Early Single-Leaflet Device Attachment After TEER: Device Orientation in Complex Mitral Anatomy

Single-leaflet device attachment (SLDA) is an uncommon but clinically significant complication of transcatheter edge-to-edge repair (TEER), associated with recurrent mitral regurgitation (MR).

A 73-year-old man with heart failure and severe MR presented with progressive dyspnea despite optimal medical therapy. Imaging demonstrated complex degenerative mitral valve anatomy. TEER with a PASCAL P10 device achieved initial MR reduction and hemodynamic improvement. Early follow-up revealed SLDA with posterior leaflet detachment and recurrent severe MR. A bailout TEER with implantation of a second PASCAL Ace device restored leaflet coaptation and stabilized the initial device.

This case highlights the importance of early imaging surveillance and suggests that device orientation may influence leaflet insertion in complex anatomy. Conventional clocking strategies, such as 11-5 orientation, may not ensure optimal leaflet engagement in all patients.

Device orientation should be individualized in complex mitral anatomy. Early SLDA can be effectively managed with imaging-guided bailout TEER.