Description of Event or Problem · 0
DEATH OCCURRED DURING AN ELECTIVE TRICUSPID TRANSCATHETER EDGE TO EDGE REPAIR USING A TRICLIP G4, XT-W DEVICE, DUE TO AN INTRAOPERATIVE TEAR OF HEART AND VENA CAVA. THE DEVICE WAS REPORTEDLY ADVANCED INTO THE RIGHT ATRIUM AND DIRECTED TOWARD THE TRICUSPID VALVE, AT WHICH TIME IT BECAME "CAUGHT UNDERNEATH" THE TRICUSPID VALVE APPARATUS AND THUS WAS NOT EXTENDED OPEN. INSTEAD, THE DEVICE WAS REPORTEDLY RETRACTED INTO THE RIGHT ATRIUM AND RE-SHEATHED. IT IS REPORTED THAT AS SOON AS THE DEVICE WAS PULLED INTO THE INFERIOR VENA CAVA, A LARGE PERICARDIAL EFFUSION WITH TAMPONADE DEVELOPED. AUTOPSY REVEALED MYOCARDIAL ABRASIONS AND A TORN CHORDA TENDINEA WHERE THE DEVICE BECAME TANGLED IN THE TRICUSPID VALVE AND A LARGE TEAR OF THE RIGHT ATRIAL WALL EXTENDING INTO THE INFERIOR VENA CAVA. THE TRICLIP WAS DISCARDED BY THE HOSPITAL WITHOUT EXAMINATION. CLINICAL DIAGNOSIS OF SEVERE TRICUSPID REGURGITATION. AUTOPSY FINDING OF FOCAL THICKENING OF ANTERIOR TRICUSPID LEAFLET.