Interatrial Septal Dissection Complicating a MitraClip Procedure

J INVASIVE CARDIOL 2018;30(11):E128.

Key words: cardiac imaging, dissection, MitraClip

A 74-year-old female with ischemic cardiomyopathy status post coronary artery bypass graft surgery and implantable cardioverter defibrillator, left ventricular ejection fraction 25%, permanent atrial fibrillation on anticoagulation, recurrent heart failure admissions, and severe symptomatic mitral regurgitation (MR) was referred for mitral valve repair. Given her prohibitive surgical risk, MitraClip (Abbott) implantation was recommended.

Transseptal puncture was performed under transesophageal echocardiographic (TEE) guidance using an 8.5 Fr SL1 guiding catheter and a transseptal radiofrequency needle (Baylis Medical). The MitraClip system was then advanced to the left atrium. A single MitraClip was deployed between the A2 and P2 segments of the mitral valve leaflets, leading to significant reduction in MR. Intraoperative TEE demonstrated interatrial septal dissection with a localized hematoma following removal of the MitraClip sheath (Figures 1 and 2; Video 1). After a multidisciplinary discussion, a conservative approach was recommended. The patient remained hemodynamically stable and asymptomatic post operation. At 1-month follow-up, echocardiogram showed resolution of the interatrial septal dissection. 

Left atrial dissection is an exceedingly rare complication of cardiac surgery, with an incidence of 0.16%-0.84%. It is defined as a false, blood-filled cavity or lumen from the mitral annular area to the left atrial free wall or into the atrial septum, creating a new chamber with or without communications into the true left atrium, and is most commonly associated with mitral valve surgery. We report the first case of interatrial dissection and hematoma in association with the MitraClip procedure. The reported mortality rate in the surgical literature is 13.8%. Hemodynamically stable patients can be managed conservatively, with echocardiographic imaging, often with resolution of the dissection over the course of weeks.

From Hartford Hospital, University of Connecticut, Hartford, Connecticut.

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 accepted May 31, 2018. 

Address for correspondence: Amged Abdelaziz, MD, Hartford Hospital, University of Connecticut, 85 Seymour Street, Hartford, CT 06106. Email: amgedabdelaziz@yahoo.com