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Description
A 75-year-old woman who had a bioprosthetic mitral valve replacement and complete left atrial appendage (LAA) ligation a year ago was found to be in atrial flutter at routine clinical follow-up. She was started on warfarin and brought back for a transoesophageal echocardiogram (TOE)-guided cardioversion. On the TOE, a left atrial thrombus overlying the ligated LAA was discovered (figure 1). The patient was asymptomatic, and since she had a CHADS score of 2, we continued her on warfarin indefinitely. She was set-up for a repeat TOE and cardioversion 1 month later. During this TOE, she demonstrated resolution of the thrombus (figure 2) and subsequent successful cardioversion. A couple of months later, she had a successful atrial flutter ablation procedure performed.
The LAA is a common site for thrombus formation and thus the origin of many cardioembolic events. Ligation of the LAA during valvular surgery is often performed with the intent of minimising the risk of thrombus formation. However, patients remain at risk for thromboembolic events even after LAA ligation.1 Prior reports have documented thrombi formation after disruption of the suture line.2 ,3 Here, we extend these findings and demonstrate that left atrial thrombus formation is still possible despite a complete and intact left atrial appendage ligation.
Learning points
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Left atrial appendage ligation does not eliminate the risk of thromboembolic events.
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Transoesophageal echocardiograms are still required in patients with left atrial appendage ligations prior to cardioversion.
Footnotes
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Competing interests None.
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Patient consent Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.