1 © Europa Digital & Publishing 2014. All rights reserved. HOW SHOULD I TREAT? EuroIntervention 2014; 9-online publish-ahead-of-print April 2014 How should I treat a challenging case of MitraClip implantation? Vincenzo Duino 1 , MD; Luigi Fiocca 1 , MD; Giuseppe Musumeci 1 , MD; Elisa Cerchierini 1 , MD; Mauro Gori 1 , MD; Emilia D’Elia 1 , MD; Paolo Ferrero 1 , MD; Attilio Iacovoni 1 , MD; Orazio Valsecchi 1 , MD; Francesco Maisano 2 , MD; Michele Senni 1 *, MD 1. Cardiovascular Department, AO Papa Giovanni XXIII, Bergamo, Italy; 2. Cardiovascular Department, Hospital San Raffaele, Milan, Italy Invited Experts: Ted Feldman 1 , MD, FESC, FACC, FSCAI; Steven Smart 1 , MD, FACC; Ilkay Bozdag-Turan 2 , MD; Stephan Kische 3 , MD, PhD; Liliya Paranskaya 2 , MD; Jasmin Ortak 3 , MD, PhD; Hüseyin Ince 3 , MD, PhD 1. NorthShore University HealthSystem, Evanston Hospital, Evanston, IL, USA; 2. Heart Center Rostock, University Hospital Rostock, Rostock School of Medicine, Rostock, Germany; 3. Vivantes Klinikum Am Urban und im Friedrichshain, Berlin, Germany *Corresponding author: Cardiovascular Department, AO Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy. E-mail: msenni@hpg23.it PRESENTATION OF THE CASE A 71-year-old woman has been followed up for several years at the Cardiovascular Department of the Ospedali Riuniti of Bergamo, affected by an idiopathic dilated cardiomyopathy with normal coro- nary arteries (angiography performed in 2002), permanent atrial fibrillation, NYHA functional Class 3, excess weight, previous thrombophlebitis of the left lower limb, total thyroidectomy for multinodular thyroid goiter, melanoma treated with interferon in 1995, bilateral coxarthrosis and depressive syndrome. On physical examination, the patient had jugular turgor, hepa- tojugular reflux, hepatomegaly, no peripheral oedema, arrhythmic cardiac tones, a 3/6 intensity systolic murmur on the precordium, attenuated vesicular murmur, BMI 29 kg/m 2 . Blood tests showed only anaemia (Hb 10.3 g/dl and Hct 32.7%). The brain natriuretic peptide (BNP) levels ranged from 199 to 644 ng/L in the last two years. The electrocardiogram showed atrial fibrillation with an average ventricular rate of 46/min, left intraventricular conduction delay (QRS duration 120 ms). The transthoracic echocardiogra- phy (TTE) showed biatrial dilation (left atrium area 40 cm 2 , vol- ume 39.6 cm 3 , right atrium area 33 cm 2 ), left ventricular dilation (EDD/ESD 68/59 mm, LVDV/LVSV 185/122 ml, LVDVI/LVSVI 101/67 ml/m 2 ), normal thickness (IVS/PW 9/9 mm), severe left ventricular systolic dysfunction related to diffuse hypokinesia (left ventricular ejection fraction 28%), with an increase in left ventricu- lar filling pressure (restrictive diastolic function with a transmitral E-wave DT 117 ms, and an E/e’ ratio >15), severe mitral regurgita- tion (effective regurgitant orifice 30 mm², regurgitant volume 41 ml, vena contracta 6 mm, ratio colour jet area/left atrial area 59%), with central jet origin, dilated ring (annulus 39 mm), and restricted motion of the posterior leaflet (with a reduced coaptation length of CASE SUMMARY BACKGROUND: A 71-year-old woman affected by idiopathic dilated cardiomyopathy with normal coronary arteries and permanent atrial fibrillation was found to have severe mitral regurgitation at transthoracic echocardiography (TTE), due to annular dilatation and restricted motion of the posterior leaflet. Because of poor quality of life, high functional class (NYHA Class 3) and the high risk of surgery, the patient agreed to undergo the implantation of a MitraClip ® device. During the procedure, the transoesophageal echocardio- graphic (TEE) images were of a poor quality since the view of the mitral valve in the mid-oesophageal and transgastric projections did not accurately show the valve leaflets and the convergence area of the regurgitation at colour Doppler, which is indispensable for the correct positioning of the clip. INVESTIGATION: Physical examination, transthoracic echo- cardiography, transoesophageal echocardiography. DIAGNOSIS: Severe mitral regurgitation suitable for Mitra- Clip™ implantation. MANAGEMENT: Transthoracic, and not transoesophageal, echocardiography approach during MitraClip™ procedure. KEYWORDS: Mitral regurgitation, MitraClip™ device, transoesophageal echocardiography, transthoracic echocardiography