CONTENT

A 75-year-old male with a history of atrial fibrillation and stroke presented with a 2-month history of chest pain. He had undergone left atrial appendage closure (LAAC) 10 years earlier. During follow-up post-LAAC, an occluding device-related thrombus (DRT) was identified. The patient received 2 years of warfarin therapy, which he self-discontinued. Three years ago, he developed renal insufficiency and required maintenance dialysis.

Upon the current evaluation, transthoracic echocardiography revealed severe aortic stenosis and a left atrial thrombus (Figure 1A). Transoesophageal echocardiography and cardiac computed tomography demonstrated a large thrombus tightly attached to the left atrial appendage occluder (LAAO) (Figure 1B-D). The DRT exhibited a unique “tree-ring” structure. Figure 1.

Multimodal imaging characterization of device-related thrombus (DRT). (A) Transthoracic echocardiogram reveals a DRT in the left atrium. (B, C) Transesophageal echocardiographic views demonstrate a DRT adherent to the left atrial appendage occluder (LAAO), showing a unique “tree-ring” structure. (D) Computed tomography confirms the presence of a “tree-ring” DRT adjacent to the LAAO.

Due to its long history and high echogenic performance, the DRT was considered to have an organized architecture and low embolic potential. Next, the patient underwent transapical aortic valve replacement without complications. Postoperatively, warfarin therapy was resumed. Over 6 months of follow-up with transthoracic echocardiography and cardiac computed tomography, no thromboembolic events occurred, and the DRT remained stable (Figure 2A and B). Figure 2.

Follow-up (A) transthoracic echocardiogram and (B) computed tomography demonstrate DRT without evidence of progression at 6 months post transapical aortic valve replacement.

In this extremely rare case, the DRT existed for more than 10 years. Notably, the DRT exhibited an unprecedented “tree-ring” layered pattern on multidimensional imaging. This distinctive architecture likely stemmed from intermittent anticoagulation therapy and chronic hemodialysis for end-stage renal disease.

Footnotes

Informed Consent: Written informed consent was given by the patient.

Acknowledgements: The work was supported by Sichuan Science and Technology Program (2024YFHZ0197), and 1.3.5 project for disciplines of excellence Clinical Research Fund, West China Hospital, Sichuan University (grant number 2020HXFH044). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Declaration of Interests: All authors have no conflicts of interest to declare.

Statement: All authors confirm that no artificial intelligence (AI)-assisted technologies, including but not limited to large language models (LLMs), chatbots, or image creation tools, were used in the preparation or completion of this manuscript.