Single-session combined mitral transcatheter edge-to-edge repair and left atrial appendage occlusion using a steerable introducer after a mitral repair-oriented transseptal puncture: a case report

Abstract

Background

Combined mitral transcatheter edge-to-edge repair (M-TEER) and left atrial appendage occlusion (LAAO) may be considered in selected high-risk patients with severe mitral regurgitation (MR) and atrial fibrillation (AF). However, the optimal transseptal puncture site differs between procedures, potentially limiting the feasibility of a single-session approach.

Case summary

An 80-year-old frail woman with severe atrial functional MR, permanent AF, chronic kidney disease, and recent severe anaemia was referred for treatment. Considering the patient’s high thromboembolic and bleeding risk and overall frailty, a combined percutaneous approach was selected. A supero-posterior transseptal puncture optimized for mitral repair enabled successful M-TEER with significant MR reduction. Subsequent LAAO was challenged by suboptimal alignment with the appendage. The use of a steerable introducer restored coaxiality, allowing stable device delivery and successful deployment of a 24-mm occluder with complete sealing and no peri-device leak.

Discussion

This case demonstrates the feasibility of a combined one-stop strategy in frail patients at high procedural risk. It highlights the importance of procedural planning and the role of steerable delivery systems in overcoming anatomical constraints imposed by a mitral-oriented transseptal puncture, thereby facilitating successful completion of both interventions in a single session.

Learning points.

• Single-session M-TEER + LAAO is a safe and effective option for selected frail, high-risk patients, reducing repeat procedures and hospitalizations.

• Optimizing transseptal puncture for mitral repair and using a steerable introducer improves coaxial alignment, enabling safe and stable first-attempt LAAO delivery.

Introduction

Combined mitral transcatheter edge-to-edge repair (M-TEER) and left atrial appendage occlusion (LAAO) may be considered in patients with severe mitral regurgitation (MR) and atrial fibrillation (AF) who are at high surgical risk. In elderly and frail patients, a staged strategy may increase the cumulative burden of anaesthesia, vascular access, and hospitalization. However, a key technical limitation of the one-stop strategy is that the transseptal puncture selected for mitral repair is often not ideal for appendage access. We report a combined single-session M-TEER and LAAO procedure in which a steerable introducer restored coaxial alignment and enabled efficient device delivery despite a transseptal puncture optimized for mitral repair.

