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Thrombus formation on transcatheter ASD occluder device in a patient with coagulation factor XII deficiency
O Gastmann1, G S Werner, U U Babic
1Department of Internal Medicine, University of Göttingen, Germany.
Insights
Transcatheter atrial septal defect closure carries a risk of thrombus formation, especially in patients with factor XII deficiency. Early transesophageal echocardiography is crucial for detecting device-related thrombi, even with anticoagulation.
Area of Science:
- Cardiology
- Hematology
- Medical Devices
Background:
- Transcatheter occlusion is a less invasive alternative to open heart surgery for cardiac defects.
- Thromboembolic complications are rare but serious risks associated with atrial septal defect closure procedures.
Observation:
- A case of thrombus formation on an atrial septal defect occluder system (ASDOS) is reported following transcatheter occlusion.
- The patient experienced an acute stroke due to embolism despite therapeutic anticoagulation with heparin.
- A coagulation disorder, specifically reduced factor XII concentration, was identified as the likely cause of the thrombus formation.
Findings:
- Patients with factor XII deficiency are at increased risk for thromboembolism after ASD occlusion.
- Transesophageal echocardiography (TEE) is essential for detecting intracardiac thrombi, as transthoracic echocardiography (TTE) may fail to visualize them.
- Anticoagulatory treatment led to the involution of the intracardiac thrombus within weeks.
Implications:
- Pre-procedural screening for coagulation disorders is indispensable for patients undergoing transcatheter ASD occlusion.
- Quantitative determination of coagulation factors is recommended based on personal history and screening results.
- Enhanced vigilance in anticoagulation monitoring and routine early TEE are crucial for patients at risk of thromboembolic complications.
Abstract:
Transcatheter occlusion of cardiac defects has become an effective and less invasive alternative to open heart surgery. Thromboembolic complications are rare events, after both surgical and transcatheter closure of atrial septal defects [Galal et al.: Eur Heart J 15:1381-1384, 1994]. We report on a case of thrombus formation on the atrial septal defect occluder system (ASDOS) [Sievert et al.: Cathet Cardiovasc Diagn 36:232-240, 1995; Hausdorf et al.: Heart 75:83-88, 1996]. Two days after transcatheter occlusion, the patient suffered an acute stroke due to embolism despite anticoagulation with intravenous heparin. A coagulation disorder with reduced factor XII concentration was deduced as the likely cause. Repeated transesophageal echocardiographic (TEE) studies revealed an involution of the intracardial thrombus within weeks of subsequent anticoagulatory treatment. First off, this case shows that patients with factor XII deficiency are at risk for thromboembolism. Second, it again clarifies that even large amounts of intraartrial thrombotic material may not be seen by transthoracic echocardiography (TTE) and underscores the necessity of performing TEE. Screening patients for coagulation disorders (Quick's value (Q), partial thromboplastin time (PTT)) before they are selected for treatment with thrombogenic devices is indispensable. With regard to their personal history (earlier thromboembolism) and the result of this screening (e.g., prolongation of PTT), quantitative determination of coagulation factors is reasonable. If patients endangered by thromboembolic complications nevertheless undergo ASD occlusion procedures, anticoagulation monitoring requires exceptional attention. Furthermore, it is recommended that TEE should be carried out in these patients 2 days after treatment, since transthoracic echocardiography (TTE) might be unable to detect thrombus formation on the device.