We read with interest the recent paper by Sedaghat
et al. (1) in which they report a high incidence of
thrombus between the left upper pulmonary vein and
the Amulet device (St. Jude Medical, St. Paul, Minnesota)
on transesophageal echocardiogram performed
11.0 8.2 weeks following left atrial appendage (LAA)
occlusion. These thrombi were observed in 4 of 24
cases (16.7%) in spite of a strategy of dual antiplatelet
therapy for 3 months post-implantation.
The high incidence of thrombus in this Amulet
series contrasts with our own experience (2) in a very
similar population of patients (mean age: 75 9 years,
median CHA2DS2VASc [Congestive Heart Failure,
Hypertension, Age $75 Years, Diabetes Mellitus,
Previous Stroke or Transient Ischemic Attack,
Vascular Disease, Age 65 to 74 Years, Sex Category]:
4) undergoing LAA occlusion with the Amulet device.
Our patients received 6 weeks of double antiplatelet
therapy and no thrombus was visualized in any of 32
patients on follow-up transesophageal echocardiogram
at 6 to 8 weeks post-implantation. Our results
are in line with the other published series of Amulet
device implants, in which the prevalence of thrombi
on follow-up imaging ranged from 0% to 4% (3).
This discrepancy between the findings of Sedaghat
et al. (1) and other published series could simply be
explained by statistical fluctuation, given the low
number of patients. However, a genuine reason for the
higher prevalence of thrombus in their patients might
be found in their observation that thrombus was
associated with incomplete coverage of the ridge between
the LAA and the left upper pulmonary vein. In
our experience (2), and that of others (3), intraprocedural
echocardiography (either transesophageal
or intracardiac) is invaluable in helping achieve
complete LAA occlusion. The mere use of fluoroscopy,
even in a biplane lab, cannot provide the level of detail
of LAA anatomy contributed by echocardiography
(4,5). It is notable that Sedaghat et al. (1) do not
mention the use of echocardiography to guide device
implantation in their methods. However, given that
their procedures were all performed under conscious
sedation and with an average procedure duration
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