Abstract
Background
Persistent left atrial appendage thrombus complicates structural intervention when anticoagulation is limited by bleeding risk.
Case Summary
A 74-year-old man with prior surgical aortic and mitral bioprostheses presented with heart failure from severe bioprosthetic aortic stenosis and persistent left atrial appendage thrombus despite 6 months of anticoagulation. Because of recent gastrointestinal bleeding and progressive valve obstruction, the heart team selected a single-session strategy using Sentinel cerebral embolic protection. Valve-in-valve transcatheter aortic valve replacement was performed first, followed by bioprosthetic valve fracture confirmed by balloon pressure drop, waist release, and gradient reduction. Left atrial appendage closure was then performed with a Watchman FLX Pro device, trapping residual thrombus. Retrieved cerebral protection filters contained thrombotic debris, and the patient recovered without neurologic complications.
Discussion
In selected high-risk patients, simultaneous valve intervention and thrombus-exclusion left atrial appendage closure under cerebral protection may reduce cumulative procedural and anticoagulation-related risks.
Key words: bioprosthetic valve fracture, cerebral embolic protection, EUPASS technique, left atrial appendage closure, left atrial appendage thrombus, valve-in-valve TAVR
Visual Summary
Visual Summary.
A Patient With Prior Surgical Aortic and Mitral Valve Replacement Developed Severe Bioprosthetic Aortic Stenosis With Heart Failure and Persistent Large Left Atrial Appendage Thrombus Despite Prolonged Anticoagulation
A one-stop strategy was performed with cerebral embolic protection, valve-in-valve transcatheter aortic valve replacement assisted by bioprosthetic valve fracture, and left atrial appendage closure using a Watchman FLX Pro 40-mm device to entrap and exclude the residual thrombus. The modified EUPASS technique facilitated rapid crossing of the degenerated surgical bioprosthesis while minimizing wire exchanges and catheter manipulation. Final outcomes included improved transvalvular flow, circularized valve geometry after fracture, successful thrombus exclusion, captured embolic debris in the Sentinel filter, and no periprocedural stroke. AS = aortic stenosis; BVF = bioprosthetic valve fracture; HF = heart failure; LAA = left atrial appendage; LAAC = left atrial appendage closure; MVR = mitral valve replacement; SAVR = surgical aortic valve replacement; TAVR = transcatheter aortic valve replacement.
History of Presentation
A 74-year-old man with a history of surgical double valve replacement (2016; aortic Mitroflow bioprosthetic valve 23 mm and mitral Magna Ease valve 31 mm) presented with progressive dyspnea and heart failure symptoms.
Take-Home Message
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In selected patients with severe bioprosthetic valve failure, persistent left atrial appendage thrombus, and limited anticoagulation options, simultaneous valve-in-valve transcatheter aortic valve replacement and left atrial appendage closure under cerebral protection may reduce cumulative procedural and embolic risk.
Transthoracic echocardiography in 2025 demonstrated severe structural valve degeneration with a mean aortic valve gradient of 46.53 mm Hg and reduced effective orifice area (0.7 cm2) (Figures 1A and 1B).
Figure 1.
Preprocedural Imaging Findings
(A) Preprocedural three-dimensional transesophageal echocardiography (TEE) demonstrating severe bioprosthetic aortic stenosis with an aortic valve area of approximately 0.7 cm2. The relatively large sinus of Valsalva and the stent frame of the degenerated bioprosthesis contributed to anticipated difficulty in valve crossing. (B) Transthoracic echocardiography (TTE) showing a degenerated aortic bioprosthesis with a mean transvalvular gradient of 46.53 mm Hg. (C) Preprocedural computed tomography (2025) revealing a large left atrial appendage thrombus extending into the left atrial cavity. (D) Follow-up imaging after 6 months of carefully monitored anticoagulation demonstrating partial thrombus resolution, now confined from the posterior lobe to the mid-portion of the anterior lobe of the left atrial appendage.
Past Medical History
His medical history was also notable for hypertension and atrial fibrillation.
Investigations
Preprocedural imaging demonstrated severe bioprosthetic aortic stenosis, a markedly enlarged left atrial appendage (34-35 mm), and extensive thrombus extending from the appendage to the left atrial roof (Figure 1C). Laboratory evaluation revealed protein C and S deficiency (protein C 47.5%, protein S 30.5%) and recent gastrointestinal bleeding from a Dieulafoy lesion confirmed by endoscopy, while hematologic workup showed no evidence of Heyde syndrome (von Willebrand factor activity 145.9%, antigen 196.6%, factor VIII 136.1%). Despite anticoagulation with warfarin targeting an international normalized ratio of 2.5 to 3.0, serial transesophageal echocardiography (TEE) performed every 1 to 2 months and preprocedural computed tomography demonstrated only partial regression of the thrombus (Figure 1D).
