Bailout clipping of a leaflet perforation during mitral transcatheter edge-to-edge repair using a larger clip size: a case report

Figure 1. Pre-operative transthoracic echocardiography. Severe mitral regurgitation with tethering of the posterior mitral leaflet. (A) Apical three-chamber image, tethering of the posterior mitral leaflet. (B) Apical four-chamber image.

Figure 2. Pre-operative transoesophageal echocardiography. (A) Three-dimensional image of the mitral valve showing a central jet from A2–P2. (B) Wide regurgitation jet slightly lateral to A2–P2. (C) Posterior mitral leaflet was tethering, PML length around 8 mm.

Figure 3. Intraoperative transoesophageal echocardiography until valve leaflet injury was recognized. (A) Positioning the NTW clip in line with central jet. (B) Mitral regurgitation decreased while the clip arm was closed. (C) Once the clip was completely closed, a new mitral regurgitation suddenly appeared. (D) The new eccentric jet came from the mid-portion of the posterior leaflet, indicating leaflet perforation caused by the clip arm. The distance from the tip of the posterior leaflet to the perforation site was around 8 mm.

Figure 4. Intraoperative transoesophageal echocardiography after recognizing valve leaflet injury. (A) Delivery of the XTW clip to the previously grasped portion, confirming that the tip of the clip arm was positioned more posteriorly to the leaflet perforation before grasping the leaflets. (B) After fully closing the clip, the mitral regurgitation decreased to mild. (C) Final transoesophageal echocardiography showed mild mitral regurgitation and no stenosis.

Figure 5. Three-dimensional multiplanar reconstruction image at the time of leaflet injury. (A) Regurgitant blood flow from the middle portion of the posterior leaflet (arrow). (B) The distance to the injured part was 5.3 mm from the leaflet tip and 4 mm from the base of the posterior leaflet.