Successful bailout clipping for rare complication of anterior mitral leaflet dissection during transcatheter edge-to-edge mitral valve repair

Abstract

A 91-year-old woman underwent transcatheter edge-to-edge mitral valve repair (TEER) due to severe mitral regurgitation (MR) with the central posterior mitral leaflet (PML) prolapse (Figure 1A; Supplementary data online, Movie S1). The XTW size of MitraClip G4 (Abbott Vascular, USA) was chosen considering the larger length of PML. Before inserting the MitraClip into left ventricle, a newly developed membranous structure was suddenly detected on the central anterior mitral leaflet (AML) by transoesophageal echocardiography (TEE) (Figure 1B). The structure appeared to spread widely from the tip of the central AML toward lateral side (Figure 1C; Supplementary data online, Movie S2) and colour jet flow of TEE penetrated in-between the AML and mobile layered structure (Figure 1D; Supplementary data online, Movie S3). Based on the TEE findings, we suspected AML dissection caused by the proximal edge of MitraClip during one of the procedural steps. The dissection area was localized in the central to lateral side of AML but did not advance further. Therefore, the bailout-TEER was performed to stabilize for both the PML prolapse and iatrogenic AML dissection. The clip was placed under the mitral valve and the clippers grasped both the leaflets (Figure 1E). After successful TEER, the part of AML dissection was minimized (Figure 1F; Supplementary data online, Movie S4). The abnormal colour jet disappeared and trivial amount of MR was present after the procedure (Figure 1G and H). Postprocedural enhanced computed tomography also confirmed absence of abnormal findings in the left atrium around mitral valve. Although extremely rare complication, caution against the occurrence of mitral leaflet dissection during TEER should be exercised.