A 79-year-old man with a medical history of arterial hypertension, dyslipidemia and previous prostate cancer presented to the emergency department in May 2025 with worsening dyspnoea (New York Heart Association class III) and respiratory insufficiency, initially attributed to severe interstitial lung disease, based on high resolution computed tomography (HRCT) findings. Following further respiratory deterioration, he was admitted to the intensive care unit (ICU) where he required invasive mechanical ventilation with a slow and progressive recovery. TOE revealed a severe primary MR due P2 flail in a myxomatous MV, a LV with normal dimensions and function, a left atrium of normal dimensions and a concomitant moderate tricuspid regurgitation. Coronary angiography showed no significant coronary artery disease. After multidisciplinary Heart-Team discussion, the patient was deemed suitable for elective, minimally invasive, surgical MV repair. The procedure was performed in October 2025, with implantation of 3 artificial chordae (NeoChords DS1000) on P2 scallop through a off-pump left mini-thoracotomy transapical access. During the postoperative monitoring in the ICU, patient developed progressive respiratory failure associated with hypotension and oligo-anuria, poorly responsive to intravenous diuretics and inotropic support, requiring sudden orotracheal intubation, invasive mechanical ventilation, femoro-femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) placement and continuous renal replacement therapy (CRRT). Repeat TOE demonstrated detachment of one NeoChord with severe residual primary MR characterized by P1–P2 prolapse and P2 flail (proximal isovelocity surface area radius 1.4 cm, effective regurgitant orifice area 0.81 cm², regurgitant volume 66 mL, MV area 7.5 cm², mean gradient 1 mmHg) ( Figure 1 ); a moderate impairment of LV ejection fraction was also observed. The patient was urgently re-evaluated by the local Heart-Team deeming unsuitable for a cardiac surgery re-do due to prohibitive surgical risk and urgent bail-out M-TEER with ECMO-VA support was indicated.

Pre-operatory transoesophageal echocardiography images. Mid-oesophageal commissural view (A) and long-axis view (B) where P2 flail can be appreciated (red arrow). Severe mitral valve regurgitation on 2D colorDoppler, mid-oesophageal commissural view (C) and long-axis view (D). Three-dimensional reconstruction of the mitral valve, surgical view (E).

Echocardiographic images were carefully reviewed, highlighting a complex MV anatomy, related to the native degenerative etiology of the MR and the reshaping of the posterior leaflet after previous surgical intervention with NeoChords still in situ. Notwithstanding, the MV anatomy was deemed suitable for M-TEER, as the regurgitation was predominantly central, the posterior leaflet was well-represented (10 mm) and the residual MV area was >4 cm². To maximize the likelihood of procedural success, the longer and wider MitraClip XTW G4 device was selected. A two-clip strategy was planned, consisting of initial implantation of a medial clip to target the flail, approximate the leaflets, and reduce the flail gap, followed by deployment of a second, more centrally positioned clip targeting the jet to effectively reduce regurgitation and stabilize the result. The procedure was performed under general anaesthesia using a single femoral venous access strategy. A 24-French sheath was inserted and left atrial access was obtained by an infero-posterior transseptal puncture. Under real-time three-dimensional TOE guidance, the first MitraClip were successfully implanted on A3-P3 position. Echocardiographic assessment showed reduced but still relevant MR, without significant increase of the transvalvular mitral gradient ( Figure 2 ). The procedure was completed with the implantation of a second device in the A2-P2 position ( Figure 3 ), resulting in mild residual MR without significant stenosis, as confirmed by the post-procedural TOE ( Figure 4 ). Patient’s hemodynamics improved within two days from the procedure, allowing veno-arterial extracorporeal membrane oxygenation removal, continuous renal replacement therapy and invasive mechanical respiratory support discontinuation. At 8-months follow-up, the patient was in NYHA class I, with sustained mild residual MR and recovery of LVEF.

First MitraClip released in A3-P3 position. Transoesophageal echocardiography evaluation: mid-oesophageal commissural view (A) and long-axis view (B). Mitral valve regurgitation on 2D colorDoppler, mid-oesophageal commissural view (C). Transvalvular mitral gradient evaluated by continuous wave (CW) Doppler after MitraClip’s release (D). Angiography image after first MitraClip’s release (E).

Second MitraClip released in A2-P2 position. Transoesophageal echocardiography evaluation: mid-oesophageal commissural view (A) and long-axis view (B) where the detached NeoChord can be seen on the atrial side of the valve (red arrow). Mitral valve regurgitation on 2D colorDoppler, mid-oesophageal commissural view (C). Angiography image after second MitraClip’s release (D).

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