Author + information
- Received March 26, 2018
- Revision received May 3, 2018
- Accepted May 15, 2018
- Published online July 2, 2018.
- Achille Gaspardone, MD, MPhila,∗ (, )
- Fabrizio D’Errico, MDa,
- Maria Iamele, MDa,
- Fabiana Piccioni, MDa,
- Cesare Iani, MDb and
- Gregory A. Sgueglia, MD, PhDa
- aDivision of Cardiology, Sant’Eugenio Hospital, Rome, Italy
- bDivision of Neurology, Sant’Eugenio Hospital, Rome, Italy
- ↵∗Address for correspondence:
Prof. Achille Gaspardone, U.O.C. Cardiologia, Ospedale S. Eugenio, Piazzale dell’Umanesimo, 10, Rome 00144, Italy.
- balloon mitral valvuloplasty
- cerebrovascular protection
- left atrial appendage closure
- transseptal puncture
A 69-year-old patient with dyspnea and sudden onset of right hemiplegia and dysarthria was admitted to our institution and rapidly underwent successful mechanical thrombectomy because of a basilar artery occlusion. A good functional outcome was achieved.
The diagnostic work-up revealed rapid–ventricular rate atrial fibrillation and severe mitral valve stenosis, left atrial spontaneous echocardiographic contrast, and a small thrombus formation in the apex of a chicken-wing-morphology left atrial appendage (LAA). Both CHA2DS2-VASc and HAS-BLED scores were 4. Because of contraindication to oral anticoagulation, a decision was made to undertake percutaneous LAA closure and combined balloon mitral valvuloplasty with total cerebrovascular protection.
From both transradial access points, 2 Sentinel (Claret Medical, Santa Rosa, California) cerebral protection systems were advanced toward the aortic arch with their embolic filters delivered to all 3 supra-aortic vessels (Figure 1). The right femoral artery was also cannulated for aortography and invasive blood pressure monitoring. Following right femoral vein access and spontaneous breathing sedation, transesophageal echocardiography–guided transseptal puncture was performed at a midposterior site (Figure 2).
After imaging and measurement of the LAA, a 32/36-mm LAmbre (Lifetech Scientific, Shenzhen, China) LAA occlusion system was implanted (Figure 3). Thereafter, balloon mitral valvuloplasty was performed with an Inoue (Toray Medical, Tokyo, Japan) 26 balloon advanced through the same transseptal access, restoring a valve area of 2.5 cm2 after 3 consecutive dilatations (Figure 4).
Finally, before embolic filter removal, external electric cardioversion (synchronous 360-J shock) restored sinus rhythm (Figure 5). Notably, a small thrombus was found in the left subclavian filter (Figure 6).
Routine neurological assessment pre- and post-intervention yielded normal neurocognitive function, and no new lesions were found on post-procedural brain magnetic resonance imaging (Figure 7).
Attention to the patient’s complex profile and careful procedural planning directed this first-reported dual cerebral protection system implementation and double left heart intervention through the same transseptal access to seek an optimal safety/efficacy ratio.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 26, 2018.
- Revision received May 3, 2018.
- Accepted May 15, 2018.
- 2018 American College of Cardiology Foundation