1. Impact of Failed Mitral Clipping on Subsequent Mitral Valve Operations
Stephan Geidel, MD, Michael Schmoeckel, MD 
The Annals of Thoracic Surgery 
Volume 97, Issue 1, Pages (January 2014)
DOI: /j.athoracsur
Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Technique of clip explantation. (A) For regular clip explantation, the lock harness was passed with a 4-0 Gore-Tex suture. (B) A conventional suction tube was pushed toward the clip by pulling the suture. Two forceps were used to open the arms and the grippers. (C) Open clip that is still connected to a nitinol wire.
The Annals of Thoracic Surgery  , 56-63DOI: ( /j.athoracsur )
Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
Intraoperative findings after multiple clip implantations. (A) Mitral valve area reduction and tissue damage after implantation of 4 clips in an 81-year-old woman (European System for Cardiac Operative Risk Evaluation II, 89%) 2 hours before. Five segments are involved, P2/P1, and the anterior commissure (AC), A1/A2. The valve was resected because of the obvious seriousness of the tissue damage. (B and C) Damage of segments P2/P3, the posterior commissure (PC), and A3/A2 after implantation of 3 clips in a 64-year-old man with a left ventricular ejection fraction of 0.25 and a prior operation; artificial atrial septal defect (ASD) with a dimension of about 10 mm.
The Annals of Thoracic Surgery  , 56-63DOI: ( /j.athoracsur )
Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
Acute artificial lesions 10 days after unsuccessful clip-intervention in a 78-year old woman with chronic ischemic MV-disease and a global myocardial remodelling process (European System for Cardiac Operative Risk Evaluation II, 45%). The large figure shows that the clip is fixed only at the posterior P2-segment and that there are artificial lesions at the A1- and A2-segments where the clip had unsuccessfully grasped the anterior leaflet tissue. The clipping had moreover caused a leaflet perforation at the P2-segment. Small figures: After explanting the clip, anterior and posterior leaflet repair was performed with (top left inset) 5-0-Cardionyl-sutures and (bottom left inset) conventional ring annuloplasty was done using a 3-dimensional configured ring (size 26) for moderate down-sizing to reduce the anterior/posterior annulus dimension adequately. Even if the clip-explantation technique was applied as described above, the clip could not be opened regularly in this patient (the bottom right inset shows that the clip is still closed).
The Annals of Thoracic Surgery  , 56-63DOI: ( /j.athoracsur )
Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
Leaflet perforation. (A) Findings in a 74-year-old woman with functional mitral regurgitation (left ventricular ejection fraction: 0.30, reoperation) 11 days after implantation of 2 clips, with severe inflammation of the posterior leaflet and the posterior annulus with additional perforation in the P2 segment. (B) Intraoperative findings 193 days after implantation of 2 MitraClips in a 72-year-old man with functional mitral regurgitation showing leaflet perforation in the segments P2/P3 and A2 chordal rupture. (C) After resection of the valve, the ventricular side became visible: the clips were intensely in-grown, and therefore, it was impossible to explant them properly.
The Annals of Thoracic Surgery  , 56-63DOI: ( /j.athoracsur )
Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

6. Fig 5
Mitral repair leaving an in-grown clip in a 69-year-old man with cardiomyopathy. (A) Findings 133 days after regular clip implantation with inadequate reduction of the anterior/posterior dimension of the annulus and the attempted implantation of a second clip. Note the deterioration with tissue damage and chordal-rupture 6 days before. (B and C) For mitral repair, the implanted clip was preserved, and annuloplasty was performed in which the annulus was downsized with a 2-dimensional ring (size 30).
The Annals of Thoracic Surgery  , 56-63DOI: ( /j.athoracsur )
Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

7. Fig 6
Impact of clip number on mitral repair. Whereas mitral repair was feasible in most patients with only 1 clip implant, the probability for reconstruction was greatly reduced with a second clip (p = , Wilcoxon–Mann-Whitney test).
The Annals of Thoracic Surgery  , 56-63DOI: ( /j.athoracsur )
Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions