Background Increased afterload and reduced left ventricular (LV) performance are sequela of mitral valve repair. However, hemodynamic left atrial and ventricular parameters that can predict outcome following mitral valve repair remain elusive. Methods One hundred and two consecutive patients undergoing MitraClip procedure from 2014 to 2017 at Banner University Medical Center were enrolled in this study. All patients underwent pre‐procedure echocardiograms and intra‐procedure invasive left atrial (LA) pressure monitoring. Clinical, laboratory, and procedural parameters were collected. The primary end‐point was the composite outcome of all‐cause mortality and repeat hospitalization within 90 days. Results The mean age was 77 ±10 years, the majority were Caucasians (93, 91.2%) and 47 (46.1%) were males. Thirty‐two patients (31.4%) had diabetes, 39 (38.2%) had renal insufficiency, and 38 (37.3%) had a history of congestive heart failure. The median society of thoracic surgeons score was 6.7% (Interquartile range [IQR]: 3.9, 10.2). Immediately post‐procedure there was a significant reduction in the LA pressure (Mean 12.0 vs. 18.6 mmHg, P < 0.001) and pulmonary artery systolic pressure (43.5 vs. 53.2 mmHg, P = 0.001) compared to baseline. LA pressure was an independent predictor of the composite outcome in an unadjusted (OR = 1.07, 95% CI: 1.00–1.13, P = 0.03) and adjusted (OR = 1.07, 95% CI: 1.00–1.14, P = 0.03) analysis respectively. Conclusion LA pressure drop is an independent predictor of outcome after the MitraClip procedure. This finding has implications for early identification of patients at risk of poor outcomes and instituting aggressive medical therapy and close follow‐up for avoiding hospitalizations for heart failure decompensation.

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Background: Device related thrombus (DRT) has an observed incidence of ~4% after left atrial appendage closure (LAAC), of which the mechanism remains incompletely understood. Objective: To present and examine the intraoperative findings of 2 cases of massive DRT occurring late post LAAC device implantation and propose potential mechanisms for these rare complications. Methods: N/A Results: Patient 1 was a 75-year-old female with paroxysmal AF and CHA2DS2-VASc Score of 5 with Watchman implanted two years prior to presentation. She had completed 45 days of warfarin and ASA after implantation. She underwent elective open heart surgery for severe mitral valve regurgitation and moderate to severe aortic valve regurgitation. Large DRT (2x2cm) was diagnosed intraoperatively, which was treated with left atrial appendage and device resection. Patient 2 was a 75-year-old female with permanent AF and CHA2DS2-VASc Score of 5, who was referred for routine postimplant surveillance TEE. She had also completed 45 days of warfarin and ASA after implantation. A large DRT measuring 2 x 2 cm was noted. The patient was treated with warfarin and subsequently dabigatran with improvement in the size of thrombus on TEE. However, a gastrointestinal bleed led to the cessation of anticoagulation. Subsequent TEE demonstrated enlargement of massive DRT (3x2 cm). She was referred to cardiac surgery for thrombectomy and resection of the Watchman device and LAA. Discussion/Conclusion: In both cases, the intraoperative findings demonstrate well-seated LAAC without gross findings of malapposition or peri-device leaks. The central screw was visible without evidence of endothelialization in both cases (Figure 1). An exposed central screw could be a possible nidus for thrombus formation.

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