Emergency Transcatheter Edge-to-Edge Mitral Valve Repair as a Bail-Out Strategy After Failed NeoChord Surgical Repair in Acute Degenerative Mitral Regurgitation.

Relevant mitral regurgitation (MR) is associated with significant morbidity and mortality. Surgical mitral valve (MV) repair represents the treatment of choice for symptomatic severe degenerative mitral regurgitation (DMR) in patients with acceptable surgical risk. However, surgical failure and high perioperative risk may limit reintervention options, particularly in elderly patients with multiple comorbidities. In this context, transcatheter edge-to-edge mitral valve repair (M-TEER) may represent a viable alternative strategy, particularly in patient who underwent previous surgery. We report the case of a 79-year-old man with severe DMR due to P2 flail, who underwent minimally invasive surgical MV repair with NeoChord implantation. The postoperative course was complicated by acute hemodynamic and respiratory deterioration requiring invasive mechanical ventilation, veno-arterial extracorporeal membrane oxygenation (VA-ECMO), and continuous renal replacement therapy (CRRT). Transoesophageal echocardiography revealed early NeoChord apical detachment, with persistence of prosthetic material attached to the posterior leaflet, recurrent severe MR and new-onset left ventricular dysfunction. Due to prohibitive surgical risk, the patient was deemed unsuitable for redo surgery and underwent urgent M-TEER with veno-arterial extracorporeal membrane oxygenation support. Two MitraClip XTW G4 devices were successfully implanted achieving successful reduction of MR without significant increase in mitral gradient. Meticulous preprocedural echocardiographic assessment and advanced intraprocedural imaging guidance was essential to optimize procedural success. This complex case highlights that transcatheter M-TEER can represent a safe and effective bail-out strategy in patients with hemodynamically unstable severe DMR after surgical repair failure when redo surgery is contraindicated.