Unusual Suspect Causing Myocardial Infarction

Abstract

An 84-year-old man with New York Heart Association functional class III/IV, due to prolapse of segment 2 of the anterior mitral valve leaflet with severe regurgitation as a result, was admitted for elective percutaneous edge-to-edge mitral valve repair. Significant coronary artery disease was ruled out previously. The left ventricular systolic function was normal with moderate concomitant aortic regurgitation. Mitral valve surgery was not considered a suitable option by the heart team due to frailty and a prohibitive surgical risk profile. The patient had an indication for transcatheter mitral-leaflet approximation, using the MitraClip-NT device (Abbott Vascular, Abbott Park, IL, USA). Implantation of the first clip resulted in insufficient reduction of mitral regurgitation. Therefore, a second device was positioned. Within minutes after release, transesophageal ultrasonography showed single leaflet device attachment of the second device, necessitating the deployment of a third device in order to stabilize the flailing clip (Figure 1a). Although regurgitation was reduced to moderate hereafter, flailing of the second device persisted. Two days later, the patient developed severe chest pain and cardiogenic shock. Electrocardiography showed ST-elevation in the inferior leads, corresponding to acute inferior wall myocardial infarction. Coronary angiography showed a dislodged clip seated in the right coronary ostium (Figure 1b). A 24Fr sheath was placed in the right femoral artery. After several attempts, a 35-mm Amplatz gooseneck snare was successfully positioned around the clip (Figure 1c). Subsequently, the device was retracted across the thoracic and abdominal aorta into the femoral sheath, which was successfully removed thereafter (Figure 1d). After the procedure, the patient was hemodynamically stable with normalization of the electrocardiogram. Transcatheter mitral-leaflet approximation using the MitraClip-NT device is used in high-risk patients with symptomatic mitral valve regurgitation. This unique case demonstrates an extremely rare complication of this procedure with a successful percutaneous solution. No potential conflict of interest was reported by the authors.