Successful management of the leaflet perforation after the transcatheter edge-to-edge repair procedure using transcatheter occlusion.

Abstract

A 57-year-old female was diagnosed with chronic heart failure and severe functional mitral regurgitation (FMR) despite guideline-directed medical therapy. An echocardiogram revealed severe mitral regurgitation (MR) (4+) vena contracta width 8 mm with ejection fraction (21%), and no calcification on the annulus and leaflets was noted. Mitral transcatheter edge-to-edge repair (TEER) was attempted for this patient. Transcatheter edge-to-edge repair was done under general anaesthesia with transoesophageal echocardiography (TEE) guidance using a novel designed SQ-Krin TEER system (Shenqi Medical). After transseptal puncture was achieved, a 24F guiding sheath was placed in the left atrium (LA). Then, one LW-size clip (6 mm width with 12 mm arm length) was placed in the A2/P2 region (Panel A). Mitral regurgitation severity was reduced to none (Panel A). However, 20 min after release, TEE revealed a large regurgitant gap (7–8 mm) between the anterior mitral leaflet (AML) and the clip arm with torrential MR (Panels B–D), and clip-induced leaflet perforation was confirmed. Considering the high risk of open-heart surgery, transcatheter occlusion was attempted. A 14F steerable catheter was placed in the LA through the previous puncture site, and the guide wire was placed into the left ventricle (LV) through the tear hole, and then a 14 mm Amplatzer Vascular Plug II (St Jude Medical, Abbott) was implanted through the delivery system to occlude the hole (Panels E and F). Mitral regurgitation was reduced to a mild degree after the procedure (Panels G and H). Post-operative recovery was uneventful and no sign of haemolysis. In the 1-year follow-up, the patient presented good condition with mild MR, and both the clip and the plug were in a stable position (Panel I). Leaflet perforation after the TEER procedure is a rare complication with a poor prognosis, especially for an FMR patient. Other than open-heart surgery, transcatheter occlusion may provide a reliable salvage management option.