Percutaneous electrosurgical cutting of an accessory left atrial chord followed by mitral transcatheter edge-to-edge repair

Felix Meincke (Hamburg)1, L. Böttcher (Hamburg)1, G. Heier (Hamburg)1, J. Didt (Hamburg)1, H. Alessandrini (Lübeck)2, P. U. Mammen (Hamburg)1, G. Schmidt (Hamburg)3, S. Geidel (Hamburg)4, T. Spangenberg (Hamburg)1, M. W. Bergmann (Hamburg)1

1Asklepios Klinik Altona Kardiologie und Internistische Intensivmedizin Hamburg, Deutschland; 2Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; 3Asklepios Klinik Altona Anästhesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie Hamburg, Deutschland; 4Asklepios Klinik St. Georg Abteilung Herzchirurgie Hamburg, Deutschland


We report the successful treatment of a severe mitral regurgitation due to accessory chordae tendinae reaching from the left atrial wall to the mitral valve by percutaneous treatment via electrosurgical cutting. To the best of our knowledge no case has been described in literature so far.


An 82-year-old female Patient presenting heart failure with preserved ejection fraction, accompanied by severe tricuspid and mitral insufficiency was admitted for evaluation of the severe secondary mitral regurgitation. Significant comorbidities included dyslipidaemia, arterial hypertension, atrial fibrillation as well as a history of transient ischemic attack several years before. Cardiac catheterization did not show any significant coronary artery disease.

TOE evaluation revealed an accessory chorda tendinae reaching from the anterior, left atrial part of the interatrial septum to the anterior mitral valve lealflet (A2 segment). 4D images suggested that the chord hindered proper closing of the mitral valve during systole.


The patient was deemed unsuitable for conventional cardiac surgery by the interdisciplinary heart team. Thus, decision was made for a percutaneous treatment.


M-TEER did not seem suitable while there is still counter-force by the chord which would most likely complicate the procedure and decrease the chance for a durable significant reduction of MR and increase the risk for partial device detachment or leaflet laceration. Therefore, the chord had to be removed prior to valve repair.


After getting access to the left atrium via a transvenous approach followed by septal puncture we passed behind the accessory chord with a terumo wire, snared it via an amplatzer gooseneck snare and exchanged for a coronary guidewire that was prepared to form a V-shape. After positioning of the V-shaped portion behind the accessory cord we attached a standard electrosurgical device, we applied 100J and a gentle pull, cutting the accessory cord.  


As the mitral regurgitation was still severe after removing the force by the chord, decision was made to perform M-TEER during the same procedure using the superior transseptal puncture site. After implantation of two MitraClip Generation 4 devices, residual MR was reduced to mild (1+).


Post-interventional hospital stay remained without further events. The patient was discharged 5 days post-procedural in good health and the follow-up showed a persistently reduced MR (1+).

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