Successful retrieval of a broken PentaRay catheter spine in a patient with mechanic mitral valve prosthesis

Abstract

A 62-year-old man was referred for ablation of atypical AFL. He already was submitted to a persistent atrial flutter ablation. He had previously undergone mitral valve replacement due to severe mitral regurgitation with a mechanical bileaflet valve (St. Jude Medical Heart Valve: St. Jude Medical and Abott). Electroanatomical activation map was performed with the CARTO 3 system (Biosense Webster) and was consistent with a counterclockwise mitral AFL (Fig. 1a). Despite careful mapping near the mechanical mitral valve, one of the spines of the PentaRay catheter was entrapped in the prosthesis. Gentle rotation in the opposite direction and traction was performed but with an unsuccessful result. In order to provide support, the steerable sheath (Agilis Nxt, St Jude Medical) was advanced to the tip of the mapping catheter, and more traction was performed. This maneuver released the PentaRay catheter from the mechanical mitral valve but one of the spines had been sheared off and remained in the left atrium (Fig. 1b). To retrieve the spine, the Expro Elite snare (Teleflex) was advanced through the steerable sheath into the left atrium and directed towards the PentaRay remnant (Fig. 1b). Fluoroscopy was used to locate the spine and guide the capture. After some attempts, the lost spine was caught with success (Fig. 1c), and the fragment was matched to the PentaRay mapping catheter to confirm the complete spine retrieval (Fig. 1d). Catheter ablation was performed in the anterior wall to achieve an anterior mitral line. This approach successfully terminated the AFL with assessment of bidirectional block with differential pacing maneuvers. A transthoracic echocardiogram demonstrated a mechanical mitral valve without any signs of dysfunction. This case demonstrates that although rare, PentaRay entrapment in mechanical valves is still a dangerous complication despite careful mapping. It underscores several maneuvers that can be performed to disengage the mapping catheter and finally, it highlights the percutaneous retrieval of the PentaRay spine remnant with a snare as an option.