Minimal Advancement Technique to Avoid Device Entrapment during Transcatheter Edge-to-edge Repair for a Non-central Pathology

Abstract

The objective of this report was to be able to understand how to use the MitraClip G4 XT/XTW device effectively without complications particularly for non-central pathologies. Case Presentation: A 76-year-old woman was hospitalized for decompensated heart failure. Transthoracic echocardiography revealed severe mitral regurgitation (MR) due to a large P3 prolapse. She was at a high risk for open-heart surgery, and our heart team decided to perform transcatheter edge-to-edge repair (TEER). Under transesophageal echocardiographic guidance, the MitraClip XTW system was placed perpendicularly above the prolapsed leaflet. Given the limited space below the lesion in the left ventricle (LV), the device was entrapped in the deep LV twice, resulting in worsening MR and a transient drop in blood pressure to 30 mmHg. Finally, the clip arm was opened to 120°, with the device being advanced only halfway, allowing for the anterior and posterior parts of the clip arms to slide under the mitral valves without deep advancement into the LV. It was then easily positioned on both leaflets. Finally, the XTW device was fully closed with adequate leaflet insertion in both arms. The degree of MR significantly decreased from severe to trace levels. The patient was then discharged. Conclusion:The "minimal advancement technique" is particularly safe and effective in patients who require TEER with a long MitraClip G4 system for non-central pathologies, as it allows the clip arms of the MitraClip device to slide under the mitral valve leaflets without advancing deep into the LV.