Mitral repair on the edge: a case report of redo transcatheter mitral edge-to-edge repair for recurrent regurgitation in Complex lateral jet anatomy.

Background: Degenerative mitral regurgitation (DMR) is associated with substantial morbidity and mortality if left untreated. While surgical repair remains the gold standard, mitral transcatheter edge-to-edge repair (M-TEER) is an established alternative for patients at high surgical risk. However, recurrent MR after initial M-TEER remains a therapeutic challenge and is associated with poor outcomes. Case summary: A 77-year-old patient presented with recurrent heart failure symptoms due to MR after prior CARILLON® device implantation for secondary MR at an external hospital in September 2019. Transoesophageal echocardiography revealed degenerative mitral valve disease characterized by a complex combination of posterior leaflet prolapse and anterior leaflet flail, resulting in a severe eccentric regurgitant jet.The patient underwent successful M-TEER with the MitraClip® system in December 2021. In June 2023, the patient was re-hospitalized for recurrent heart failure symptoms. Imaging revealed severe recurrent MR originating lateral to the implanted device. A redo M-TEER was performed using the PASCAL® system, requiring careful navigation through a narrow residual lateral orifice. The procedure resulted in a durable reduction to mild MR with sustained clinical stability at 18-month follow-up. Discussion: This case illustrates the anatomical challenges of DMR and demonstrates the feasibility and durability of redo M-TEER in high surgical risk patients with recurrent MR. It emphasizes the importance of individualized anatomical assessment and tailored device selection in complex valve anatomies.