2022 Volume 4 Issue 12 Pages 611-612
We describe a percutaneous coronary intervention in a 66-year-old man for acute myocardial infarction of left main trunk disease supported by extracorporeal membrane oxygenation (ECMO). The patient experienced refractory heart failure because of severe ischemic mitral regurgitation (MR). He was transferred to our hospital for transcatheter edge-to-edge mitral valve repair (TEER) to stabilize the severe MR (Figure A). Surprisingly, transesophageal echocardiography (TEE) identified a giant floating structure attached to the atrial septum in the right atrium (RA; Figure B). We speculated this was a thrombus around the large sheath inserted in the vein artery during ECMO, because the medical records indicated that the patient was positive for heparin-induced thrombocytopenia antibody. Considering the patient’s situation for an emergency TEER, we performed thrombus aspiration using a 7-Fr multipurpose guide catheter supported by a transseptal 8-Fr Swartz braided SL0 sheath under fluoroscopic and TEE guidance (Figure C). Removal of the systems revealed massive thrombi inside the guide catheter and sheath (Figure D). TEE confirmed eviction of the abnormal structure from the RA after thrombus aspiration. Subsequently, TEER was performed successfully without complications using a MitraClip (G4-XTW device; Abbott Vascular) alongside a continuous argatroban infusion (Figure E,F). After the TEER, the degree of MR was decreased to less than mild (Figure G), and heart failure status improved significantly.
(A) Severe mitral valve regurgitation with ischemic cardiomyopathy. (B) A giant floating structure in the right atrium (arrow). (C) The guide catheter (arrowhead) and transseptal sheath (arrow). (D) Thrombi in the catheter and sheath. (E) Disappearance of the abnormal structure. (F) The MitraClip device on fluoroscopy. (G) The MitraClip creating a tissue bridge on the mitral valve. (H) A “less-than-mild” degree of mitral regurgitation.
Herein, we report thrombus aspiration in the RA using a guide catheter as an effective bailout technique in patients undergoing TEER.
M.Y. has received lecture fee from Edwards, Medtronic, Boston, Abbott, and Daiichi-Sankyo. M.Y. and A.I. are MitraClip training faculties of Abbott. The other authors have nothing to disclose.
The present study was approved by the Institutional Review Board of Nagoya Heart Center (Reference no. NHC2021-1021-1012-06).
