A case report of repeat clipping for recurrent severe mitral regurgitation from both sides of the clip: those who run after two hares may catch both.

Background: Recurrent mitral regurgitation (MR) can occur even after successful transcatheter edge-to-edge mitral valve repair (TEER). While some reports show the utility of repeat clipping for recurrent MR, the results are unsatisfactory. We describe a patient who underwent repeat clipping for MR that recurred from both sides of the original clip. Case summary: An 89-year-old male was admitted to our hospital with congestive heart failure. Transthoracic and transoesophageal echocardiograms (TTE/TEE) revealed severe MR due to A2 (middle segment of the anterior leaflet) prolapse. Because of his high operative risk, we performed TEER. An NTW clip was placed between A2 and P2 (middle scallop of the posterior leaflet), markedly reducing MR to mild. Six months after TEER, he complained of dyspnoea, and severe MR was evident from both sides of the clip. Although the risk of iatrogenic mitral stenosis was considered, we assessed that there might be a chance to succeed in repeat clipping if the additional two clips were placed only in the P2 beside the original clip following a careful review of TEE images. We challenged repeat clipping. After we placed NT clips on each side of the original NTW clip, MR was reduced to mild without creating iatrogenic mitral stenosis, and his symptoms subsequently improved. Discussion: Anatomical features such as no valve thickening at the leaflet's grasping site and the presence of posterior leaflet indentation may increase the likelihood of a successful repeat clipping outcome. Repeat clipping should be considered after careful anatomical assessment, even in patients with challenging anatomy.

Multimodality assessments of wild-type transthyretin cardiac amyloidosis with no ventricular hypertrophy.

While patients with transthyretin cardiac amyloidosis (ATTR-CA) typically present with concentric or asymmetric hypertrophy, a small percentage of ATTR-CA is known to present with 'atypical' cardiac morphologies such as eccentric hypertrophy or even no hypertrophy. However, detailed report of multimodality assessments of ATTR-CA with no ventricular hypertrophy is lacking. Herein, we report detailed multimodality assessments of an 81-year-old Japanese woman with heart failure and history of carpal tunnel syndrome and lumbar canal stenosis, presenting no ventricular hypertrophy and negative 99m technetium-pyrophosphate scintigraphy, who was eventually diagnosed as having wild-type ATTR-CA. Our case highlights the role of multimodality assessments for early diagnosis of ATTR-CA in patients with atypical cardiac morphologies and also emphasizes the limitations of bone scintigraphy and the importance of considering ATTR-CA in patients with non-cardiac manifestations of ATTR amyloidosis.