A Novel Exit Strategy for Removal of a Mitraclip Device From the Left Atrium

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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00198. Epub August 29, 2024.

It is known that the leading edge of the steerable guide catheter (SGC) used for MitraClip (Abbott) procedures is constructed of a semirigid plastic, which can become wedged between the arm and gripper when withdrawing the clip. In the case reported here, attempts to advance the delivery system caused the frictional elements of the grippers to penetrate deeper into the semirigid plastic component of the guide, preventing the operator from freeing the clip from the guide.  Failure to remove the device from the left atrium (LA) could require conversion to surgery, which is associated with poor outcomes in the transcatheter edge-to-edge repair (TEER) population.¹ This case demonstrates an issue retrieving a MitraClip into the SGC and presents a novel solution to facilitate an exit strategy.

A 79-year-old woman presented with severe atrial-functional mitral regurgitation for TEER. A third MitraClip was attempted to improve moderate residual regurgitation but was not deployed (due to elevated transmitral gradients) and withdrawn into the SGC (Figure 1A and B). In 2 coplanar views, it appeared that the MitraClip entered the SGC, however, significant resistance was encountered upon attempt to remove it. Another fluoroscopy view confirmed that 1 clip arm was wedged outside the SGC (Figure 1C and D, Video 1). We attempted to retract the entire unit together, but the edge of the MitraClip protruding out of the SGC prevented removal from the LA (Video 2).

Next, we used an 8.5-French steerable sheath and positioned it adjacent to the MitraClip system. Using a ‘push-pull’ technique, forward pressure was applied to the septum with the steerable sheath as the MitraClip system was retracted across the septum (Figure 2A and B, Video 3). There remained a small iatrogenic septal defect with left-to-right flow (Figure 2C). The delivery system was removed with a surgical cut-down and the patient had an uneventful postoperative course (Figure 2D).

Affiliations and Disclosures

Craig Basman, MD; Karla Rodriguez-Barragan, MD; Jessica Willert, MD; Sung-Han Yoon, MD; Ryan Kaple, MD

From the Hackensack University Medical Center, Hackensack, New Jersey, USA.

Disclosures: Dr. Kaple is a consultant for Abbott and Edwards Lifesciences. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: The authors confirm that informed consent was obtained from the patient for the intervention described in the manuscript and to the publication thereof.

Address for correspondence: Craig Basman, MD, 30 Prospect Avenue 1 Link, Hackensack, NJ 07601, USA. Email: craigbasman@gmail.com, craig.basman@hmhn.org; X: @craigbasman

Reference

1. Kaneko T, Hirji S, Zaid S, et al; CUTTING-EDGE Investigators. Mitral valve surgery after transcatheter edge-to-edge repair: mid-term outcomes from the CUTTING-EDGE international registry. JACC Cardiovasc Interv. 2021;14(18):2010-2021. doi: 10.1016/j.jcin.2021.07.029