Backward Migration of a MitraClip Through a Patent Transseptal Orifice

JACC: CARDIOVASCULAR INTERVENTIONS

VOL. 8, NO. 14, 2015

ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 1936-8798/$36.00

PUBLISHED BY ELSEVIER INC.

http://dx.doi.org/10.1016/j.jcin.2015.07.030

Backward Migration of a MitraClip Through a Patent Transseptal Orifice The Salmon Syndrome Christophe Caussin, MD,* Christelle Diakov, MD,* Patrice Dervanian, MD,y Nicolas Amabile, MD, PHD*

A

70-year-old man with severe mitral regurgi-

The patient underwent surgical MR correction.

tation (MR) was referred to our institution

Periprocedural analysis revealed a large interatrial

for percutaneous mitral valve repair. A Mitra-

defect, a diffuse hematoma on the anterior leaflet, and

clip (Abbott Vascular, Santa Clara, California) was

a tear on the initial clip tethering zone (Figures 1G 1

implanted but did not correctly tether the posterior

and 1G 2 ). The patient benefited from a bioprosthesis

leaflet and was solely attached to the anterior leaflet.

implantation with a subsequent uneventful clinical

A second clip was thus implanted to stabilize the first

course. The most plausible hypothesis explaining

clip. However, a residual severe eccentric MR was still

this case is a primary leaflet tear induced by the

present on final transesophageal echocardiographic

clip, followed by its migration toward the right

control, after full retraction of the delivery system

atrium through the transseptal puncture orifice and,

(Figures 1A and 1B).

finally, backward migration within the inferior vena

Although the patient was asymptomatic, trans-

cava.

thoracic echocardiography revealed dislodgment of clip 1 on day 2. A computed tomography scan

REPRINT REQUESTS AND CORRESPONDENCE: Dr.

without contrast revealed the device’s presence

Nicolas Amabile, Department of Cardiology, Institut

within the right renal hilum (Figure 1C). Selective

Mutualiste Montsouris, 42 Boulevard Jourdan, 75014

renal

Paris, France. E-mail: [email protected].

arteriography

and

phlebography

localized

the detached clip in the right ostial renal vein (Figures 1D and 1E, Online Videos 1 and 2). The

KEY WORDS complications, mitral surgery, percutaneous mitral repair

device was successfully retrieved using a doublesnare technique through an 18-F sheath (Figures 1F 1 to 1F 3, Online Videos 3 and 4).

APP EN DIX For supplemental videos, please see the online version of this article.

From the *Department of Cardiology, Institut Mutualiste Montsouris, Paris, France; and the yDepartment of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received June 26, 2015; accepted July 16, 2015.

1908

Caussin et al.

JACC: CARDIOVASCULAR INTERVENTIONS VOL. 8, NO. 14, 2015

Backward Migration of a MitraClip

DECEMBER 21, 2015:1907–8

F I G U R E 1 Different Steps in Mitral Clip Implantation and Retrieval

(A, B) Post-procedural transesophageal echocardiographic views showing the presence of 2 MitraClips (arrows). (C) Computed tomography scan localized the detached clip in the right renal hilum. Selective renal arteriography (D, Online Video 1) and phlebography (E, Online Video 2) localized the clip in the right ostial renal vein. (F1 to F3) Clip extraction through the venous femoral vein (Online Videos 3 and 4). Mitral valve gross pathology examination (G1, atrial; G2, ventricular views) showing a hematoma related to tethering attempts (white arrows) and a leaflet tear (white arrowhead) on clip 1 at the previous implantation site.