Embolic stroke due to left atrial thrombus 2 years after PFO closure

Excerpt

A 38-year-old female patient was referred to our cardiology clinic for evaluation of an asymptomatic left atrial mass detected during a routine cardiology examination. She had undergone percutaneous closure of a patent foramen ovale (PFO) with an Occlutech® Figulla (Occlutech GmbH, Germany) device 2 years earlier because of recurrent cryptogenic strokes during warfarin therapy. Clopidogrel (75 mg/day) was added to warfarin (INR 2.0–3.0) for 6 months, and thereafter warfarin therapy alone was continued. No residual right-to-left shunt was detected via agitated saline injection with the Valsalva maneuver on transesophageal echocardiographic (TEE) examinations at the 6- and 12-month follow-up. The patient was well and asymptomatic for 12 months. She underwent total abdominal hysterectomy for multiple uterine myomas in the 2^nd year after PFO closure. Before surgery, warfarin was discontinued and bridge anticoagulation therapy with enaxoparin sodium (1 mg/kg, b.i.d.) was initiated. The patient underwent surgery without any complication and was discharged uneventfully from the hospital on warfarin therapy. Although she was asymptomatic, a left atrial mass was detected on transthoracic echocardiography (TTE) during a routine cardiology examination 2 weeks after surgery. The patient was referred for further evaluation and management. She was asymptomatic and the examination was unremarkable. An electrocardiogram was obtained that was also normal. TTE revealed a mobile left atrial thrombus with a 20 × 10-mm diameter (Fig. 1 a, b). The patient underwent TEE to delineate the relationship between the thrombus and the PFO occluder device. TEE revealed a mobile thrombus of 22 × 10-mm diameter originating from the inferior arm of the left atrial disc; the device and the heart appeared normal (Fig. 2 a, b). Right after the TEE evaluation (while straightening up after the test), the patient developed left-sided motor deficiency in the echocardiography room. She was immediately transferred to the emergency room for a neurological examination. The patient was intubated for airway protection. Cranial computerized tomography showed acute ischemia in the right parietal lobe. A follow-up TTE examination revealed a residual left atrial thrombus with approximately the same diameters. Blood test results were normal and the international normalized ratio (INR) was 2.2 (0.8–1.2). Deep vein thrombosis was excluded after performing a lower-extremity Doppler ultrasound examination. Because of her recent surgery, fibrinolytic therapy was contraindicated. The patient was given unfractionated heparin (UFH) as anticoagulant and subsequently transferred to the intensive care unit; she underwent surgical excision of the left atrial thrombus 4 h later. Because there was complete endothelization of the occluder device, it was left in place and the left atrial thrombus was removed completely (Fig. 3 a). Pathological examination also confirmed the diagnosis of thrombus (Fig. 3 b). Postoperative echocardiography showed no residual left atrial thrombus. We tested for the presence of prothrombotic coagulation factors, protein C and S deficiency, factor V Leiden mutation, lupus anticoagulant, antiphospholipid syndrome, prothrombin 20210A, and MTHFR mutations, but all results were negative. The remaining hospital stay was uneventful and the patient improved completely with the help of physical rehabilitation. She was discharged on warfarin and clopidogrel. At the 1-, 6-, and 12-month follow-up visits, she was asymptomatic and the TTE and TEE examinations revealed no recurrent thrombus. …