Multi-modality approach to detect device-related thrombus after left atrial appendage occlusion

Background: There has been a growing interest in using left atrial appendage occlusion (LAAO) for stroke prevention in patients with atrial fibrillation (AF) who are ineligible for oral anticoagulation. However, device-related thrombus (DRT) may occur after LAAO implantation and poses significant diagnostic and treatment challenges. Case summary: We describe a case of a patient who suffered an intracranial pontine haemorrhage while on anticoagulation with rivaroxaban for permanent atrial fibrillation and successfully underwent implantation of the LAAO device. Early follow-up transoesophageal echocardiography (TOE) with 3D multi-plane reconstruction revealed a large echo-dense mass on the left atrial aspect of the device. Cardiac computed tomography angiography confirmed a thrombus adherent to the LAAO device. After deciding on the treatment strategy, complete thrombus resolution was achieved at the 6 months follow-up and the patient was free of any thromboembolic and bleeding events. Discussion: Although DRT is a rare complication following LAAO procedure, an accurate diagnosis is crucial for the specific treatment. Multi-modality imaging approach with TOE and cardiac computed tomographic angiography as complementary methods is helpful to detect complications after LAAO procedure in challenging cases.