A case of cerebral embolism due to device-related thrombosis one and a half years after implantation of the left atrial appendage closure device

Abstract

The patient was a 73-year-old male. Although he was medicated DOAC for non-valvular atrial fibrillation (NVAF), a percutaneous left atrial appendage closure device (LAACD) was applied due to anemia due to recurrent gastrointestinal bleeding. After implantation, low-dose DOAC was administered. Transesophageal echocardiography (TEE) showed no residual blood flow in the left atrial appendage on day 45. DOAC was switched to clopidogrel 90 days after placement. Eighteen months after LAACD placement, a left MCA region embolic cerebral infarction occurred. Because device-related thrombus (DRT) was observed on TEE, DOAC was resumed, and DRT disappeared one month later. The CYP2C19 gene polymorphism test suggested resistance to CLP. Furthermore, he had permanent NVAF, a history of TIA and stroke, and an enlarged left atrial appendage diameter, risk factors for DRT. For the high-risk of DRT cases like this case, we should consider the decision of antithrombotic drugs based on the loss-of-function polymorphisms of the CYP2C19.