A clover-like repair strategy for posterior mitral leaflet cleft using transcatheter edge-to-edge repair

A 75-year-old man presented with acute decompensated heart failure due to severe mitral regurgitation caused by central malcoaptation associated with a deep posterior mitral leaflet cleft and a tri-leaflet-like mitral valve configuration. Because of high surgical risk and frailty, transcatheter edge-to-edge repair was performed using the PASCAL Ace system. Initial direct approximation across the cleft caused leaflet distortion and residual mitral regurgitation between A2 and the lateral posterior mitral leaflet. A second device was therefore placed laterally, resulting in a clover-like configuration, reduced mitral regurgitation, and improved left atrial pressure.