An unusual complication of cardiac catheterisation during BMV

Description

Rheumatic heart disease is the most common cause of mitral stenosis, and percutaneous balloon mitral valvotomy (BMV) has stood the test of time as the standard therapy for the same. We describe a very unusual complication of cardiac catheterisation that occurred during an otherwise uneventful procedure.

A 65-year-old woman was diagnosed with severe mitral stenosis due to rheumatic heart disease. She was in atrial fibrillation and was admitted for BMV. She had a history of stroke from which she had recovered. Patient was on oral anticoagulation that was stopped and unfractionated heparin was given instead, prior to the procedure. Patient's mitral valve was suitable for BMV, with no demonstrable left atrial/left atrial appendage clot on transoesophageal echocardiography (TEE). The patient underwent a fluoroscopy and transthoracic echocardiography (TTE) guided BMV. Intraprocedural heparin according to bodyweight (70 µ/kg) was administered following septal puncture. Intraprocedural ACT was not monitored as the procedure time was only 30 min. Balloon dilatation was done using Inoue balloon. Postdilation TTE showed good commissural splitting with an increase in MV area and a mild postprocedural MR. There was no clot/pericardial effusion with normal interatrial septum (IAS). However, TTE done 10 min after procedure revealed a mass attached to the IAS (figures 1 and 2). Balloon integrity checked immediately was normal. A possibility of IAS haematoma¹/thrombus was considered. TEE subsequently done confirmed that it was an IAS mobile thrombus projecting into both the atria (figure 3). Patient's anticoagulation was intensified. Repeat ECHO done after 1 month showed complete resolution of the clot.

Figure 1.

Interatrial septal (IAS) clot – 4-chamber TTE view showing an IAS clot ( arrow). LA, left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle.

Figure 2.

Interatrial septal (IAS) clot – transthoracic subcostal short-axis view showing an IAS clot (arrow). LA, left atrium; RA, right atrium.

Figure 3.

Interatrial septal (IAS) clot – TEE 4-chamber (0 – degree) view showing a dumbbell-shaped interatrial septal clot (arrow) protruding into both atria. LA, left atrium; RA, right atrium.

An IAS thrombus occurring years after BMV has been reported in the literature.² We present this case for its rarity in that an IAS thrombus occurred immediately following BMV.