- Email: [email protected]
Combined percutaneous balloon mitral valvuloplasty and left atrial appendage occlusion device implantation for rheumatic mitral stenosis and atrial fibrillation
Combined Percutaneous Balloon Mitral Valvuloplasty and Left Atrial Appendage occlusion device implantation for Rheumatic Mitral Stenosis and Atrial Fibrillation Dale Murdoch, Laura McAulay, Darren L. Walters PII: DOI: Reference:
S1553-8389(14)00134-1 doi: 10.1016/j.carrev.2014.04.007 CARREV 652
To appear in:
Cardiovascular Revascularization Medicine
Received date: Revised date: Accepted date:
16 March 2014 13 April 2014 14 April 2014
Please cite this article as: Murdoch Dale, McAulay Laura, Walters Darren L., Combined Percutaneous Balloon Mitral Valvuloplasty and Left Atrial Appendage occlusion device implantation for Rheumatic Mitral Stenosis and Atrial Fibrillation, Cardiovascular Revascularization Medicine (2014), doi: 10.1016/j.carrev.2014.04.007
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title Page Combined Percutaneous Balloon Mitral Valvuloplasty and Left Atrial Appendage
RI PT
occlusion device implantation for Rheumatic Mitral Stenosis and Atrial Fibrillation
SC
Dale Murdoch,1,2* MBBS FRACP, Laura McAulay,1 MBBS and Darren L Walters,1,2 MBBS MPhil FRACP FSCAI
NU
1. The Prince Charles Hospital, Brisbane, Australia 2. The University of Queensland, Brisbane, Australia
MA
Correspondence
CE
Indexing words
PT ED
Dr Dale Murdoch Cardiology Department The Prince Charles Hospital Rode Rd, Chermside QLD 4032 [email protected]
Rheumatic heart disease
AC
Thromboembolism Anticoagulation Watchman® Short title
Mitral valvuloplasty and LAA occluder for RHD
Word Count Abstract:
126 words
Manuscript:
1182 words
ACCEPTED MANUSCRIPT Abstract:
RI PT
Rheumatic heart disease is a common cause of cardiovascular morbidity and mortality worldwide, mostly in developing countries. Mitral stenosis and atrial fibrillation often coexist, related to both structural and inflammatory changes of
SC
the mitral valve and left atrium. Both predispose to left atrial thrombus formation, commonly involving the left atrial appendage. Thromboembolism can
NU
occur, with devastating consequences. We report the case of a 62 year old
MA
woman with rheumatic heart disease resulting in mitral stenosis and atrial fibrillation. Previous treatment with warfarin resulted in life-threatening
PT ED
gastrointestinal bleeding and she refused further anticoagulant therapy. A combined procedure was performed, including percutaneous balloon mitral valvuloplasty and left atrial appendage occlusion device implantation with the
CE
Atritech® Watchman® device. No thromboembolic or bleeding complications were encountered at one year follow-up. Long-term follow-up in a cohort of
AC
patients will be required to evaluate the safety and efficacy of this strategy.
ACCEPTED MANUSCRIPT
RI PT
INTRODUCTION
Rheumatic heart disease is a common cause of cardiovascular morbidity and mortality worldwide, mostly in developing countries. Mitral stenosis is a
SC
common consequence, causing disabling symptoms when severe. Atrial fibrillation also occurs, both as a result of atrial hypertension and dilation related
NU
to mitral stenosis, and persistent rheumatic inflammation and fibrosis. Patients
MA
are strongly predisposed to atrial thrombus formation and subsequent thromboembolic stroke and systemic embolism. Anticoagulation with a vitamin
PT ED
K antagonist is effective in reducing thromboembolism, but alternate management strategies are required in patients with contraindications to
CE
anticoagulation.
AC
CASE REPORT
A 62 year old female with longstanding rheumatic heart disease and mixed mitral valve pathology (predominantly stenosis) and concomitant atrial fibrillation (AF) presented with progressive dyspnea (NYHA Class III) and decreased exercise tolerance. Anticoagulant therapy was contraindicated due to previous life-threatening gastrointestinal bleeding on warfarin and the patient was subsequently treated with Aspirin 100mg daily. Physical examination revealed an irregular pulse, rate 70 bpm and BP 120/70mmHg. Pan systolic and mid-diastolic murmurs were present. 12-lead ECG demonstrated atrial fibrillation.
