Guest Editorial
 

Percutaneous Balloon Mitral Valvuloplasty with Bilateral Carotid
Protection in 2 cases of Left atrial Thrombus
N. O. Bansal MD, DM 1 Bhanu Duggal, MD,DM2, R Omnath MD3

Department of Cardiology, Grant Medical College & sir J J Group of Hospitals, Mumbai, Maharatra

ABSTRACT

Abstract: We present 2 cases of mitral stenosis with left atrial thrombus who underwent Balloon Mitral Valvotomy with bilateral carotid protection using SpiderFX , distal protection devices to minimize the risk of neuroembolic stroke. One patient was critical MS in congestive heart failure with a highly mobile left atrial appendage clot (LAA) and the second patient was a young female who declined surgery and had an LAA clot which did not respond to warfarin therapy.

Key words- Key words: balloon mitral valvotomy; left atrial thrombus,carotid protection

Introduction

Rheumatic Mitral stenosis(MS) is often associated with left atrial thrombus (8-13%)1 and has been an important exclusion criteria for balloon mitral valvotomy (BMV). BMV in this scenario can lead to the catastrophic complication of an embolic stroke with the manipulation of guide wires and balloons in the left atrium. At the same time if one could avoid this dreaded complication, this otherwise safe procedure would be an alternative in certain subsets of patients who would be high risk candidates for surgery .
Another subset of deserving patients are young women of developing countries who are disadvantaged by existing social practices, and a scar of cardiac bypass surgery could mar their prospective marriage and family life. These women constitute a significant subset of Rheumatic mitral stenosis patients and often decline to have the surgery or delay it till they have deteriorated to a terminal stage of mitral stenosis . We present 2 cases of critical mitral stenosis(MS) with an underlying milieu of left atrial thrombus, who underwent BMV , with neuroembolic protection.
Case History
The first case was a 55 year old male with severe mitral stenosis and a highly mobile left atrial appendage clot . He was put on intense oral anticoagulation (INR maintained between 3.5-4.5) and a repeat transoesophageal echocardiogram (TOE) at 6 weeks showed that the clot had decreased in size. However after about 10 weeks he presented with severe biventricular failure and atrial fibrillation with

fast ventricular rate . He was in a low cardiac output state and had raised renal parameters. He was stabilized with inotropes and TOE revealed an LAA clot which was freely mobile. As he was at a high risk case for surgical bypass (EUROSCORE 6)2 we took him up for an emergent BMV with bilateral carotid protection using bilateral SPIDERFx Embolic Protection Device s(ev3,Plymouth,MN,USA). The size of the device was decided on the basis of the pre-procedure carotid angiogram. The devices were deployed using 2 , 6F JR4 guiding catheters placed through a Cook’s 12 F sheath in the right femoral
artery. BMV was successfully performed and the mean gradient decreased from 15 mm Hg to 4 mm Hg and the valve area increased from 0.5 cm2to 1.2 cm2. Post-procedure the right femoral arterial pulse was feeble and an intravenous infusion of heparin was required for a few hours.
The second case was of a young, unmarried female , 28 years of age who had critical MS and had symptoms of breathlessness on exertion and orthopnoea and functional (NYHA) Class III symptoms. She had an LAA clot extending into the left atrium (Figure1 ). She was put on anticoagulation with warfarin but there was only a marginal decrease in the thrombus size even after 2 months. As the patient was unwilling for the surgical option , it was decided to proceed with mitral valvuloplasty in her case , with neuroembolic protection, again using the Spider Fx distal protection devices in both the internal carotids(Figure 2).She underwent a successful BMV and the valve area increased from 0.6 cm2 to 1.8 cm2 post procedure.

Discussion
These two cases provide an alternative approach to surgery in a patient with co-morbid conditions at a high risk for perioperative mortality ,as well as patients unwilling for the same due to social implications, provided cost is not a consideration. Only one case has been previously reported in literature of a patient with severe comorbid conditions in whom this approach has been used3.

Correspondence:Dr.Department of Cardiology, 4th floor, Main Building, Grant Medical College & Sir JJ group of Hospitals,Byculla;Mumbai 400 008.
Email: [email protected]

Indian Heart J. 2010; 62:179-180
 
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Though the ACC/AHA guidelines emphasis the absence of left atrial thrombus as a prerequisite for BMV many operators feel that sessile LA appendage clots are no longer a contraindication to the percutaneous approach. . Others have warranted BMV under TEE guidance while a recent study has put forth an approach of  low septal puncture to avoiding  left atrial clots in certain locations 4,5.

Distal protection  devices(DPDs) have been shown to reduce cerebrovascular complications to less than1% in patients undergoing carotid angiography , in the hands of  experienced operators. As embolisation into the carotid artery and anterior cerebral circulation is catastrophic, we decided to deploy neuro-embolic protection devices in bilateral carotids to protect  them from any shower of embolic debris

during the procedure. There was no evidence of any systemic embolisation  post-procedure. Carotid angiography and placement of internal carotid artery filters was done with Spider RX filters which have been shown to have the best wall apposition and capture efficiency6. This is the first use of this second generation mobile basket DPDs in this scenario.

References

1) Shaw TRD, Northridge DB, Sutaria N; Mitral balloon valvotomy and left atrial thrombus: Heart 2005; 91:1088-1089.
2) Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow s, Salamon R: European system for cardiac operative risk evaluation. European Journal of Cardio-thoracic surgery;1999 16.9-13.
3) Blake JWH, Hanzel GS, O’Neill WW:Neuroembolic protection during BMV .Cathet Cardiovascular Int 2007;69(1):52-55.
4) Kamalesh M, Burger AJ, Shubrooks SJ: The use of transesophageal echocardiography to avoid left atrial thrombus during percutaneous mitral valvotomy. Cathet Cardiovascular Diagn 1993; 28:320-322.
5) Manjunath CN, Srinivasa KH, Ravindranath KS, Manohar JS, Prabhavathi, Dattatreya PV et al . Balloon Mitral valvotomy in patients with mitral stenosis and left atrial thrombus . Catheter Cardiovasc Interv 2009 June;9999 (999A):published online.
6) Siewiorek GM, Wholey MH, Finol EA In vitro performance assessment of distal protection devices for carotid artery stenting: effect of physiological anatomy on vascular resistance. J Endovasc Ther 2007Oct:14(5): 712-24.

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Indian Heart J. 2010; 62:179-180