# Transcatheter edge-to-edge repair for complex mitral regurgitation: a case report of prolapse with leaflet perforation

## TL;DR

This case report shows that a minimally invasive heart procedure can successfully treat a complex heart valve issue in a high-risk patient.

## Contribution

The paper presents a novel application of TEER in a rare case of mitral regurgitation with leaflet perforation.

## Key findings

- TEER successfully reduced severe mitral regurgitation to mild in a patient with leaflet perforation.
- Detailed pre-operative imaging and clip size selection were critical for successful repair.
- The patient showed sustained improvement with no complications for one year post-procedure.

## Abstract

Transcatheter edge-to-edge repair (TEER) is an established treatment for high-risk surgical candidates with severe mitral regurgitation (MR). However, its application in cases with leaflet perforation is rarely reported.

An 86-year-old woman presented with worsening dyspnoea. Transthoracic echocardiography revealed severe primary MR with P2 prolapse. Transoesophageal echocardiography (TOE) demonstrated chordae tendineae rupture and a 2.8 mm wide perforation at P2, suggestive of healed infective endocarditis. The distance from the tip of P2 in front of the perforation and the far end was measured to be ∼5.0 and 7.0 mm, measured using 3D multi-planar reconstruction. Given the patient's high surgical risk, TEER was planned after careful heart team discussion. The procedure successfully achieved intended grasping on the first attempt using one MitraClip® (XTW), reducing MR to mild without leaflet injury. One-week follow-up echocardiography showed no leaflet injuries or single leaflet device attachment. The patient's heart failure symptoms improved, with no recurrence or infection for a year.

Although TEER is not primarily recommended for MR with a perforation even in a patient at high surgical risk, this case demonstrates that TEER can be a viable option for high surgical risk patients with mitral valve prolapse and perforation when guided by detailed pre-operative TOE evaluation and careful heart team decision-making. The proximity of perforation to leaflet edge and use of appropriate clip size were crucial for successful repair.