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LAA Thrombus Preventing Ablation — EECC MCQ

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ModerateArrhythmia & ElectrophysiologyLAA Thrombus Preventing AblationEECC

A 60-year-old man with persistent AF undergoes left atrial appendage (LAA) assessment during catheter ablation. TOE shows LAA thrombus. Can ablation proceed?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Ablation should be DEFERRED until the LAA thrombus has resolved with intensified anticoagulation (typically warfarin INR 2-3 or DOAC for ≥3-6 weeks) with repeat TOE confirming resolution — proceeding with ablation risks thrombus dislodgement and stroke

LAA thrombus is an absolute contraindication to catheter ablation for AF. The risk of catheter manipulation in the LA (transseptal puncture, catheter movement, cardioversion) dislodging the thrombus and causing stroke is unacceptable. The 2024 ESC AF Guidelines recommend: (1) pre-procedural TOE (or cardiac CT) for all patients undergoing AF ablation to exclude LA/LAA thrombus; (2) if thrombus detected: defer ablation, intensify anticoagulation (ensure compliance, consider switching from DOAC to warfarin, or adding bridge with LMWH), and repeat TOE in 3-6 weeks; (3) if thrombus persists despite anticoagulation: ablation should not proceed — investigate compliance, consider heparin bridging, and assess LAA occlusion if long-term thrombus management is problematic. Intracardiac echocardiography (ICE) during the procedure can provide real-time LAA assessment but does not replace pre-procedural TOE.

Reference: ESC (2024): AF Guidelines