Description of Event or Problem · 0
DURING A MITRACLIP CASE INVOLVING MIXED MITRAL REGURGITATION (ATRIAL-FUNCTIONAL MR WITH A3 PROLAPSE), A PERICARDIAL EFFUSION OCCURRED, AND THE PATIENT EXPIRED. A SWARTZ SHEATH AND NON-ABBOTT RF NEEDLE WERE INITIALLY USED IN AN ATTEMPT TO PERFORM TRANSSEPTAL PUNCTURE. HOWEVER, DUE TO THE PATIENT¿S KYPHOSIS, ADVANCING THE SHEATH GUIDEWIRE INTO THE SUPERIOR VENA CAVA (SVC) WAS DIFFICULT. SUBSEQUENTLY, THE GUIDEWIRE WAS MANIPULATED TOWARDS THE FORAMEN OVALE TO PERFORM THE TRANSSEPTAL PUNCTURE. ALTHOUGH THE TARGET REGION WAS REACHED AND ELECTRICAL ENERGY WAS APPLIED, THE RF NEEDLE TIP DID NOT ENTER THE LEFT ATRIUM. THE POSITION WAS REASSESSED, AND ENERGY WAS APPLIED A SECOND TIME; HOWEVER, THE NEEDLE TIP STILL COULD NOT BE VISUALIZED WITHIN THE LEFT ATRIUM. AFTER THE GUIDEWIRE WAS REDIRECTED TOWARD THE SVC, THE RF NEEDLE TIP WAS FOUND TO BE BENT AND WAS SUBSEQUENTLY REPOSITIONED TOWARD THE FORAMEN OVALE. TEE IMAGING CONFIRMED A POSTERIOR-WALL LOCATION IN THE MID-SAX AND BICAVAL VIEWS, AFTER WHICH ENERGY WAS DELIVERED. FLUSHING TOWARD THE LEFT ATRIAL SIDE WAS OBSERVED, AND THE NEEDLE WAS ADVANCED; HOWEVER, IT DID NOT PASS THROUGH THE SWARTZ SHEATH AND RESISTANCE WAS NOTED. FURTHER ADVANCEMENT WAS CONSIDERED TECHNICALLY DIFFICULT AND UNSAFE; THEREFORE, THE DEVICES WERE WITHDRAWN. UPON REMOVAL OF THE SHEATH, A PERICARDIAL EFFUSION WAS IDENTIFIED, ATTRIBUTED TO INJURY OF THE RIGHT ATRIAL WALL, FOLLOWED BY IMMEDIATE HYPOTENSION. PERICARDIAL DRAINAGE WAS PERFORMED; HOWEVER, THE PATIENT¿S HEMODYNAMIC STATUS DID NOT IMPROVE, AND EMERGENT OPEN-HEART SURGERY WAS INITIATED. FOLLOWING SURGICAL HEMOSTASIS, THE PATIENT INITIALLY STABILIZED, AND CARDIOPULMONARY RESUSCITATION WAS TRANSITIONED TO PERCUTANEOUS CARDIOPULMONARY SUPPORT (PCPS). RECURRENT BLEEDING SUBSEQUENTLY OCCURRED, AND THE PATIENT WAS DIAGNOSED WITH DISSEMINATED INTRAVASCULAR COAGULATION (DIC). DESPITE CONTINUED MANAGEMENT UNDER PCPS SUPPORT, THE PATIENT EXPIRED. IT IS THE PHYSICIANS¿ OPINION THAT THE PERICARDIAL EFFUSION WAS CAUSED BY THE SHEATH DURING ATRIAL SEPTAL PUNCTURE.