Summary figure

Case presentation

An 80-year-old woman was referred after two episodes of acute heart failure related to severe functional MR and a recent hospitalization for severe anaemia requiring blood transfusion. Her medical history included permanent AF treated with a non-vitamin K antagonist oral anticoagulant, chronic kidney disease (stage 3), and prior hysterectomy. At presentation, she reported marked exertional dyspnoea and reduced exercise tolerance. Physical examination revealed an apical systolic murmur and mild signs of volume overload. Laboratory tests showed haemoglobin 8.8 g/dL (reference range 12.1–15.1 g/dL), serum creatinine 1.5 mg/dL (reference range 0.50–0.95 mg/dL), estimated glomerular filtration rate 33 mL/min/1.73 m² (reference value ≥60 mL/min/1.73 m²), and NT-proBNP 4200 pg/mL (non-acute reference value <125 pg/mL). The anaemia work-up did not identify an active bleeding source, and the condition was interpreted as chronic multifactorial anaemia. Electrocardiography demonstrated permanent AF with a ventricular rate of 90 bpm, while chest radiography showed mild pulmonary vascular congestion and small bilateral pleural effusions. The patient was receiving edoxaban 30 mg once daily, furosemide 125 mg/day, bisoprolol 5 mg/day, spironolactone 50 mg/day, and empagliflozin 10 mg/day. Based on her documented baseline clinical and functional status, frailty was retrospectively graded as 5/9 on the Clinical Frailty Scale, corresponding to mild frailty. Her vulnerability was further characterized by severe underweight status (body mass index 14.8 kg/m²), poor nutritional reserve, limited functional capacity, and multiple comorbidities. Transthoracic and transoesophageal echocardiography (TEE) showed a normal left ventricular size with preserved systolic function [left ventricular ejection fraction (LVEF) 55%], a moderately enlarged left atrium (volume index 45 mL/m²), a normal right ventricle, and moderate tricuspid regurgitation. Mitral valve assessment demonstrated leaflet tethering related to atrial enlargement, consistent with atrial functional MR, with a severe central-medial regurgitant jet. Quantitative measurements confirmed severe MR [effective regurgitant orifice area (EROA) 45 mm²; regurgitant volume 58 mL], a mitral valve area of 6.5 cm², and a posterior leaflet length of 12 mm. The fossa ovalis height was 45 mm. The left atrial appendage had a single-lobed chicken-wing morphology and measured 19 × 21 mm. Following multidisciplinary Heart Team evaluation, the patient was considered unsuitable for surgery because of advanced age, marked frailty, recurrent heart failure, chronic kidney disease, and recent transfusion-requiring anaemia. Given the coexistence of severe symptomatic MR, elevated thromboembolic risk (CHA₂DS₂-VASc score 4), and increased bleeding risk (HAS-BLED score 3), together with concerns regarding the long-term safety of oral anticoagulation, a combined percutaneous strategy consisting of M-TEER and LAAO was deemed the most appropriate therapeutic approach. The procedure was performed under general anaesthesia with fluoroscopic and TEE guidance via right femoral venous access. Transseptal puncture was performed with a Brockenbrough needle (Abbott Laboratories, Illinois, USA), targeting a supero-posterior site in the fossa ovalis according to the short-axis, bicaval, and four-chamber TEE views (Figure 1A). After transseptal access, M-TEER was performed using a MitraClip G4 XTW system (Abbott Laboratories). Leaflet grasping at the A2-P2 scallops achieved a marked reduction in MR and the clip was successfully deployed (Figure 1B–D). LAAO was then undertaken. A pigtail catheter was advanced into the appendage for selective angiography in two orthogonal projections to assess the landing zone and confirm sizing. Because the puncture site had been optimized for mitral repair rather than appendage access, alignment toward the appendage neck was suboptimal (Figure 1E). To overcome this limitation, a TrueSteer Steerable Introducer (Philips) was used. Its steerability allowed controlled distal deflection of ∼45° toward the appendage neck, facilitating coaxial alignment and stable device delivery (Figure 1F). A 24-mm WATCHMAN device was then deployed with optimal positioning on the first attempt. Device position and stability were assessed in multiple TEE views (Figure 1G and H). Colour Doppler and three-dimensional TEE confirmed complete coverage of the appendage ostium without peri-device leak. After satisfactory tug testing, the device was released and final angiography confirmed successful appendage occlusion (Figure 1I–L). The immediate procedural outcome was therefore favourable for both interventions. Representative moving images of M-TEER guidance and result, LAAO deployment, and final post-procedural assessment are provided as Supplementary material online, Videos S1 and S2. At the 6-month follow-up, the patient showed improved functional status, with reduced dyspnoea and New York Heart Association functional class II symptoms. She was discharged on clopidogrel 75 mg once daily, tailored to her recent severe anaemia and bleeding risk. No recurrent bleeding, rehospitalization for heart failure, stroke, or procedure-related complications occurred during the 6-month follow-up.

Figure 1.

Multimodality imaging during single-session mitral transcatheter edge-to-edge repair and left atrial appendage occlusion. (A) Baseline transoesophageal echocardiography showing transseptal puncture for M-TEER. (B) Fluoroscopic view after transseptal access during M-TEER. (C) TEE-guided leaflet grasping and clip positioning at the A2–P2 scallops. (D) Colour Doppler TEE demonstrating marked reduction of mitral regurgitation after clip deployment. (E) Initial fluoroscopic attempt to access the left atrial appendage, showing suboptimal alignment due to the mitral-oriented transseptal puncture. (F) Use of a steerable introducer to achieve distal deflection and improved coaxial alignment with the LAA. (G, H) TEE views confirming appendage device positioning and stability before release. (I) Final fluoroscopic appearance after successful deployment of the LAA occluder. (J) TEE confirmation of correct device position. (K, L) Three-dimensional TEE demonstrating complete sealing of the LAA ostium without peri-device leak.

