Mitral Valve Leaflet Perforation and TEER Feasibility

Transcatheter edge-to-edge repair has transformed structural heart interventions for high-risk surgical patients. Traditionally, interventional cardiologists consider mitral valve leaflet perforation an absolute contraindication for transcatheter edge-to-edge repair. Leaflet perforations typically arise from infective endocarditis, degenerative erosion, or prior cardiac surgical procedures. Historically, published clinical experience remains strictly limited to emergency bailout maneuvers during iatrogenic valve injuries. Most operators believed that catheter-based clips could not seal isolated leaflet perforations without causing excessive mechanical stress. Furthermore, standard leaflet grasping often fails when regurgitation originates distant from the free coaptation margin. Consequently, clinical guidelines routinely direct these high-risk patients toward conventional surgical repair or valve replacement. However, open cardiotomy poses prohibitive mortality in elderly patients who present with severe comorbidities and cardiorespiratory compromise. In such fragile candidates, clinicians urgently need minimally invasive therapeutic alternatives. Therefore, structural heart teams increasingly explore customized catheter techniques to manage complex leaflet defects. Emerging evidence shows that experienced operators can achieve successful repair by adapting existing devices. Thus, refined transcatheter strategies now challenge classical anatomic restrictions through precise procedural planning.

Unexpected Intraprocedural Findings and Clinical Presentation

A seventy-five-year-old man presented with decompensated heart failure and severe symptomatic mitral regurgitation. Given his advanced age and significant comorbidities, the heart team referred him for transcatheter edge-to-edge repair. Initial diagnostic evaluations suggested severe degenerative regurgitation suitable for standard catheter therapy. However, intraprocedural transesophageal echocardiography unexpectedly revealed a large posterior mitral leaflet perforation. This anatomical defect generated a massive regurgitant jet directly into the left atrium during systole. Consequently, this unexpected finding created a major therapeutic dilemma for the intervention team. Conventional edge-to-edge clipping techniques typically address free-edge coaptation failure rather than central leaflet holes. Furthermore, attempting improper tissue grasping risked tearing delicate leaflet tissue or worsening the regurgitant orifice. The clinical team immediately recognized that abandoning the procedure offered poor long-term survival. In addition, emergency open-heart surgery carried prohibitive operative risks for this elderly patient. Therefore, the interventional operators decided to formulate an individualized, real-time transcatheter repair plan. They selected a targeted double-clip strategy to neutralize the defect while maintaining valvular competence and forward flow.

Procedural Strategy: The MitraClip Sandwiching Technique

To address the complex posterior perforation, the structural team executed an innovative clipping strategy. Specifically, the operators planned to sandwich the perforated leaflet defect between two parallel devices. The team selected two MitraClip XTW implants because their wider arm spans optimize tissue purchase. First, the operator steered the initial clip across the interatrial septum into the left ventricle. They positioned this device precisely along the medial border of the leaflet perforation. After confirming secure leaflet insertion and stability, the team deployed the first clip. Subsequently, the interventionalist aligned the second XTW device along the lateral margin of the defect. This deliberate dual deployment effectively compressed and approximated the surrounding leaflet tissue across the perforation. As a result, the parallel clips isolated the defect and eliminated mechanical stress on adjacent margins. Color Doppler echocardiography demonstrated an immediate, dramatic reduction in regurgitation from severe to mild. Moreover, the transmitral gradient remained acceptably low, avoiding functional mitral stenosis. The sandwiching technique thus achieved outstanding anatomical stabilization without compromising valve mechanics.

The Critical Role of 3D Multiplanar Reconstruction

Successful transcatheter execution in unconventional mitral anatomy depends entirely on precise intraprocedural imaging. While two-dimensional echocardiography offers essential baseline views, it often lacks sufficient spatial depth. In this case, two-dimensional views could not reliably define the spatial relationship between the perforation and surrounding tissue. Consequently, the imaging team utilized real-time three-dimensional multiplanar reconstruction to guide every procedural step. This sophisticated modality provides simultaneous orthogonal cut planes, enabling comprehensive assessment of leaflet geometry. Furthermore, multiplanar reconstruction allows accurate measurement of perforation margins, defect depth, and residual grasping tissue. By manipulating orthogonal axes dynamically, the imaging specialist tracked device orientation relative to the defect continuously. In addition, this technique ensured perpendicular clip alignment against the coaptation line before grasping. Therefore, the operator avoided dangerous chordal entanglement and achieved symmetrical leaflet capture on both sides. Post-release multiplanar evaluation confirmed stable clip placement without leaflet tear or detachment. Thus, three-dimensional multiplanar reconstruction proved vital in converting an anatomical contraindication into a clinical victory.

