This is filed to report unintended movement.
It was reported that this was a mitraclip procedure to treat functional mitral regurgitation (mr) with a grade of 4.
On (b)(6) 2021, the steerable guide catheter (sgc) was advanced to the mitral valve; however, advancement was difficult due to the high tortuosity of the femoral vein and the sgc was advanced too much in the left atrium.
After the sgc crossed the septum, the clip delivery system (cds) was advanced through the sgc, but then the sgc and clip moved unintentionally.
Then the clip went through the left atrium wall and came outside the heart wall, causing a clinically significant delay in the procedure.
The procedure was aborted and was converted to surgery which resulted in the patient to remain hospitalized longer.
The clip was extracted prior to surgery.
Then the hole of the left atrium wall was patched and a drainage was placed.
The patient arterial blood pressure was very low and a long massage was required to recover the patient.
No clips were implanted, and mr is 4.
On (b)(6) 2021, the patient died due to decompensation of organs following the surgery performed.
No other information was provided.
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