Challenging the Guidelines: Successful Percutaneous Mitral Valvuloplasty in a Case of Left Atrial Thrombus

Abstract

Aims: Mitral stenosis is strongly associated with atrial fibrillation and consequent thrombus formation in the left atrial appendage (LAA), posing a significant risk for cardioembolic stroke. Oral anticoagulation remains the standard of care; however, challenges such as persistent thrombus, bleeding risks, and patient non-compliance have prompted investigation into alternative strategies, including percutaneous LAA closure. Traditionally considered a contraindication, the presence of LAA thrombus is now being reevaluated in light of emerging techniques and procedural safeguards. Presentation of Case: A 57-year-old woman with rheumatic mitral stenosis presented with progressive exertional dyspnea and orthopnea. Examination revealed signs consistent with severe mitral stenosis, and TTE confirmed a valve area of 0.7 cm² without thrombus. She was scheduled for PBMV, but pre-procedural TEE revealed a small left atrial thrombus (1.2 × 1.1 cm), leading to temporary postponement. After three days of intravenous heparin, follow-up TEE showed thrombus reduction, and PBMV was successfully performed using a 25-mm Inoue balloon. Post-procedure, the mitral valve area improved to 1.5 cm² with no complications. The patient was discharged on warfarin and remained symptom-free on follow-up. Discussion and Conclusion: Left atrial (LA) thrombus occurs in 10–25% of patients with rheumatic mitral stenosis and is often associated with atrial fibrillation and left atrial enlargement. In this case, type of LA thrombus responsive to iv anticoagulant, allowing safe PBMV using a modified over-the-wire technique that minimized thrombus disturbance. This suggests that, with careful assessment and technique, LA thrombus may not be an absolute contraindication to PBMV.