Recurrent mitral regurgitation with haemolytic anaemia after MitraClip procedure: an autopsy case report

Figures

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  Figure 1. Pre-procedural echocardiography findings. (A) Transthoracic three-chamber view; (B) Transesophageal (3D) surgeon’s view; (C) Transesophageal long-axis view; and (D) Transesophageal bi-commissure view.

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  Figure 2. Post-procedural transesophageal echocardiography findings. (A) Mild residual mitral regurgitation; (B) mitral valve pressure gradient was measured; and (C and D) 3D surgeon’s view indicated two regurgitant orifices bilateral to the second clips.

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  Figure 3. Transition of echocardiographic findings over time. (A) Mild mitral regurgitation immediately after the procedure; (B) Moderate MR on the 5th day and (C) Severe mitral regurgitation on the 12th day after the procedure; (D) Appearance of schizocytes in the blood smear (black arrows); and (E–G) The clip on the lateral side protruded into the left atrium (white arrow) with severe regurgitation on the 12th day after the procedure. Gap on the lateral side of A2 was indicated in black arrow. MR, mitral regurgitation.

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  Figure 4. Macroscopic and microscopic findings of the ruptured mitral leaflet. (A) The clip on the lateral side protruded into the left atrium (left white arrow) and the tear on the lateral side of A2 leaflet was indicated (yellow arrow); (B) single leaflet device attachment (SLDA) of the clip on the lateral side was evident; (C) The clip on the medial side appropriately grasped the leaflets; (D) haematoxylin and eosin staining, A2 leaflet was thick and layered structure was obscured; (E) Azan staining, severe fibrosis and (F) CD34 staining, the growth of fibroblasts were evident in the leaflet tissue; (G) Kossa staining, no evidence of microcalcification; and (H) Comparison of transesophageal 3D surgeon’s views. Transient annulus deformation after the procedure suggested excessive tension on the lateral side of A2 leaflet (white arrows).

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