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• W2062817070 abstract "HomeCirculation: Arrhythmia and ElectrophysiologyVol. 2, No. 4Right Atrial Thrombus Aspiration Guided by Intracardiac Echocardiography During Catheter Ablation for Atrial Fibrillation Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBRight Atrial Thrombus Aspiration Guided by Intracardiac Echocardiography During Catheter Ablation for Atrial Fibrillation Dan Blendea, Conor D. Barrett, E. Kevin Heist, Jeremy N. Ruskin and Moussa C. Mansour Dan BlendeaDan Blendea From the Massachusetts General Hospital, Heart Center, Boston, Mass. Search for more papers by this author , Conor D. BarrettConor D. Barrett From the Massachusetts General Hospital, Heart Center, Boston, Mass. Search for more papers by this author , E. Kevin HeistE. Kevin Heist From the Massachusetts General Hospital, Heart Center, Boston, Mass. Search for more papers by this author , Jeremy N. RuskinJeremy N. Ruskin From the Massachusetts General Hospital, Heart Center, Boston, Mass. Search for more papers by this author and Moussa C. MansourMoussa C. Mansour From the Massachusetts General Hospital, Heart Center, Boston, Mass. Search for more papers by this author Originally published1 Aug 2009https://doi.org/10.1161/CIRCEP.109.859918Circulation: Arrhythmia and Electrophysiology. 2009;2:e18–e20A 56-year-old man with psoriasis and a 2-year history of paroxysmal atrial fibrillation and flutter was admitted for catheter ablation. The procedure was performed under general anesthesia. The patient arrived to the electrophysiology laboratory in atrial flutter. A preprocedural transesophageal echocardiogram confirmed the absence of intraatrial thrombus. The patient was chronically anticoagulated with warfarin, and the international normalized ratio (INR) on the day of the procedure was 2.4.After vascular access was obtained, a duodecapolar catheter was placed from the left femoral vein with the 10 distal electrodes in the coronary sinus and 10 proximal electrodes in the right atrium (RA). A phased-array intracardiac echo (ICE) catheter was placed via the left femoral vein into the RA. Intravenous heparin, 5000 U, was given after initial catheter placement. The presence of typical clockwise atrial flutter was confirmed by activation and entrainment mapping. A cavo-tricuspid isthmus ablation line was created using a 3.5-mm externally irrigated radiofrequency catheter, which terminated the tachycardia. Two transseptal punctures were performed, and 2 sheaths were inserted in the left atrium: A fixed-curve SL1 sheath was used for the circular mapping catheter, and a deflectable sheath was used for the ablation catheter. The 2 sheaths were continuously flushed with heparinized saline at a rate of 30 mL/h. Another 5000 U of heparin was given after the second transseptal puncture, and the patient was started on a heparin infusion of 1200 U/h.After the 2 transseptal sheaths were placed, a right atrial serpiginous thrombus (23�2 mm) was detected by ICE. The thrombus appeared to be attached to the interatrial septum at the transseptal puncture site of the deflectable sheath (Figure 1). The activated clotting time (ACT) was 243 seconds, which is below our target of 300 seconds. An additional heparin bolus was given to aim for an ACT of 300 seconds. In an attempt to aspirate the thrombus, the fixed-curve sheath was pulled into the RA and advanced using ICE guidance to the proximity of the thrombus (Figure 2). Using a 10-mL syringe attached to the proximal end of the fixed-curve sheath, the thrombus was aspirated (Figure 1). ICE imaging confirmed complete removal of the thrombus. All pulmonary veins were then successfully isolated and the patient was discharged in sinus rhythm the following day. Download figureDownload PowerPointFigure 1. A, Intracardiac echo visualization of the thrombus attached to the right atrial side of the interatrial septum at the transseptal puncture site. B, Fragments of the thrombus retrieved by aspiration via the transseptal sheath.Download figureDownload PowerPointFigure 2. Position of the catheters during thrombus aspiration via the fixed-curve sheath as depicted on fluoroscopy (A) and on intracardiac echocardiogram (B).Left atrial thrombus formation on the transseptal sheath or mapping catheters, detected by ICE, was reported in 10.3% of patients undergoing radiofrequency ablation for AF despite anticoagulation with heparin to ACT >250 seconds.1 This is the first report of an intraatrial thrombus detected by ICE in a patient with heparin anticoagulation and also on warfarin with a therapeutic INR.Right atrial thrombus formation at the site of the transseptal puncture was also noted after radiofrequency