Single-session combined mitral transcatheter edge-to-edge repair and left atrial appendage occlusion using a steerable introducer after a mitral repair-oriented transseptal puncture: a case report.

Background: Combined mitral transcatheter edge-to-edge repair (M-TEER) and left atrial appendage occlusion (LAAO) may be considered in selected high-risk patients with severe mitral regurgitation (MR) and atrial fibrillation (AF). However, the optimal transseptal puncture site differs between procedures, potentially limiting the feasibility of a single-session approach. Case summary: An 80-year-old frail woman with severe atrial functional MR, permanent AF, chronic kidney disease, and recent severe anaemia was referred for treatment. Considering the patient's high thromboembolic and bleeding risk and overall frailty, a combined percutaneous approach was selected. A supero-posterior transseptal puncture optimized for mitral repair enabled successful M-TEER with significant MR reduction. Subsequent LAAO was challenged by suboptimal alignment with the appendage. The use of a steerable introducer restored coaxiality, allowing stable device delivery and successful deployment of a 24-mm occluder with complete sealing and no peri-device leak. Discussion: This case demonstrates the feasibility of a combined one-stop strategy in frail patients at high procedural risk. It highlights the importance of procedural planning and the role of steerable delivery systems in overcoming anatomical constraints imposed by a mitral-oriented transseptal puncture, thereby facilitating successful completion of both interventions in a single session.