Large thrombus formation on an Amplatzer™ Cardiac Plug.

An 81-year-old woman with permanent atrial fibrillation (CHA2DS2-VASc score=5) was referred for left atrial appendage (LAA) closure. She had a history of hypertension, stage IV chronic kidney disease and chronic anemia, secondary to gastrointestinal bleeding (HAS-BLED score=3). Percutaneous LAA closure with a 22 mm firstgeneration device (Amplatzer Cardiac Plug [ACP]) was performed (Figure 1A, Video 1). The procedure was guided by three-dimensional transesophageal echocardiography (TEE) and complete occlusion was confirmed (Figure 1B, Videos 2 and 3). She was treated with aspirin 100 mg plus clopidogrel 75 mg daily for one month, clopidogrel 75 mg daily for six months, and no antithrombotic drug thereafter. By protocol, follow-up TEE was performed at 12 months and revealed a large mobile thrombus attached to the atrial surface of the ACP (Figure 1C and D, Videos 4 and 5). Warfarin was started and TEE was scheduled for six months later. In the meantime, the patient developed septic