# A case report of delayed left ventricular rupture after mitral transcatheter edge-to-edge repair: clip entrapment in hypercontractile left ventricle

## TL;DR

This case report describes a rare delayed left ventricular rupture after a heart procedure, successfully treated with surgery.

## Contribution

The report highlights a novel complication of clip entrapment in a hypercontractile left ventricle after M-TEER.

## Key findings

- Clip entrapment between a hypertrophied papillary muscle and LV wall may cause delayed LV rupture.
- Surgical repair and mitral valve replacement successfully treated the complication.
- Elderly patients with limited LV space are at higher risk for this rare complication.

## Abstract

Left ventricular (LV) rupture is an extremely rare but possible complication after mitral transcatheter edge-to-edge repair (M-TEER). We describe a delayed LV rupture after M-TEER that was successfully treated with surgical repair.

An 83-year-old Asian male with congestive heart failure was referred for treatment of severe mitral regurgitation (MR) due to A1/A2 segment prolapse with abnormally hypertrophied anterior papillary muscle. The patient was at high surgical risk, and M-TEER with MitraClip (Abbott Vascular, Minneapolis, MN, USA) was performed. During the procedure, an NT clip became entangled between the hypertrophied papillary muscle and the LV inferolateral wall. After disentangling the clip, we aimed the clip for a second attempt slightly towards the medial side and inserted it into the LV, avoiding interference with the subvalvular apparatus or LV wall. Grasping in this position significantly reduced MR to mild. The patient was initially stable, but sudden cardiac arrest occurred 75 min post-procedure, and subsequent echocardiography revealed massive pericardial effusion. Emergent sternotomy revealed a tear at the LV basal inferolateral wall just behind the anterior papillary muscle. Surgical patch repair and mitral valve replacement were performed, and the patient was discharged without neurological sequelae.

The entrapment of the clip between the hypertrophied papillary muscle and the hypercontractile LV wall may have caused a crack in the LV wall, disrupting the endocardium. In elderly patients with primary MR, especially those with commissural lesions and limited LV space, clinicians should be cautious of LV rupture even after the procedure.