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

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: medhawini2k@yahoo.com

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

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3) Blake JWH, Hanzel GS, O’Neill WW:Neuroembolic protection during BMV .Cathet Cardiovascular Int 2007;69(1):52-55.
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