Simultaneous Valve-in-Valve TAVR With Bioprosthetic Valve Fracture and Left Atrial Appendage Closure for Refractory...

Persistent left atrial appendage thrombus complicates structural intervention when anticoagulation is limited by bleeding risk.

A 74-year-old man with prior surgical aortic and mitral bioprostheses presented with heart failure from severe bioprosthetic aortic stenosis and persistent left atrial appendage thrombus despite 6 months of anticoagulation. Because of recent gastrointestinal bleeding and progressive valve obstruction, the heart team selected a single-session strategy using Sentinel cerebral embolic protection. Valve-in-valve transcatheter aortic valve replacement was performed first, followed by bioprosthetic valve fracture confirmed by balloon pressure drop, waist release, and gradient reduction. Left atrial appendage closure was then performed with a Watchman FLX Pro device, trapping residual thrombus. Retrieved cerebral protection filters contained thrombotic debris, and the patient recovered without neurologic complications.

In selected high-risk patients, simultaneous valve intervention and thrombus-exclusion left atrial appendage closure under cerebral protection may reduce cumulative procedural and anticoagulation-related risks.