Europace Advance Access originally published online on February 7, 2006
Europace 2006 8(3):191-192; doi:10.1093/europace/euj049
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ELECTROPHYSIOLOGY
Development of thrombus on a transseptal sheath in the left atrium during attempted electrical pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation
Osaka Police HospitalCardiovascular Division, 10-31 Kitayama-cho, Tennoji-ku, Osaka 543-8502 Japan
Manuscript submitted 27 May 2005. Accepted after revision 19 November 2005.
* Corresponding author. Tel: +81 6 6771 6051; fax: +81 6775 2845. E-mail address: y-okuyama{at}oph.gr.jp
Key Words: Catheter ablation, Urokinase, Transoesophageal echocardiogram
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We describe a patient who developed thrombus on a transseptal sheath in the left atrium (LA) during attempted electrical pulmonary vein (PV) isolation for a paroxysmal atrial fibrillation.
A 65-year-old man with a paroxysmal atrial fibrillation was scheduled to undergo radiofrequency PV isolation. The patient was on warfarin (4 mg/day) with INR 
1.7. Transoesophageal echocardiogram (TOE) showed no thrombus in the atria before transseptal puncture. The first transseptal puncture was performed under TOE guidance without difficulty. An 8 F long sheath (SR0: Daig Corp, Minnetonka, MN, USA) was inserted into the LA with the second transseptal puncture. We had difficulty in seeing the so-called ‘tent formation’ probably because the first transseptal sheath prevented the septum from moving towards LA. Therefore, we passed two 0.035 in. steel wires into the first transseptal sheath and removed the sheath. Using the two wires in the LA, two transseptal sheaths (SR0 and SL1: Daig Corp) were inserted through one introducing site in the groin. Then, we administered 7000 units (120 units/kg body weight) of heparin. At that time, TOE detected a mobile hyperechoic mass (13x25 mm2) attached to one of the transseptal sheaths in the LA (Figure 1A), the appearance of which was consistent with thrombus. Around 12 min had passed from the first transseptal puncture to the introduction of the two transseptal sheaths. We gave 7000 units of heparin additionally and then urokinase (240 000 IU, 4070 IU/kg body weight) over 20 min. The size of the mass decreased to two-thirds that of the original (Figure 1B) and disappeared suddenly about 40 min after the injection of urokinase was started (Figure 1C). Then, we pulled out the two transseptal sheaths and closed the session without any clinical signs of systemic embolization. His hospital course was otherwise uneventful.
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The risk of systemic embolism associated with therapeutic procedures in the LA has been emphasized and more thromboembolic complications in the electrical isolation of PV may be expected because it usually requires at least two sheaths in the LA.1
Recently, Ren et al.2 reported that an intracardiac diagnostic ultrasound catheter revealed thrombus attached to a sheath in the LA in two patients who underwent electrical PV isolation. They simply withdrew the sheath without any thromboembolic complications related to the procedure. A previous report on an intra-left atrial procedure attributed the cause of clot formation to either the delay in the heparinization or the use of the two guidewires. We employed thrombolytic therapy, intending to reduce the possibility of systemic thromboembolism. There is no standard therapy for thrombus attached to the sheath in the LA. Therapeutic approach to the thrombus attached to the sheath in the arterial system should be different from that for the mural thrombus because the former might migrate if the sheath is removed from the chamber. Urokinase made the thrombus smaller and might have reduced the fibrin component, resulting in no serious thromboembolic complication, even though residual thrombus suddenly disappeared.
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[1] Kok LC, Mangrum JM, Haines DE, Mounsey JP. Cerebrovasucular complication associated with pulmonary vein ablation. J Cardiovasc Electrophysiol 2002; 13: 764–7.[CrossRef][Web of Science][Medline]
[2] Ren JF, Marchlinski FE, Callans DJ, Herrmann HC. Clinical use of AcuNav diagnostic ultrasound catheter imaging during left heart radiofrequency ablation and transcatheter closure procedures. J Am Soc Echocardiogr 2002; 15: 1301–8.[Medline]
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