Catheterization and Cardiovascular Interventions 00:00–00 (2014)
Case Report Percutaneous Balloon Mitral Valvuloplasty Under Neuroprotection: Too Early for Knighthood Saujatya Chakraborty, MD, Ramalingam Vadivelu, MD, DM, and Shiv Bagga,* MD, DM The case describes the successful percutaneous balloon mitral valvuloplasty under neuroprotection in a patient with severe symptomatic mitral stenosis and persistent left atrial appendage thrombus despite chronic warfarin therapy. Although the procedure was uneventful for any systemic embolism, the limitations of this approach are highlighted with authors still advocating that surgery remains the benchmark treatment for these patients. VC 2014 Wiley Periodicals, Inc. Key words: PBMV; LAA
INTRODUCTION
Percutaneous balloon mitral valvuloplasty (PBMV) is currently the treatment of choice for suitable patients with symptomatic mitral stenosis due to rheumatic heart disease. However, presence of left atrial (LA)/left atrial appendage (LAA) clot has generally been considered to be a contraindication to such a procedure. This is primarily because of the risk of systemic embolization, especially cerebrovascular accidents. In this case report, we present a patient in whom conventional PBMV was performed in spite of the presence of LAA clot, using filter type distal embolization protection devices.
zem, digoxin, warfarin, and diuretics and was advised mitral valve replacement with LAA clot removal. However, she was not willing for the same and was, consequently continued on medical management. Three months after starting the above mentioned treatment, the patient was admitted with complaints of vomiting and loss of appetite and worsening dyspnea associated with orthopnea and paroxysmal nocturnal dyspnea. The electrocardiogram (ECG) showed atrial fibrillation with controlled ventricular rate and ST depressions suggestive of digoxin toxicity, which was confirmed by increased serum digoxin levels (2.88 ng/mL). Cessation of digoxin therapy led to normalization of digoxin levels however there was no significant relief of dyspnea. In view of progressive dyspnea, relief of valvular stenosis was
CASE HISTORY
The patient was a 65 year old female who had a history of progressively worsening shortness of breath on exertion. On evaluation, she was found to have rheumatic heart disease with mitral stenosis. Mitral valve area was 0.7 cm2 with a mean trans-mitral gradient of 20 mm of Hg on Doppler echocardiography. The Wilkins score was 7. Echocardiography also showed trivial mitral regurgitation, trivial tricuspid regurgitation, and severe pulmonary arterial hypertension (pulmonary artery systolic pressure of 64 mm Hg). Transesophageal echocardiography (TEE) showed a thrombus localized to the LAA (Fig. 1). She also had atrial fibrillation with fast ventricular rate. The patient was started on diltiaC 2014 Wiley Periodicals, Inc. V
Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India Conflict of interest: Nothing to report. *Correspondence to: Shiv Bagga, MD, DM, Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India. E-mail: [email protected] Received 10 September 2013; Revision accepted 27 January 2014 DOI: 10.1002/ccd.25421 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com)
2
Chakraborty et al.
Fig. 1. Transesophageal echocardiography image demonstrating stenosed mitral valve, spontaneous echo contrast, and LAA full of thrombus.
considered prudent. Repeat TEE showed persistence of LAA clot. Since patient declined surgery, considering the moderate risk of surgery (EuroSCORE of 4) along with a persistent LAA thrombus despite long term warfarin therapy, the option of PBMV with neuroprotection was offered to her. An informed consent was taken after explaining the details of the procedure, its risks and benefits with the patient and her relatives. Selective angiography of both the common carotid arteries to assess suitability for embolic protection device (EPD) deployment was performed using a 6 French Judkins right diagnostic catheter, after obtaining bilateral femoral arterial (6 French sheaths) and right femoral venous (9 French sheath) access. 7-mm and 6-mm Angioguard XP Emboli Capture Guidewire System (Cordis, A Johnson & Johnson company; Miami Lakes, FL) were deployed in the right and left internal carotid arteries, respectively under fluoroscopic guidance (Fig. 2), using 6 French, 90 cm Shuttle sheaths (Cook, Bloomington, IN). Septal puncture was performed using a standard Brockenbrough needle technique. A 0.025 inch coiled guide wire was introduced into the left atrium using a Mullin’s sheath. Care was taken to avoid approaching the left atrial appendage. Dilatation of the puncture site was performed with a 9 French septal dilator, following which conventional mitral valvuloplasty was performed with a 26 mm Inoue balloon inflated to 25 mm. The transmitral gradient fell from 26 to 0 mm Hg. The mitral valve area as calculated by the Gorlin formula increased from 0.7 to 1.54 mm2 while the cardiac output increased from 3.25 to 3.5 l/min. Subsequently, both the neuroembolic protection devices were retrieved without complication (Fig. 3). No macroscopic debris was seen in either filter. Fluoroscopy time was 25 min. There was no periprocedural
Fig. 2. Left lateral view of neck demonstrating bilateral internal carotid artery filters (arrows).
