Simultaneous procedure of MitraClip and WATCHMAN implantation in a patient with atrial fibrillation and severe mitral re
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IMAGES IN CARDIOVASCULAR INTERVENTION
Simultaneous procedure of MitraClip and WATCHMAN implantation in a patient with atrial fibrillation and severe mitral regurgitation: the first case in Japan Kazunori Mushiake1 · Shunsuke Kubo1 · Takeshi Maruo1 · Kazushige Kadota1 Received: 15 September 2020 / Accepted: 5 November 2020 © Japanese Association of Cardiovascular Intervention and Therapeutics 2020
A 73-year-old man with atrial fibrillation was admitted to hospital for heart failure (HF) caused by severe functional mitral regurgitation (MR) and severe left ventricular (LV) dysfunction. As he had multiple HF hospitalizations and high operative risk due to low LV function, we decided to perform MitraClip (Abbott Vascular, Santa Clara, California) implantation. He also had a history of left main stent thrombosis and cerebral hemorrhage. We, therefore, planned left atrial appendage (LAA) closure with WATCHMAN device (Boston Scientific, Marlborough, Massachusetts) to minimize the anticoagulant period simultaneously performing a MitraClip procedure. At first, we performed WATCHMAN implantation because spontaneous echocardiographic contrast, which sometimes appears right after MR reduction, maybe a risk of periprocedural stroke. The interatrial septum was punctured at an inferior/posterior position of the fossa ovalis with 36.5 mm above the mitral valve annulus (Fig. 1a), and we inserted an access sheath coaxially to the LAA ostium. On the basis of transesophageal echocardiography (TEE) and LAA angiography findings, a 33-mm WATCHMAN device was selected and deployed. After confirming the device position and stability, we released the device (Fig. 1b). Then, the Amplatz super-stiff guidewire (Boston Scientific) was inserted into the left upper pulmonary vein, and an access sheath was replaced with a steerable guide catheter of the MitraClip. TEE demonstrated severe MR from A2/P2 due to leaflet tethering. The clip was implanted in the middle of A2/
P2, and the MR was successfully reduced to mild (Fig. 1c, d). The procedure time was 93 min, and he was uneventfully discharged under warfarin and dual antiplatelet therapy. At 45 days follow-up, TEE showed only mild MR, no thrombus, and no peri-device leak around the WATCHMAN (Fig. 1e, f). His symptoms improved from NYHA 3 to NYHA 1, and warfarin therapy was discontinued. The feasibility of the simultaneous MitraClip and LAA closure was reported in a Western country [1]. The assessment of the transseptal puncture point by TEE before and during the procedure is critical in this combined procedure. There are some possible anatomical limitations in both procedures particularly in the small body size of the Japanese population, and the optimal transseptal puncture point may not always be the same in the LAA closure and MitraClip procedure. Therefore, a multidisciplinary heart-team approach familiar to both procedures is the key to the success in this combined procedure. In this case, we selected an inferior/posterior position in the atrial septal puncture to deploy the WATCHMAN devi
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