A 90-year-old woman with severe symptomatic mitral regurgitation (MR) and prohibitive surgical risk was referred for transcatheter mitral valve repair with MitraClip (Abbott Vascular, Santa Clara, CA). A, On transesophageal echocardiography (TEE), there was a large flail gap (arrow) due to multiple ruptured chords. B, Severe MR in association with this flail segment was present (arrowhead). C, The predominant jet of MR was lateral on TEE imaging with a bi-commissural view. Multiple attempts at grasping the lateral segments were unsuccessful. D, A grasp medial to the target location was then performed (arrow). This placement did not alter the degree of MR (arrowhead). E, However, the medial grasp brought the lateral segments (arrowhead) closer together (i.e., “bunching” or “zipping”), thereby reducing the gap height and enabling additional clipping to be performed. F, Residual MR with third clip in place is trivial on imaging with bi-commissural views. G, TEE with 3-dimensional imaging showing the tissue bridge created from placement of three clips. H, Final echocardiographic result with color compare imaging shows trivial residual MR.
Ao, Ascending aorta; L, lateral; LA, left atrium; LV, left ventricle.