during cerebral aneurysm treatment, prompting contrast-enhanced computed tomography.
Fortunately, stent patency was confirmed, but a large ball-like structure was unexpectedly identified within the ligated LAA (Figure A,B). Transesophageal echocardiography revealed a rolling thrombus with heterogeneous echogenicity within the LAA (Figure C,D, Supplementary Movie). Although the residual ostial communication was small (2.3×6.8 mm), the mobile nature and considerable size of the thrombus (13×15 mm), together with the history of postoperative transient ischemic attack, justified surgical intervention. The thrombus was removed through a direct incision at the residual orifice (Figure E), and the LAA was completely ligated to prevent recurrence. The retrieved thrombus had a red, smooth outer surface with a heterogeneous core (Figure F). Histological examination revealed platelet aggregations with fibrin and red blood cells, with a few leukocytes. No evidence of malignancy was found. She was discharged in good condition 1 month after surgery but passed away 3 years later due to progressive heart failure.
(A,B) Computed tomography images showing the ball-like thrombus within the ligated left atrial appendage. (C,D) Transesophageal echocardiography images demonstrating the rolling thrombus. (E) Intraoperative view of the ostial communication. (F) Retrieved thrombus.
Thrombus formation in this case can be explained by Virchow’s triad;1 that is, blood stasis within the ligated LAA, transient hypercoagulability due to anticoagulation interruption, and endothelial injury associated with advanced age and prior cardiac surgery. Recognizing incomplete LAA ligation and maintaining appropriate anticoagulation is essential to minimize the risk of delayed thrombus formation.
None.
Supplementary Movie. Transesophageal echocardiography images illustrating a rolling thrombus in motion.
Please find supplementary file(s);
https://doi.org/10.1253/circrep.CR-25-0059
