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case_images: Fluoroscopy (A) and computed tomography (B-D) revealed that both the radiofrequency ablation catheter and the 0.035 in spring coil wire could not advance from the femoral vein to the right atrium due to calcified venous thrombosis blocking the inferior vena cava at the renal vein level. The white arrowhead indicates the radiofrequency ablation catheter and the 0.035 in spring coil wire, while the white arrowhead shows calcified venous thrombosis.
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case_images: Association (NYHA) class IV], a history of dilated cardiomyopathy, a cardiac resynchronization therapy defibrillator implanted for ventricular tachycardia, and pulmonary embolism secondary to deep vein thrombosis. A year ago, a femoral vein radiofrequency ablation attempt for ventricular tachycardia was unsuccessful as the catheter could not be advanced into the right atrium (Figure 1A). Computed tomography revealed IVC occlusion from calcified venous thrombosis (Figure 1B-D).
case_images: Preprocedural transthoracic echocardiography images show severe mitral regurgitation from A2/P2 (A-C). The quantification of mitral regurgitation by the Proximal Isovelocity Surface Area method showed an effective regurgitant orifice area of 72 mm2 and a regurgitant volume of 92 mL (D).
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case_images: Transthoracic echocardiography (TTE) showed a reduced ejection fraction (35%) and severe functional MR at A2/P2 (Carpentier type I and effective regurgitant orifice area, 72 mm2; Figure 2).
case_images: Schematic illustration of room setup for transcatheter edge-to-edge mitral valve repair via the right internal jugular vein. This approach positions the implanters at the patient's head on their right side, with an additional table 80 cm from the chest for the MitraClip stabilizer and display screens for fluoroscopy and transoesophageal echocardiography in front of the physicians. A locking table is essential for the stabilizer. The echocardiographer is positioned on the patient's left, while the anaesthetist is at the foot of the bed.
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case_images:   Figure 3  details the room setup and positioning for the RIJ approach.
case_images: Transoesophageal echocardiography images (A, C, and E) and concurrent fluoroscopy images (B, D, and F) are shown. The left-side images display the bicommissural view, while those on the right side illustrate the left ventricular outflow tract view in transoesophageal echocardiography. Guided by transoesophageal echocardiography, a 5-French pigtail catheter was advanced through the mitral valve at the A2/P2 scallop into the left ventricle using a coil wire (A, bicommissural view, and B), ensuring it did not entangle with the chordae tendineae as it was directed towards the apex (C and D). The catheter was subsequently replaced with a Confida wire, and the tip was confirmed at the apex, enabling the safe insertion of the guiding catheter (E and F). In the transoesophageal echocardiography images, the arrow identifies the pigtail catheter, while the arrowhead points to the Confida wire.
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case_images: TEE guidance (Figure 4). A Confida wire was placed in the LV to support SGC crossing the septum. The clip delivery sheath (CDS) was mis-keyed at a 90  counterclockwise rotation.
case_images: Postprocedural transthoracic echocardiography images showed mild residual mitral regurgitation (A-C).
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case_images: Postprocedural TTE showed reduced MR (Figure 5).