ACCEPTED MANUSCRIPT
3-dimensional transoesophageal echocardiogram (3D-TOE) showed a rheumatic
RI PT
mitral valve with moderately severe mitral stenosis (MPG 9mmHg and MVA 0.8cm2 by planimetry) and 2/4 mitral regurgitation. (Figure 1) Wilkins’ score for mitral stenosis was 8/16. Other findings included 2/4 tricuspid regurgitation
SC
and a left atrial appendage with characteristics which appeared suitable for
NU
device closure.
MA
Given the high risk of stroke related to valvular atrial fibrillation in the setting of rheumatic valve disease, anticoagulation therapy with warfarin was once again
PT ED
recommended, but the patient refused. Anticoagulation with one of the novel oral anticoagulant medications was considered, but not chosen because a) use in valvular atrial fibrillation is not studied and is therefore off-label and b) the risk
CE
of major gastrointestinal bleeding is similar to that of warfarin. Therefore combined percutaneous balloon mitral valvuloplasty and LAA occlusion were
AC
considered appropriate for this patient.
Under general anesthesia, arterial and venous sheaths were placed in the right groin. A Brockenbrough needle (St. Jude, Inc., Minneapolis, USA) was used to puncture the interatrial septum under both fluoroscopic and echocardiographic guidance (Figure 2). Transseptal puncture was performed in the mid to lower part of the posterior interatrial septum, which is ideal for LAA occluder device implantation. Multiple dilations of the mitral valve were performed with a 28mm Toray Inoue-balloon catheter (Toray Medical Co., Tokyo, Japan), inflated to 25cc,
ACCEPTED MANUSCRIPT resulting in the reduction of mean transmitral pressure gradient to 6mmHg, with
RI PT
no increase of mitral regurgitation. (Figure 3).
After mitral valvuloplasty was completed, the Inoue-balloon catheter was exchanged for an SL1 catheter (St. Jude, Inc., Minneapolis, USA), through which
SC
an 0.035in Amplatz super-stiff guide wire (Boston Scientific, Natick, USA) was placed into the left upper pulmonary vein. Subsequently a 14Fr single-curve
NU
delivery sheath was passed over the wire, with a 6Fr pigtail catheter delivered
MA
into the left atrium. (Figure 4) The left atrial appendage was then sized via both TOE and fluoroscopy; with an ostium of 17.7mm diameter. A 21mm Watchman®
PT ED
left atrial appendage (LAA) occluder device (Atritech, Inc., Plymouth, USA) was chosen. Prior to device deployment, the delivery sheath position was confirmed with contrast injection. Once deployed, the stability and positioning of the device
CE
were confirmed with the tug test and injection of contrast. Once disconnected, the device position and seal were again confirmed using both contrast injection
AC
and colour flow Doppler TOE imaging.
The patient was initiated on daily aspirin 100mg and clopidogrel 75mg and monitored in the coronary care unit post procedure. A transthoracic echocardiogram performed day one post procedure showed moderate mitral stenosis with MPG 7mmHG, 1-2/4 MR, a well seated watchman LAA occluder device and trivial pericardial fluid. A TOE performed on day 45 post procedure also showed moderate mitral stenosis with a well seated watchman device with no intra-device flow.
ACCEPTED MANUSCRIPT At six month follow-up the patient exhibited a significant symptomatic improvement, with complete resolution of dyspnoea. There were no bleeding
RI PT
complications during the 6 months of dual antiplatelet therapy and this was reduced to single agent Aspirin 100mg daily. No stroke or systemic embolism
SC
occurred in follow-up at one year.
NU
DISCUSSION
MA
Patients with both mitral stenosis and atrial fibrillation as a result of rheumatic heart disease have increased risk of thromboembolic stroke and systemic
PT ED
embolism compared to those with non-valvular AF (1). Left atrial thrombus is observed over 30% of patients and occurs in both the left atrial appendage and the body of the left atrium(2,3). Without anticoagulation, annual risk of
CE
thromboembolism is 17-18%(4). Importantly, traditional risk estimating tools such as CHADS2 and CHA2DS2-VASc do not apply to patients with rheumatic
AC
atrial fibrillation(5,6).
