An 84-year-old female with symptomatic severe MR presented with dyspnea and heart failure, classified as NYHA class III. She had past medical history of AF and ASD which underwent transcutaneous ASD device closure eight years prior (26 mm Amplatzer closure device). Despite optimized medication, patient still had symptom.

Echocardiography : showed severe MR from flail P1 segment adjacent to lateral commissure with rupture cordae tendineae, P1 length was 7.7 mm. The ASD device was well seated and no color Doppler flow across the device. The interatrial septum had no space of anterior rim and had space at posterior rim apart from the ASD deviced for 5 mm for septal puncture.

     Under general anesthesia, a transesophageal echocardiography (TEE) probe was advanced for imaging guidance. Venous access was obtained via the right femoral vein with 16F Ultimum sheath and preclosure technique with proglide.     An atrial septal puncture was performed under fluoroscopic and TEE guidance. The puncture site was selected at the mid-portion and posterior aspect of the interatrial septum, posterior to the ASD device which causing high transseptal puncture height (4.7 cm, concerning of too high puncture for lateral commissural lesion that require lower end of 4-4.5 cm). We use an 18G AKS curve A transseptal needle for transseptal puncture. A 8.5F transseptal long introducer was advanced over a Amplatz Super Stiff guidewire.     After optimal transeptal puncture, a 25F Abbott Clip steerable guide catheter was gently advanced into the left atrium. MitraClip G4 NTw clip was selected for treating commissural lesion with short posterior leaflet length. However, the puncture site was too high for lateral lesion. Therefore, advanced steering manuever was required to loose height by using P knob and anterior guide torque. Finally the NTw clip could reach the mitral annular plane. The clip was rotated to 2 and 8 o’clock fashion. The anterior and posterior leaflets were successfully grasped P1-M1 position. 

The Mitral valve Transcatheter Edge-to-Edge repair (M-TEER) in patient with an ASD closure device might be challenge due to the complexity of transeptal approach.This condition required careful consideration between puncturing though the device, which may lead to significant residual defect or device deformity and performing a transeptal puncture adjacent to the ASD device, which may result in a high puncture location and difficulty in catheter manipulation. However, even with a suboptimal transeptal puncture (too high or too low), M-TEER procedure can be adjusted by using advanced clip steering to modify height. Therefore, we prefer to puncturing approach outside the device.