Catheter Entrapment During Posterior Mitral Leaflet Pushing Maneuver for MitraClip Implantation

Abstract: MitraClip (Abbott Vascular) therapy has been reported to be an effective procedure for mitral regurgitation, especially in high-risk patients. Recently, the novel pushing maneuver technique has been described for approaching restricted and short posterior leaflets with a pigtail catheter in order to facilitate grasping of the clip. However, complications or unexpected situations may occur. We report the case of an 84-year-old patient who underwent MitraClip implantation wherein the pushing maneuver was complicated by the clip accidentally gripping the pigtail catheter along with the two leaflets. 

J INVASIVE CARDIOL 2016;28(6):E52-E53

Key words: MitraClip implantation, complications, catheter impingement

We report the case of an 84-year-old male with past medical history of hypertension and stage 3 chronic kidney disease. In September 2015, he suffered a posterior myocardial infarction with evidence of disease in the right coronary artery and circumflex artery, which were both treated with bare-metal stents in two procedures. In December 2015, he was admitted due to heart failure secondary to severe mitral regurgitation concomitant with severe pulmonary hypertension. The mechanism was the restricted movement of a relatively short posterior mitral leaflet with a pseudoprolapse of the anterior mitral leaflet (Figure 1A; Video 1). The ejection fraction was preserved. MitraClip (Abbott Vascular) implantation was decided due to high risk (logistic EuroScore, 23.12%). Given the challenging anatomy, a pigtail catheter (Figure 1B, arrow) was used to bring the posterior leaflet into closer approximation with the anterior leaflet. After grasping the leaflets successfully, angiography showed that the pigtail catheter was also gripped by the clip (Figure 1C; Videos 2 and 3). This forced us to partially reopen the clip and remove the pigtail catheter (Video 4). The leaflets remained within the clip, which could finally be implanted with optimal result (Figure 1D). Mild regurgitation remained after the procedure (Video 5) and the patient was extubated and discharged with no complications. To date, the patient has remained in New York Heart Association functional class I with no new hospital admissions.

Several strategies, including adenosine-induced asystole and ventilation maneuvers, have been described to ensure the correct depth of leaflet insertion to guarantee a correct leaflet approach during MitraClip implantation. The strategy described by Jones et al¹ utilizes a pigtail catheter to push the posterior mitral leaflet in cases of severe restrictive movement¹ or when facing a highly mobile anterior mitral leaflet. However, the potential risk of catheter impingement by the clip has not been previously reported and could lead to damage of the mitral apparatus or even device embolization if not identified. To the best of our knowledge, this is the first report of this unusual and unexpected complication.

References 

1.    Jones BM, Tuzcu EM, Kapadia SR. Pushing with the pigtail: a novel approach to placing the MitraClip in a patient with a severely restricted posterior mitral leaflet. Catheter Cardiovasc Interv. 2015;85:906-908.

From the Hospital Clínico Universitario de Valladolid, Valladolid, Spain.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted March 15, 2016, provisional acceptance given March 17, 2016, final version accepted March 23, 2016.

Address for correspondence: I.J. Amat-Santos, MD, PhD, Hospital Clínico Universitario de Valladolid, Avenida Ramón y Cajal, 3, 47005 Valladolid, Spain. Email: ijamat@gmail.com