Anticoagulation with warfarin is recommended, with a target international normalized ratio (INR) of 2.5 – 3.5 for patients with rheumatic mitral stenosis and 3.0 – 4.0 for patients with a mechanical mitral valve prosthesis (4). Large trials of the novel oral anticoagulants have excluded patients with rheumatic/valvular atrial fibrillation and they are not currently indicated. In fact, a massive left atrial thrombus has been reported in a patient with rheumatic mitral stenosis and atrial fibrillation whilst anticoagulated with dabigatran (Pradaxa®)(7).
ACCEPTED MANUSCRIPT The combined procedure we have described may reduce the risk of stroke and systemic embolism by more than one mechanism. First, occlusion of the left
RI PT
atrial appendage with the Watchman® LAA occluder prevents thrombus formation within the appendage. Thrombus forms within the LAA in more than 50% of patients with rheumatic atrial fibrillation(3). In the PROTECT-AF study,
SC
the WATCHMAN LAA occluder device was shown to be non-inferior to warfarin in preventing stroke and systemic embolism in patients with non-valvular AF(8).
NU
Second, treatment of mitral stenosis with balloon mitral valvuloplasty may help
MA
to reduce the thrombotic risk. Relief of mitral stenosis reduces stasis within the left atrium(9) and may prevent left atrial enlargement, which is a risk factor for
PT ED
thromboembolism(4). In addition, mitral stenosis causes a hypercoagulable state which is likely to contribute to thrombus formation and embolism, and balloon
CE
mitral valvuloplasty has been shown to reduce this hypercoagulable state(10).
Technical considerations for combining these two procedures are important. The
AC
location of the transseptal puncture is vital for placement of the LAA occluder device, and thus this takes priority. The mid to lower part of the posterior interatrial septum is considered ideal, although this may make the balloon mitral valvuloplasty more challenging in some patients. The exchange procedure also requires careful consideration. An SL1 guiding catheter was used to maintain position in the left atrium whilst exchanging the Inoue-balloon catheter for a stiff wire. This allows delivery of the 14-Fr delivery sheath and routine implantation of the Watchman LAA occluder device.
ACCEPTED MANUSCRIPT Further evaluation of this strategy in a larger number of patients with long term follow-up is required. A cohort study reporting procedural safety, bleeding and
SC
RI PT
embolic events would provide further useful information.
NU
CONCLUSION
MA
We present a case of a combined procedure to reduce mitral stenosis and prevent thromboembolism in a patient with rheumatic heart disease, atrial
PT ED
fibrillation and contraindication to warfarin. Patients with rheumatic atrial fibrillation are at high risk of thromboembolism, and warfarin is first line therapy. Novel oral anticoagulants are untested and may be ineffective.
CE
Combined mitral valvuloplasty and LAA occluder device therapy should be considered in the rare instance where a patient has an indication for both
AC
procedures, although the long term efficacy of this approach is yet to be determined.
SC
RI PT
ACCEPTED MANUSCRIPT
NU
Figure Legend
MA
Figure 1. A 3-dimensional transesophageal echocardiographic (TEE) image of
PT ED
the stenotic mitral valve. Mitral valve area by planimetry was 0.8cm2.
Figure 2. A TEE image of the Brockenbrough needle ‘tenting’ the interatrial
AC
CE
septum (arrow), prior to transseptal puncture.
Figure 3. Fluoroscopic (left) and TEE (right) images of the inflated 28mm Toray Inoue-balloon catheter.
Figure 4. The exchange procedure. After balloon mitral valvuloplasty, the Inoueballoon catheter was exchanged for an SL1 catheter (A). Via the SL1 catheter, an 0.035in extra support wire was placed into the left upper pulmonary vein (B). Subsequently, a 14 Fr single-curve delivery catheter was passed over the wire
ACCEPTED MANUSCRIPT (C). Finally, a 6 Fr pigtail catheter was delivered into the left atrium so that the
SC
RI PT
left atrial appendage could be imaged (D).
