Metal Beyond Metal: Cardiology in 2018

Consult this Twitter Case concerning an 80-year-old female with chronic atrial fibrillation

This case was originally published on Twitter by @DocStrom via #CardioTwitterCase

Clinical presentation

She previously had a history of coronary artery disease requiring three-vessel coronary artery bypass grafting, hypertension, dyslipidemia, type 2 diabetes mellitus, and severe degenerative mitral regurgitation requiring placement of two MitraClip prostheses. This procedure resulted in the formation of an iatrogenic atrial septal defect that was closed with an Amplatzer septal occluder device. 

She had frequent recurrent gastrointestinal bleeding made her high risk for continued anticoagulation. As a result, a Watchman left atrial occluder device was placed in November 2017. She presented at this time for 45-day surveillance for periprosthetic leak assessed by trans-oesophageal echocardiogram. 

Case Management

She was brought to the cardiac catheterization laboratory where her procedure was performed. Her electrocardiogram demonstrated fine atrial fibrillation. Blood pressure and heart rate were normal prior to the procedure. She was given two sprays of 20% Benzocaine oral spray, 10 mL of viscous lidocaine gargle, and given 0.1 mg glycopyrrolate intravenously. She was sedated with 3 mg of midazolam and 50 mcg of fentanyl given intravenously and oesophagal intubation was performed without complication. A General Electric (General Electric, Boston, MA) e95-2 echocardiograph and 4D-3 transesophageal echocardiogram probe was used to acquire images which were interpreted on an EchoPAC 2.0 workstation.

A 4D zoomed mode was used to acquire a surgical view of the mitral valve with demonstrated thickened, myxomatous mitral valve leaflets with two well-seated MitraClips attached to both leaflets (A1/P1 and A2/P2 commissures) with severe eccentric mitral regurgitation originating from the A3/P3 commissure.

It additionally demonstrated a well seated Watchman left atrial occluder device without evidence for residual communication between the body of the left atrium and the left atrial appendage.

A well-seated Amplatzer septal occluder device was noted across the interatrial septum without residual interatrial shunting. Left ventricular systolic function was grossly normal with depressed right ventricular systolic function. There was mild to moderate tricuspid regurgitation with a normal estimated pulmonary artery systolic pressure. 

The patient tolerated the procedure well and after 19 minutes of sedation time, was moved to the catheterization lab holding area for post-procedural recovery. She was discharged to home, accompanied by her spouse, with plans for outpatient follow-up.