Abstract 1124: Biatrial Enlargement and Recurrent Cardioembolism in a 55 Year-Old Man with Atrial Fibrillation
A 55-year-old Haitian man with a history of atrial fibrillation (AF) was admitted with recurrent thromboembolic infarcts. He was admitted 6 months prior with splenic infarcts in the setting of AF and massive biatrial enlargement in spite of anticoagulation with warfarin. The infarcts were presumed to be cardioembolic and he was discharged on ASA and warfarin with a higher target INR of 3 – 4. On the day of admission, he presented with recurrent splenic infarcts in spite of an INR of 4.3. Testing for a hypercoagulable state was negative. TEE showed biatrial dilation and a left atrial appendage (LAA) thrombus. Right heart catheterization demonstrated elevated filling pressures with a restrictive pattern, and coronary angiography was normal. RV biopsy showed myocyte fibrosis and no evidence of infiltrative disease. The patient subsequently developed a right femoral artery embolus in spite of treatment with enoxaparin and ASA. The patient had recurrent cardioembolism in the context of AF, massive bilatrial dilation, and a possible idiopathic restrictive cardiomyopathy (IRCM). Given the failure of aggressive medical therapy, the patient was taken for high risk LAA resection with biatrial reduction. Intraoperative atrial specimens revealed amyloid deposition. The post-operative course was complicated and he eventually died in the setting of multisystem failure. On autopsy, he had isolated atrial amyloidosis (IAA) with no amyloid in the ventricles. There was extensive fibrosis of the left ventricle. This patient’s clinical course was notable for refractory cardioembolism. The clinical presentation and invasive hemodynamics suggested the presence of an IRCM, which is known to be associated with biatrial dilation. However, the presence of IAA, as well as the degree of biatrial dilation and thrombophilia are unusual features. Given that aggressive medical therapy was ineffective, we explored alternative strategies with multidisciplinary input. The prospect of a devastating recurrent embolism ultimately prompted proceeding with surgery. There is no clear consensus on the optimal management of such patients, but surgical approaches that address thrombus burden and the anatomic substrate for intracardiac thrombosis appear to be too high risk in this setting.