Incidence of left atrial appendage thrombus on pre-procedural TOE before catheter ablation of atrial tachyarrhythmias

Introduction Transoesophageal echocardiography (TOE) is routinely performed before catheter ablation of atrial tachyarrhythmias to rule out the presence of possible left atrial thrombi. However, data to support this practice are scarce. Methods We analysed consecutive pre-procedural TOE in a high-volume electrophysiology centre for the presence of left atrial thrombi and a relevant flow reduction in the left atrial appendage (LAA) defined as LAA sludge or pronounced spontaneous echo contrast. Possible predictors of reduced flow were recorded and compared in a multivariate logistic regression analysis. Results 1676 consecutive TOE were included (1122 before pulmonary vein isolation (PVI), 436 before atrial flutter ablation, 166 before other EP studies in patients with a history of atrial tachyarrhythmias). 543 patients (32%) were female, mean age was 63±12 years and BMI was 27±5 kg/m2. Nine patients (0.5%) had an LAA thrombus on pre-procedural TOE. Ninety-five further patients (5.7%) had a relevant reduction in LAA flow as characterized by LAA sludge or spontaneous echo contrast. Further patient characteristics by LAA flow state are shown in the table. While a higher CHA2DS2-VaSc-Score was associated with the presence of LAA sludge and LAA thrombus (p=0.01), no further clinical parameters such as choice of oral anticoagulation agent were independently predictive of reduced flow velocities or thrombus in a logistic regression model (see table). Importantly, LAA thrombi also occurred in patients with a CHA2DS2-VaSc-Score ≤1 (n=1) or in sinus rhythm (n=2). Of note, 6 out of 9 patients with a LAA thrombus were anticoagulated with phenprocoumon. Conclusion LAA thrombus is a rare occurrence before an elective catheter ablation. In patients with CHA2DS2-VaSc-Score ≤1 the likelihood of LAA thrombus is so low (0.2%) that it may be considered to give up routine TOE before an EP study/ablation. FUNDunding Acknowledgement Type of funding sources: None.

Massive Right Atrial Thrombosis: Are You Brave Enough to Start Anticoagulation? A Case Report

Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping myelodysplastic and myeloproliferative features. The disease is generally characterized by blood monocytosis, bone marrow dysplasia, cytopenia, and hepatosplenomegaly. While malignant blood diseases are frequently associated with a high risk of thromboembolism, CMML is often accompanied by immune-mediated hemorrhagic diathesis. Indeed, very few reports in literature report thrombotic complications of CMML patients. We will briefly present here the case of a patient with CMML who developed a massive right atrial thrombus. We aim to highlight the non-negligible thrombotic burden of the disease, and we will get through the differential diagnosis of right atrial masses and the management of right atrial thrombi, which are a rare and poorly known entity.

Minimally invasive procedure for removal of infected ventriculoatrial shunts

Background Ventriculoatrial shunts were one of the most common treatments of hydrocephalus in pediatric and adult patients up to about 40 years ago. Thereafter, due to the widespread recognition of the severe cardiac and renal complications associated with ventriculoatrial shunts, they are almost exclusively implanted when other techniques fail. However, late infection or atrial thrombi of previously implanted shunts require removal of the atrial catheter several decades after implantation. Techniques derived from management of central venous access catheters can avoid cardiothoracic surgery in such instances. Methods We retrospectively investigated all the patients requiring removal of a VA shunt for complications treated in the last 5 years in our institution. Results We identified two patients that were implanted 28 and 40 years earlier. Both developed endocarditis with a large atrial thrombus and were successfully treated endovascularly. The successful percutaneous removal was achieved by applying, for the first time in this setting, the endoluminal dilation technique as proposed by Hong. After ventriculoatrial shunt removal and its substitution with an external drainage, both patients where successfully weaned from the need for a shunt and their infection resolved. Conclusion Patients carrying a ventriculoatrial shunt are now rarely seen and awareness of long-term ventriculoatrial shunt complications is decreasing. However, these complications must be recognized and treated by shunt removal. Endovascular techniques are appropriate even in the presence of overt endocarditis, atrial thrombi, and tight adherence to the endocardial wall. Moreover, weaning from shunt dependence is possible even decades after shunting.

Technical implementation of percutaneous thrombus aspiration using the AngioVac system

Objectives: The AngioVac system (AngioDynamics, Latham, NY, USA) provides a method for the minimally invasive, percutaneous aspiration of thrombus formations originating from the central venous system as well as solid matter such as lead vegetations and right atrial thrombi. Methods: This retrospective, observational study describes the initial experience in 52 adult patients with the AngioVac system, focusing mainly on the development of the extracorporeal circuit to improve usability and safety. Results: The mean patient age was 62.9 years (range 23-86 years). 22 patients were female and 30 were male. Indications for percutaneous aspiration were lead vegetations (n = 36; 69.2%), right atrial thrombi (n = 9; 17.3%), central venous thrombi (n = 5; 9.6%) and pulmonary embolisms (n = 2; 3.8%). Successful aspiration was performed in 44 cases (84.6%) and partial success was achieved in five patients (9.6%), while failure to remove thrombi or vegetations occurred in three cases (5.8%). Our practical experience led to the installation of a shunt line for recirculation and the implementation of safety features concerning air handling, which are also employed in minimally invasive extracorporeal bypass circuits. Initial tests monitored the level of negative pressure according to differences in flow and access sites but these still have to be validated on a larger scale. Conclusion: In this initial experience, the AngioVac system appeared to be safe regarding the extracorporeal circulation and the elimination of thrombi and lead vegetations.