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Acute occlusion of the right coronary artery: an unusual case.

An 86-year-old gentleman was hospitalized for progressive dyspnoea New York Heart Association (NYHA) functional class III–IV. He had a history of coronary artery disease and left ventricular dysfunction. Echocardiography revealed a coaptation defect of the mitral valve with resulting severe functional mitral regurgitation (MR) (vena contracta width 1 cm, effective regurgitant orifice area 0.4 cm, and regurgitant volume 65 mL/beat) (Panel A). Following Heart-Team decision, due to frailty and elevated surgical risk (EuroScore II: 8.6%), a catheter-based approach with the edge-toedge technique was planned. Using two MitraClip-NT devices (Abbott Vascular, Abbott Park, IL, USA), MR grade could be reduced from severe to mild (Panels B and C). One day after the MitraClip procedure, the patient was discharged from intensive care unit to a peripheral ward. On Day 5, the clinical status of the patient deteriorated acutely: he complained severe chest pain and electrocardiogram (ECG) showed ST elevation in leads II, III, and aVF. The patient was immediately transferred to the cath-lab with beginning cardiogenic shock. Coronary angiography showed that the clip that had been implanted in the A1/P1segment had been embolized in the right coronary artery (RCA) ostium (Panel D). Using a 20 mm micro snare (Medtronic, Minneapolis, MN, USA), the device could be retrieved, and removal from the groin after surgical cut-down (Panel E) was tried. Unfortunately the clip was detached from the micro snare and embolized into the right femoral artery. It could finally be retrieved using a micro-biopsy forceps. After removal of the clip from the RCA ostium, thrombolysis in myocardial infarction (TIMI) 3 flow was restored, the patient was haemodynamically stabilized (Panel F). Unfortunately, the patient deceased due to pneumogenic sepsis 2 weeks after clip retrieval. Complete detachment and embolization of a MitraClip is extremely rare, with only very few reported cases. Anatomic factors, such as relevant coaptation defect, might lead to difficult clip-deployment and contribute to detachment of the device. Snaring of an embolized clip should be done extremely cautiously, giving the risk of (e.g. cerebral) re-embolization. (Panel A) Severe MR before the procedure; (Panel B) mild MR after implantation of two MitraClips; (Panel C) fluoroscopic result after implantation of two clips; (Panel D) embolized MitraClip in the ostium of the RCA; (Panel E) successful snaring of the MitraClip; (Panel D) angiographic result after snaring of the device with restoration of TIMI 3 flow. *MitraClip device.