Title
Successful Endovascular Retrieval from Left Atrium of G4 NTW Mitraclip in Open Position After Unexpected Detachment from Delivery Mandril with only Lock Line Attached.
Introduction
G4 NTW Mitraclip (Abbott Vascular) is used for endovascular edge-to-edge repair of mitral regurgitation (MR), with independently moving arms and wide paddles. We describe a case where the clip unexpectedly detached from the delivery system while in the open position above the mitral valve in the left atrium, held only by the lock line, and our technique of successful endovascular retrieval and completion of procedure.
Clinical Case
82 year old female with severe MR, ejection fraction of 20% and prohibitive surgical risk referred for Mitraclip. The guide sheath had been placed into the left atrium; the clip delivery catheter had been advanced out of the guide. The arms of the clip were opened; however, after beginning to rotate the clip with standard technique, the clip failed to respond and was seen to have unexpectedly detached in the open position from the delivery mandril, attached to the delivery catheter only by the lock line. It was not possible to close the clip (20 mm wide when open), and the tensile strength of the lock line was felt insufficient to attempt to pull the clip completely into the delivery sheath without risk of full detachment. Retrieval: Under fluoroscopy, the delivery catheter was carefully withdrawn to the guide and the clip, in the open position, brought into mouth of guide as far as possible without excessive tension. This served to reduce the width of the open clip to some degree. A second transeptal puncture from LFV was made next to first guide. Extra stiff wire was advanced to left pulmonary vein. To facilitate withdrawal of the guide and device as a unit from the left atrium, an atrial septostomy was performed, creating an iatrogenic ASD. We kept tension on the device/guide, and carefully withdrew across the septum through the iatrogenic ASD into the right atrium and then down to the to right iliac vein, and “parked” the catheter below the IVC. Completion of procedure: We advanced a second Mitraclip system from the LFV, and successfully performed the edge-to-edge repair with a single NTW clip. The iatrogenic ASD was closed with a 14 mm ASO occluder device. Lastly, we prepared for removal of the device/guide. The open clip were carefully removed percutaneously from venotomy site, with successful hemostasis obtained with manual compression and mattress stitch. Completion venography showed intact vein and no bleeding. The second guide was then removed from the LFV site with a mattress stitch. Patient recovered uneventfully, with stable hemoglobin, and was discharged home on POD #1.
Discussion:
We describe a step-by-step technique for successful, completely endovascular removal of Mitraclip that had detached from delivery system in the open position in the left atrium, secured only by the lock line, in a patient at prohibitive risk for open surgery. This will be of potential benefit for other operators facing similar intraprocedural challenges.