Delayed Device Embolization After TEER of the Mitral Valve as a Rare But Dangerous Complication

Abstract

Background

Delayed device embolization is a rare but dangerous complication after transcatheter edge-to-edge repair (TEER).

Case Summary

A 79-year-old man with acute decompensated severe structural mitral regurgitation underwent TEER with 2 clips after failed medical attempts at recompensation. Six days later, 1 clip embolized into the abdominal aorta, resulting in recurrent, progressive decompensation and severe mitral regurgitation, requiring urgent mitral valve replacement. Despite initial stabilization, the patient died because of septic complications.

Discussion

Although delayed device embolization is rare, it may be underreported in the current literature and can have serious consequences. This underscores the importance of careful heart team evaluation when choosing between interventional vs surgical strategies.

Take-Home Message

Device embolization after TEER must be discussed as a rare but serious complication, and particular attention should be given to close post-TEER monitoring, especially in patients with complex anatomy.

Graphical Abstract

History of Presentation

A 79-year-old man presented with symptoms of progressive dyspnea and angina pectoris. Initial blood pressure and oxygen saturation were 160/90 mm Hg and 85%, respectively. Auscultation revealed a holosystolic murmur related to the mitral valve (MV).

Past Medical History

In addition to his heart valve failure, the patient suffered from arterial hypertension and hepatic steatosis.

Differential Diagnosis

Differential diagnoses included mitral regurgitation (MR), acute coronary syndrome, pulmonary dysfunction, or acute decompensated heart failure because of nonvalvular causes.

Investigations

Laboratory examinations at admission showed elevated brain natriuretic peptide levels (2.128 pg/mL) and a reduced glomerular filtration rate (51 mL/min), which rapidly decreased to 22 mL/min within 12 days. Chest radiographs revealed significant congestion. Pulmonary infiltrates could not be ruled out and, in combination with elevated leukocyte counts (11.4 Gpt/L), an infectious constellation was suspected. Transthoracic echocardiography showed a dilated left ventricle with normal ejection fraction (55%) and a dilated left atrium (139 mL) associated with severe structural MR because of prolapse of the P2 segment. Despite recompensation attempts, including intravenous application of diuretics, the patient developed tachycardic atrial fibrillation, progressive pleural effusions, and sonographically detectable B-lines.

Management

The diagnosis of acute cardiac decompensation with acute kidney injury and pulmonary congestion because of severe structural MR was made (Video 1). The case was discussed in our interdisciplinary heart conference. Because of the acute decompensation, the risk of mortality or major perioperative morbidity was considered too high (STS [The Society of Thoracic Surgeons Score for Short-term and Operative Risk] score morbidity/mortality: 50.8%) for surgery. Instead, the decision for optimal medical treatment in combination with transcatheter edge-to-edge repair (TEER) was made.

The procedure was performed using the MitraClip system (XTW, Abbott). After several attempts at adapting the mitral leaflets (Video 2), the transesophageal echocardiography confirmed a median positioning of the clip and relevant reduction of MR. Therefore, the device system was released. Unfortunately, the following transesophageal echocardiography revealed hypermobility of the clip, suggesting single leaflet device attachment. Another clip was placed, which grasped enough material. The second clip achieved an acceptable result with a reduction from severe to moderate MR, but the first clip remained hypermobile (Figure 1, Video 3). During the following days, the patient stabilized without further complications. However, 6 days after device implantation, the patient developed progressive decompensation requiring inotropic support. Transthoracic echocardiography revealed recurrence of severe MR. Heart team discussion came to the consensus that another interventional treatment did not seem feasible, specifically because the inotropic stimulation would increase technical complexity even more. Thus, the decision for surgical intervention was made despite the high risk in the decompensated state. The preoperative chest radiograph performed 9 days after TEER revealed an unexpected embolization of 1 clip into the abdominal aorta (Figure 2), which likely explains the recurrence of severe MR, because the last radiograph performed 5 days after implantation showed its consistent presence. Because there was no evidence of intestinal ischemia, the embolized device was not removed and an urgent biological MV replacement was performed 10 days after clipping. Because of relevant damage to the MV through the clips, repair was not possible. A postoperative computed tomography scan (Figure 3) showed the constant projection of the embolized device at the posterior wall of the abdominal aorta.

Figure 1.

Postinterventional Imaging

Intrainterventional fluoroscopy (left) and postinterventional chest radiograph (right) showing both transcatheter edge-to-edge repair devices in the correct position (red arrows).

Figure 2.

Radiograph After 9 Days

Chest radiograph performed 9 days after transcatheter edge-to-edge repair showing device embolization of one clip into the abdominal aorta (red arrows).

Figure 3.

Postoperative Computed Tomography

Postoperative computed tomography showing constant position of the embolized transcatheter edge-to-edge repair device in the aorta (red arrow) and the implanted mitral valve prothesis (blue arrow).

