Bailout PASCAL implantation for salvation of iatrogenic leaflet perforation during transcatheter edge-to-edge repair with MitraClip

Clinical case:

A 72-year old male patient was referred to our tertiary clinic for transcatheter edge-to-edge repair (TEER) for severe atrial functional mitral regurgitation (AFMR). He presented with dyspnea at moderate-to-light exertion (NYHA class II) and peripheral edema. Persistent atrial fibrillation (AF) with history of previous pulmonary vein ablation as well as heart failure with preserved ejection fraction (HFpEF) and diastolic dysfunction III° were identified as underlying pathophysiologic culprits. The Heart Team deemed the patient as high surgical risk due to chronic pulmonary sarcoidosis with reduced lung expiratory capacity, and TEER was planned using MitraClip G4 (Abbott). Transesophageal echocardiography (TEE) revealed annular dilation and atriogenic hamstringing of the posterior mitral leaflet, leading to wide mitral regurgitation (MR) convergence zone. A XTW MitraClip device could be implanted without complications at medial A2/P2, leading to reduction of MR to trace in this region but with still residual severe convergence zone at the lateral segments. A second XTW device was used for this cause. Interaction with posterior leaflet was observed, and a new small convergence zone was identified in TEE. Grasping slightly next to this position initially reduced the MR; however, about one minute later and before clip release, tear enlargement war clearly seen in TEE, revealing leaflet perforation. The XTW was therefore implanted more lateral on stable leaflet tissue to avoid further aggravation of perforation, reducing the lateral part of MR. Nevertheless, there was still severe MR between the two XTW devices, mainly due to leaflet perforation. A PASCAL ACE (Edwards Lifesciences) was introduced as a bailout option to treat the perforation, which was close to the leaflet edge. TEE guiding enabled to identify the exact location of the perforation, which was intentionally loaded on the device paddle and covered by lowering the clasp. Consequently, the singular retention element touched on the annular part of the leaflet, which remained unaffected by the perforation, and the PASCAL closed to enclose the damaged leaflet tissue. MR was reduced to mild grade, and all three devices showed no signs of increased mobility after deployment. Final TEE and TTE at discharge excluded further aggravation of mild residual MR, which was confirmed at outpatient follow-up two months after procedure.

Leaflet injury can inevitably occur during TEER, which may be treated by adequately grasping adjacent healthy leaflet tissue; however this can sometimes exert overt traction on leaflets, leading to perforation. The more distally located singular retention element of the PASCAL device clasp, having the same width as the underlying paddle, may enable adequate grasping in damaged leaflets and stabilization of iatrogenic leaflet perforations during TEER.