Transcatheter edge-to-edge repair for bileaflet commissural prolapse with reduced mitral valve orifice area: a case report

Abstract

Transcatheter edge-to-edge repair (TEER) is a standard therapy for high-risk patients with severe mitral regurgitation (MR); however, its application in complex anatomies - such as multi-scallop commissural prolapse involving both commissures combined with a reduced mitral valve orifice area (MVOA) - poses significant challenges, including high risks of iatrogenic stenosis and leaflet grasping failure. This case report describes a 76-year-old female who presented with symptomatic severe degenerative MR. Transesophageal echocardiography confirmed multi-scallop commissural prolapse involving both commissures with a reduced MVOA of 3.9 cm2. The patient’s Society of Thoracic Surgeons score was 4.31%. A TEER procedure was performed using the DragonFlyTM system with a staged dual-clip strategy: a short-wide clip was first deployed in the C2 zone, followed by a short-narrow clip in the A1/P1 region. The inherent difficulty of addressing oblique coaptation lines at both commissures was mitigated by the system’s adjustable grasping angle, which allowed precise perpendicular orientation. The risk of iatrogenic stenosis from multiple clips within a small native orifice was managed through a strategic clip-size sequence - prioritizing a short-wide clip for stability followed by a short-narrow clip to minimize added obstruction - along with continuous hemodynamic monitoring. The device’s independent leaflet capture capability was crucial for securing the short, tethered posterior leaflet. This case demonstrates that a meticulously planned, imaging-guided TEER procedure using a staged, size-tailored dual-clip strategy can be a safe and effective treatment for multi-scallop commissural prolapse involving both commissures, even in the presence of a reduced MVOA, achieving durable hemodynamic and clinical improvement.