Outcome and Follow-Up

The following intensive care unit stay was complicated by ventilator-associated pneumonia caused by Klebsiella pneumonia, leading to sepsis and multiorgan failure. The patient died on postoperative day 10.

Discussion

We report the case of a patient showing delayed device embolization and recurrent severe MR after TEER, requiring urgent surgical treatment in a decompensated state and ultimately resulting in the patient's demise. This case shows a rare but serious complication. Awareness of this potential problem may assist the decision-making process of similar cases.

Studies show that results after TEER might be less durable and the need for MV surgery is observed in 24.8% of cases.¹ In contrast, the need for redo surgery occurs in only 5.5% of patients after primary surgical repair at 4-year follow-up.¹ Nevertheless, in case of high surgical risk, TEER represents a feasible and guideline-conforming treatment strategy for symptomatic severe structural MR.²

At the same time, TEER devices carry their own risks, including device embolization. The literature states a probability of 0.1%.³ Considering that >200,000 patients have undergone MitraClip implantation worldwide,⁴ this means that >200 patients should have experienced this complication since device introduction. Surprisingly, there is only a limited number of cases available reporting device embolization (ie, into axillar, renal artery or apex of the left ventricle).5, 6, 7 Because only a few of these publications report a lethal outcome, it is conceivable that device embolization associated with poor outcomes is underreported. Even though a relevant number of embolizations could probably be successfully solved by interventional removal or remain without signs of acute ischemia, as in our case, cranial or limb embolizations are able to cause significant clinical events.

In addition, device embolization may also lead to recurrent or worsening MR by separating the attachment, causing changes in valve geometry or even causing damage to the leaflets. Our case also illustrates how TEER failure increases surgical risk even further through the recurrent decompensation which, in our case, was associated with preoperative inotrope use, that was not necessary at the time of the initial TEER procedure. Studies reporting a mortality rate of 23.2% at 1-year follow-up after surgical treatment secondary to clipping support those findings.⁸ Thus, one may argue that an initial surgical approach might have been associated with lower risk. That is why heart team discussions are so important, because there would have been no guarantee that a surgical approach would have been without complications. In our case, the decision for TEER made by the heart team appeared to be the right one at the time.

It is also important to realize at the time of decision-making that a surgical approach after TEER usually requires valve replacement even in valves that normally have a very high likelihood of being repairable.⁹ Although the clip can intraoperatively be opened and the arms may be released, the fragile leaflet tissue is often damaged and, depending on the time since implantation, clip ingrowth has occurred, making damage-free removal a true challenge if not impossible. Therefore, it is crucial to be aware of the potential complications of TEER when a decision between surgical and interventional strategy is made, specifically if a valve has the potential to be successfully and durably repaired, which is generally associated with best long-term outcomes.¹⁰

Conclusions

We report late device embolization and recurrent severe MR after urgent TEER as a rare but dangerous complication that should be considered by heart teams when choosing between interventional and surgical treatment.

Visual Summary.

Timeline of Clinical Management in a Case of Severe Structural MR

Timeline	Events
Day 1	A 79-year-old man presenting with symptoms of progressive dyspnea and angina pectoris because of acute decompensated structural severe MR
Day 1-14	Medical treatment attempts for recompensation and heart team discussion
Day 14	TEER with implantation of 2 clips
Day 19	Last confirmation of correct clip position on imaging
Day 20	Recurrent severe MR leading to progressive decompensation and heart team decision for surgical intervention
Day 23	Preoperative radiograph reveals embolization of 1 clip as cause of the recurrent decompensation
Day 24	Urgent biological MV replacement
Day 34	Patients demise because of ventilator-associated pneumonia and sepsis

MR = mitral regurgitation; MV = mitral valve; TEER = transcatheter edge-to-edge repair.

Funding Support and Author Disclosures

Dr Caldonazo has been funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) Clinician Scientist Program OrganAge (funding number 413668513), Bonn, Germany, the Deutsche Herzstiftung (DHS, German Heart Foundation) (funding number S/03/23), Frankfurt am Main, Germany, and the Interdisciplinary Center of Clinical Research of the Medical Faculty Jena, Germany. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Take-Home Messages

• •Delayed device embolization is a rare but potentially dangerous complication after TEER.
• •Awareness of this complication is important and requires attention during follow-up of patients after TEER, especially in cases with challenging anatomy or complex procedures.

Appendix

Video 1

Severe Structural Mitral Regurgitation

Three-dimensional reconstruction (left) and color flow Doppler echocardiography (right) showing severe mitral regurgitation

Video 2

First Clip Release

Transesophageal echocardiography performed during transcatheter edge-to-edge repair showing the first clip implantation

Video 3

Fluoroscopy After Transcatheter Edge-To-Edge Repair

Fluoroscopy performed after transcatheter edge-to-edge repair showing remaining hypermobility