Overcoming the challenge of persistent left atrial appendage thrombosis: a case report of successful left atrial appendage occlusion using a cerebral protection system.

Background: Atrial fibrillation significantly increases the risk of ischaemic stroke, primarily due to left atrial appendage (LAA) thrombosis. Percutaneous left atrial appendage occlusion (LAAO) offers an alternative approach to oral anticoagulation. However, the presence of LAA thrombosis has been considered a contraindication due to the risk of cerebral embolization. Case summary: An 82-year-old woman presented to our department with dyspnoea and history of non-valvular persistent atrial fibrillation as well as heart failure. Serial transoesophageal echocardiography revealed persistent LAA thrombosis despite optimal oral anticoagulation. As a therapeutic alternative, percutaneous LAA closure with cerebral embolic protection was carried out successfully with no severe adverse events reported. In the following, the patient also underwent cryoballoon pulmonary vein isolation to achieve rhythm control. In the follow-up examination, the anticoagulation was replaced with aspirin and transthoracic echocardiography showed normalization of the left ventricular ejection fraction in sinus rhythm. Discussion: This case report illustrates that in highly selected patients with persistent LAA thrombus despite prolonged, optimized anticoagulation, LAAO performed under meticulous procedural precautions and cerebral embolic protection may represent a carefully justified, individualized bail-out strategy.