The procedure was performed under general anesthesia by a multidisciplinary team consisting of interventional cardiologists, a cardiologist with special expertise in cardiac imaging, cardiac anesthesiologist, nurses, and a technician. The patient was carefully monitored and hemodynamically optimized. To assess the feasibility of a traditional approach, grasping in the A2-P2 position was attempted.

After six failed attempts to grasp the leaflet in A2-P2 position, we optimized conditions by temporarily ceasing mechanical ventilation and also took advantage of a compensatory pause following an extrasystole. This facilitated successful grasping of the leaflet in A2-P2 position and deployment of a clip. Mild improvement of the MR from 4+ to 3+ was noted with the jet split (Fig. 14.3a, b, Videos 14.4). A second clip was placed in a medial position close to the first one, resulting in a consistent reduction of the medial jet (Fig. 14.4, Video 14.5). Finally, a third clip was placed laterally to the first clip which led to a sustained improvement of the MR from 4+ to 1+ (Fig. 14.5a–c, Videos 14.6, 14.7, and 14.8), with a transmitral gradient of 2 mmHg. The patient was successfully weaned from mechanical ventilation and discharged home 5 days later. At time of discharge, the severity of his MR was assessed as 1+/4 by TTE (Fig. 14.6, Video 14.9).