Breaking Barriers: Introduction: Percutaneous Trans-Mitral Commissurotomy (PTMC) Success in Expectant Mother with Left Atrial Appendage (LAA) clot

Abstract

Background: Rheumatic heart disease is the leading cause of Mitral Stenosis (MS). About 15% of MS patients develop Left Atrial thrombus, with 90% confined to the LAA. Hemodynamic changes in pregnancy may decompensate stable patients, worsening maternal and fetal outcomes. While PTMC is the preferred treatment for isolated MS in RHD, LA thrombus is usually a contraindication. This case presents a pregnant MS patient with a type 1A LAA clot who successfully underwent PTMC. Case: A 32-year-old pregnant woman, at 22 weeks of gestation, presented with shortness of breath (NYHA-III-IV) for one month. On examination, she was in respiratory distress with oxygen saturation of 90%. Transthoracic echocardiogram: Severe MS, mitral valve area (MVA) of 0.8 cm², mild mitral regurgitation (MR), pulmonary artery systolic pressure of 90 mm Hg. Transesophageal echocardiography confirmed type 1A LAA thrombus. After stabilization and shared decision-making, she underwent PTMC via right femoral access, with shielding to minimize fetal radiation. A 6Fr arterial and 8Fr venous sheath were introduced. A Mullin’s sheath was advanced over a 0.032” guide wire into the Innominate vein. A pigtail catheter was placed in the aortic root. Interatrial septum was punctured with a Broken borough needle at 3-5 o’clock posteriorly, a coiled guide wire was introduced to avoid LAA entry. The septum was dilated with a 14F dilator, and a 26mm Inoue balloon was inflated across the mitral valve. Post-procedure, MVA=1.4 cm² and patient’s symptoms improved. Conclusion: This case demonstrates that PTMC can be safely performed during pregnancy with proper precautions, resulting in improved maternal and fetal outcomes.