Successful Mitral Valve Repair for Single Leaflet Device Attachment Following Transcatheter Edge-to-Edge Repair: A Case Report.

An 87-year-old man underwent transcatheter edge-to-edge repair (TEER), one MitraClip NT︎ from anterior commissure (AC), 8 months prior for severe mitral regurgitation (MR) due to functional etiology and A1 chordal rupture, complicated by heart failure. Following improvement in heart failure, he was discharged home independently 2 weeks postprocedure. However, 4 months ago, he experienced worsening heart failure, and echocardiography revealed recurrent severe MR due to single leaflet device attachment (SLDA) at P1, prompting a surgical intervention. Intraoperatively, after establishing cardiopulmonary bypass and inducing cardiac arrest, transseptal access revealed the MitraClip NT︎ firmly adhered to the P1 leaflet and extensive rupture of the A1 chordae. The MitraClip NT︎ and involved leaflet tissue were excised en bloc, the defect was repaired, artificial chordae were implanted, edge-to-edge repair of the AC region was performed, and a prosthetic annuloplasty ring was sutured in place, successfully eliminating regurgitation. Since MitraClip NT︎ becomes encapsulated by fibrous tissue within 2-3 months postimplantation, isolated removal becomes technically difficult in the late phase. Therefore, en bloc resection with the leaflet is necessary in cases of SLDA-related recurrent MR. SLDA involving the posterior mitral leaflet is considered more amenable to mitral valve repair than that involving the anterior mitral leaflet. Patients selected for TEER generally have limited surgical tolerance; thus, minimizing operative and cardiopulmonary bypass times is essential. Surgical approach should be tailored based on leaflet morphology and clip location.