Successful release of multiple splines of a multipolar catheter entrapped in a mechanical mitral valve: video presentation of a validated method

Case report

A 72-year-old woman with a bileaflet mechanical mitral valve (MV) (ATS Medical, Inc., Minneapolis, MN; 27 mm) underwent radiofrequency catheter ablation for atrial tachycardia (AT). The patient had undergone mitral commissurotomy for mitral stenosis at age 29 and MV replacement and Maze surgery at age 48. At age 72, the patient developed AT and underwent radiofrequency catheter ablation. Because of the previous surgical history in the presence of a dilated left atrium, activation mapping of the AT was performed using a PentaRay catheter through non-steerable sheath (Swartz SL0 Transseptal Guiding Introducer; Abbott Laboratories, Abbott Park, IL, USA) under the guidance of a three-dimensional electroanatomic mapping system (CARTO, Biosense Webster, Diamond Bar, CA, USA).

Despite careful mapping of the left atrium, two PentaRay catheter splines were suddenly entrapped in a mechanical MV (see Supplementary material online, Videos S1 and S2). Catheter manipulation was first interrupted because splines easily sheared off upon manual traction, and a biplane fluoroscopic video image was acquired to confirm the exact site of entrapment. The splines were entrapped in the same leaflet. Mild traction of the PentaRay catheter was performed to avoid spline disruption but did not release the spline. Through the same transseptal puncture site, a steerable sheath (Agilis NxT Large curve; Abbott Laboratories, Abbott Park, IL, USA) was inserted into the left atrium perpendicular to the mechanical MV (Figure 1A). An ablation catheter (ThermoCool SmartTouch SF; Biosense Webster) was advanced through the sheath to the stuck leaflet, pushing open the leaflet and releasing the splines (Figure 1B and C, Supplementary material online, Videos S3 and S4). The released splines and electrodes were intact. Fluoroscopic imaging confirmed that mechanical MV movement was unrestricted, and catheter ablation resumed.

Figure 1.

Fluoroscopic images obtained before (A) and after (B) the entrapment of a PentaRay catheter in a mechanical mitral valve in right anterior oblique view. (C) Schematic representation of the release of an entrapped spline by advancing an ablation catheter to the leaflet.

One complication during left atrial mapping in patients with mechanical MV is the entrapment of the multipolar mapping catheter in this valve. PentaRay catheter splines entrapped in a mechanical MV are easily sheared off or stretched by manual traction.^1–3 Due to the high incidence of complex atrial arrhythmias in patients undergoing prosthetic valve replacement, we used the PentaRay catheter in this particular case of highly symptomatic AT despite the contraindication. In one case, an entrapped spline was released by pushing the leaflet of a mechanical MV using an ablation catheter, although it was partially broken.³

We report the first fluoroscopic video of the successful release of multipolar mapping catheter splines entrapped in a mechanical MV. It is considered to be an educational video that should be known before ablation as the proposed method to release a catheter entrapped in a bileaflet mechanical MV.

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports online.

Consent: The authors confirm that written informed consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with Committee on Publication Ethics (COPE) guidance.

Funding: None declared.

Data availability

The data underlying this article are available in the article and in its online supplementary material.