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Updated: Jun 4, 2026

Fully Endoscopic Mitral Valve Repair with Percutaneous Cannulation of Groin Vessels
Published on: May 26, 2023
Staged Annuloplasty Enabling TEER in Extreme Secondary Mitral Regurgitation
Firas Jaly1, Holger Priebe-Brämer1, Boris Dickmann1
1Department of Cardiology, Marien Hospital Witten; University Witten/Herdecke.
Background:
Severe secondary mitral regurgitation (SMR) with extreme annular dilatation may preclude transcatheter edge-to-edge repair (TEER).
Case Summary:
A 71-year-old man with advanced nonischemic cardiomyopathy, severe SMR, and prior cardiac resynchronization therapy with a coronary sinus left ventricular lead was declined for TEER due to a massively dilated mitral annulus (7.4 cm). A staged strategy was undertaken with indirect mitral annuloplasty using the Carillon system, achieving significant annular reduction. The preexisting coronary sinus lead served as a fluoroscopic landmark, facilitating device positioning while minimizing contrast use. Device-related left circumflex artery compression required bailout percutaneous coronary intervention. Following annular reduction, TEER using the MitraClip G4 system was successfully performed, reducing regurgitation to trace. The patient demonstrated marked symptomatic and biomarker improvement with sustained benefit at 1 year.
Discussion:
This case highlights a staged transcatheter strategy to overcome anatomical limitations of TEER and expands treatment options in advanced SMR.
Take-Home Messages:
Staged annuloplasty may enable TEER in otherwise ineligible patients. Cardiac resynchronization therapy coronary sinus leads do not preclude Carillon implantation and may facilitate the procedure, whereas coronary compression in selected cases can be managed safely with percutaneous coronary intervention.
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