Complications of the Percutaneous Mitral Valve Edge-To-Edge Repair: Role of Transesophageal Echocardiography

Abstract

The use of transcatheter edge-to-edge repair for the treatment of mitral regurgitation has markedly increased in the last few years. The rate of adverse events related to the procedure is low; however, some of the complications that may occur are potentially dangerous. Due to the growing popularity of the technique, which is no longer limited to high-volume centers, knowledge of the complications related to the procedure is fundamental. Transesophageal echocardiography has a key role in the guidance of the intervention while allowing for the avoidance of most of these adverse events, as well as enabling us to diagnose them early. In this article, we review the main complications that might present during a transcatheter mitral edge-to-edge repair procedure (tamponade, thromboembolic events, single leaflet device attachment, device embolization, vascular injury…) while highlighting key aspects of transesophageal echocardiographic monitoring in the prevention and prompt diagnosis of these complications.

Keywords: complications; edge-to-edge repair; mitral regurgitation.

Figure 1

Three-dimensional transesophageal echocardiogram showing a clip inside the left atrium touching the lateral wall (red arrow).

Figure 2

Three-dimensional transesophageal echocardiogram TEE image showing a large thrombus (red arrow) at the tip of the clip that is emerging from the delivery catheter within the left atrium.

Figure 3

Severe mitral stenosis after implantation of a mitral clip measured by Doppler echo.

Figure 4

Transesophageal echocardiogram during grasping. (Left) Two-dimensional transesophageal echocardiogram in the view of the left ventricular outflow tract, showing the tension of both leaflets and the measurement of the posterior leaflet introduced in the clip (red line delimited by plus sings). (Right) En-face 3D transesophageal echocardiogram view of the mitral valve with a clip between A2 and P2 with 2 symmetrical pyramids (red dotted lines).

Figure 5

Two-dimensional transesophageal echocardiogram showing a very severe mitral regurgitation after the partial detachment of a clip and a leaflet tear prolapsing in the left atrium (yellow arrow). Three-dimensional transesophageal echocardiogram in the enface mitral view, where a clip can be seen attached to the anterior leaflet (red arrow) and loose from the posterior with a lack of diastolic tissue bridge. In the lower panel, simultaneous recording of left atrium (green), pulmonary artery (yellow), and aortic pressure (purple): baseline, post clip implantation and after detachment.

Figure 6

Clip embolization. (Left) Two-dimensional transesophageal echocardiogram showing a posterior leaflet prolapse (yellow arrow) after retrograde embolization of a clip to the right ventricle through the procedural atrial septal defect (red arrow). (Right) Fluoroscopy image at the end of the procedure showing two clips implanted in the mitral valve and another one embolized in the apex of the right ventricle (red arrow).

Figure 7

Persistent atrial septal defect. (Left) Three-dimensional transesophageal echocardiogram image showing a large atrial septal defect with tearing of the tissue through the transseptal puncture area (yellow arrow) from the left atrium. (Right): Two-dimensional transesophageal echocardiogram showing an Amplatzer device closing the iatrogenic atrial septal defect (red arrow).