Incremental value of three-dimensional transoesophageal echocardiography for guiding double percutaneous MitraClip ® implantation in a 'no option' patient.

Mitral valve repair for significant mitral regurgitation (MR) is preferred to valve replacement, whenever feasible. Freedom from re-operation is high, reaching 92% at 15 years. However, high-risk patients develop more complications and may be refused surgery. The results from the Endovascular Valve Edge-to-Edge Repair Study (EVEREST) II showed they might benefit from the percutaneous edge-to-edge mitral valve repair using MitraClip(®) system (Evalve, Inc., Menlo Park, CA, USA). We present a case of a ventilator-dependent 57-year-old man with ischaemic A2, A3 prolapse and severe MR causing persistent haemodynamic instability and pulmonary oedema. Attempts to wean the ventilator failed during the 7 month period. High predicted surgical mortality ruled out surgical mitral repair. The percutaneous mitral valve repair became the only option. The use of real-time three-dimensional transoesophageal echocardiography (RT 3D-TOE) to navigate through the cardiac chambers has been previously described. Here, the precise positioning and placement of a second clip, after failure of the first one, was facilitated by 3D-TOE. These images provided 'en-face' views of the mitral valve from both the atrial and ventricular perspective, allowing safe advancement and positioning of the second clip delivery system. Failure of the second clip would have resulted in emergency open heart surgery. This case demonstrates the incremental value of RT 3D-TOE images for a percutaneous double clip mitral repair with the MitraClip(®) system in a patient with no other treatment options.