Abstract 18572: Mimickers of Chiari Network in the Left Atrium

Abstract

Case: 84-year-old female with ischemic cardiomyopathy and severe secondary mitral regurgitation with restricted leaflet mobility due to chordae tethering and a large central regurgitant jet. She underwent trans-catheter edge to edge repair with Mitra Clip NTW. The clip was aligned in the 12 to 6 o'clock position in the middle of A2/P2 scallop and appropriate graft was obtained with good tissue bridging. The trans mitral gradient at the end of the procedure was 3 mmHg and final V-waves at 10 mmHg. After the guiding catheter was moved back to the right atrium, the transesophageal echocardiogram (TEE) showed the presence of an echo dense flickering, bubble-like mobile structure around the right upper pulmonary vein. The heart team agreed that it looked like an endothelial disruption induced by the guiding catheter. After careful consideration and using shared decision making, the patient was maintained on Eliquis for 6 months without evidence of thromboembolic phenomena. Repeat TEE showed a healed dissection flap and no echo dense structure seen previously. Discussion: Unlikely to be thrombus or air bubbles, this structure looked like what we would see in a Chiari network. Complications after Mitra Clip procedure have been well described and can be broadly divided into procedure related and device related. Endothelial disruption with the imaging characteristics shown in this case has not been described. There are no evidence-based guidelines on how to proceed with this type of complication. It is well known that endothelial damage increases the risk for thrombosis and embolic phenomena. Due to concerns of a stroke, the decision was made to start anticoagulation with the plan of redo TEE. This case demonstrates the importance of performing TEE after Mitra Clip procedure to look for lesions that would increase the risk of stroke. It also demonstrates that patients with endothelial disruption after Mitra clip may benefit from short term anticoagulation for stroke prevention.