Right internal jugular approach for transcatheter edge-to-edge mitral valve repair using the MitraClip G4 system after failed transfemoral access: a case report

Transcatheter edge-to-edge repair of the mitral valve is conventionally performed via transfemoral venous access. When this route is not feasible, the right internal jugular vein may provide an alternative, but procedural experience remains limited.

A 93-year-old woman with refractory heart failure had atrial functional mitral regurgitation and low-flow, low-gradient aortic stenosis. After transcatheter aortic valve implantation, moderate-to-severe mitral regurgitation persisted. Transfemoral edge-to-edge repair was unsuccessful because severe iliac venous tortuosity prevented adequate catheter control. The procedure was subsequently performed via the right internal jugular vein using the MitraClip G4 system. A pre-existing iatrogenic atrial septal defect was reused, and temporary left ventricular apical wire support facilitated advancement of the steerable guiding catheter into the left atrium. Stepwise + knob rotation increased height and working space, improved the markedly under-straddled configuration, and permitted further advancement of the clip delivery system. Subsequent M- and P-knob adjustments achieved an appropriate trajectory towards A2/P2, with an S-shaped fluoroscopic configuration. Leaflet grasping reduced mitral regurgitation to mild without access-site complications. Mild mitral regurgitation was maintained at 6 months without heart-failure rehospitalization.

Right internal jugular access may be a feasible alternative when transfemoral access is not possible. Successful navigation requires recognition of access-specific catheter behaviour and adaptation of steering under real-time fluoroscopy and transoesophageal echocardiography. An S-shaped fluoroscopic configuration may serve as a practical landmark of a favourable trajectory towards the mitral valve.