Clinical Implications, Patient Selection, and Future Practice

This remarkable procedural success demonstrates the expanding therapeutic potential of catheter-based valve therapies. However, structural heart specialists must maintain rigorous patient selection criteria before attempting off-label interventions. In particular, clinicians must differentiate healed, non-infectious perforations from active infective endocarditis. Active microbial endocarditis remains an absolute contraindication because device implantation risks devastating bacterial seeding. Furthermore, procedural feasibility requires adequate healthy leaflet margins around the defect to ensure secure device anchoring. Perforations situated too close to the annulus typically preclude effective grasping. In addition, operators must assess baseline mitral orifice area to avoid creating significant valvular stenosis. Deploying multiple wide clips inherently reduces effective valve area and may elevate mean gradients. Therefore, comprehensive multidisciplinary heart team consensus remains mandatory for every prospective candidate. When performed by experienced operators with advanced three-dimensional imaging guidance, TEER offers a life-saving alternative for non-surgical patients. Ultimately, this pioneering case provides a practical blueprint for treating select complex leaflet defects.

Frequently Asked Questions

Can TEER be performed safely in mitral valve leaflet perforation?

Transcatheter edge-to-edge repair is technically feasible for select non-infectious mitral perforations in high-risk patients. However, operators must confirm adequate healthy leaflet tissue surrounding the defect to ensure stable device anchoring. Clinicians must strictly avoid this procedure during active endocarditis because prosthetic implants carry high bacteremic seeding risks. In stable chronic cases, a customized dual-clip strategy can successfully sandwich the defect, dramatically reduce regurgitation, and avoid high-risk open sternotomy.

How does 3D multiplanar reconstruction enhance TEER procedural success?

Three-dimensional multiplanar reconstruction enables simultaneous, orthogonal visualization of complex mitral valve architecture in real time. Furthermore, this advanced modality allows echocardiographers to accurately quantify perforation dimensions, orientation, and surrounding coaptation surfaces. By eliminating visual foreshortening and geometric ambiguity, imaging specialists guide precise catheter steering and perpendicular clip trajectory. Consequently, interventionalists achieve optimal leaflet capture while preventing chordal entanglement, single-leaflet detachment, or elevated transvalvular inflow gradients during deployment.

What clinical factors favor transcatheter repair over open surgery?

Multidisciplinary heart teams favor transcatheter repair when patients present with prohibitive surgical risk, advanced frailty, or severe extracardiac comorbidities. Specifically, conditions like porcelain aorta, prior mediastinal radiation, severe pulmonary dysfunction, or renal failure significantly elevate surgical mortality. In such vulnerable individuals, open cardiopulmonary bypass carries substantial risks of multi-organ failure. Therefore, minimally invasive transcatheter clipping provides an attractive therapeutic alternative, preserving cardiac hemodynamics while promoting rapid recovery and functional independence.

Disclaimer: This content is for informational and educational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Refer to the latest local and national guidelines for clinical practice.

References

1. Shen M et al. Transcatheter Edge-to-Edge Repair of Mitral Valve Leaflet Perforation Guided by 3D Multiplanar Reconstruction Imaging. JACC Case Rep. 2026 Oct 13. doi: undefined. PMID: 42867422.


2. Little SH, Quader N, Brady MB, et al. Guidelines for the Intraprocedural Imaging for Mitral Valve Transcatheter Edge-to-Edge Repair (M-TEER): Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2026;39(6):529-550.


3. Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. N Engl J Med. 2018;379(24):2307-2318.


4. Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011;364(15):1395-1406.