Left atrial thrombus discovered post intra-operative Maze procedure: the dilemma of thrombus screening before the percutaneous pulmonary vein isolation

<span class="paragraphSection">A 55-year-old man with symptomatic persistent atrial fibrillation (AF) underwent an intraoperative maze procedure (IMP), which included left atrial appendage ligation (LAAL). Three months later, patient had recurrent persistent AF despite multiple cardioversions, amiodarone and warfarin. Prior to a planned percutaneous pulmonary vein isolation (PVI), the patient underwent a transoesophageal echocardiogram (TEE) which showed a laminar left atrial thrombus (LAT) without mobile components (<span style="font-style:italic;">Panel</span><span style="font-style:italic;">s</span><span style="font-style:italic;">A and B</span>). A cardiac magnetic resonance imaging (CMR) study confirmed a linear filling defect along the posterior wall of the left atrium measuring up to 1.8 cm in thickness without any contour of mass (<span style="font-style:italic;">Panel</span><span style="font-style:italic;">s</span><span style="font-style:italic;">C and D</span>). PVI was cancelled and the therapeutic INR target was increased to 2.5–3.5 with a plan to repeat TEE in 1 month. We hypothesized that such a rare finding of laminar LAT was due to stunned left atrium resulting from IMP. To date, no standard imaging recommendations exist for patients undergoing PVI for recurrent AF following IMP with LAAL, who have had more than three consecutive weeks of therapeutic anticoagulation such as the patient presented in this report. Warfarin, LAAL and IMP have individually been associated with stroke rate reduction. Thus, the benefit of pre-PVI imaging in this setting is unclear and currently based on clinical judgment. Our case highlights the necessity of a high index of suspicion for LAT on an individual patient basis. We propose CMR as an appealing modality as it provides both pulmonary vein and left atrial anatomy for mapping purposes and LAT detection. </span>

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