Management
Given the patient's persistent heart failure due to severe bioprosthetic valve stenosis, the presence of residual left atrial appendage thrombus conferring a high embolic risk, and the limited feasibility of further intensified anticoagulation in the setting of recent gastrointestinal bleeding, a multidisciplinary heart team determined that an interventional strategy was warranted. To address both the hemodynamic compromise and thromboembolic risk in a single setting, the team elected to proceed with valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) with bioprosthetic valve fracture, followed by simultaneous left atrial appendage closure (LAAC) under protection with a Sentinel cerebral protection system.
Because valve crossing was expected to be difficult in the degenerated surgical bioprosthesis, a modified EUPASS technique was used to minimize catheter manipulation. A straight-tip guidewire and Safari XS guidewire were advanced through a 7F AL1 guiding catheter, allowing rapid alignment and crossing of the stenotic bioprosthetic orifice (Figure 2A, Videos 1 and 2). A 23-mm MyVal transcatheter heart valve was then deployed under rapid pacing at an approximate 8:2 depth (Figure 2B), followed by bioprosthetic valve fracture using a 22-mm Atlas GOLD balloon. Fracture was confirmed by an abrupt balloon inflation pressure drop at approximately 14 atm, release of the constrained balloon waist, and simultaneous hemodynamic assessment demonstrating near-complete elimination of the transvalvular gradient (Figure 2C, Video 3). After confirming the absence of acute complications, the procedure proceeded to LAAC via the pre-established right femoral venous access, which was exchanged for an SL0 sheath, and transseptal puncture was performed at the posterior-inferior fossa ovalis using an radiofrequency needle. To minimize the risk of thrombus dislodgement, only low-pressure contrast injections were used at the left atrial appendage ostium (Figure 3B, Video 4). Under TEE guidance, a Watchman FLX Pro 40-mm device was carefully advanced and deployed in the mid-portion of the anterior lobe, successfully trapping the residual thrombus with a single deployment and achieving satisfactory PASS criteria (Figure 3C, Video 5). Upon retrieval and flushing of the Sentinel cerebral protection system filters, 3 fragments of red thrombus or tissue measuring approximately 0.5 to 2 mm were identified (Figure 4).
Figure 2.
Procedural Steps of Valve-in-Valve Transcatheter Aortic Valve Replacement and Bioprosthetic Valve Fracture
(A) Modified EUPASS technique for rapid valve crossing. A straight-tip guidewire and a Safari XS guidewire were simultaneously introduced through a 7F AL1 guiding catheter. The support provided by the Safari wire enabled centralization of the guiding catheter and facilitated precise alignment of the straight wire toward the narrowed orifice of the degenerated bioprosthetic valve, allowing efficient valve crossing and direct advancement of the Safari wire with minimal catheter or wire exchange. (B) Deployment of a 23-mm MyVal transcatheter heart valve at the intended depth. (C) Bioprosthetic valve fracture was confirmed by abrupt balloon pressure drop, release of the constrained balloon waist, and immediate gradient reduction. Notably, in Mitroflow bioprosthetic valves, disruption of a radiopaque band is not visualized during fracture, as the band represents a positioning marker rather than the true structural stent frame.
Figure 3.
Intraprocedural Imaging During Left Atrial Appendage Closure
(A) Intraprocedural transesophageal echocardiography (TEE) demonstrating dense spontaneous echo contrast within the left atrial appendage under progressively titrated anticoagulation (activated clotting time 400-500 seconds), with sufficient space identified in the anterior lobe to accommodate a 40-mm Watchman FLX Pro. (B) Careful low-pressure contrast injection at the left atrial appendage ostium using a guiding catheter and pigtail catheter, revealing a filling defect (asterisk) consistent with residual thrombus. (C) Final deployment of the occlusion device with a single-shot release, achieving complete sealing of the left atrial appendage.
Figure 4.
Cerebral Embolic Protection and Captured Debris
(A) Fluoroscopic image demonstrating the Sentinel cerebral protection system in position. (B) Postprocedural inspection of the retrieved filters after flushing revealed 3 fragments of red debris of varying sizes, with the largest measuring approximately 2 mm.
Outcome and Follow-Up
The patient remained neurologically intact without evidence of periprocedural stroke or transient ischemic attack, was monitored in the intensive care unit for 1 day, and was subsequently discharged in stable condition on postoperative day 3.
