Mitral balloon valvuloplasty followed by closure of the left atrial appendix in presence of thrombi and recurrent stroke

Hemodynamic consequences of mitral stenosis as well as inflammatory and structural changes in the left atrium increase the risk of developing atrial fibrillation and predispose to thrombus formation, primarily in the left atrial appendage. Percutaneous mitral balloon valvuloplasty for hemodynamically severe rheumatic mitral stenosis with favorable valve anatomy reduces the risk of thromboembolic events and stroke. Although the presence of left atrial thrombus is determined as a contraindication, percutaneous intervention has been found to be safe when the thrombus is localized to the atrial appendix. Left atrial appendix occlusion is an alternative treatment of choice for stroke prevention in patients with high stroke risk in whom oral anticoagulation is contraindicated or in patients with thromboembolic events in spite of adequate anticoagulation. Here we report a case of a 91-year-old-woman with very severe mitral stenosis and chronic atrial fibrillation, with a left atrial appendix thrombus and a history of recurrent stroke despite warfarin. Balloon valvuloplasty was performed firstly without encountering any embolic events. The thrombus was dissolved following restored of the left atrial flow. Subsequently, atrial appendix occlusion device was implanted in order to reduce the risk of recurrent thromboembolic events.