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A 70 years old male with non-ischaemic dilated cardiomyopathy (left ventricular end-diastolic volume, LVEDV, 200 mL), reduced left ventricular ejection fraction (LVEF, 30%) and worsening dyspnoea was screened for transcatheter repair of severe mitral regurgitation (MR). Baseline echocardiogram showed marked symmetrical bi-leaflet tethering with a symmetrical central jet. Etiology was predominantly functional with organic features including partial flail scallop (A1) and a ruptured second order chorda (Figure 1A). Pre-operative strategy was to deploy a single MitraClip NT in the central position. After correct deployment of the first clip, we observed a remarkable reduction of regurgitant jets in the lateral position accompanied by a complete holosystolic lack of leaflet coaptation in the medial orifice which caused significant residual regurgitation. (Figure 1B) MitraClip deployment in the commissural position is associated with technical challenges, including limited maneuvering, risk of chordae rupture and inability to retrieve the device if entangled. (1) Therefore, after careful crossing of the medial neo-orifice and rapid positioning a second MitraClip NT was implanted medial to the first device in the commissural position (Figure 2). As a result, the medial orifice was obliterated resulting in an atypical mono-orifice morphology which resembles a commissural edge-to-edge plasty. Anterograde flow was normal (G med 2.5 mmHg) and the trivial residual jet of MR was lateral to the two clips implanted. At 1-year follow-up the patient was asymptomatic (NYHA functional class I) with a stable mild MR and no change in anterograde gradients; positive remodelling of the left ventricle (LVEDP: −48 ml) and increased LVEF (+8%) were observed. 369 Figure 1.

369 Mono-orifice mitral valve after transcatehter repair with mitraclip system