MA
NU
References
1. Marijon E, Mirabel M, Celermajer DS, Jouven X. Rheumatic heart disease.
PT ED
Lancet 2012; 379: 953–64.
2. Srimannarayana J, Varma RS, Satheesh S, Anilkumar R, Balachander J.Prevalence of left atrial thrombus in rheumatic mitral stenosis with
CE
atrial fibrillation and its response to anticoagulation: a transesophageal echocardiographic study. Indian Heart J. 2003;55(4):358-61.
AC
3. Blackshear JL,Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755 759.
4. Vora A. Management of atrial fibrillation in rheumatic valvular heart disease. Current Opinion in Cardiology 2006, 21:47–50. 5. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of Clinical Classification Schemes for Predicting Stroke: Results From the National Registry of Atrial Fibrillation. JAMA. 2001;285(22):2864-2870.
ACCEPTED MANUSCRIPT 6. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJGM. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial
RI PT
fibrillation using a novel risk factor-based approach. Chest. 2010;137(2):263-72.
7. Luis SA, Poon K, Luis C, Shukla A, Bett N, Hamilton-Craig C. Massive left
SC
atrial thrombus in a patient with rheumatic mitral stenosis and atrial
Imaging. 2013;6:491-492.
NU
fibrillation while anticoagulated with dabigatran. Circ Cardiovasc
MA
8. Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P. Percutaneous closure of the left atrial appendage versus
PT ED
warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 2009; 374: 534–42 9. Carabello BA. Modern management of mitral stenosis. Circulation.
CE
2005;112:432-437.
10. Chen MC, Wu CJ, Chang HW, Yip HK, Chen YH, Cheng CI, Chai HT.
AC
Mechanism of reducing platelet activity by percutaneous transluminal mitral valvuloplasty in patients with rheumatic mitral stenosis. Chest.
2004;125:1629 –1634.
PT ED
MA
NU
SC
RI PT
ACCEPTED MANUSCRIPT
AC
CE
Fig. 1
PT ED
MA
NU
SC
RI PT
ACCEPTED MANUSCRIPT
AC
CE
Fig. 2
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SC
RI PT
ACCEPTED MANUSCRIPT
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CE
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Fig. 3
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ACCEPTED MANUSCRIPT
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Fig. 4
S1553-8389(14)00134-1 doi: 10.1016/j.carrev.2014.04.007 CARREV 652
To appear in:
Cardiovascular Revascularization Medicine
Received date: Revised date: Accepted date:
16 March 2014 13 April 2014 14 April 2014
Please cite this article as: Murdoch Dale, McAulay Laura, Walters Darren L., Combined Percutaneous Balloon Mitral Valvuloplasty and Left Atrial Appendage occlusion device implantation for Rheumatic Mitral Stenosis and Atrial Fibrillation, Cardiovascular Revascularization Medicine (2014), doi: 10.1016/j.carrev.2014.04.007
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title Page Combined Percutaneous Balloon Mitral Valvuloplasty and Left Atrial Appendage
RI PT
occlusion device implantation for Rheumatic Mitral Stenosis and Atrial Fibrillation
SC
Dale Murdoch,1,2* MBBS FRACP, Laura McAulay,1 MBBS and Darren L Walters,1,2 MBBS MPhil FRACP FSCAI
NU
1. The Prince Charles Hospital, Brisbane, Australia 2. The University of Queensland, Brisbane, Australia
MA
Correspondence
CE
Indexing words
PT ED
Dr Dale Murdoch Cardiology Department The Prince Charles Hospital Rode Rd, Chermside QLD 4032 [email protected]
Rheumatic heart disease
AC
Thromboembolism Anticoagulation Watchman® Short title
Mitral valvuloplasty and LAA occluder for RHD
Word Count Abstract:
126 words
Manuscript:
1182 words
ACCEPTED MANUSCRIPT Abstract:
RI PT
Rheumatic heart disease is a common cause of cardiovascular morbidity and mortality worldwide, mostly in developing countries. Mitral stenosis and atrial fibrillation often coexist, related to both structural and inflammatory changes of
SC
the mitral valve and left atrium. Both predispose to left atrial thrombus formation, commonly involving the left atrial appendage. Thromboembolism can
NU
occur, with devastating consequences. We report the case of a 62 year old
MA
woman with rheumatic heart disease resulting in mitral stenosis and atrial fibrillation. Previous treatment with warfarin resulted in life-threatening
PT ED
gastrointestinal bleeding and she refused further anticoagulant therapy. A combined procedure was performed, including percutaneous balloon mitral valvuloplasty and left atrial appendage occlusion device implantation with the
CE
Atritech® Watchman® device. No thromboembolic or bleeding complications were encountered at one year follow-up. Long-term follow-up in a cohort of
AC
patients will be required to evaluate the safety and efficacy of this strategy.
