pulm vein ablation and clots

[reedbanz]

my father is 65 and was at the cleveland clinic 2 years ago for a pulmanory vein ablation with dr dressing. he had a touch up in i think march of this year with dr dressing and everything had gone well. he had been in sinus rhythm all along and has still been on coumadin with his inr around 2. last saturday he experienced severe bilateral leg pain and numbness and had emergency vascular surgery where they removed a large clot. he was doung well until yesterday when he developed a stroke affecting his right side. the doctors now have found more clots in his spleen and 3 clots in his left atruim.. he is on dopamine drip. heprin drip, coumadin therapy. his last inr was a little over 2 with his pt at arounf 79. i think that his inr should be closer to 3 to 3.5. Is there anything else that can be done to remove the clots. the doctor said that the clots are large and may not dissipate on their own. we are alittle out of our comfort zone because we live in nashville tn and dr dressing is in cleveland. i have called the doctor that dr dressing requests him to see but he does not practice at the hospital that my father was sent to.

[Cleveland Clinic]

One other possibility, in some who flies a lot, is that people who had an afib ablation procedure have a whole in their atrial septum.  If he formed a clot in the veins of his legs due to frequent flying, that clot could propagate up to the heart and cross over to the left side of the heart via that opening in the septum.  The clots would end up on the arterial side and cause those embolization.  He should, therefore, have an ultrasound of his lower extremities to rule out DVT.  

I think it is perfectly reasonable to have him transferred to another hospital, as long as he would tolerate the transfer, ie, be stable enough.    

[reedbanz]

the only thing that i can figure out is that my father flys alot and last week he flew from nashville to phoenix and then to L.A  to cincinnati, and then home to nashvile for business. i wonder if the flying and maybe he missed a dose of his coumadin. as far as we know his inr at the time of incident was 2.0. he has been on coumadin and was due to come off the coumadin this december becasue he has been is sinus rythym since last touch up in march. The doctors cannot figure out how he has gotten so many clots. he also has some clots in his spleen but they are not concerned about this. i am worried because his b/p sometimes goes below 80/50 and his heart rate has been sinus tachy 120-130. his last today inr was 1.7 and his ptt 76. i have been told by the cardiologist that they cannot remove the clots in is left atruim. they are not sitting in his appendage but near the pulmonary vein. we are discussing now about the need to transfer him to another hospital in nashville tn or try to get him to the cleveland clinic. my dad has been checked for an enlarged heart and does not have this and his artieries are fine also. both dr. dressing at the cleveland clinic and dr. jones who was referred to us by dr. dressing had recently checkd him out and he has been in good health. we are at williamson medical center in nashville and we really like the vascular surgeon but my fathers cardiologist practices at centennial hospital. the cardiologist that has been called in wants standard medication treatment and not any other interventions. you asked if  his inr drifted down and i think from what the nurse was telling me that the cardiologist was wanting the inr around 1.5 i think that this is to low. the nurse told me that they are giving the coumadin on an day by day basis. at the time that my fathers emergency when he went into the er depart he was is sinus rythym but i did notice that on 3 occassions when he was in sinus tachy he converted afib and then when his heart rate came down he as in rythym. he went for an mri of the head today. would you think that trying to get him stabilized then getting him to cleveland clinic or centennial hospital would be appropriate. thanks for all your input

[Cleveland Clinic]

Vascular surgeons can sometimes go in an remove the clots.  Given the clot burden it would be difficult to get them all out, however, maybe the larger ones could be removed.  What do they think this was due to?  did his INR drift down?  what is his rhythm and does he have any evidence of atrial fibrillation recurrence.  Also, large heart attacks or low heart function can lead to to ventricular clot formation and massive embolization.  One has to be very careful with anticoagulation in the setting of embolic stokes because they can convert to hemorrhagic (bleeding) stokes which would cause further deficits and complications.