Catch Not Just the Wings
Dr. Pok-Him LEE, Dr. Shing-Fung CHUI
Queen Elizabeth Hospital, Hong Kong
A 77-year-old lady had history of mitral valve and aortic valve replacement in 1989 and redo AVR in 1999. She also had history of diabetic mellitus, atrial fibrillation and ischemic heart disease with PCI done in 2004. She presented with recurrent abdominal distension and bilateral lower limb oedema. Echocardiogram showed normal MVR and AVR function and satisfactory left ventricular ejection fraction but with torrential tricuspid regurgitation. There was no significant pulmonary hypertension. Left and right heart catheterization showed a mildly elevated mean pulmonary arterial pressure of 36mmHg, a normal pulmonary capillary wedge pressure and a depressed cardiac index of 1.9L/min/m2. Coronary angiogram showed patent LAD stent. Clinical impression was significant tricuspid regurgitation with recurrent right heart failure and tricuspid valvular intervention was deem necessary. The case was discussed in heart team meeting and she was considered inoperable in view of repeated history of open-heart surgery. Transcatheter tricuspid valvular edge to edge repair using MitraClip system was planned.
The procedure was performed under general anaesthesia with transoesophageal and intra-cardiac echocardiographic guidance. 1st MitraClip was deployed successfully and grasped the anteroseptal leaflet (Figure 1). Echocardiographic assessment showed residual torrential tricuspid regurgitation (Figure 2). 2nd Clip was used to further reduce the tricuspid regurgitation. While attempting to advance and orientated the 2nd Clip, the 1st clip detached and dislodged to the basal right atrial region (Figure 3, Movie 1). The 2nd clip was successfully deployed with residual moderate residual tricuspid regurgitation (Figure 4, Figure 5).
The next step was to snare the dislodged 1stclip. Because of its size, a Micra introducer sheath (23F inner and 27Fr outer) was used and exchanged with the Mitraclip guide catheter. Agilis steerable catheter was used for more controllable retrieval of the dislodged Clip (Figure 6, Movie 2). An En-snare with large loop was used and successful grasped the dislodged clip (Figure 7). It was removed down to the lower inferior vena cava. Only one arm of the Clip was grasped which prevented its entry into the Micra sheath (Figure 8). Left femoral venous access was obtained so that another En-snare could help to grasp the dislodged Clip and help to “re-orientate” its position (Figure 9). Repeated attempt was failed to bring the dislodged clip back to the big sheath with one arm in and one arm out (Figure 10, Movie 3). Next, we advanced the En-snare through the same Micra sheath and grasped the dislodged from another direction so that the clip could turn upside down (Figure 11). Because of this better orientation towards the sheath, it was successfully retrieved into the sheath and removed outside the body (Figure 12, Movie 4, Movie 5). The femoral wounds were successfully closed with figure of 8 suture and final TEE showed residual moderate tricuspid regurgitation. The patient was discharged home uneventfully later.