Partial clip detachment and posterior mitral leaflet perforation after mitraclip implantation (original) (raw)

2014, International Journal of Cardiology

A 64-year-old woman with a history of essential hypertension, left ventricular systolic dysfunction, chronic obstructive pulmonary disease, and recurrent flash pulmonary edema despite adequate pharmacological therapy was admitted to our hospital for acute decompensated heart failure. Transthoracic echocardiography (TTE) showed a reduced left ventricular ejection fraction (36%), severe mitral regurgitation (MR) (effective regurgitant orifice area of 33 mm 2 in mesosystole) and elevated pulmonary artery systolic pressure (55 mmHg). The patient was treated with high-dose intravenous furosemide and non-invasive ventilation. After improvement of her clinical condition, conventional two-dimensional transesophageal echocardiography (TEE) and coronary angiography were planned to establish the etiology of cardiomyopathy and MR, to localize the origin of the regurgitant jet and to assess mitral valve (MV) anatomy. TEE with midesophageal intercommissural (at 60°) and left ventricular outflow tract (at 120°) views revealed a central jet involving the A2-P2 scallops due to symmetric leaflet tethering. The vena contracta was estimated to be 7 mm, and no additional regurgitant jets were visualized. Several parameters that need to be measured for planning MitraClip (MC) (Abbott Vascular, Menlo Park, CA, USA) implantation were also calculated, including tenting area, coaptation depth (11 mm), coaptation length (3.1 mm) and the distance from the fossa ovalis to leaflet coaptation (48 mm). In addition, an estimate of MV area (5.27 cm 2 ) was obtained from the transgastric view. No significant coronary stenosis was observed on coronary angiography. The patient was judged to have severe functional MR by the local "heart team", including a clinical and interventional cardiologist, an echocardiographer and a cardiac surgeon, and was considered to be amenable to percutaneous treatment because of high surgical risk and patient's preference. After successful transseptal puncture, a MC device was implanted with standard technique under conventional TEE monitoring. The leaflets were grasped by the clip with residual moderate regurgitation. However, given the relatively high transmitral gradient (5.6 mmHg) and the risk for worsening stenosis, a second clip was not implanted. Two months later the patient was readmitted for fatigue and reduced effort tolerance with clinical signs of heart failure. TTE showed recurrence of severe MR due to single leaflet clip attachment to the anterior mitral leaflet (see movies 1 and 2). TEE confirmed partial clip detachment. Additionally, color flow mapping revealed a flow convergence area on the posterior mitral leaflet , suggesting leaflet perforation that was confirmed by real-time three-dimensional (3D) acquisition (General ElectricVivid E9; GE Vingmed ultrasound -Horten, Norway. ; see also movies 3 and 4). Surgical MV replacement was proposed but the patient refused.