Risk Factors and Prognosis for Clot Formation on Cardiac Device Leads

Rahbar, Ata Soleimani; Azadani, Peyman N.; Thatipelli, B A Sindhura; Fleischmann, Maximilian; Nguyen, Betty; Lee, M.A.S. Byron K.

doi:10.1111/pace.12210

Cited by 25 publications

(27 citation statements)

References 10 publications

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“…Our data supports the study by Rahbar et al,[21] where they showed that the initiation of intensified anticoagulation therapy resulted in reduction or shrinkage of thrombus in 9 of their patients whom they had follow up data on. The one major limitation of their study is that they only used TTE as the imaging modality.…”

Section: Discussionsupporting

confidence: 92%

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Mobile thrombus on cardiac implantable electronic device leads of patients undergoing cardiac ablation: incidence, management, and outcomes

Sugrue

DeSimone

Lenz

et al. 2015

J Interv Card Electrophysiol

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Purpose The rates of cardiovascular implantable electronic device (CIED) implantations and cardiac ablation procedures are increasing worldwide. To date, the management of CIED lead thrombi in the periablation period remains undefined and key clinical management questions remained unanswered. We sought to describe the clinical course and management strategies of patients with a CIED lead thrombus detected in the periablative setting. Methods We performed a retrospective analysis of all patients who underwent a cardiac ablation procedure at Mayo Clinic Rochester from 2000-2014. Patients were included in our study cohort if they had documented CIED lead thrombus noted on periablation imaging studies. Electronic medical records were reviewed to determine the overall management strategy, outcomes, and embolic complications in these patients. Results Our overall cohort included 1833 patients, with 27(1.4%) having both cardiac ablation procedures as well as CIED lead thrombus detected on imaging. Of these 27 patients, 21 were male (77%), and the mean age was 59.2 years. The mean duration of follow-up was 16.5 months (range; 3 days – 48.3 months). Anticoagulation was an effective therapeutic strategy, with 11/14 (78.6%) patients experiencing either resolution of the thrombus or reduction in size on re-imaging. For atrial fibrillation ablation, the most common management strategy was a deferment in ablation with initiation/intensification of anticoagulation medication. For ventricular tachycardia ablations, most procedures involved a modified approach with the use of a retrograde aortic approach to access the left ventricle. No patient had any documented embolic complications. Conclusions The incidence of lead thrombi in patients undergoing an ablation was small in our study cohort (1.4%). Anticoagulation and deferral of ablation represented successful management strategies for atrial fibrillation ablation. For patients undergoing ventricular tachycardia ablation, a modified approach using retrograde aortic access to the ventricle was successful. In patients who are not on warfarin anticoagulation at the time of thrombus detection, we recommend initiation of this medication, with a goal INR of 2-3. For patients on warfarin at the time of thrombus detection, we recommend an intensification of anticoagulation with a goal INR of 3.0.

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Section: Discussionsupporting

confidence: 92%

“…Our data is similar to Rabher et al[21] who reported lead thrombus in 1.4% of their population who underwent a TTE. Our incidence is smaller when compared to Supple et al,[18] who reported thrombus at 30%.…”

Section: Discussionsupporting

confidence: 92%

Mobile thrombus on cardiac implantable electronic device leads of patients undergoing cardiac ablation: incidence, management, and outcomes

Sugrue

DeSimone

Lenz

et al. 2015

J Interv Card Electrophysiol

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“…In two patients, we observed complete resolution of the echogenic mass. This is consistent with a recently reported case series by Rahbar et al in which eight out of nine patients had some response to intensification of warfarin therapy and seven out of nine had complete resolution of the echogenic masses [16]. In their case series, none of the patients who had resolution of the echogenic mass had a therapeutic INR prior to intensification of warfarin therapy.…”

Section: Discussionsupporting

confidence: 91%

Cardiac implantable electronic device lead-based masses and atrial fibrillation ablation: a case-based illustration of periprocedural anticoagulation management strategies

Lenz

DeSimone

Ponamgi

et al. 2016

J Interv Card Electrophysiol

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Introduction Cardiac implantable electronic device (CIED) leads frequently develop echogenic masses. However, the nature of these masses is not well understood. In patients in whom atrial fibrillation (AF) catheter ablation is planned, there is concern that transseptal puncture may result in cerebrovascular embolism of these masses. The optimal therapeutic strategy in this setting remains undefined. Methods We describe six patients identified over a 6-year period (2008–2014) with device lead-based masses prior to or at the time of AF ablation. We examined the anticoagulation strategy and periprocedural management based on mass identification. Results In all six patients (age 39–73; four males), the device lead mass was found in the right atrium. The average mass size was 11 ± 1.3 mm. The majority of patients were already on anticoagulation (5/6; 83 %), and an intensified anticoagulation regimen was initiated (INR goal 3.0). In all six patients, the size of the device lead mass decreased on repeat imaging. In two sixths (33 %) patients, the lead-based mass completely resolved within 2 months. The remaining four patients had persistent lead-based masses (average follow-up of 10.9 ± 9.6 months). Discussion We describe a series of patients with CIED lead-based masses found at the time of ablation. These cases illustrate that lead-based masses can disappear while patients are on high-intensity anticoagulation, most compatible with a thrombotic origin. These early data will need to be assessed in larger cohorts for further validation and evaluation of safety.

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“…There are a few cases reported in literature in which a clot was formed on the pacemaker lead 9. Our presenting patient had a pacemaker lead in the RA, but the mass origin revealed in surgery was away from the leads.…”

Section: Discussionmentioning

confidence: 75%

Clot in Lung, Clot in Heart: A Case Report of Tumor-Like Thrombus in Right Atrium

Habibi

Altamirano

Dadkhah

2017

Clin Med Insights Case Rep

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Tumor-like formation of thrombus in the right atrial cavity is rare. It may be mistaken for a myxoma. The exact pathophysiology of an isolated thrombus in the heart is still unclear. Management to prevent complications such as pulmonary thromboembolism depends on the clinical judgment of a cardiologist. This report describes a 76-year-old woman with right atrial thrombus causing subsequent pulmonary thromboembolism in right lung. She initially presented to us with pulmonary embolism, and later, an incidental finding of a mass in her right atrium revealed an association of thrombus in heart with thrombus in lung. The challenging management was to resect this thrombus which was fixed to atrial septum, and a trial of anticoagulation did not resolve it. Exact management of such incidental findings in right heart cavities is not well established. Some cases may benefit from resection of such formed fixed thrombus.

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Risk Factors and Prognosis for Clot Formation on Cardiac Device Leads

Abstract: Patients with AF are at higher risk for clot formation on device leads. After clot detection, treatment with anticoagulants usually results in resolution of the clot without embolic phenomenon.

Cited by 25 publications

References 10 publications

Mobile thrombus on cardiac implantable electronic device leads of patients undergoing cardiac ablation: incidence, management, and outcomes

Mobile thrombus on cardiac implantable electronic device leads of patients undergoing cardiac ablation: incidence, management, and outcomes

Cardiac implantable electronic device lead-based masses and atrial fibrillation ablation: a case-based illustration of periprocedural anticoagulation management strategies

Clot in Lung, Clot in Heart: A Case Report of Tumor-Like Thrombus in Right Atrium

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