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Presence of left atrial appendage thrombus in patients presenting for left atrial ablation of atrial fibrillation despite pre-operative anticoagulation.


One of the recognised complications of left atrial ablation for atrial fibrillation (AF) is stroke. Left atrial (LA) thrombus, which may be dislodged by catheter manipulation, is an absolute contraindication to ablation. It is unclear whether imaging of the left atrial appendage (LAA) by transesophageal echo (TEE) is mandatory to exclude LA clot prior to ablation, particularly in “low-risk” patients with paroxysmal AF and normal left ventricular (LV) function.

Methods and results:

We carried out a retrospective analysis of pre-ablation TEE in patients presenting for ablation of AF. All patients received a minimum of 4 weeks therapeutic anticoagulation before stopping oral anticoagulants 3 days before their procedure. Images from 244 ablation procedures carried out in 148 patients were examined, including 106 patients with paroxysmal AF and normal LV function.

Despite at least 4 weeks of pre-operative therapeutic anticoagulation with Coumadin (INR>2.0), LAA thrombus was identified in 4 patients (2.7%). These included 2 patients with paroxysmal AF and normal LV function, although both had a high arrhythmia burden. The thrombi regressed with intensification of anticoagulation.


In conclusion, pre-operative imaging of the LAA remains advisable to exclude thrombus prior to ablation for AF even in patients with paroxysmal AF and normal LV function.

Credits: Joseph P. de Bono; Sacha Bull; John Paisey; David Tomlinson; Kim Rajappan; Yaver Bashir; Harald Becher; Timothy R Betts

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