Description
A 57-year-old man with 16-year history of persistent atrial fibrillation (AF) was admitted for electrophysiology study and catheter ablation. He was on amiodarone, carvedilol and warfarin. His international normalised ratio (INR) was 2.2. Intracardiac echocardiogram (ICE) prior to atrial septum puncture did not show any spontaneous echo contrast. After advancing the sheath across the interatrial septum, it was flushed with heparin. A few seconds after sheath placement and prior to placement of lasso catheter a linear thrombus developed which was visible on ICE (figure 1; videos 1 and 2). Activated clotting time (ACT) of >250 ms was maintained prior to trans-septal puncture and after thrombus was seen; heparin was administered to maintain ACT>300 ms. The sheath and catheter were retracted into the inferior vena cava, and with continuous heparin infusion, the thrombus resolved. During hospitalisation and follow-up, patient remained asymptomatic without neurological complications.
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