Discussion
This case highlights a strategy integrating simultaneous structural interventions in a patient with competing thrombotic and bleeding risks. The patient had 2 competing problems: progressive heart failure from severe bioprosthetic aortic stenosis and persistent left atrial appendage thrombus despite anticoagulation, with recent gastrointestinal bleeding limiting further intensification of antithrombotic therapy. The decision to perform combined ViV TAVR and LAAC, with TAVR performed first, was guided by both hemodynamic and embolic considerations. ViV TAVR is known to carry a relatively higher risk of cerebral embolization than native TAVR due to manipulation within a degenerated prosthesis and constrained orifice geometry, which may increase debris generation.1,2 A staged approach would have required repeated vascular access, repeated periods of periprocedural anticoagulation, and potential interruption or adjustment of anticoagulation between procedures. Performing both procedures in a single session allowed continuous cerebral embolic protection with the Sentinel system during both high-risk procedural phases, while also avoiding the cumulative risks of staged procedures.1
The procedural sequence was deliberately selected. Although LAAC first could theoretically exclude the thrombus before aortic valve manipulation, ViV TAVR was performed first because severe bioprosthetic aortic stenosis was the dominant hemodynamic lesion and the immediate driver of heart failure. Restoring forward flow and reducing the transvalvular gradient before transseptal left atrial manipulation provided greater hemodynamic stability for the subsequent LAAC. This sequence also avoided prolonged left atrial instrumentation while severe outflow obstruction remained untreated. Because the Sentinel device had already been deployed, cerebral protection was maintained throughout both the valve intervention and the subsequent thrombus-trapping LAAC. During the ViV procedure, a modified EUPASS technique facilitated rapid valve crossing and minimized wire exchanges and catheter manipulation within the left ventricle and aortic root.3 Nevertheless, the optimal sequence should be individualized according to thrombus morphology, valve severity, hemodynamic status, and procedural feasibility.
In addition, given the patient's relatively young age and the importance of lifetime management, bioprosthetic valve fracture was intentionally performed to optimize expansion of the transcatheter valve within the small surgical bioprosthesis and to reduce residual gradient. Prior studies have demonstrated that incomplete or elliptical expansion in ViV TAVR is associated with higher residual gradients and suboptimal durability, whereas high-pressure fracture can improve effective orifice area and transvalvular hemodynamics.4 In this case, effective fracture was supported by balloon pressure drop, release of the constrained balloon waist, and immediate hemodynamic improvement. Because Mitroflow valves may not show obvious radiopaque ring disruption, these procedural findings were more informative than cine appearance alone. This geometry-oriented strategy was therefore relevant not only for immediate gradient reduction but also for long-term valve performance.
LAAC in the presence of residual thrombus remains controversial but may be feasible in highly selected cases under strict procedural control. In this case, LAAC was performed only after partial thrombus regression, under TEE guidance, with low-pressure contrast injection, intensified intraprocedural anticoagulation, and continuous cerebral protection. The Watchman FLX Pro was partially unsheathed to achieve its spherical configuration before advancement, facilitating coaxial alignment and controlled positioning within the anterior lobe where thrombus burden was lower. A single-shot deployment strategy was intentionally adopted to avoid recapture and repeated manipulation, allowing residual thrombus to be excluded within the appendage. Emerging reports and registries have suggested that, when combined with cerebral protection and careful technique, such “thrombus trapping” approaches may be performed with acceptable safety in selected high-risk patients.5
Conclusions
In a high-risk patient with residual left atrial thrombus and bioprosthetic valve failure, a strategy combining ViV TAVR with bioprosthetic valve fracture followed by LAAC under cerebral protection is feasible, enabling restoration of valve hemodynamics and effective thrombus exclusion while minimizing embolic and bleeding risks.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Modified EUPASS Setup for Difficult Valve Crossing.
Rapid Valve Crossing With Minimized Wire Exchanges and Catheter Manipulation.
Bioprosthetic Valve Fracture With Waist Release.
Low-pressure Left Atrial Appendage Contrast Injection Showing Residual Filling Defect.
Single-Deployment Watchman FLX Pro Closure With Thrombus Entrapment.
References
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Associated Data
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Supplementary Materials
Modified EUPASS Setup for Difficult Valve Crossing.
Rapid Valve Crossing With Minimized Wire Exchanges and Catheter Manipulation.
Bioprosthetic Valve Fracture With Waist Release.
Low-pressure Left Atrial Appendage Contrast Injection Showing Residual Filling Defect.
Single-Deployment Watchman FLX Pro Closure With Thrombus Entrapment.