Guide-sheath-assisted bailout technique for intra-procedural single-leaflet device attachment using the PASCAL system: a case report

Single-leaflet device attachment (SLDA) is a rare but serious complication of mitral valve transcatheter edge-to-edge repair (MTEER). When SLDA occurs after full device release, management options are limited. In contrast, intra-procedural SLDA recognized before full implant release may allow a specific bailout strategy.

A 77-year-old man with severe degenerative mitral regurgitation (MR) underwent MTEER using the PASCAL Ace system because of high surgical risk. Initial device implantation reduced MR from severe to mild. However, after removal of both clasp lines during the release process, SLDA occurred at the posterior leaflet, resulting in recurrent severe MR. Although standard retrieval was no longer feasible, the implant remained connected to the steerable catheter. Under fluoroscopic and transoesophageal echocardiographic guidance, a guide sheath was advanced coaxially towards the implant. Controlled insertion of the guide sheath between the clasp and paddle, followed by gradual paddle opening, enabled leaflet disengagement and successful device retrieval without leaflet injury. A second implantation achieved a sufficient reduction in mitral regurgitation.

This case demonstrates a novel bailout technique for intra-procedural SLDA. Successful retrieval requires precise coaxial device alignment, careful catheter manipulation, continuous monitoring of leaflet tension, and meticulous guidance using fluoroscopy and transoesophageal echocardiography (TEE). Importantly, prompt recognition of SLDA by TEE is a prerequisite for this technique. In conclusion, the guide-sheath-assisted retrieval technique can represent a potential bailout strategy for intra-procedural SLDA before full implant release during MTEER.