Emergent valve replacement after circular mapping catheter entrapment in mitral valve apparatus

Abstract

We present the case of a 47-year-old male patient with a history of symptomatic paroxysmal atrial fibrillation who failed guideline-directed medical treatment and cardioversion. Electrical mapping was attempted and complicated with catheter entrapping in the mitral valve (MV) apparatus, and multiple attempts for retrieval were unsuccessful and caused severe valvular dysfunction. Emergent valve replacement was required secondary to the extensive disruption of the valvular apparatus and posterior annulus. Mapping catheter entrapment in the valvular apparatus is an uncommon complication, but when it occurs, there is a high risk of injury to the MV apparatus during retrieval. To avoid extensive MV damage, operators should use minimal force during standard manoeuvres to extract the catheter. If gentle retrieval manoeuvres fail, surgical exploration and open retrieval may prevent MV damage. Early surgical consultation and exploration could result in open catheter retrieval or MV repair versus MV replacement.

INTRODUCTION

Catheter-based pulmonary vein isolation is an established procedure for atrial fibrillation (AF) ablation. However, the entrapment of the mapping catheter in the mitral valve (MV) apparatus has been reported [1–5]. Unlike other cases, traditional manoeuvres could not dislodge the catheter, and the patient’s extensive MV damage required emergency surgery and valve replacement.

CASE REPORT

A 47-year-old male with symptomatic paroxysmal AF resistant to medical treatment and cardioversion was referred to our institution for AF ablation. Preoperative assessments included transoesophageal echocardiography and transthoracic echocardiography and a coronary computed tomography angiogram. The left atrial dimension was 40 mm. The left atrial appendage was of normal size with no evidence of left atrial thrombus. The mitral and tricuspid valves showed unremarkable anatomy and function. All pulmonary veins opened to the left atrium in normal anatomic configuration.

In the catheterization laboratory, the patient was noted to have intermittent atrial flutter with proximal and distal activation sequence. The cavotricuspid isthmus was mapped, and a series of linear RF lesions were delivered from the tricuspid annulus to the inferior vena cava. The interatrial septum was crossed with 2 transseptal SL1™ (St Jude Medical) sheaths. Transseptal access allowed for a ThermoCool^® SmartTouch^® catheter (4 mm, Biosense Webster Inc.) to pass through 1 sheath and a LASSO^® circular mapping catheter (Biosense Webster Inc.) was passed through the other. Both were advanced into the left atrium. After creating a 3-D electro-anatomic map of the left atrium, radiofrequency ablations were completed on each ostium of the left pulmonary veins. While the LASSO^® catheter was being repositioned, it became lodged within the MV apparatus (Fig. 1).

Figure 1:

LASSO^® catheter wrapped in and around the mitral valve apparatus.

Different manoeuvres, including rotation, traction and straightening, were applied multiple times and by different operators. All manoeuvres failed to dislodge the LASSO^® catheter. Emergency open-heart surgery ensued, and an intraoperative transoesophageal echocardiography confirmed severe mitral regurgitation due to the coiled catheter (Fig. 2).

Figure 2:

Pre-op transoesophageal electrocardiogram; the LASSO^® catheter is entrapped in the mitral valve apparatus causing severe mitral regurgitation.

An aortic and double venous cannulation was performed, and the heart was arrested by antegrade, cold-crystalloid cardioplegia infusion. The right atrium was opened. The SL1 sheaths were visualized in the interatrial septum. The left atrium was opened by a superior septal approach. We identified that the LASSO^® catheter had punctured the posterior mitral annulus at the 4 o’clock position and was wrapped around the chordae. The posterior mitral leaflet was also punctured, and the catheter passed around and through the posterior papillary muscle. The posterior mitral leaflet, posterior annulus, and papillary muscle were destroyed. The LASSO^® catheter was cut into pieces and removed incrementally. Repair of the MV was not possible, and it was replaced by an On-X mechanical prosthetic valve (27–29 mm, CryoLife Inc.). The left atrial appendage was ligated using a 40 mm Atriclip (AtriCure Inc.).

The postoperative course was uncomplicated. The patient remained in a sinus rhythm and was discharged home on day 7 on warfarin.

DISCUSSION

The first reported case of catheter entrapment with a circular catheter and extensive MV damage was published in 2002 [1]. LASSO^® catheter entrapment in the MV apparatus has been reported with an incidence of up to 0.09% [2]. Mandawat et al. [3] reported that small left atrial chambers and left-sided accessory pathways for arrhythmias requiring ablation may increase the risk of entrapment. Furthermore, when deciding between the retrograde approach (transaortic valve approach) and antegrade approach (transeptal), the operator must remember that the retrograde approach is associated with more entrapment.

Once entrapment is known, the operator must choose from a series of manoeuvres to extract the device. Standard options include straightening the circular catheter by advancing the sheath, advancing the catheter apically, retraction, or use of rotational movements to release the catheter. If catheter removal is unsuccessful or if there is considerable MV regurgitation present, emergency or elective MV surgeries are often necessary [4, 5].

During standard manoeuvres to extract an entrapped catheter, the operator should avoid extensive catheter manipulation and excessive force. Since the mitral valvular and subvalvular apparatus could be extensively damaged, attaining an early surgical consult and exploration could provide additional options to safely retrieve the catheter surgically and/or repair the MV.

If the damage to the MV apparatus prevents repair, especially if the posterior mitral annulus, leaflet, and papillary muscle are damaged, MV replacement is the only option. Avoiding extensive percutaneous catheter retrieval manoeuvres and excessive force in addition to early surgical consult is paramount as it can make the difference between an open surgical retrieval or MV repair versus an MV replacement.

Conflict of interest: The authors acknolwedge the receipt of in kind support in the form of food/beverage, education and/or travel support; however, none rise to the level of a conflict of interest and all are documented on the Open Payments website.

Reviewer information

Interactive CardioVascular and Thoracic Surgery thanks Hugh Calkins and the other anonymous reviewer(s) for their contribution to the peer review process of this article.