AUCTORES
Globalize your Research
Case Report
*Corresponding Author: Ajmer Singh, Department of Cardiac AnaesthesiaInstitute of Critical Care and AnaesthesiologyMedanta-The Medicity, Gurugram (Haryana)-122001, India.
Citation: Ajmer Singh, Ravina Mukati, (2024), Chordal Entanglement following MitraClipTM Implantation Necessitating Open Heart Surgery, J Clinical Cardiology and Cardiovascular Interventions, 7(12); DOI: 10.31579/2641-0419/420
Copyright: © 2024, Ajmer Singh. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 16 September 2024 | Accepted: 30 October 2024 | Published: 29 October 2024
Keywords: transcatheter intervention; mitraclip implantation; chordal entanglement; open heart surgery
MitraClip implantation has become an alternative technique to reduce the severity of mitral regurgitation for patients with prohibitive surgical risk. It can, however, lead to either procedure-related or device-related complications. Here, we describe a patient which the MitraClipTM arms were entangled to the chordae tendinae and papillary muscles, and the device could neither be deployed nor removed. The patient required open heart surgery for the removal of the clips and emergent MV replacement. The remaining perioperative course and follow-up of the patient was unremarkable.
For the last two decades, mitral valve (MV) edge-to-edge repair by MitraClip implantation has become the most popular, alternative technique to alter the mitral valve morphology, annular diameter, and reduce the severity of mitral regurgitation (MR) for patients with prohibitive surgical risk.1 Since the first MitraClip implantation in 2003, over 200,000 patients have undergone this procedure worldwide.2 The MitraClip implantation is a transcatheter method that is similar to the Alfieri technique in that it connects the middle scallops of the anterior (A2) and the posterior (P2) leaflet of a regurgitant MV. Echocardiography is an essential imaging modality for patient selection, guidance of the procedure, the identification of periprocedural complication/s, and the evaluation of the final result after clip implantation. The MitraClip implantation can cause procedure-related or device-related complications.3 The procedure-related complications include cardiac perforation, cardiac tamponade, vascular trauma/dissection, cardiac arrhythmias, myocardial infarction, stroke, bleeding, thrombosis, and infective endocarditis. The device-related complications include leaflet perforation, leaflet tear, dislodgement of the device, single leaflet device attachment, and chordal entanglement/ entrapment/rupture. We report a case in which the MitraClipTM arms were entangled to the chordae tendinae and papillary muscles, and the device could neither be deployed nor removed. The patient required open heart surgery for the removal of the clips and emergent MV replacement.
A 72-year-old man was admitted to our institution for worsening dyspnea (New York Heart Association functional class III) for the last two months. Clinical evaluation and investigations including echocardiography revealed degenerative MV disease causing severe MR. The specific signs of severe MR included a vena contracta width of 0.8 cm, a large central regurgitant jet occupying >40% of the left atrium, systolic flow reversal in the pulmonary veins, a dense continuous-wave Doppler MR jet with a peak velocity of 5.1 cm/s, effective regurgitant orifice area of > 0.4 cm2 (Figure 1), dilated left atrium (5.7 cm), and enlarged left ventricle (end-diastolic dimension 6.0 cm). The MV leaflets were thickened with prolapse of the anterior mitral leaflet and tethered posterior leaflet (Figure 2). The left ventricular ejection fraction (LVEF) was 30%. The co-morbid conditions included systemic hypertension, type II diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease (serum creatinine 2.7 mg/dl). The calculated EuroSCORE II for MV repair/replacement was 7.2%. Given the symptoms, echocardiography findings, and co-morbid conditions, the ‘Heart-team’ advised percutaneous MitraClipTM edge-to-edge repair and informed consent was obtained.
Under standard cardiac monitoring including three-dimensional transesophageal echocardiography (TEE, X7-2t probe, Philips), general anesthesia was induced in the hybrid operating room. The cardiac surgical team and cardiopulmonary bypass (CPB) machine were kept on standby. Using fluoroscopy and TEE guidance, the MitraClipTM G4 XTW (Abbott Laboratories, Abbott Park, IL, USA) implantation procedure was started. The standard procedural guidelines were followed which included trans-septal puncture in the superior and posterior part of the interatrial septum (Figure 3), introduction of the steerable guide catheter and clip delivery system into the left atrium, positioning of the MitraClipTM perpendicular to the MV plane and coaptation line of MV leaflets, and advancing it into the left ventricle (Figure 4). After grasping the leaflets (A2 and P2) between the clip arms and the grippers, the clip was closed, but there was a residual lateral jet causing 3+ MR (Figure 5). The second clip was deployed as parallel as possible and lateral to the first one, but still, there was 3+ MR. We attempted to implant a third device but grasping was suboptimal and an entrapment of the device in the subvalvular apparatus was suspected on TEE. All possible maneuvers to release the device failed, and the decision to remove it by open heart surgery was taken. During surgery, the MitraClipTM arms entangled with chordae and papillary muscles were removed (Figure 6) and the MV was replaced by using a 25 mm SJM Epic mitral tissue valve. Follow-up visits at three and six months showed normal functioning of the bioprosthetic MV.
