Successful Mitral Valve Repair for Single Leaflet Device Attachment Following Transcatheter Edge‐to‐Edge Repair: A Case Report

Figure 1. Pre‐TEER TEE. A dominant jet was observed between A1 and P1, extending along the PML to the base of the left atrium. A lateral jet was also seen in the commissural view. The jet persisted throughout systole without attenuation and was broad. Straight jets were also noted from A2‐P2 and A3‐P3, similarly showing no attenuation during systole. The length of PML measured 9 mm, and the length of AML measured 18 mm; the AML leaflet was mildly thickened and showed signs of degeneration (3.7 mm). The subvalvular apparatus appeared to be normal. The annular dimensions were: 35 mm at 0°, 38 mm at 60°, 21 mm at 135°; transverse × vertical diameter: 23 × 38 mm (3D); annular circumference: 90 mm; annular area: 7.5 cm2; mitral valve orifice area: 6.6 cm2; left atrial diameter: 51.6 mm. The PISA‐derived effective regurgitant orifice was 1.0 cm2, and the regurgitant volume was 135 mL. Pulmonary vein flow showed systolic reversal. The vena contracta was 1.0 cm.

Figure 2. Post‐TEER TEE. A single MitraClip NT︎ was placed at the AC/P1 segment. MR on the AC side was adequately suppressed; however, residual MR remained on the A2/P2 side. Moderate MR was observed at the end of the procedure.

Figure 3. A broad jet with significant suction flow from the AC/A1 region reached the base of the left atrium. A straight jet with broad suction flow was also observed from the A2/P2 region. Detachment of the clip at the AC region was noted, along with prolapse of both the AC and A1 segments. Functional MR was present from A2/P2. Both the AML and PML showed evidence of tethering. TEER = transcatheter edge‐to‐edge repair, TEE = transesophageal echocardiography, AML = anterior mitral leaflet, PML = posterior mitral leaflet, and MR = mitral valve regurgitation.

Figure 4. Intraoperative findings. (a) The MitraClip NT had adhered as a single mass to the P1 leaflet, and extensive chordal rupture was observed in A1. (b) The MitraClip NT was excised along with the leaflet tissue, the defect was closed, and three artificial chordae were implanted at the site from the posterior head of the anterior papillary muscle. (c) Two artificial chordae were placed to A1 and one to A2 from the anterior head of the anterior papillary muscle. (d) Edge‐to‐edge repair was performed at the AC region, and a 29‐mm Tailor Ring was sewn to the mitral annulus.

Figure 5. TTE after MVP MR was reduced to trivial levels.