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

BACKGROUND: Leaflet tear and perforation are serious complications of transcatheter edge-to-edge repair (TEER) using the MitraClip system for severe mitral regurgitation (MR). However, no optimal bailout strategy has been established. CASE SUMMARY: An 80-year-old woman developed heart failure due to acute ischaemic severe MR after primary percutaneous coronary intervention. Given the requirement for inotropic drugs and an intra-aortic balloon pump to stabilize her heart failure, we decided to perform TEER using the MitraClip G4 system. The NTW clip was selected considering the limited posterior leaflet, wide central MR, and delivery to the central A2/P2. The leaflet was successfully grasped, and the MR jet dramatically decreased while the clip was closed. However, the MR jet suddenly appeared after completely closing the clip arm. A new eccentric jet was detected coming from the mid-portion of the posterior leaflet, indicating leaflet perforation. We decided to manage the leaflet perforation by covering the perforated portion with a longer type of clip. An XTW clip was then carefully delivered to the previously grasped portion, after which we confirmed that the tip of the clip arm was positioned more posteriorly to the leaflet perforation. After slowly closing the clip, MR decreased to mild, with transoesophageal echocardiography showing no eccentric MR. After her haemodynamics stabilized, she was discharged 28 days after the procedure. DISCUSSION: This case details a successful bailout clipping of a leaflet perforation using an XTW clip. Leaflet anatomy evaluation is important to ensure that the injured portion is covered by the longer clip arm.