Fig. 3. Right anterior oblique view of neck demonstrating patent bilateral internal carotid artery filters without any evidence of thrombus or slow flow (arrows).
clinical evidence of cerebral or systemic embolization. Postprocedure, the patient experienced a marked improvement in symptoms with resolution of congestive heart failure. She was discharged in New York
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
PBMV Under Neuroprotection
Heart Association (NYHA) Class II on warfarin and rate controlling drugs. DISCUSSION
Conventional management of patients of severe mitral stenosis with LA/LAA thrombus focuses on mitral valve surgery, if the thrombi do not resolve after continued anticoagulation therapy. Though embolism has been reported in 0.5 to 5% in different series [1], PBMV in such scenarios is associated with increased risk of systemic embolism. However, there have been reports of use of PBMV in patients with LA/LAA clot. In one report, 66 patients with LAA thrombus persisting after at least 6 weeks of warfarin therapy were taken up for PBMV [2]. No embolic episodes were seen. In another case report, six patients with thrombus confined to LAA underwent PBMV without complications [3]. Though these data are encouraging there still remains a significant possibility of causing systemic thromboembolism due to the hardware coming in contact with the clot during the procedural manipulations. With these concerns in mind, a recent study has put forth an approach of low septal puncture to avoid left atrial clots in certain locations. In this study, 108 patients with LA thrombus were taken up for PBMV. Of these, 39 had thrombus extending up to the LA body/roof. There was only one case of transient ischemic attack seen [4]. On the basis of this data, the authors proposed a classification scheme of LA/ LAA thrombi with PBMV being a reasonable option for type Ia, Ib, and IIa thrombi. However the limitation of this approach remains that not all operators are skilled in this low septal puncture technique as this study was reported from a high volume centre for PBMVs and these results may be difficult to replicate in other centres. Others have advocated PBMV under TEE guidance [5] or use of “over-the-wire” technique [6,7] to make the procedure safe. Use of neuroprotection devices seems an intuitive approach in such patients however the data is limited to case reports only. The first case was reported in a 71 year old female with NYHA IV symptoms who was considered high risk for surgery [8]. This patient had a large LAA thrombus protruding into the LA cavity, which persisted despite 6 weeks of intensive warfarin therapy. There were no embolic events postprocedure. A recent article reported successful PBMV under bilateral carotid neuroprotection without any embolic sequale in two patients of severe rheumatic MS with LAA clot [9]. Our patient also had a clot confined to the LAA, which persisted despite chronic oral anticoagulant therapy. The satisfactory completion of PBMV along with salutary improvement of symptoms achieved, seems to
3
suggest that this technique can be safely pursued by experienced operators and may provide an alternative approach to surgery in these patients with co-morbid conditions at a high risk for perioperative mortality. However limitations of this approach needs to be appreciated. Though experimental models of brain embolism do show a high incidence of anterior cerebral circulation localization, this in no way means that the posterior circulation is always spared [10]. In addition, necropsy studies of patients with brain embolism of cardiac origin with fatal strokes nearly always show embolic infarcts in other organs, especially the spleen and kidneys [11]. Also the time course of embolic stroke after the manipulation of thrombus by the hardware can be difficult to predict. This might have a bearing on the timing of the stroke because cardiac embolism can still manifest postprocedure once the cerebral circulation is unprotected after removal of the EPDs. Further, the LAA clot in our case might have got organized by the time we took our patient for PBMV and by minor modification of the procedure as discussed above, balloon dilatation of mitral valve could have been performed without resorting to use of neuroprotection devices. However, even under these circumstances surgical options remain a safer option. CONCLUSION
Although PBMV under neuroprotection may provide an alternative approach to surgery in patients with LAA clot especially in those with comorbidities and a high risk for perioperative mortality, the procedure suffers from inherent limitations. Until the time, we have more robust data on both the short and long-term results of this approach it should not be advocated as an alternative approach to the gold standard surgical approach unless being in extenuating circumstances. REFERENCES 1. Drobinski G, Montalescot G, Evans J, Nivet M, Thomas D, Grosgogeat Y. Systemic embolism as a complication of percutaenous mitral valvuloplasty. Catheter Cardiovasc Diagn 1992; 25:327–330. 2. Yeh KH, Hung JS, Wu CJ, Fu M, Chua S, Chern MS. Safety of Inoue balloon mitral commisurotomy in patients with left atrial appendage thrombi. Am J Cardiol 1995;75:302–304. 3. Chen WJ, Chen MF, Liau CS, Wu CC, Lee YT. Safety of percutaneous transvenous mitral commisurotomy in patients with mitral stenosis and thrombus in the left atrial appendage. Am J Cardiol 1992;70:117–119. 4. Manjunath CN, Srinivasa KH, Ravindranath KS, et al. Balloon mitral valvotomy in patients with mitral stenosis and left atrial thrombus. Catheter Cardiovasc Interv 2009;74:653–661. 5. Kamalesh M, Burger AJ, Shubrooks SJ. The use of transesophageal echocardiography to avoid left atrial thrombus during percutaneous mitral valvotomy. Catheter Cardiovasc Diagn 1993; 28:320–322.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
4
Chakraborty et al.
