Author + information
- Received December 26, 2016
- Revision received January 19, 2017
- Accepted January 26, 2017
- Published online March 15, 2017.
- John Roosen, MDa,
- Peter Haemers, MDa,b,∗ (, )
- Peter Verhamme, MD, PhDb,
- Koen Ameloot, MDa,b and
- Herbert De Praetere, MDa,b
- aCardiology Department, Imelda Hospitals Bonheiden, Bonheiden, Belgium
- bDepartment of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
- ↵∗Address for correspondence:
Dr. Peter Haemers, Cardiology Department, Imelda Hospitals Bonheiden, Imeldalaan 9, 2820 Bonheiden, Belgium.
An 82-year-old female patient with a history of aortic valve replacement and mitral valve repair was admitted several times with severe heart failure due to severe mitral valve regurgitation (Figure 1A). Given the poor prognosis and the high operative risk of redo surgery (European System for Cardiac Operative Risk Evaluation II 40.63%), the heart team scheduled the patient for a valve-in-ring procedure. A left anterolateral minithoracotomy was performed, the apex was punctured and a Safari wire (Boston Scientific, Marlborough, Massachusetts) was placed in the left atrium. Using a BOLT sheath (Boston Scientific), a 23-mm LOTUS valve (size based on the preoperative ultrasound with valve diameter of 1.5 mm × 1.8 mm) (Boston Scientific) was smoothly delivered in the mitral annulus and gradually deployed (Figure 1B). In the final position, the grade of mitral regurgitation was reduced to less than grade 1 with only slight obstruction of the left ventricular outflow tract (Figure 1C). Hemodynamics improved immediately after valve implantation, dual antiplatelet therapy (aspirin, clopidogrel) was started, and patient was discharged home after 10 days. Six weeks later, the patient presented with pulmonary edema. Ultrasound revealed a severe increase of the mitral valve gradient with confirmation of prosthetic valve thrombosis (Figure 1D). Low-dose alteplase (1 mg/h) in combination with fondaparinux (2.5 mg, given previously positive heparin-induced thrombocytopenia antibodies) was administered. During 38 hours of thrombolysis, gradual improvement of the clinical condition and the mitral valve gradient were observed. Echocardiography confirmed resolution of thrombotic material (Figures 1E to 1H). Patient was discharged with oral vitamin K antagonists in combination with aspirin. To the best of our knowledge, this is the first case of thrombosis of a transcatheter valve in the mitral position. The position of the transcatheter valve is more atrialized compared to the conventional position of a surgical mitral valve. This might cause a worse wash-out of blood by the flow in the outflow tract. It remains open to discussion whether patients with transcatheter valves in more prothrombotic mitral position would benefit from post-operative anticoagulation as suggested for surgical mitral valve replacement.
Drs. Roosen and Haemers contributed equally to this study.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 26, 2016.
- Revision received January 19, 2017.
- Accepted January 26, 2017.
- 2017 American College of Cardiology Foundation