Left Atrial Appendage Occlusion for Persistent Thrombus Preventing Rhythm Control

Atrial fibrillation is the most common sustained arrhythmia and a major risk factor for cardioembolic stroke. Left atrial appendage occlusion (LAAO) is an established alternative to long-term anticoagulation in selected patients; however, active left atrial appendage (LAA) thrombus is generally considered a contraindication.

A 69-year-old man with hypertension, hyperlipidemia, newly diagnosed nonvalvular atrial fibrillation, and severe left ventricular systolic dysfunction (ejection fraction 20% to 25%) underwent transesophageal echocardiography (TEE) before cardioversion. A large apical LAA thrombus was identified, preventing cardioversion. Despite 9 months of anticoagulation, with apixaban for 2 months followed by warfarin for 7 months, serial TEEs demonstrated persistent thrombus despite supratherapeutic international normalized ratio values as high as 6.9. Following multidisciplinary evaluation, TEE-guided 27-mm Watchman FLX device was successfully performed without complication allowing direct-current cardioversion to normal sinus rhythm with return to normal ejection fraction.

This case highlights the potential role of LAAO in patients when persistent thrombus prevents definitive rhythm control.

Persistent LAA thrombus may remain despite prolonged anticoagulation and can prevent definitive rhythm-control therapy in patients with atrial fibrillation. To recognize persistent LAA thrombus as a barrier to rhythm-control therapy and review the role of LAAO in carefully selected patients with thrombus refractory to anticoagulation.