Late Device Embolization after MitraClip Procedure for Degenerative Mitral Regurgitation

Abstract

Objective: MitraClip is currently indicated for symptomatic severe mitral regurgitation (MR) in surgical high-risk patients. After the MitraClip procedure, single leaflet device attachment and device embolization appear as potential risks that have yet to be clarified. We present a case with occult single leaflet device attachment followed by late device embolization.

Case Presentation: A 60-year-old man presented with severe symptomatic MR due to wide prolapse of the posterior leaflet, resembling Barlow syndrome. Medical history included pancreatic cancer (Stage IVb) at 52 years old, and lung metastases at 59 years old. He became aware of heart failure symptoms due to MR and surgery was indicated. After a multidisciplinary heart team conference, the decision was made to perform the MitraClip procedure. During the MitraClip procedure, attempted placement of the second clip interfered with the chorda tendineae, control of the clip was lost and both clips became entangled. Eventually, two clips were placed, and MR improved to a mild degree, but stability of the first clip was insufficient. Five months later, the first clip became detached from the posterior leaflet. At 6 months after the procedure, the clip had dropped to the inferior wall of the left ventricular. We diagnosed clip embolization of the first clip, performed emergency open heart surgery.

Conclusion: Clip instability may impose a higher risk of clip embolization in the MitraClip procedure. We recognized not only reduction of MR but also clip stability as important factors to determine success of the MitraClip procedure, particularly with degenerative MR.