Abstract
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 the mitral valve and left atrium. Both predispose to left atrial thrombus formation, commonly involving the left atrial appendage. Thromboembolism can occur, with devastating consequences. We report the case of a 62 year old woman with rheumatic heart disease resulting in mitral stenosis and atrial fibrillation. Previous treatment with warfarin resulted in life-threatening 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 Atritech® Watchman® device. No thromboembolic or bleeding complications were encountered at one year follow-up. Long-term follow-up in a cohort of patients will be required to evaluate the safety and efficacy of this strategy.
1
Introduction
Rheumatic heart disease is a common cause of cardiovascular morbidity and mortality worldwide, mostly in developing countries. Mitral stenosis is a common consequence, causing disabling symptoms when severe. Atrial fibrillation also occurs, both as a result of atrial hypertension and dilation related to mitral stenosis, and persistent rheumatic inflammation and fibrosis. Patients are strongly predisposed to atrial thrombus formation and subsequent thromboembolic stroke and systemic embolism. Anticoagulation with a vitamin K antagonist is effective in reducing thromboembolism, but alternate management strategies are required in patients with contraindications to anticoagulation.
2
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 100 mg daily. Physical examination revealed an irregular pulse, rate 70 bpm and BP 120/70 mmHg. Pan systolic and mid-diastolic murmurs were present. Twelve-lead ECG demonstrated atrial fibrillation.
Three-dimensional transoesophageal echocardiogram (3D-TOE) showed a rheumatic mitral valve with moderately severe mitral stenosis (MPG 9 mmHg and MVA 0.8 cm 2 by planimetry) and 2/4 mitral regurgitation ( Fig. 1 ). Wilkins’ score for mitral stenosis was 8/16. Other findings included 2/4 tricuspid regurgitation and a left atrial appendage with characteristics which appeared suitable for device closure.
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 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 of major gastrointestinal bleeding is similar to that of warfarin. Therefore combined percutaneous balloon mitral valvuloplasty and LAA occlusion were 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 ( Fig. 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 28 mm Toray Inoue-balloon catheter (Toray Medical Co., Tokyo, Japan), inflated to 25 cc, resulting in the reduction of mean transmitral pressure gradient to 6 mmHg, with no increase of mitral regurgitation ( Fig. 3 ).
After mitral valvuloplasty was completed, the Inoue-balloon catheter was exchanged for an SL1 catheter (St. Jude, Inc., Minneapolis, USA), through which a 0.035in Amplatz super-stiff guide wire (Boston Scientific, Natick, USA) was placed into the left upper pulmonary vein. Subsequently a 14Fr single-curve delivery sheath was passed over the wire, with a 6Fr pigtail catheter delivered into the left atrium ( Fig. 4 ). The left atrial appendage was then sized via both TOE and fluoroscopy; with an ostium of 17.7 mm diameter. A 21 mm Watchman® 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 were confirmed with the tug test and injection of contrast. Once disconnected, the device position and seal were again confirmed using both contrast injection and colour flow Doppler TOE imaging ( Fig. 5 ).
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