Correspondence

A Hypercoagulable State in the Left Atrium of Patients with Mitral Stenosis

N Engl J Med 1993; 328:1043-1044April 8, 1993

Article

To the Editor:

Thromboembolism is a frequent and serious complication of valvular heart disease, particularly mitral stenosis1,2. Recently, sensitive molecular markers for assessing thrombotic and fibrinolytic states have been identified3. We measured the levels of these markers in blood from a peripheral vein, the right atrium, and the left atrium of eight patients with mitral stenosis who were undergoing percutaneous mitral valvuloplasty.

The study group consisted of three men and five women (mean age, 53 years; range, 39 to 61) with rheumatic mitral stenosis (mean mitral-valve area, 0.69 ±0.06 cm2) but without left atrial thrombus. Seven patients had chronic atrial fibrillation, and one had sinus rhythm. All the patients with atrial fibrillation had received warfarin therapy for at least three months, with the International Normalized Ratio maintained at 2.0 to 4.0. Peripheral-blood samples were obtained one week before valvuloplasty, which was performed with an Inoue catheter according to a previously described technique4. Before the operation, blood was obtained from the right atrium and the left atrium through a thermodilution catheter and an Inoue catheter, respectively. A preliminary study showed no difference in the levels of molecular markers in samples obtained from the same sites through the two types of catheters. The plasma samples were stored at -80 °C until assayed. We used plasma molecular markers to measure the platelet activity (platelet factor 4 and β-thromboglobulin), the thrombotic state (fibrinopeptide A and the thrombin-antithrombin III complex), and the fibrinolytic state (d-dimer, plasmin-α₂-plasmin inhibitor complex, tissue-type plasminogen-activator antigen and activity, and total plasminogen-activator inhibitor-1 antigen).

Plasma levels of these molecular markers in blood from a peripheral vein were not significantly different from the levels in blood from the right atrium. In addition, the levels of the plasma markers indicating the platelet activity and fibrinolytic state (listed above) in blood from the right atrium were not significantly different from levels in blood from the left atrium. However, as shown in Figure 1Figure 1Mean (±SE) Plasma Levels of Fibrinopeptide A and Thrombin-Antithrombin III Complex in the Right and Left Atrium of Eight Patients with Mitral Stenosis., the levels of molecular markers indicating the thrombotic state were significantly higher in blood from the left atrium (right vs. left atrium: fibrinopeptide A, 6.49 ±0.67 vs. 24.78 ±7.28 ng per milliliter; thrombin-antithrombin III complex, 4.15 ±0.82 vs. 13.40 ±3.45 ng per milliliter); the levels in blood from the left atrium did not correlate well with the mitral-valve area, the mean mitral-pressure gradient, or the size of the left atrium. In eight control patients with stable angina pectoris, who did not have mitral stenosis and were not receiving anticoagulation therapy, blood samples were drawn from the right atrium only; the level of fibrinopeptide A was 4.28 ±0.88 ng per milliliter, and the level of the thrombin-antithrombin III complex was 3.64 ±0.39 ng per milliliter.

This report suggests the existence of a thrombotic state in the left atrium of patients with mitral stenosis. It appears that coagulation activity is significantly increased in the left atrium of these patients, even with appropriate anticoagulation therapy. The results also suggest that platelet activity is not increased in the left atrium, and thus antiplatelet drugs may not be an appropriate choice for the prevention of thromboembolism in patients with mitral stenosis.

Keiji Yamamoto, M.D.
Uichi Ikeda, M.D.
Kazuyuki Shimada, M.D.
Jichi Medical School, Tochigi 329-04, Japan

4 References

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Citing Articles (3)

Citing Articles

1. 1

   Hirohiko Motoki, Takeshi Tomita, Kazunori Aizawa, Hiroki Kasai, Atsushi Izawa, Setsuo Kumazaki, Hiroshi Tsutsui, Jun Koyama, Uichi Ikeda. (2009) Coagulation Activity is Increased in the Left Atria of Patients With Paroxysmal Atrial Fibrillation During the Non-Paroxysmal Period. Circulation Journal 73:8, 1403-1407
   CrossRef

2. 2

   Satoshi Kataoka, Genjiro Hirose, Ariyuki Hori, Tomoyasu Shirakawa, Tsukasa Saigan. (2000) Activation of thrombosis and fibrinolysis following brain infarction. Journal of the Neurological Sciences 181:1-2, 82-88
   CrossRef

3. 3

   Keiji Yamamoto, Uichi Ikeda, Kyoko Furuhashi, Masahiko Irokawa, Toshio Nakayama, Kazuyuki Shimada. (1995) The coagulation system is activated in idiopathic cardiomyopathy. Journal of the American College of Cardiology 25:7, 1634-1640
   CrossRef