A 55-year-old female patient with a history of myxomatous bi-leaflet mitral valve prolapse and sudden cardiac death (6 months prior) presented for mitral valve repair of symptomatic severe mitral regurgitation. Pre-procedure transoesophageal echocardiography confirmed normal biventricular systolic function and bi-leaflet prolapse of the mitral leaflets (Panel A, Supplementary material online, Video S1) with severe mitral regurgitation (Panel B). Tissue Doppler of the lateral mitral annulus was notable for a peak systolic lateral mitral annulus velocity of 35.2 cm/s, consistent with a Pickelhaube sign (Panel C). A mitral valve repair was performed (Supplementary material online, Video S2) and consisted of triangular resection of the P2 scallop, free-edge remodelling of the posterior leaflet, neochord fixation to correct the tendency of the A2 scallop to prolapse, and a flexible annuloplasty band. Post-cardiopulmonary bypass transoesophageal echocardiography confirmed complete correction of the mitral valve leaflets (Panel D, Supplementary material online, Video S3) and absence of any residual mitral regurgitation (Panel E). A repeat tissue Doppler interrogation of the lateral mitral annulus confirmed resolution of the Pickelhaube sign and a systolic velocity of 9.2 cm/s (Panel F). The patient remained arrhythmia free post-operatively.Funding: Intramural departmental funding.