From where do patients bleed post-operatively after a Mitral Valve Transcatheter Edge-to-Edge Repair (MTEER) procedure?

Common Bleeding Sites After Mitral Valve Transcatheter Edge-to-Edge Repair (MTEER)

Post-MTEER bleeding most commonly occurs at non-access sites (66.7% of cases), with access site-related bleeding accounting for only about one-third of all bleeding complications. 1

Primary Bleeding Sources

Access Site-Related Bleeding (33.3% of cases)

• Femoral vascular access site complications
  • Groin hematoma
  • Retroperitoneal bleeding
  • Femoral artery pseudoaneurysm formation
  • Vascular perforation requiring covered stent placement

Non-Access Site Bleeding (66.7% of cases)

Cardiac Sources

• Puncture site on the interatrial septum during transseptal access
• Thrombus formation at:
  • Delivery catheters
  • MTEER device itself
  • Mitral annulus
  • Puncture site on the interatrial septum 2
• Cardiac perforation (rare but potentially fatal complication)

Procedure-Related Coagulopathy

• Blood loss from prolonged procedures (intervention duration is an independent predictor of bleeding) 1
• Obscure bleeding with hemoglobin decrease ≥3 g/dl without visible bleeding (occurs in 9.5% of patients) 1

Risk Factors for Post-MTEER Bleeding

1. Presence of coronary artery disease (2.8-fold increased risk) 1
2. Longer procedure duration (1% increased risk per minute) 1
3. Inadequate periprocedural anticoagulation leading to thrombus formation 2
4. Prothrombotic state in patients with very low cardiac output 2

Clinical Significance

• Patients experiencing bleeding complications have longer hospital stays 1
• Major MVARC bleeding (hemoglobin decrease ≥3 g/dl) occurs in 7.4% of patients 1
• Obscure bleeding with hemoglobin decrease ≥4 g/dl is associated with worse survival outcomes 1

Prevention Strategies

1. Maintain sufficient intraprocedural anticoagulation (activated clotting time 200-300s) 3
2. Ensure meticulous de-airing of all delivery components to prevent air embolization 3
3. Avoid protamine use during or after TEER except in emergent situations (cardiac perforation or tamponade) 3
4. Careful monitoring of femoral access site after procedure 2
5. Early mobilization with attention to potential complications in this high-risk patient population 2

Post-Procedure Management

• For patients already on oral anticoagulation before MTEER, continuation is recommended 3
• Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for 1-6 months is commonly used in patients with sinus rhythm 3
• Close monitoring for signs of bleeding, particularly in the first 11 days after discharge (median time to out-of-hospital mortality) 4

Understanding these bleeding sources and implementing appropriate preventive measures are crucial for improving outcomes in patients undergoing MTEER procedures, as bleeding complications are associated with prolonged hospitalization and potentially worse survival in certain patient subgroups.