Impella Entrapment in the Mitral Subvalvular Apparatus in a Patient With Dilated Cardiomyopathy: Snare-Assisted Retrieval
© 2026 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.
J INVASIVE CARDIOL 2026. doi:10.25270/jic/26.00314. Epub September 11, 2026.
A 74-year-old woman with dilated cardiomyopathy (DCM), marked left ventricular (LV) enlargement, and severe functional mitral regurgitation (MR) remained in decompensated heart failure despite dobutamine therapy (Figure A and B). Coronary angiography showed no significant stenosis, and Impella CP (Abiomed) placement was performed.
After a pigtail catheter and 0.018-inch guidewire were advanced to the LV apex, the device was introduced through a 16F right femoral peel-away sheath. Transthoracic echocardiography (TTE) suggested that the tip was directed toward the apex. Shortly after pump activation, the pressure waveform flattened, and fluoroscopy showed severe kinking with the tip displaced into the aorta (Figure C). TTE demonstrated entrapment in the mitral subvalvular apparatus, and traction alone failed (Figure D-F). A snare catheter was advanced from a 7F left brachial sheath through a 7F Judkins Right 4.0 guiding catheter to capture the Impella tip (Figure G). Advancing the guiding catheter while withdrawing the Impella released the kink and enabled successful removal (Figure H and I; Video). Subsequent TTE showed no worsening of MR or new aortic regurgitation.
Snare-assisted retrieval has been reported previously,1,2 and our case was successfully managed in a similar manner. In this case, DCM-related remodeling may have altered the LV geometry and displaced the papillary muscle-chordal complex, increasing the likelihood of device-subvalvular interaction. However, reliance on a single fluoroscopic projection may also have been an important procedural limitation. Multiplanar fluoroscopy with echocardiographic guidance, together with gentle pigtail-catheter “flossing” before device advancement, may help confirm the true apex and freedom from chordal entanglement. Accordingly, in patients with marked LV dilatation, Impella placement should be performed with particular caution, with careful attention to the relationship between the device trajectory and the mitral subvalvular apparatus.
Affiliations and Disclosures
Tomoki Nakatsu, MD1; Ryota Usui, MD2; Masahiko Narita, MD1,3; Hana Fukuta, MD1; Yuya Tamaru, MD1; Yusuke Okazaki, MD2
From the 1Department of Cardiovascular Surgery, Steel Memorial Muroran Hospital, Muroran, Japan; 2Department of Cardiology, Steel Memorial Muroran Hospital, Muroran, Japan; 3Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan.
Dr Nakatsu and Dr Usui contributed equally to this work.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Consent statement: The authors confirm that informed consent was obtained from the patient for the intervention(s) described in the manuscript and for the publication thereof, including any and all images.
Address for correspondence: Masahiko Narita, MD, Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan. Email: m.s.e.narita@hotmail.com
References
- Elsherif A, Nadir A, Ludman PF, Khan SQ. Retrieval of entrapped catheter-mounted axial flow pump from mitral subvalvular apparatus using a snare catheter. JACC Case Rep. 2021;3(13):1494-1498. doi:10.1016/j.jaccas.2021.06.041
- Eleid MF, Melduni RM, Joyce DL. Snare-facilitated retrieval of entangled Impella device. J Interv Cardiol. 2016;29(3):332-333. doi:10.1111/joic.12275