Figure 1: Transesophageal echocardiography long-axis view showing severe mitral regurgitation (Figure 1A), effective regurgitation orifice area >0.7 cm2 (Fig 1B), and mitral valve area > 4 cm2 on planimetry (Figure 1C)
Figure 2: Three-dimensional en-face view of the mitral valve showing prolapse of the anterior mitral leaflet (white arrow), tethered posterior leaflet (black arrow, Figure 2A), and a central jet of severe mitral regurgitation (Figure 2B)
Figure 3: X-plane view of the interatrial septum depicting the site of trans-septal puncture (Fig 3A) at the superior and posterior part (Figure 3B). SVC: superior vena cava, IVC: inferior vena cava
Figure 4: Introduction of the steerable guide catheter (arrow, Figure 4A) and clip delivery system into the left atrium (Fig 4B), and positioning of the MitraClipTM into the left ventricle (Figure 4C)
Figure 5: Residual mitral regurgitation after implantation of first clip (Figure 5A) due to non-coaptation of leaflets (arrow, Figure 5B). Residual mitral regurgitation after implantation of clip 1 and 2 (Fig 5C) and final result showing severe mitral regurgitation (Figure 5D)
Figure 6: MitraClipTM arms (1, 2, and 3) entangled with chordae of the posterior mitral leaflet (PML) and anterior mitral leaflet (AML) removed during surgery
The most plausible explanation for the entrapment of chordae and papillary muscles in this patient is the inappropriate positioning of the MitraClipTM. There is also a possibility that the clip might have rotated during translation from the left atrium to the left ventricle. The first step to extract the entangled clip includes the reversal of the most recent maneuvers to the MitraClipTM. On the contrary, a considerable adjustment in clip arm orientation in the left ventricle can itself result in clip-entanglement in the subvalvular apparatus. If the clip position is not satisfactory, raising the grippers and inverting the clip-arms, followed by retracting the inverted clip-arms into the left atrium may be helpful. Entanglement of the device in the subvalvular apparatus prevented raising the grippers and inverting the clip-arms in this patient. If the clip cannot be removed despite exhaustive attempts, an option is to deploy the clip onto the entangled subchordal mitral apparatus and remove it surgically, rather than tearing chords.
The MitraClipTM procedure is preferably performed in the hybrid operating room, a location capable of handling CPB and open-heart surgery.4 The advantages of a hybrid room include the immediate availability of critical personnel and resources, such as additional anesthesiologists, perfusionists, and CPB equipment. Severely impaired LVEF and comorbidities make MitraClipTM candidates less suitable for surgery. Franzen et al5 demonstrated that MitraClipTM implantation can be safely performed with promising results in patients with very reduced LVEF as 34% of their patients had an LVEF <20>
In a recent study performed by Chhatriwalla et al, the complication rate of MitraClipTM implantation was 8.5%.6 They assessed the relationship between operator experience and procedural results of the MitraClipTM in a cohort of 14,923 patients and found that 1,266 developed complications related to the procedure. The complications that arose due to the clip implantation itself, included: single leaflet device attachment,
partial clip detachment, isolated leaflet damage, clip embolization, conversion to open heart surgery, and lack of procedural success. Mid-term results of the EVEREST trial have reported a conversion rate of 1.8% for open heart surgery and a procedural failure rate of 26%.7 With the development of technology and the availability of ‘extended clip-arms’ the risk of partial clip detachment has reduced from 11% to 0.2%. Another complication that requires urgent conversion to open heart surgery is clip embolization. Fortunately, it is extremely rare and constitutes only 0.1% of the cases.3 An anatomic variant, the intermediate accessory papillary muscle, and central chordae tendineae originating from it can impede the smooth handling of the clip and increase the risk of clip entanglement during the procedure.8
Compared to other transcatheter therapies such as transcatheter aortic valve implantation, periprocedural complication rates of MitraClipTM implantation are relatively low. Nevertheless, complications such as entanglement of the device in the subvalvular apparatus necessitating open heart surgery can happen.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