ACCEPTED MANUSCRIPT
RI PT
INTRODUCTION
Rheumatic heart disease is a common cause of cardiovascular morbidity and mortality worldwide, mostly in developing countries. Mitral stenosis is a
SC
common consequence, causing disabling symptoms when severe. Atrial fibrillation also occurs, both as a result of atrial hypertension and dilation related
NU
to mitral stenosis, and persistent rheumatic inflammation and fibrosis. Patients
MA
are strongly predisposed to atrial thrombus formation and subsequent thromboembolic stroke and systemic embolism. Anticoagulation with a vitamin
PT ED
K antagonist is effective in reducing thromboembolism, but alternate management strategies are required in patients with contraindications to
CE
anticoagulation.
AC
CASE REPORT
A 62 year old female with longstanding rheumatic heart disease and mixed mitral valve pathology (predominantly stenosis) and concomitant atrial fibrillation (AF) presented with progressive dyspnea (NYHA Class III) and decreased exercise tolerance. Anticoagulant therapy was contraindicated due to previous life-threatening gastrointestinal bleeding on warfarin and the patient was subsequently treated with Aspirin 100mg daily. Physical examination revealed an irregular pulse, rate 70 bpm and BP 120/70mmHg. Pan systolic and mid-diastolic murmurs were present. 12-lead ECG demonstrated atrial fibrillation.
ACCEPTED MANUSCRIPT
3-dimensional transoesophageal echocardiogram (3D-TOE) showed a rheumatic
RI PT
mitral valve with moderately severe mitral stenosis (MPG 9mmHg and MVA 0.8cm2 by planimetry) and 2/4 mitral regurgitation. (Figure 1) Wilkins’ score for mitral stenosis was 8/16. Other findings included 2/4 tricuspid regurgitation
SC
and a left atrial appendage with characteristics which appeared suitable for
NU
device closure.
MA
Given the high risk of stroke related to valvular atrial fibrillation in the setting of rheumatic valve disease, anticoagulation therapy with warfarin was once again
PT ED
recommended, but the patient refused. Anticoagulation with one of the novel oral anticoagulant medications was considered, but not chosen because a) use in valvular atrial fibrillation is not studied and is therefore off-label and b) the risk
CE
of major gastrointestinal bleeding is similar to that of warfarin. Therefore combined percutaneous balloon mitral valvuloplasty and LAA occlusion were
AC
considered appropriate for this patient.
Under general anesthesia, arterial and venous sheaths were placed in the right groin. A Brockenbrough needle (St. Jude, Inc., Minneapolis, USA) was used to puncture the interatrial septum under both fluoroscopic and echocardiographic guidance (Figure 2). Transseptal puncture was performed in the mid to lower part of the posterior interatrial septum, which is ideal for LAA occluder device implantation. Multiple dilations of the mitral valve were performed with a 28mm Toray Inoue-balloon catheter (Toray Medical Co., Tokyo, Japan), inflated to 25cc,
ACCEPTED MANUSCRIPT resulting in the reduction of mean transmitral pressure gradient to 6mmHg, with
RI PT
no increase of mitral regurgitation. (Figure 3).
