Transcatheter edge-to-edge repair with the PASCAL device for failed MitraClip procedure

A 79-year-old male with severe primary MR, due to flail of the lateral (P1) scallop with a commissural jet (Figure 1A), underwent attempted transcatheter edge-to-edge repair (TEER) with the MitraClip system (Abbott). The transseptal puncture was performed in the mid-position in the bicaval view and in the mid-posterior position in the short-axis view (Figure 1B), with a transseptal puncture height of 4 cm (Figure 1C). The MitraClip system was noted to have an anterior-to-posterior trajectory (aorta hugger) (Figure 1D, Figure 1E). Correcting the aorta hugger trajectory − using the “+” knob on the steerable guide catheter to move the guide posteriorly (away from the aorta) and the “M” knob to move the MitraClip system medially − resulted in loss of height of the MitraClip system from the mitral valve. The loss of height from the mitral valve could not be adequately corrected with posterior steering of the guide catheter and addition of the “A” knob to move the MitraClip system anteriorly and laterally to the mitral plane. A repeat transseptal puncture was performed with a transseptal height of...