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Mitral regurgitation is associated with a worsened prognosis in dilated cardiomyopathy. First standard therapy consists of a mitral valve reconstruction through heart surgery including the heart–lung machine. In patients with high comorbidity, catheter-based techniques have been developed. In the Evolution I study, the MONARC system was implanted in the coronary sinus in the functional mitral regurgitation. A reduction in regurgitation by >1 grade was documented in 50% of the patients. MitraClip is an alternative, edge-to-edge technique, which joined the posterior and anterior leaflet by implanting a clip. It can be used for both functional and degenerative mitral regurgitations. We reported a case of MitraClip procedure with the use of two clips and a reduction of mitral regurgitation to grade 0–1 after implanting a MONARC device four years ago with missing relevant reduction in mitral regurgitation. With this report, we illustrated the management of Mitraclip in a patient with an implanted MONARC device and technical difficulties through the bowing of the posterior annulus. INTRODUCTION Mitral regurgitation in dilated cardiomyopathy is often a functional reason of either ischemic or idiopathic origin. Persistent severe mitral regurgitation leads to left ventricular and atrial chamber remodeling with poor clinical outcomes [1]. In most patients, effective surgical repair of the mitral valve causes a decrease in the left ventricular volume overload and leads to reverse left ventricular and left atrial remodeling [2]. In cases of patients with high comorbidity and higher mortality after surgery, less invasive catheter-based techniques have been developed. The MONARC device (Edwards Livesciences) is implanted in the coronary sinus as an indirect annuloplasty. It is constructed of nitinol and consists of a larger proximal anchor, a bridge segment with bio-absorbing coating, and a smaller distal anchor. In the Evolution I study, a patient with functional mitral regurgitation between 2+ and 4+ revealed at 12 months a reduction by >1 grade in 50%, that is less than what it obtained with surgical mitral valve repair. Patients with severe mitral regurgitation (grade >3+) seemed most likely benefitted [3]. Mitral valve repair is performed to reduce the mitral regurgitation by creating a double orifice that was first performed by Alfiri [4]. Based on this surgical technique, endovascular mitral repair has been developed with the use of a clip [5]. The posterior and the anterior leaflets are joined by implanting one or more clips resulting in reduction of mitral regurgitation. Percutaneous mitral valve repair in edge-to-edge procedure with the MitalClip device has been shown to be associated with good clinical outcomes in patients with high risk for surgery [6]. Furthermore, it demonstrated superior safety compared to surgical mitral valve repair with similar improvement in clinical outcomes [7]. In contrast to the MONARC device, the MitraClip can be used for both functional and structural mitral regurgitations. CASE REPORT We describe a case of a 73-year-old man with severe mitral regurgitation in ischemic cardiomyopathy and implanted MONARC device four years ago. The medical history included an ischemic cardiomyopathy with highly reduced ejection fraction (30%). He had a single bypass surgery in 1995 (RIVA) and stenting of the RCX in 2009. A defibrillator was implanted in case of ventricular tachycardia. Furthermore, he had impaired renal function and a moderately combined lung disease (Euroscore 51%). In 2009, he was included in the Evolutian trial and got uncomplicated a 120 cm 6/15 mm anchor (Figure 1) with a reduction of the mitral regurgitation from grade 3 to 2 after six months. Since the end of 2010, a continuing increase in mitral regurgitation was documented with a parallel increase in the New York Heart Association (NYHA) class. In the beginning of 2013 he had dyspnoea with SOR-MED

MitraClip procedure with two MitraClips after indirect annuloplasty with the MONARC device