Marek Woźnicki

Successful reduction of severe mitral regurgitation after implantation of four MitraClip devices

Mitral regurgitation (MR) is one of the most common valvular heart diseases. According to the current guidelines, surgical treatment may be considered in symptomatic patients with severe functional MR. A therapy using the MitralClip (MC) system may be an alternative approach for patients who are at high surgical risk. The presented case report illustrates, as the first one in Poland, a very rare need for the implantation of 4 MC devices in a symptomatic patient with severe functional MR and indicates feasibility and safety of such management.

Device-associated thrombus after percutaneous left atrial appendage closure: a case report and literature review

Introduction. In the setting of atrial fibrillation (AF), left atrial appendage (LAA) closure using the Watchman TM device (WD) was proven to effectively prevent stroke, systemic embolism and cardiovascular death when compared with warfarin therapy. However, this procedure is potentially associated with the risk of complications, including device-attached thrombus formation. Case presentation. We report a case of a 65-year-old woman with permanent non-valvular AF, a history of ischemic stroke on warfarin treatment, hypertension, diabetes mellitus, heart failure with preserved left ventricular ejection fraction, labile values of the international normalized ratio, enlarged left atrium (LA) and spontaneous echo contrast in echocardiography, who was qualified for percutaneous LAA closure using the WD. The pre-procedural patient assessment indicated high thromboembolic (CHA 2 DS 2 -Vasc Score = 5) and bleeding risk (HAS-BLED Score = 4), and optimal morphology of LAA in transesophageal echocardiography (TEE). After a successful procedure using a 30 mm-sized WD, and despite appropriate antiplatelet and anticoagulation therapy, 6-month follow-up TEE revealed a mobile thrombus (2.4 cm × 0.6 cm) at the atrial side of the WD. Therapy with intravenous heparin was started. However, a control TEE examination after one week revealed progression of the thrombus size (4.2 cm × 0.7 cm) and its protrusion across the mitral valve orifice into the left ventricle. Although the patient remained asymptomatic, cardiosurgical excision of the thrombus was performed due to high risk of thrombus embolization. Conclusions. Late device-associated thrombus formation after implantation of the WD remains a rare but severe complication. Formal recommendations regarding prevention and management of device-related thrombosis are still lacking. In this complex clinical setting, we suggest: 1) careful long-term echocardiographic monitoring after percutaneous LAA closure, especially in patients with permanent AF, high thromboembolic risk, large LA and dense spontaneous echo contrast in echocardiography, and 2) an individualized treatment approach.

Percutaneous left atrial appendage closure for thromboembolic prophylaxis in patients with atrial fibrillation. The impact of operator's experience on the procedure course

Background. Left atrial appendage (LAA) closure represents an alternative strategy to oral anticoagulants in thromboembolic prophylaxis in patients with atrial fibrillation (AF). The LAA closure with the WATCHMAN™ device has been proved to be non-inferior to warfarin therapy. Nevertheless, this strategy is associated with numerous periprocedural complications. This study was conducted to determine whether the experience of the operating team affects the duration of the procedure and its complication rate. Methods. This retrospective single-centre study examined LAA percutaneous closure procedures in 43 consecutive AF patients with contraindications to oral anticoagulation (13 female, 30 male; mean age 70.98 ± 10.69 years). All device implantations were performed by two operators using the WATCHMAN™ device and the result was assessed by two echocardiographers. We compared the first 22 (group A) with the subsequent 21 procedures (group B). Results. For group B, a decrease in the overall procedure time (PT) by 28% (from 83.41 min ± 36.49 to 59.76 min ± 21.70; p = 0.006) was found, with a subsequent reduction in fluoroscopy time (FT) by 33% (from 16.59 min ± 7.25 to 11.2 min ± 7.21; p = 0.019) and the volume of contrast medium (CV) by 40% (from 129.14 mL ± 79.81 to 78.05 mL ± 33.82; p = 0.004). The incidence of periprocedural adverse events and complications was 55% (12 patients) in group A and 33% (7 patients) in group B. Conclusions. The increasing operators’ and echocardiographers’ experience in LAA closure is associated with reduction in procedure time, fluoroscopy time and contrast volume.