Clinical Benefit of Simultaneous Pulmonary Vein Isolation and Percutaneous Transvenous Mitral Commissurotomy in Patients with Mitral Stenosis and Atrial Fibrillation

We report the case of a 54 years old female with moderate mitral stenosis. She had a history of acute heart failure due to new onset of paroxysmal atrial fibrillation (AF). Transthoracic echocardiography showed dilated left atrium (LA) and normal left ventricular ejection fraction. Mitral valve area was 1.12 cm² and Wilkins echocardiographic score was 7 (thickening 2, mobility 2, subvalvular apparatus 1 and calcification 2). Simultaneous pulmonary vein isolation (PVI) and percutaneous transvenous mitral commissurotomy (PTMC) were done in the same session. As a part of this combination procedure, intracardiac echocardiography (ICE) provides useful information in several situations. As the first step, transseptal puncture was safely performed after rule-out of left atrial thrombus. As the next step, three-dimensional LA anatomical image was described using ICE. LA anatomical image merged with computed tomography before PVI. Finally, PTMC procedure was performed via the antegrade transvenous approach using an Inoue balloon immediately after PVI. ICE was useful in determining position of ballooning in mitral valve. ICE showed us real-time monitoring of cardiac tamponade during procedure. Both procedures were successfully performed in the same session without complication. No AF recurrence, mitral valve restenosis, nor acute heart failure was occurred after 18-month follow-up. This simultaneous catheter procedure was safe and promising strategy in patients with MS and AF.