Recurrent Infective Endocarditis Following Transcatheter Edge-to-Edge Mitral Valve Repair with MitraClip System

A 61-year-old man with a history of posterolateral myocardial infarction and end-stage renal disease developed decompensated heart failure secondary to severe functional mitral regurgitation (MR) (Supplementary Video 1). Since he was high-risk surgical patient with advanced frailty, we performed percutaneous edge-to-edge mitral valve repair using the MitraClip system (Abbott Vascular, Santa Clara, CA, USA) and corrected severe MR to mild degree (Supplementary Video 2). Two months postoperatively, he developed a sudden fever. Three separate blood cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA). Although signs of bacterial vegetation were inconclusive on initial transesophageal echocardiography (TEE), we suspected infective endocarditis. Given the prohibitive surgical risk, we selected a conservative approach with intravenous antibiotics. Initially, the patient was hemodynamically stable with no evidence of vegetations on repeated transthoracic echocardiography. However, after 5 weeks, MR exacerbated acutely with hemodynamic deterioration. TEE revealed large mobile vegetation on the clip (Figure 1A and B, Supplementary Videos 3 and 4). We performed an emergency surgery and intraoperatively confirmed nodular vegetations on the anterior mitral valve leaflet (Figure 1C-E). Despite successful valve replacement surgery, the patient developed recurrent prosthetic valve endocarditis, possibly due to pathogenic factors of MRSA, and died 49 days after surgery.

Figure 1
Infective endocarditis following MitraClip implantation.
Transesophageal echocardiography showing large vegetations (arrowheads); (A) Long-axis view, (B) Four-chamber view. (C) Surgical view from the left atrium showing several nodular vegetations. (D) Excised vegetations and a clipped native mitral valve (arrows). (E) Histological findings reveal bacterial colonies.

RV = right ventricle; LV = left ventricle; Ao = aorta.

• Click for larger image
• Download as PowerPoint slide

Infective endocarditis after MitraClip implantation is a rare but serious complication with a high mortality rate of 42%.1) Although the optimal treatment strategy for this life-threatening complication remains unknown, all but one reported patient (who was managed medically) underwent surgical valve replacement.1), 2) Early surgical intervention should be considered even in cases of high surgical risk.