Challenging the limits of mitral-TEER: a PASCAL case in the anatomical 'red zone': a case report

Transcatheter edge-to-edge repair (TEER) has emerged as an effective therapeutic option for patients with severe mitral regurgitation (MR) deemed high risk for surgery. Two devices are currently available in Europe, MitraClip (Abbott Vascular, Santa Clara, CA, USA) and PASCAL (Edwards Lifesciences, Irvine, CA, USA). The PASCAL system provides unique features, such as a central spacer and nitinol flexibility, that may expand eligibility in anatomically and clinically challenging cases.

We present the case of a 78-year-old female with ischaemic cardiomyopathy and advanced heart failure (HF) [ejection fraction (EF) of 25%), severe secondary MR (SMR), chronic kidney disease, and recurrent pulmonary oedemas with hospitalizations with an STS score of 26.8%]. Thus, transcatheter TEER was deemed the best option. The baseline mitral valve area (MVA) and mean gradient were 2.7 cm² and 2.4 mmHg, respectively. Therefore, TEER with the PASCAL P10 device was selected as the most optimal device. A single device was implanted at the A₂-P₂ scallops, resulting in significant MR reduction and an acceptable final mean gradient of 4.5 mmHg. The patient was discharged clinically improved and without any hospitalizations for heart failure in 1-year follow up period.

This case illustrates the feasibility of TEER with PASCAL in a frail, high-risk patient with severe SMR and borderline anatomy. The spacer technology and leaflet-friendly design allowed safe and effective MR reduction while maintaining acceptable gradients. This case highlights the importance of individualized heart team decision-making, the potential advantages of the PASCAL device in anatomically challenging scenarios and increased operator experience.