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Introduction Intraprocedural assessment of mitral regurgitation (MR) is a challenging issue during the MitraClip procedure, which might influence not only the position but also the number of MitraClips implanted. Though transesophageal echocardiography (TEE) is the predominant tool used during the MitraClip procedure, MR assessment might be facilitated by a multimodality approach including continuous and simultaneous determination of left atrial and left ventricular (LV) pressure. Methods 86 consecutive patients (76.5 ± 8 years) who qualified for the MitraClip procedure were included into the study. In all patients, the multimodal assessment of MR (TEE, LV angiogram, TEE bubble evaluation, left atrial (LA) pressure => MitraScore) was performed after introducing the MitraClip guide catheter. In the first 42 patients (group A, no CAP), left atrial (LA) pressure (peak pressure of V-wave) was determined only before and after MitraClip implantation, whereas, in the subsequent 44 patients (group B, with CAP), continuous left atrial pressure monitoring (CAP) was performed. Results Patients with CAP (group B) had similar total procedural durations and no increase in the complication rate. MitraScore decreased from 10.5 to 3.5 in group A compared to 10.7 to *2.8 in group B (*P = 0.021 vs. group B). Whether the significant improvement of intraprocedural MR in group B translated into superior MR reduction in the conscious patient, was analyzed by transthoracic echocardiography (TTE) in a blinded fashion. Again MR reduction was significantly greater (P = 0.03) in group B (MR grade 2.8 to 0.9) as compared to group A (MR grade 2.8 to 1.3) and 2D vena contracta decreased from 0.54 ± 0.15 cm to 0.17 ± 0.10 in group B compared to group A (0.56 ± 0.19 cm to *0.23 ± 0.12; *P = 0.01 vs. group B). Conclusions Multimodality assessment of intraprocedural MR supported by continuous left atrial pressure monitoring was associated with superior intraprocedural results translating into improved MR reduction also at the end of the hospital stay. © 2016 Wiley Periodicals, Inc.

A 75-year-old male presented to the emergency department at 2 a.m. with acute onset pulmonary oedema and evidence of cardiogenic shock (blood pressure 70/40 mmHg, tachycardia with a heart rate of 110/min). The initial oxygen saturation was 86 % with room air. The ECG showed ST-elevation in II, III, aVF and V5 ? V6 with corresponding ST-segment depression in V1–V4. A history of lung fibrosis and osteoporosis is reported, no cardiac comorbidity was known prior to admission. After haemodynamic stabilisation with inotropes, the patient was immediately transferred to the catheter lab with the working diagnosis of ST-segment elevation myocardial infarction (MI) and acute cardiogenic shock. An occlusion of the circumflex artery (RCX) causing lateral infarction was diagnosed (Fig. 1a). After recanalization and stenting a good reperfusion (TIMI III) was documented (Fig. 1b). During the procedure the patient remained in cardiogenic shock and required an intraaortic balloon counterpulsation system (IABP). Biochemistry from initial blood samples showed elevated creatine kinase (CK 2,577 U/l, CK-MB 429 U/l, Troponin-T 3.47 ng/ml), confirming the diagnosis of acute myocardial infarction. Furthermore blood samples showed an elevated creatinine and leucocyte count (creatinine 1.6 mg/dl, leucocytes 18 9 10 ll). After returning to the intensive care unit (ICU), an unstable haemodynamic situation remained with increasing inotrope requirement. Transthoracic echocardiography showed slightly reduced left ventricular (LV) function and a severe excentric mitral valve (MV) regurgitation. Partial rupture of the anterior papillary muscle, floating between left ventricle (LV) and left atrium (LA), was confirmed on transesophageal echocardiography (TEE) (Fig. 1c–f; Supplemental Video 1 and 2). Despite revascularisation and IABP support, the patient’s condition continued to progressively deteriorate. Therefore rescue cardiac surgery was considered, but the cardiac surgeon complained the patient to be at extremely high risk for emergency cardiac surgery. The heart team decided to use endovascular edge-to-edge valve repair as via MitraClip-implantation as bail-out procedure to eventually bridge the patient for later cardiac surgery. At 8:30 a.m. the patient was transferred to the catheter lab again, TEE-guided septal puncture and passage of the MitraClip-Device from the left atrium into the left ventricle was performed without difficulty (Fig. 2a). After a first unsuccessful attempt to simultaneously trap the ruptured papillary muscle and grab the posterior mitral leaflet, we inserted the MitraClip (open grippers, *140 ) slightly more medial in the A2/P2 segment. Now, we were able to push the ruptured papillary muscle back into the left ventricle by pushing with the posterior orientated cliparm against chordae connecting the posterior leaflet and the floating ruptured papillary muscle (Fig. 2b, step 1). When the posteriorly oriented cliparm was approximately 1 cm below the plane, a relatively strong movement towards Electronic supplementary material The online version of this article (doi:10.1007/s00392-014-0789-9) contains supplementary material, which is available to authorized users.