6. Meier B. Modified Inoue technique for difficult mitral balloon commissurotomy. Catheter Cardiovasc Diagn 1992;26:316–318. 7. Manjunath CN, Srinivasa KH, Patil CB, Venkatesh HV, Bhoopal TS, Dhanalakshmi C. Balloon mitral valvuloplasty: Our experience with a modified technique of crossing the mitral valve in difficult cases. Catheter Cardiovasc Diagn 1998;44:23–26. 8. Blake JWH, Hanzel GS, O’Neill WW. Neuroembolic protection during percutaneous balloon mitral valvuloplasty. Catheter Cardiovasc Interv 2007;69:52–55.
9. Bansal N, Duggal B, Omnath R. Percutaneous balloon mitral valvuloplasty with bilateral carotid protection in 2 cases of left atrial thrombus. Indian Heart J 2010;62:179–180. 10. Helgason CM. Cardioembolic stroke: Topography and pathogenesis. Cerebrovasc Brain Metab Rev 1992;4:28–58. 11. Abboud H, Labreuche J, Gongora-Riverra F, Jaramillo A, Duyckaerts C, Steg PG, Hauw JJ, Amarenco P. Prevalence and determinants of subdiaphragmatic visceral infarction in patients with fatal stroke. Stroke 2007;38:1442–1446.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Case Report Percutaneous Balloon Mitral Valvuloplasty Under Neuroprotection: Too Early for Knighthood Saujatya Chakraborty, MD, Ramalingam Vadivelu, MD, DM, and Shiv Bagga,* MD, DM The case describes the successful percutaneous balloon mitral valvuloplasty under neuroprotection in a patient with severe symptomatic mitral stenosis and persistent left atrial appendage thrombus despite chronic warfarin therapy. Although the procedure was uneventful for any systemic embolism, the limitations of this approach are highlighted with authors still advocating that surgery remains the benchmark treatment for these patients. VC 2014 Wiley Periodicals, Inc. Key words: PBMV; LAA
INTRODUCTION
Percutaneous balloon mitral valvuloplasty (PBMV) is currently the treatment of choice for suitable patients with symptomatic mitral stenosis due to rheumatic heart disease. However, presence of left atrial (LA)/left atrial appendage (LAA) clot has generally been considered to be a contraindication to such a procedure. This is primarily because of the risk of systemic embolization, especially cerebrovascular accidents. In this case report, we present a patient in whom conventional PBMV was performed in spite of the presence of LAA clot, using filter type distal embolization protection devices.
zem, digoxin, warfarin, and diuretics and was advised mitral valve replacement with LAA clot removal. However, she was not willing for the same and was, consequently continued on medical management. Three months after starting the above mentioned treatment, the patient was admitted with complaints of vomiting and loss of appetite and worsening dyspnea associated with orthopnea and paroxysmal nocturnal dyspnea. The electrocardiogram (ECG) showed atrial fibrillation with controlled ventricular rate and ST depressions suggestive of digoxin toxicity, which was confirmed by increased serum digoxin levels (2.88 ng/mL). Cessation of digoxin therapy led to normalization of digoxin levels however there was no significant relief of dyspnea. In view of progressive dyspnea, relief of valvular stenosis was
CASE HISTORY
The patient was a 65 year old female who had a history of progressively worsening shortness of breath on exertion. On evaluation, she was found to have rheumatic heart disease with mitral stenosis. Mitral valve area was 0.7 cm2 with a mean trans-mitral gradient of 20 mm of Hg on Doppler echocardiography. The Wilkins score was 7. Echocardiography also showed trivial mitral regurgitation, trivial tricuspid regurgitation, and severe pulmonary arterial hypertension (pulmonary artery systolic pressure of 64 mm Hg). Transesophageal echocardiography (TEE) showed a thrombus localized to the LAA (Fig. 1). She also had atrial fibrillation with fast ventricular rate. The patient was started on diltiaC 2014 Wiley Periodicals, Inc. V
Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India Conflict of interest: Nothing to report. *Correspondence to: Shiv Bagga, MD, DM, Department of Cardiology, Advanced Cardiac Centre, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India. E-mail: [email protected] Received 10 September 2013; Revision accepted 27 January 2014 DOI: 10.1002/ccd.25421 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com)
2
Chakraborty et al.
