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    Review of 'MitraClip-procedure with two Mitra-Clips after indirect anuloplasty with the MONARC-device'

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    MitraClip-procedure with two Mitra-Clips after indirect anuloplasty with the MONARC-deviceCrossref
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    MitraClip-procedure with two Mitra-Clips after indirect anuloplasty with the MONARC-device

    Abstract: Mitral regurgitation is associated with a worsened prognosis in dilated cardiomyopathy. First standard therapy consists of a mitral valve reconstruction through heart surgery including heart lung machine. In patients with high co-morbidity, catheter-based techniques, have been developed. In the Evolution I study the MONARC-system which was implanted in the coronary sinus in the functional mitral regurgitation. A reduction in regurgitation by over 1 grade was documented in 50% of patients. MitraClip is an alternative, edge-to-edge technique, which joined the posterior and anterior leaflet by implanting a clip. It can be used for both functional and degenerativ mitral regurgitation. We reported a case of MitraClip procedure with the use of two clips and a reduction of mitral regurgitation to grade 0-1 after implanting a MONARC-device four years ago with missing relevant reduction in mitral regurgitation. With this report we illustrated the management of Mitraclip in a patient with implanted MONARC-device and technical difficulties through the bowing of the posterior anulus.
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      Review text

      I am happy to review this interesting paper regarding the use of MitraClip for challenging cases.
      MitraClip has gained wide clinical since it can be used for treating both functional and degenerative mitral regurgitation. Moreover, recent publications have addressed that this device may be useful as well in different and complex clinical scenarios such as acute MR after AMI, failed annuloplasty rings or MR associated to hypertrophic cardiomyopathy.
      This interesting paper highlights a new use for the MitraClip. Two clips were implanted in a patient with a prior indirect annuloplasty device and nearly complete reduction of MR was achieved. The case is appropriate and the images are interesting.
      However, the paper has as well some shortcomings. The English style is far from ideal and some sentences are poorly built. There is no description of how operators dealt with this difficult PML or if they used a special image technique for increasing the visibility of such leaflet.

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