After mitral valvuloplasty was completed, the Inoue-balloon catheter was exchanged for an SL1 catheter (St. Jude, Inc., Minneapolis, USA), through which
SC
an 0.035in Amplatz super-stiff guide wire (Boston Scientific, Natick, USA) was placed into the left upper pulmonary vein. Subsequently a 14Fr single-curve
NU
delivery sheath was passed over the wire, with a 6Fr pigtail catheter delivered
MA
into the left atrium. (Figure 4) The left atrial appendage was then sized via both TOE and fluoroscopy; with an ostium of 17.7mm diameter. A 21mm Watchman®
PT ED
left atrial appendage (LAA) occluder device (Atritech, Inc., Plymouth, USA) was chosen. Prior to device deployment, the delivery sheath position was confirmed with contrast injection. Once deployed, the stability and positioning of the device
CE
were confirmed with the tug test and injection of contrast. Once disconnected, the device position and seal were again confirmed using both contrast injection
AC
and colour flow Doppler TOE imaging.
The patient was initiated on daily aspirin 100mg and clopidogrel 75mg and monitored in the coronary care unit post procedure. A transthoracic echocardiogram performed day one post procedure showed moderate mitral stenosis with MPG 7mmHG, 1-2/4 MR, a well seated watchman LAA occluder device and trivial pericardial fluid. A TOE performed on day 45 post procedure also showed moderate mitral stenosis with a well seated watchman device with no intra-device flow.
ACCEPTED MANUSCRIPT At six month follow-up the patient exhibited a significant symptomatic improvement, with complete resolution of dyspnoea. There were no bleeding
RI PT
complications during the 6 months of dual antiplatelet therapy and this was reduced to single agent Aspirin 100mg daily. No stroke or systemic embolism
SC
occurred in follow-up at one year.
NU
DISCUSSION
MA
Patients with both mitral stenosis and atrial fibrillation as a result of rheumatic heart disease have increased risk of thromboembolic stroke and systemic
PT ED
embolism compared to those with non-valvular AF (1). Left atrial thrombus is observed over 30% of patients and occurs in both the left atrial appendage and the body of the left atrium(2,3). Without anticoagulation, annual risk of
CE
thromboembolism is 17-18%(4). Importantly, traditional risk estimating tools such as CHADS2 and CHA2DS2-VASc do not apply to patients with rheumatic
AC
atrial fibrillation(5,6).
Anticoagulation with warfarin is recommended, with a target international normalized ratio (INR) of 2.5 – 3.5 for patients with rheumatic mitral stenosis and 3.0 – 4.0 for patients with a mechanical mitral valve prosthesis (4). Large trials of the novel oral anticoagulants have excluded patients with rheumatic/valvular atrial fibrillation and they are not currently indicated. In fact, a massive left atrial thrombus has been reported in a patient with rheumatic mitral stenosis and atrial fibrillation whilst anticoagulated with dabigatran (Pradaxa®)(7).
ACCEPTED MANUSCRIPT The combined procedure we have described may reduce the risk of stroke and systemic embolism by more than one mechanism. First, occlusion of the left
RI PT
atrial appendage with the Watchman® LAA occluder prevents thrombus formation within the appendage. Thrombus forms within the LAA in more than 50% of patients with rheumatic atrial fibrillation(3). In the PROTECT-AF study,
SC
the WATCHMAN LAA occluder device was shown to be non-inferior to warfarin in preventing stroke and systemic embolism in patients with non-valvular AF(8).
NU
Second, treatment of mitral stenosis with balloon mitral valvuloplasty may help
MA
to reduce the thrombotic risk. Relief of mitral stenosis reduces stasis within the left atrium(9) and may prevent left atrial enlargement, which is a risk factor for
PT ED
thromboembolism(4). In addition, mitral stenosis causes a hypercoagulable state which is likely to contribute to thrombus formation and embolism, and balloon
CE
mitral valvuloplasty has been shown to reduce this hypercoagulable state(10).
Technical considerations for combining these two procedures are important. The
AC
location of the transseptal puncture is vital for placement of the LAA occluder device, and thus this takes priority. The mid to lower part of the posterior interatrial septum is considered ideal, although this may make the balloon mitral valvuloplasty more challenging in some patients. The exchange procedure also requires careful consideration. An SL1 guiding catheter was used to maintain position in the left atrium whilst exchanging the Inoue-balloon catheter for a stiff wire. This allows delivery of the 14-Fr delivery sheath and routine implantation of the Watchman LAA occluder device.
