To the Editor Transcatheter edge-to-edge repair (TEER) of mitral valves has emerged as an innovative treatment for significant mitral regurgitation. However, procedure-related complications, while infrequent, warrant careful consideration. Unno et al. recently reported a rare case in which a patient with heart failure developed subacute thrombus formation in the left atrium following TEER, despite a prior history of left atrial appendage occlusion (LAAO) (1). This case raised several pertinent concerns.
Based on their findings, the authors advocate prophylactic short-term anticoagulation therapy post-TEER in patients with an elevated risk of thrombus formation in the left atrium (1). Critical issues include identifying the optimal patient selection criteria and determining the most appropriate anticoagulation regimens.
Our team previously reported successful outcomes with combined TEER and LAAO procedures, demonstrating comparable thromboembolism and bleeding rates relative to LAAO alone, provided that anticoagulation therapy was administered judiciously (2). Furthermore, a recent meta-analysis supports the routine use of short-term anticoagulation therapy after TEER, citing a reduction in stroke rates without a concomitant increase in bleeding risk.
Conversely, a subset of patients, particularly those undergoing LAAO, present a heightened bleeding risk, which constitutes a primary indication for LAAO. Therefore, routine anticoagulation therapy may not be universally applicable following TEER in patients with prior LAAO. Identifying the appropriate candidates for anticoagulation therapy after TEER remains a critical question.
Device-related thrombus formation after LAAO has been observed in some patients (2). For instance, individuals with elevated baseline B-type natriuretic peptide levels, such as those reported by Imamura et al., are at greater risk for thromboembolic complications after LAAO (3). This prompts a deeper inquiry into the physiological mechanisms underlying thrombus formation in such cases following TEER and LAAO.
Furthermore, anatomical considerations, such as the characteristics of the interatrial septal puncture site, left atrial function, and degree of mitral stenosis induced by TEER, may influence the likelihood of procedure-related thrombus formation in the left atrium. Addressing these multifaceted factors is crucial for optimizing patient outcomes and improving the safety and efficacy of TEER procedures.
The authors state that they have no Conflict of Interest (COI).
References
- 1.Unno K, Ohtani H, Sakamoto A, et al. Left atrial thrombus after transcatheter mitral edge-to-edge repair in a patient with left appendage occlusion. Intern Med 64: 1862-1866, 2025. [DOI] [PMC free article] [PubMed] [Google Scholar]
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