Transcatheter Edge-to-Edge Repair in Small Mitral Valve Area: Overcoming Anatomical Constraints

Patients with severe mitral regurgitation (MR) and a small mitral valve area (MVA) pose a significant challenge for transcatheter edge-to-edge repair, given the increased risk of iatrogenic mitral stenosis. The PASCAL Precision system (Edwards Lifesciences)-featuring a central spacer, independent leaflet grasping, and flexible paddles-is designed to minimize leaflet tension, preserve annular dynamics, and maintain effective valve area. This case series describes 3 high surgical risk patients with severe MR and MVA <4.0 cm² who underwent successful transcatheter edge-to-edge repair with the PASCAL system, with both PASCAL P10 and Ace devices used based on individual anatomical characteristics. All procedures achieved effective MR reduction and symptomatic improvement despite modest increases in mean transmitral gradient. These findings highlight the feasibility of PASCAL in anatomically constrained valves and support its potential to mitigate hemodynamic risks in patients with a small native MVA.