ACCEPTED MANUSCRIPT Further evaluation of this strategy in a larger number of patients with long term follow-up is required. A cohort study reporting procedural safety, bleeding and
SC
RI PT
embolic events would provide further useful information.
NU
CONCLUSION
MA
We present a case of a combined procedure to reduce mitral stenosis and prevent thromboembolism in a patient with rheumatic heart disease, atrial
PT ED
fibrillation and contraindication to warfarin. Patients with rheumatic atrial fibrillation are at high risk of thromboembolism, and warfarin is first line therapy. Novel oral anticoagulants are untested and may be ineffective.
CE
Combined mitral valvuloplasty and LAA occluder device therapy should be considered in the rare instance where a patient has an indication for both
AC
procedures, although the long term efficacy of this approach is yet to be determined.
SC
RI PT
ACCEPTED MANUSCRIPT
NU
Figure Legend
MA
Figure 1. A 3-dimensional transesophageal echocardiographic (TEE) image of
PT ED
the stenotic mitral valve. Mitral valve area by planimetry was 0.8cm2.
Figure 2. A TEE image of the Brockenbrough needle ‘tenting’ the interatrial
AC
CE
septum (arrow), prior to transseptal puncture.
Figure 3. Fluoroscopic (left) and TEE (right) images of the inflated 28mm Toray Inoue-balloon catheter.
Figure 4. The exchange procedure. After balloon mitral valvuloplasty, the Inoueballoon catheter was exchanged for an SL1 catheter (A). Via the SL1 catheter, an 0.035in extra support wire was placed into the left upper pulmonary vein (B). Subsequently, a 14 Fr single-curve delivery catheter was passed over the wire
ACCEPTED MANUSCRIPT (C). Finally, a 6 Fr pigtail catheter was delivered into the left atrium so that the
SC
RI PT
left atrial appendage could be imaged (D).
MA
NU
References
1. Marijon E, Mirabel M, Celermajer DS, Jouven X. Rheumatic heart disease.
PT ED
Lancet 2012; 379: 953–64.
2. Srimannarayana J, Varma RS, Satheesh S, Anilkumar R, Balachander J.Prevalence of left atrial thrombus in rheumatic mitral stenosis with
CE
atrial fibrillation and its response to anticoagulation: a transesophageal echocardiographic study. Indian Heart J. 2003;55(4):358-61.
AC
3. Blackshear JL,Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755 759.
4. Vora A. Management of atrial fibrillation in rheumatic valvular heart disease. Current Opinion in Cardiology 2006, 21:47–50. 5. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of Clinical Classification Schemes for Predicting Stroke: Results From the National Registry of Atrial Fibrillation. JAMA. 2001;285(22):2864-2870.
ACCEPTED MANUSCRIPT 6. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJGM. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial
RI PT
fibrillation using a novel risk factor-based approach. Chest. 2010;137(2):263-72.
7. Luis SA, Poon K, Luis C, Shukla A, Bett N, Hamilton-Craig C. Massive left
SC
atrial thrombus in a patient with rheumatic mitral stenosis and atrial
Imaging. 2013;6:491-492.
NU
fibrillation while anticoagulated with dabigatran. Circ Cardiovasc
MA
8. Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P. Percutaneous closure of the left atrial appendage versus
PT ED
warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 2009; 374: 534–42 9. Carabello BA. Modern management of mitral stenosis. Circulation.
CE
2005;112:432-437.
10. Chen MC, Wu CJ, Chang HW, Yip HK, Chen YH, Cheng CI, Chai HT.
AC
Mechanism of reducing platelet activity by percutaneous transluminal mitral valvuloplasty in patients with rheumatic mitral stenosis. Chest.
2004;125:1629 –1634.
PT ED
MA
NU
SC
RI PT
ACCEPTED MANUSCRIPT
AC
CE
Fig. 1
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MA
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SC
RI PT
ACCEPTED MANUSCRIPT
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CE
Fig. 2
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Fig. 3
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Fig. 4