Answer
Though PTMC in the presence of LA clot is an option in low risk clots , my strategy would be the last one ,whenever feasible. Intensive, monitored Heparin /Oral anticoagulants ( Heparin 5000 units tds or qid or Low molecular weight heparin Enoxaparin 40-60mg twice a day , Tablet Warfarin /Acitrom with an INR of 3 ) will dissolve LA clot in 30-50% of times.(Our experience).
The percutaneous clot retrieval system is not available as on 2018.Aortic filters are FDA approved during TAVR. (Why not use the same in PTMC ?) LA Catheter based regional lysis through PFO is can be an option if patient agrees to the risk.
How long to wait for clot dissolution with Heparin /OAC?
Most small clots or intermediate sized clots ((Up to 2 CM ?) have been dissolved by 3 months. Even large clots gets dissolved at least in few Instances.Please note, this strategy is applicable only with valves that is fit for PTMC. All others are referred for surgery.
How does heparin lyse a clot ?
Its a miracle to see it happen, though heparin / OAC are never considered as thrombolytic agents .It happens because both heparin and OAC tilts the local endogenous fibrinolytic forces and thrombus melts , dissolves or disappear altogether. (I am waiting for the day , the scientific community to re-label heparin as a thrombolytic agent, Indirectly though !)
Is there a risk of dislodgement of LA clot during heparin /OAC therapy ?
This question shall be addressed to God ! It all happens if bad luck strikes you and your patient.
Be wise . . . and call your surgeon Immediately when you encounter something like this !
Even if the valve is perfectly eligible for PTMC , high risk mobile clots, history of embolic episodes , probing and hyper-googling patients , its better to refer for surgery Immediately. Wait and watch game has a definite risk of stroke and it is especially bound to happen if your patient or their family is anxious !
Reference
Dr.S.Venkatesan MD 
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