Fig. 1. Transesophageal echocardiography image demonstrating stenosed mitral valve, spontaneous echo contrast, and LAA full of thrombus.
considered prudent. Repeat TEE showed persistence of LAA clot. Since patient declined surgery, considering the moderate risk of surgery (EuroSCORE of 4) along with a persistent LAA thrombus despite long term warfarin therapy, the option of PBMV with neuroprotection was offered to her. An informed consent was taken after explaining the details of the procedure, its risks and benefits with the patient and her relatives. Selective angiography of both the common carotid arteries to assess suitability for embolic protection device (EPD) deployment was performed using a 6 French Judkins right diagnostic catheter, after obtaining bilateral femoral arterial (6 French sheaths) and right femoral venous (9 French sheath) access. 7-mm and 6-mm Angioguard XP Emboli Capture Guidewire System (Cordis, A Johnson & Johnson company; Miami Lakes, FL) were deployed in the right and left internal carotid arteries, respectively under fluoroscopic guidance (Fig. 2), using 6 French, 90 cm Shuttle sheaths (Cook, Bloomington, IN). Septal puncture was performed using a standard Brockenbrough needle technique. A 0.025 inch coiled guide wire was introduced into the left atrium using a Mullin’s sheath. Care was taken to avoid approaching the left atrial appendage. Dilatation of the puncture site was performed with a 9 French septal dilator, following which conventional mitral valvuloplasty was performed with a 26 mm Inoue balloon inflated to 25 mm. The transmitral gradient fell from 26 to 0 mm Hg. The mitral valve area as calculated by the Gorlin formula increased from 0.7 to 1.54 mm2 while the cardiac output increased from 3.25 to 3.5 l/min. Subsequently, both the neuroembolic protection devices were retrieved without complication (Fig. 3). No macroscopic debris was seen in either filter. Fluoroscopy time was 25 min. There was no periprocedural
Fig. 2. Left lateral view of neck demonstrating bilateral internal carotid artery filters (arrows).
Fig. 3. Right anterior oblique view of neck demonstrating patent bilateral internal carotid artery filters without any evidence of thrombus or slow flow (arrows).
clinical evidence of cerebral or systemic embolization. Postprocedure, the patient experienced a marked improvement in symptoms with resolution of congestive heart failure. She was discharged in New York
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
PBMV Under Neuroprotection
Heart Association (NYHA) Class II on warfarin and rate controlling drugs. DISCUSSION
Conventional management of patients of severe mitral stenosis with LA/LAA thrombus focuses on mitral valve surgery, if the thrombi do not resolve after continued anticoagulation therapy. Though embolism has been reported in 0.5 to 5% in different series [1], PBMV in such scenarios is associated with increased risk of systemic embolism. However, there have been reports of use of PBMV in patients with LA/LAA clot. In one report, 66 patients with LAA thrombus persisting after at least 6 weeks of warfarin therapy were taken up for PBMV [2]. No embolic episodes were seen. In another case report, six patients with thrombus confined to LAA underwent PBMV without complications [3]. Though these data are encouraging there still remains a significant possibility of causing systemic thromboembolism due to the hardware coming in contact with the clot during the procedural manipulations. With these concerns in mind, a recent study has put forth an approach of low septal puncture to avoid left atrial clots in certain locations. In this study, 108 patients with LA thrombus were taken up for PBMV. Of these, 39 had thrombus extending up to the LA body/roof. There was only one case of transient ischemic attack seen [4]. On the basis of this data, the authors proposed a classification scheme of LA/ LAA thrombi with PBMV being a reasonable option for type Ia, Ib, and IIa thrombi. However the limitation of this approach remains that not all operators are skilled in this low septal puncture technique as this study was reported from a high volume centre for PBMVs and these results may be difficult to replicate in other centres. Others have advocated PBMV under TEE guidance [5] or use of “over-the-wire” technique [6,7] to make the procedure safe. Use of neuroprotection devices seems an intuitive approach in such patients however the data is limited to case reports only. The first case was reported in a 71 year old female with NYHA IV symptoms who was considered high risk for surgery [8]. This patient had a large LAA thrombus protruding into the LA cavity, which persisted despite 6 weeks of intensive warfarin therapy. There were no embolic events postprocedure. A recent article reported successful PBMV under bilateral carotid neuroprotection without any embolic sequale in two patients of severe rheumatic MS with LAA clot [9]. Our patient also had a clot confined to the LAA, which persisted despite chronic oral anticoagulant therapy. The satisfactory completion of PBMV along with salutary improvement of symptoms achieved, seems to
