Thrombus Formation During Pulmonary Vein Ablation: When Routine Turns Risky

Atrial fibrillation (AF) is the most common sustained arrhythmia and a major contributor to thromboembolic events. Pulmonary vein isolation is the main therapy to achieve rhythm control, and intraoperative transesophageal echocardiography (iTEE) enhances procedural safety by guiding transseptal puncture and detecting possible complications such as thrombi formation. Nevertheless, intraprocedural catheter thrombosis remains remarkably infrequent and is poorly documented in medical literature. A 59-year-old man with paroxysmal AF and a prior transient ischemic attack, under anticoagulation with apixaban, presented for redo pulmonary vein ablation. Due to premature interruption of anticoagulation, iTEE revealed a large thrombus attached to the ablation catheter after transseptal puncture, so the procedure was postponed and the patient recovered without complications. A second ablation under uninterrupted anticoagulation was performed 4 weeks later, with successful isolation of all pulmonary veins and restoration of stable sinus rhythm. Intraprocedural catheter thrombosis is a rare but potentially life-threatening complication not currently addressed in AF management guidelines. This case underscores the pivotal role of iTEE in the early detection of this unexpected event, supporting its use for both procedural guidance and surveillance of thromboembolic complications. Effective anticoagulation management, favoring uninterrupted anticoagulant use, remains essential to mitigate thromboembolic risk. Overall, this report highlights the importance of integrating advanced imaging and strict anticoagulation protocols to prevent catheter-related thrombotic events during AF ablation.