Bail-out use of the Amplatzer Septal Occluder for treatment of acute iatrogenic leaflet perforation during the MitraClip procedure in a patient with functional mitral regurgitation

Introduction

Surgery is the treatment of choice for patients with significant symptomatic mitral regurgitation (MR). However, up to 50% of them are denied the procedure due to high operative risk [1]. The MitraClip procedure has been recently widely adopted for the treatment of symptomatic patients with significant degenerative and functional mitral regurgitation who are deemed inoperable [2]. Percutaneous edge-to-edge repair is an efficient technique for the majority of patients with significant MR. Nevertheless, there are still cases with residual significant mitral regurgitation after the device deployment, which cannot be fixed with additional clip implantation (i.e. significant jets in the commissural areas). Recently, a novel procedure was reported using the Amplatzer Duct Occluder II or Amplatzer Vascular Plug for residual MR after MitraClip implantation [3, 4]. Kubo et al. presented 9 patients treated electively for residual jets localized either between previously implanted clips or in the commissural areas [3].
In the main, the MitraClip procedure is safe with a 30-day mortality rate up to 3% and a relatively small number of serious complications. Even so, in some cases it may occur and the operators should be able to fix them. The treatment of acute iatrogenic leaflet perforation with the implantation of an Amplatzer septal occluder (ASO) during a complicated MitraClip procedure is presented in the current report.

Case report

The 74-year old woman was referred to hospital due to recurrent symptoms of heart failure which twice caused hospitalization during the previous 12 months. The patient had a history of anterior myocardial infarction that was treated with primary PCI 7 years ago. Other comorbidities included diabetes mellitus, chronic kidney disease grade III and a history of colorectal cancer successfully treated 3 years ago. Recent coronary angiography did not reveal obstructive disease that required revascularization. The transthoracic echocardiography (TTE) showed left ventricular enlargement (left ventricular end diastolic diameter = 61 mm), depressed systolic function (EF = 25%), left atrial enlargement, severe functional mitral regurgitation, moderate tricuspid regurgitation and right ventricular systolic pressure of 70 mm Hg. The therapy for a heart failure in accordance with the guidelines was prescribed to the patient and consisted of full doses of -blockers, angiotensin-converting enzyme inhibitor...


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