3
suggest that this technique can be safely pursued by experienced operators and may provide an alternative approach to surgery in these patients with co-morbid conditions at a high risk for perioperative mortality. However limitations of this approach needs to be appreciated. Though experimental models of brain embolism do show a high incidence of anterior cerebral circulation localization, this in no way means that the posterior circulation is always spared [10]. In addition, necropsy studies of patients with brain embolism of cardiac origin with fatal strokes nearly always show embolic infarcts in other organs, especially the spleen and kidneys [11]. Also the time course of embolic stroke after the manipulation of thrombus by the hardware can be difficult to predict. This might have a bearing on the timing of the stroke because cardiac embolism can still manifest postprocedure once the cerebral circulation is unprotected after removal of the EPDs. Further, the LAA clot in our case might have got organized by the time we took our patient for PBMV and by minor modification of the procedure as discussed above, balloon dilatation of mitral valve could have been performed without resorting to use of neuroprotection devices. However, even under these circumstances surgical options remain a safer option. CONCLUSION
Although PBMV under neuroprotection may provide an alternative approach to surgery in patients with LAA clot especially in those with comorbidities and a high risk for perioperative mortality, the procedure suffers from inherent limitations. Until the time, we have more robust data on both the short and long-term results of this approach it should not be advocated as an alternative approach to the gold standard surgical approach unless being in extenuating circumstances. REFERENCES 1. Drobinski G, Montalescot G, Evans J, Nivet M, Thomas D, Grosgogeat Y. Systemic embolism as a complication of percutaenous mitral valvuloplasty. Catheter Cardiovasc Diagn 1992; 25:327–330. 2. Yeh KH, Hung JS, Wu CJ, Fu M, Chua S, Chern MS. Safety of Inoue balloon mitral commisurotomy in patients with left atrial appendage thrombi. Am J Cardiol 1995;75:302–304. 3. Chen WJ, Chen MF, Liau CS, Wu CC, Lee YT. Safety of percutaneous transvenous mitral commisurotomy in patients with mitral stenosis and thrombus in the left atrial appendage. Am J Cardiol 1992;70:117–119. 4. Manjunath CN, Srinivasa KH, Ravindranath KS, et al. Balloon mitral valvotomy in patients with mitral stenosis and left atrial thrombus. Catheter Cardiovasc Interv 2009;74:653–661. 5. Kamalesh M, Burger AJ, Shubrooks SJ. The use of transesophageal echocardiography to avoid left atrial thrombus during percutaneous mitral valvotomy. Catheter Cardiovasc Diagn 1993; 28:320–322.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
4
Chakraborty et al.
6. Meier B. Modified Inoue technique for difficult mitral balloon commissurotomy. Catheter Cardiovasc Diagn 1992;26:316–318. 7. Manjunath CN, Srinivasa KH, Patil CB, Venkatesh HV, Bhoopal TS, Dhanalakshmi C. Balloon mitral valvuloplasty: Our experience with a modified technique of crossing the mitral valve in difficult cases. Catheter Cardiovasc Diagn 1998;44:23–26. 8. Blake JWH, Hanzel GS, O’Neill WW. Neuroembolic protection during percutaneous balloon mitral valvuloplasty. Catheter Cardiovasc Interv 2007;69:52–55.
9. Bansal N, Duggal B, Omnath R. Percutaneous balloon mitral valvuloplasty with bilateral carotid protection in 2 cases of left atrial thrombus. Indian Heart J 2010;62:179–180. 10. Helgason CM. Cardioembolic stroke: Topography and pathogenesis. Cerebrovasc Brain Metab Rev 1992;4:28–58. 11. Abboud H, Labreuche J, Gongora-Riverra F, Jaramillo A, Duyckaerts C, Steg PG, Hauw JJ, Amarenco P. Prevalence and determinants of subdiaphragmatic visceral infarction in patients with fatal stroke. Stroke 2007;38:1442–1446.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
