Transcatheter Edge-to-Edge Repair for Acute Papillary Muscle Rupture After Transvenous Lead Extraction in a d-TGA

Abstract

We present a case of a patient known for dextrotransposition of the great arteries corrected with a Mustard procedure, in whom severe mitral valve regurgitation secondary to transvenous lead extraction was successfully repaired with transcatheter edge-to-edge repair using the TriClip device (Abbott Vascular).

Keywords: TriClip; congenital; valve replacement.

Graphical abstract

Figure 1

Drawing of d-TGA and Anatomy Post-Mustard Repair (A) Depiction of d-TGA with a systemic right ventricle with the tricuspid valve, that is connected to the aorta. The blue arrows demonstrate the flow of deoxygenated blood from the systemic venous return to the aorta resulting in cyanosis after birth. The subpulmonary left ventricle (LV) with the mitral valve is connected to the pulmonary artery, such that oxygenated blood (red arrows) returning via the pulmonary veins is recirculated to the lungs. (B) After surgical repair with the Mustard procedure, a prosthetic baffle is attached to the vena cava and systemic venous return is directed via the baffle to the mitral valve of the subpulmonary left ventricle, which is connected to the pulmonary artery. Flow from the pulmonary veins flows behind the baffle to the tricuspid valve and systemic right ventricle. The correct flow of deoxygenated and oxygenated blood has been restored as shown by the arrows. ASD = atrial septal defect; d-TGA = dextrotransposition of the great arteries; RV = right ventricle.

Figure 2

Still Echo Images Still echo images of anterior mitral leaflet flail after lead extraction illustrating the ruptured papillary muscle, flail fap, and restricted posterior leaflet.

Figure 3

CT Images (A) Axial and coronal computed tomography (CT) imaging of patient with identification of baffles and stents and mitral annular plane. In the axial image the systemic RV is visualized directly behind the sternum with a mild pectus deformity. In the coronal image, a stent can be visualized in the superior systemic venous baffle and pacing leads are seen in the subpulmonary LV. The mitral annular plane has been drawn in to illustrate the position on the CT scan. (B) Images of MitraClip and TriClip guide catheter with planned trajectory on CT scan imaging. Abbreviations as in Figure 1.

Figure 4

TriClip Procedure (A) Triclip wide clip (XTW) device maneuvered in the systemic venous baffle. (B) Lealfet grasping with the XTW. (C) Two clips in position, XTW at A2P2 and NT at the lateral segment of A2P2. (D) Echo imaging showing 2 clips in place. (E) Trace residual mitral regurgitation.