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Title: Predictors of left atrial thrombus resolution in patients with mitral stenosis planned for percutaneous transvenous mitral commissurotomy(PTMC)
Authors: Ravikanth Telikicherla
Issue Date: Dec-2019
Publisher: SCTIMST
Abstract: Mitral stenosis (MS) is a common finding in Rheumatic Heart Disease (RHD). The current management of symptomatic mitral stenosis is Percutaneous Transvenous Mitral Commissurotomy (PTMC) unless it is contraindicated. The presence of Left Atrial Thrombus (LAT), however, is generally considered a contraindication to PTMC, leaving the open surgery as the treatment option. Left atrial thrombus occurs frequently in patients with Rheumatic Mitral Stenosis1 .Most of Left Atrial thrombus occurs in Left Atrial Appendage(LAA)2. The association of LAT in patients with MS and atrial fibrillation (AF) is well known3 . But it also occurs in patients with sinus rhythm (SR). And patients in Sinus Rhythm (SR) of rheumatic mitral stenosis were also noted to have larger LAA and poorer LAA contractile function3,4.This enhances stagnation and thrombus formation in the Left atrial appendage or Left atrium. The presence of thrombus increases the risk of systemic and peripheral embolism and it is a relative contraindication for PTMC. Framingham study showed 17 fold increase in risk of stroke for patients with AF and MS5. The reported incidence of LAT in severe Rheumatic MS is between 10% and 25%6,7,8 . Various studies have shown that Transesophageal Echocardiography(TEE) identifies Left atrial thrombus better than Transthoracic Echocardiography(TTE). The presence of LAT in patients with mitral Stenosis may alter the therapeutic approaches to the disease. In some circumstances, complete resolution of LAT can be achieved with oral anticoagulant therapy (OAC), allowing patients to undergo PTMC safely. Knowing the likelihood of LAT disappearance would help the physician to decide whether to proceed with surgical repair or to continue oral anticoagulation until LAT resolution and then to perform PTMC. The current management of severe MS is PTMC unless contraindicated. After complete resolution of LAT following adequate anticoagulation,2 these patients with severe MS can undergo PTMC without any added risk. Especially a model would help in predicting the likelihood of LA thrombus resolution, and hence, the treatment plan can be altered accordingly. Hence it is very essential to develop a model to identify patients who would respond to Oral anticoagulants on short term.
Appears in Collections:Cardiology

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