Author + information
- Received September 3, 2018
- Revision received September 25, 2018
- Accepted October 2, 2018
- Published online January 21, 2019.
- aDivision of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
- bCARID–Cardiovascular Research Institute Düsseldorf, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
- ↵∗Address for correspondence:
Dr. Patrick Horn, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Moorenstrasse 5, 40225 Düsseldorf, Germany.
Transcatheter mitral valve repair with the MitraClip system (Abbott Vascular GmbH, Santa Clara, California) is an established therapy of severe mitral regurgitation in patients at increased surgical risk. Periprocedural thrombus formation on the MitraClip device is a rare but dreaded complication because of the risk of embolization and ischemic stroke. The management of a thrombus on the right atrial side has been described previously (1). We here present a novel strategy for the management of left atrial (LA) thrombus formation with periprocedural low-dose thrombolysis to prevent thromboembolism and stroke.
In the first patient, transseptal puncture was hampered by a stiff interatrial septum requiring several attempts over a time-span of 30 min. When the needle finally passed the septum an interatrial septum–adherent but otherwise free-floating thrombus immediately formed at the puncture site in the LA, rapidly growing up to 4.5 cm of length (Figure 1A, Online Video 1). Needle and sheath were immediately extracted, but despite an activated clotting time of 280 s the thrombus did not dissolve.
The second patient suffered from heparin intolerance and argatroban was used for periprocedural anticoagulation. A first clip was deployed successfully, and a second clip was passed into the LA. Despite an effective activated clotting time of 266 s, a floating mobile thrombus formed at its tip and a second one attached lateral to the clip arms (Figure 1B, Online Video 2), prohibiting the device retraction of the nondeployed clip because of incalculable risk of thrombus shedding.
In both patients, we had serious concerns about embolism and ischemic stroke. Surgery was not a valid option in these high-risk patients. We thus opted for the use of intravenous low-dose thrombolysis on top of maintained anticoagulation (total dose of 0.3 mg/kg alteplase, given as a 10-mg initial bolus followed by the remainder within 40 min), which successfully dissolved the thrombi over this time in both cases (Figures 1C and D, Online Videos 3 and 4). Both patients were free from any signs or symptoms of embolization. Minor bleeding at the femoral access site occurred in 1 patient and was easily controlled by manual compression and without need for blood transfusion.
Taken together, periprocedural low-dose thrombolysis during MitraClip procedures may represent a viable rescue option for the treatment of LA thrombus formation to prevent embolization and stroke.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 3, 2018.
- Revision received September 25, 2018.
- Accepted October 2, 2018.
- 2019 American College of Cardiology Foundation