ablation of other atrial tachyarrhythmias. There is a paucity of data from prospective, randomized studies regarding the optimum approach to reduce the thromboembolic risk in the periablation period.2 Using higher concentrations of heparin (target ACT >300 seconds) for the transseptal system before deployment reduces the risk, especially in patients with spontaneous echo contrast.3 Also, starting the heparin administration before the transseptal puncture and performing the ablation4 on therapeutic INR5 seem to reduce the risk of thrombus formation. In our case, a thrombus developed despite a therapeutic INR and initiation of heparin before the transseptal puncture.Even though our patient did not have major factors predisposing to thrombosis, he did have psoriasis, which has been associated with hyperhomocystinemia, increased platelet activation, and increased tendency to develop arterial and venous thrombosis.6This case shows that an intraatrial thrombus can occur despite adequate anticoagulation with heparin and warfarin and illustrates the utility of monitoring the atrial fibrillation ablation procedure with ICE. This method has the advantage of allowing early detection of intracardiac thrombus and thus allowing early intervention for thrombus removal.7DisclosuresDr Heist received grants and speaker and consultant fees from St Jude Medical; Dr Ruskin received grants and honoraria from St Jude Medical; and Dr Mansour received grants and consultant fees from St Jude Medical.FootnotesCorrespondence to Moussa Mansour, MD, Cardiac Arrhythmia Service, Massachusetts General Hospital, 55, Fruit St, Boston, MA 02114. E-mail [email protected]References1 Ren JF, Marchlinski FE, Callans DJ. Left atrial thrombus associated with ablation for atrial fibrillation: identification with intracardiac echocardiography. J Am Coll Cardiol. 2004; 43: 1861–1867.CrossrefMedlineGoogle Scholar2 Natale A, Raviele A, Arentz T, Calkins H, Chen SA, Haissaguerre M, Hindricks G, Ho Y, Kuck KH, Marchlinski F, Napolitano C, Packer D, Pappone C, Prystowsky EN, Schilling R, Shah D, Themistoclakis S, Verma A. Venice Chart international consensus document on atrial fibrillation ablation. J Cardiovasc Electrophysiol. 2007; 18: 560–580.CrossrefMedlineGoogle Scholar3 Ren JF, Marchlinski FE, Callans DJ, Gerstenfeld EP, Dixit S, Lin D, Nayak HM, Hsia HH. Increased intensity of anticoagulation may reduce risk of thrombus during atrial fibrillation ablation procedures in patients with spontaneous echo contrast. J Cardiovasc Electrophysiol. 2005; 16: 474–477.CrossrefMedlineGoogle Scholar4 Bruce CJ, Friedman PA, Narayan O, Munger TM, Hammill SC, Packer DL, Asirvatham SJ. Early heparinization decreases the incidence of left atrial thrombi detected by intracardiac echocardiography during radiofrequency ablation for atrial fibrillation. J Interv Card Electrophysiol. 2008; 22: 211–219.CrossrefMedlineGoogle Scholar5 Wazni OM, Beheiry S, Fahmy T, Barrett C, Hao S, Patel D, Di Biase L, Martin DO, Kanj M, Arruda M, Cummings J, Schweikert R, Saliba W, Natale A. Atrial fibrillation ablation in patients with therapeutic international normalized ratio: comparison of strategies of anticoagulation management in the periprocedural period. Circulation. 2007; 116: 2531–2534.LinkGoogle Scholar6 Karabudak O, Ulusoy RE, Erikci AA, Solmazgul E, Dogan B, Harmanyeri Y. Inflammation and hypercoagulable state in adult psoriatic men. Acta Derm Venereol. 2008; 88: 337–340.MedlineGoogle Scholar7 Keane D, Mansour M, Singh J. Detection by intracardiac echocardiography of early formation of left atrial thrombus during pulmonary vein isolation. Europace. 2004; 6: 109–110.CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited ByQuintana R, Dong T, Vajapey R, Reyaldeen R, Kwon D, Harb S, Wang T and Klein A (2022) Intra- and Postprocedural Multimodality Imaging in Atrial Fibrillation, Circulation: Cardiovascular Imaging, 15:11, (e014804), Online publication date: 1-Nov-2022. Qian P and Tedrow U (2021) Intracardiac Echocardiography to Guide Catheter Ablation of Ventricular Arrhythmias in Ischemic Cardiomyopathy, Cardiac Electrophysiology Clinics, 10.1016/j.ccep.2021.02.002, 13:2, (285-292), Online publication date: 1-Jun-2021. Jacobson J and Knight B (2012) Use of Intracardiac Echocardiography to Guide Ablation of Atrial and Ventricular Arrhythmias Cardiac Mapping, 10.1002/9781118481585.ch74, (809-818) August 2009Vol 2, Issue 4 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCEP.109.859918PMID: 19808487 Originally publishedAugust 1, 2009 PDF download Advertisement SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-DefibrillatorEchocardiography" @default.
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