HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

We present the case of a woman with a history of atrial fibrillation (AF), intracavitary thrombus and absolute contraindication for long-term anticoagulant treatment due to associated comorbidities.

BACKGROUND:
No known drug allergies.
Cardiovascular risk factors (CVRF): Hypertension and dyslipidaemia. No known diabetes.
Diagnosed with hypertensive heart disease with mild ischaemia in latero-apical segments and admitted in July 2014 for transient ST elevation without evidence of significant coronary lesions on coronary angiography.
Paroxysmal AF of uncertain chronology diagnosed in February 2014, anticoagulated with synthrom.
Small vessel cerebrovascular disease being monitored by neurology. Doppler of
TSA normal.
Hiatal hernia. Haemorrhoidal syndrome.
Previous surgical interventions: appendectomy.
Usual treatment: Synthrom according to established guidelines based on periodic INR controls, diltiazem 120 mg every 12 hours, carvedilol 25 mg every 12 hours. Torasemide 5mg every 24 hours, atorvastatin 40 mg every 24 hours. Omeprazole 20 mg every 24 hours.
Lorazepam 1 mg in the evening.

CURRENT ILLNESS:
Admitted to cardiology for worsening functional class of months of evolution with clear onset of dyspnoea on moderate exertion, occasional episodes of palpitations and paroxysmal nocturnal dyspnoea in the days prior to ED consultation.
On admission, he presented fever of up to 38oC maintained for 3 days without an objectifiable focus, and a microbiological examination was performed, which was negative. The condition progressed to a deterioration in the level of consciousness and a cranial CT scan was requested, showing a right frontal intraparenchymal haematoma that did not move the midline or open to the ventricles, and did not require surgical drainage. For this reason, anticoagulation with low molecular weight heparin (started on admission instead of synthroid) was suspended and neurology was contacted to assess the case. Magnetic resonance imaging (MRI) of the skull was performed and a diagnosis of probable amyloid angiopathy was made.
Once the haemorrhagic focus was stabilised and given the high embolic risk (CHA2DS2 VASc 4) and high haemorrhagic risk (HAS-BLED 3 points), the patient was proposed as a candidate for programmed left atrial appendage closure (class IIb-B indication according to the ESC 2016 guidelines on the diagnosis and treatment of AF), and was referred for discharge with mono-antiplatelet therapy (acetylsalicylic acid (ASA) 100 mg every 24 hours).

PHYSICAL EXAMINATION:
Good general condition. Conscious, oriented and cooperative. Afebrile on admission.
Haemodynamically stable with blood pressure (BP) 110/70 mmHg and heart rate (HR) 85 bpm. Eupneic at rest and speech with head at 30o. No jugular ingurgitation or hepatojugular reflux.
On auscultation, arrhythmic cardiac tones without audible murmurs. Vesicular murmur preserved with bibasal crackles.
Lower limbs without oedema or signs of DVT. No other noteworthy findings on examination.

COMPLEMENTARY TESTS
ELECTROCARDIOGRAM (ECG): AF at 130 bpm. Wide QRS with morphology of complete left bundle branch block (LBBB), previously known.
ANALYSIS: no mobilisation of cardiac biomarkers (ultrasensitive troponin T [TnTus] peak 16 ng/l). Other findings were unremarkable.
THORAX RADIOGRAPHY: cardiomegaly, no other pathological findings. Absence of pulmonary congestion.
TRANSTORACIC ECOCARDIOGRAPHY: LA diameter AP 31mm. Apical area 24 cm2 and volume 79 ml. Dilated left ventricle (LV) (LVEDV 57 mm), globular morphology. Left ventricular ejection fraction (LVEF) severely depressed, by Simpson LVEF 17%, with global hypokinesia. Monophasic E filling pattern. Mitral valve with tenting closure resulting in mild functional mitral regurgitation (MR). Aortic valve with preserved opening and function. Non-dilated right ventricle (RV) (RVDVD 22.6 mm) with TAPSE 14 mm.
Tricuspid insufficiency (TI) grade II with peak RV-RA gradient 29 mmHg, which allows estimating a systolic pulmonary artery pressure (PAPs) 35-40 mmHg. Inferior vena cava (IVC) not dilated with normal inspiratory collapse. No pericardial effusion.
UROCULTURE and HEMOCULTURE: negative.
Cranial CT scan: right frontal intraparenchymal haematoma that did not displace the midline or open into the ventricles.
Cranial MRI: right frontal lobar haemorrhage and small vessel vasculopathy, findings compatible with probable amyloid angiopathy.
ANGIO-CT chest: drainage of left pulmonary veins into normal left atrium, through two independent ostia. The left atrial appendage has a digitiform morphology and an implantation base with a wide neck, approximately 2 x 2 cm. Adherent thrombotic material, probably of chronic evolution, can be seen in its cul-de-sac. Dilated LV (transverse diameter of about 55 mm). Right atrium (RA) 55 mm. Left atrium (LA) 47 mm.
Transesophageal echocardiography: left atrial appendage with an entrance of 17 x 19 mm, depth of 30 mm, thrombus is seen inside the left atrial appendage.

CLINICAL EVOLUTION
After discharge, the patient was scheduled for a chest CT angiography and transesophageal echocardiography prior to atrial appendage closure. Both tests showed the existence of thrombus in the left atrial appendage, a situation that contraindicated its closure. Therefore, the case was assessed in a medical session (heart team) and it was decided to start anticoagulation with dabigatran 110 mg every 12 hours for 3 months, for resolution of the thrombus and subsequent echocardiographic control.
During these 3 months of treatment with dabigatran, she evolved without incident, being asymptomatic and without haemorrhagic complications. After echocardiographic control confirmed the resolution of the thrombus (video 3), the left atrial appendage was closed with the Amplatzer Amulet device, without complications during the procedure and with a good final result.
Subsequently, anticoagulation was maintained with dabigatran 110 mg every 12 hours for a further 45 days, with no associated haemorrhagic complications, and after its withdrawal the patient was kept on mono-antiplatelet therapy indefinitely with ASA 100 mg every 24 hours.
Subsequent echocardiographic controls showed the Amulet device to be correctly placed and the left atrial appendage to be free of thrombus. Likewise, due to the patient's baseline cardiomyopathy with severe ventricular dysfunction, it was decided to implant an implantable cardioverter defibrillator (ICD) for primary prevention. Currently, she maintains a good functional class and is asymptomatic from the cardiological point of view.

DIAGNOSIS
Dilated cardiomyopathy with severe ventricular dysfunction (LVEF 17%).
Permanent AF (CHA2DS2-VASc 4 points, HAS-BLED 3 points).
Probable amyloid angiopathy leading to right lobar lobar intraparenchymal haematoma.
Thrombus in left atrial appendage.