Discussion

This case illustrates the feasibility of a combined percutaneous strategy for M-TEER and LAAO in a frail, elderly patient with multiple comorbidities. Given the patient’s marked frailty and high procedural risk, performing both interventions in a single session was favoured over a staged approach to minimize cumulative anaesthesia exposure, hospital stay, and overall procedural stress. Recent observational data and a systematic review suggest that the combined strategy is feasible and is associated with high procedural success in carefully selected high-risk patients.^1–3 In the WATCH-TEER prospective registry, combined M-TEER and LAAO was performed in a high-risk population and was associated with procedural feasibility, effective MR reduction, and acceptable short-term safety, although adverse events at 45 days, including death, stroke, and major bleeding, were reported after discharge.¹ In the recent systematic review and meta-analysis, the combined M-TEER/LAAO strategy achieved procedural success in ∼90% of cases and technical success in more than 95%, with outcomes broadly comparable to isolated M-TEER for procedural and technical success. Safety outcomes were generally reassuring, with no significant increase in bleeding, acute kidney injury, or all-cause death compared with M-TEER alone; however, non-significant signals for in-hospital death, stroke, and vascular complications underline the need for careful patient selection and further evidence.² The main technical lesson from this case is that success of the second intervention may depend on a device able to compensate for septal geometry chosen to favour the first. In combined procedures, the transseptal puncture is usually planned around mitral repair. That choice may make appendage access less coaxial and can impair stability during LAAO. In this setting, alternative technical strategies included performing a second transseptal puncture specifically dedicated to LAAO or attempting appendage closure with a standard non-steerable delivery system. A second puncture was considered less attractive because it would have increased septal manipulation, procedural complexity, and potential risk in a frail high-risk patient. Conversely, continued use of a non-steerable system could have resulted in insufficient coaxiality and unstable device positioning. The steerable introducer was therefore selected as a pragmatic solution to compensate for the mitral-oriented transseptal trajectory, restore an appropriate delivery axis, avoid repeat septal puncture, and provide sufficient support for controlled device deployment. In the present case, a steerable introducer restored the delivery axis, avoided the need for repeat puncture, and enabled first-attempt deployment with stable position and no residual leak. This technical concept is illustrated in the additional schematic figure, which compares the ideal transseptal orientation for M-TEER and LAAO and shows how the steerable introducer allowed redirection of the delivery axis toward the left atrial appendage after an initial mitral-oriented puncture (Figure 2). Contemporary valvular heart disease guidance frames transcatheter mitral intervention within Heart Team-based decision-making for symptomatic patients with significant MR who are poor surgical candidates, while current AF guidance recognizes LAAO as a potential option when long-term anticoagulation is unsuitable because bleeding risk is high.^4,5 The present report therefore supports a tailored structural strategy in which careful patient selection and dedicated catheter technology can expand the practicality of a one-stop approach. A limitation of this report is the absence of longer-term follow-up in the present manuscript; however, the immediate technical lesson is directly applicable to combined structural procedures.

Figure 2.

Schematic comparison of transseptal puncture orientation for M-TEER and LAAO. Panel (A) illustrates the transseptal trajectory generally preferred for M-TEER, optimized for mitral valve access. Panel (B) illustrates the orientation typically favoured for LAAO, which aims to achieve coaxial alignment with the left atrial appendage. Panel (C) shows the present case scenario, in which a steerable introducer was used to compensate for a mitral-oriented transseptal puncture (blue arrow) and to restore a favourable delivery axis (red dotted arrow) for appendage closure.

Lead author biography

Michela Bonanni, MD, PhD is a consultant cardiologist in Rome, Italy. She completed her cardiology training at Policlinico Tor Vergata Hospital and an International Fellowship in Echocardiography and Multimodality Imaging at Cardiocentro Ticino, Lugano, Switzerland. She also holds a second-level Master’s degree in Cardiac Magnetic Resonance from the University of Padua and EACVI certification in adult transoesophageal echocardiography. Her clinical and research interests focus on cardiovascular imaging, structural heart disease, and transcatheter valve interventions. She is the author of multiple peer-reviewed publications in cardiovascular medicine.

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports online.

Author contributions

Michela Bonanni (Conceptualization, Writing—original draft [lead], Validation [equal]), Matteo Pelliccia (Investigation [lead], Writing—review & editing [supporting]), Giorgio Maria De Sanctis (Data curation [lead], Visualization [equal], Writing—review & editing [supporting]), and Carmine Musto (Supervision [lead], Writing—review & editing [equal])

Consent: Written informed consent for publication of this case report and the accompanying images was obtained from the patient in accordance with local institutional policy.

Funding

None declared.

Data availability

There are no new data associated with this article.