Sirs: Although mitral valve (MV) repair remains the treatment of choice to treat severe mitral valve regurgitation (MR), there is still a plethora of patients that, in light of their complex comorbid profile, could be approached in a less invasive fashion [1]. Timely echocardiography evaluation of the valve anatomy and the regurgitation flow-dynamics are crucial to plan an adequate percutaneous repair strategy [2, 3]. In this context, the MR often results from an annular dilatation that leads to a decreased MV leaflets coaptation. The percutaneous transvenous MitraClip -System (MitraClip, Abbot, USA) has been recently introduced and popularized to mimic the ‘‘edge to edge’’ MV repair firstly described by Alfieri et al. The results of the EVEREST II trial have demonstrated that the procedure is safe and associated with improvements in clinical outcomes [4]. Implantation of a percutaneous transvenous mitral annuloplasty (PTMA) device to reduce the MV annular size has also been shown to be feasible and safe [5–7]. After percutaneous annuloplasty with the MONARC device (Edwards Lifesciences, Irvine, California), a 12-months reduction in MR by C1 grade was observed in 85 % of patients with baseline MR grade C3 [6]. We report on a 74-year-old multi-morbid female patient (EuroScore 24, STS 14) presenting with severe MR recurring 2 years after implantation of a MONARC device. The patient was admitted in our institution with increasing shortness of breath and signs of heart failure (New York Heart Association (NYHA) class III). Echocardiography revealed a reduced left ventricular ejection fraction (LVEF 43 %) secondary to ischaemic cardiomyopathy. A markedly eccentric MR grade 3 (type IIIb Capentier’s functional classification) was also reported. The MV annulus was measured 3.9 cm (lateral–medial) and 3.6 cm (anterior–posterior) with a MV orifice area (MVOA) of 6.9 cm. An interventional strategy to address the MR was planned after exacerbation of the heart failure picture in spite of maximal medical treatment. Percutaneous placement of the MitraClip to maximize MV leaflets cooptation and reduce MR was performed under general anaesthesia and with continuous twoand three-dimensional echocardiography and fluoroscopy imaging. After standard implantation of the first clip within the main jet area, the severity of MR was reduced to grade 1? to 2. A second clip was implanted parallel to the first one to eliminate the residual regurgitation. At the end of the procedure there was no mitral stenosis (mean gradient of 3 mm Hg, MVOA of 2.5 cm) and only a trivial MR. Notice that there was a significant reduction of the MV anterior–posterior annular dimension (2.3 cm postinterventional) and no changes in the latero-medial size (unchanged at 3.8 cm) (Fig. 1). The patient was discharged home on the 8th postoperative day in NYHA class I–II. A 6-month follow-up confirmed the clinical and echocardiographic improvement. To the best of our knowledge MitraClip therapy to treat recurrent MR after previous PTMA has never been described before. In fact, PTMA with an incomplete ring decreases the septal-lateral annular diameter [6]. MitraClip implantation can facilitate MV leaflets coaptation and indirectly decrease the anterior–posterior MV annulus L. Paranskaya G. D0Ancona C. A. Nienaber H. Ince (&) Department of Cardiology, Heart Center Rostock, University Hospital of Rostock, E-Heydemann-Str. 6, 18057 Rostock, Germany e-mail: hueseyin.ince@med.uni-rostock.de