PASCAL repair of severe mitral regurgitation from posterior leaflet cleft in a critical patient: a case report.

Background: Mitral regurgitation due to leaflet cleft is a rare pathology typically managed surgically. In high-risk patients, transcatheter edge-to-edge repair may be a feasible alternative. Case summary: A 65-year-old man with chronic obstructive pulmonary disease, coronary artery disease, and paroxysmal atrial fibrillation presented in acute respiratory failure due to coronavirus disease 2019 pneumonia and pulmonary oedema from severe mitral regurgitation caused by a posterior mitral leaflet cleft. After failed non-invasive ventilation, he required intubation and 4 days of veno-venous extracorporeal membrane oxygenation (VV-ECMO). Following clinical stabilization and ECMO decannulation, the Heart Team opted for transcatheter edge-to-edge repair using the PASCAL system. Intraprocedural 3D transoesophageal echocardiography localized a pronounced posterior mitral leaflet cleft. Initial leaflet-grasping attempts between A2/P2 and A2/P3 produced mean transmitral gradients of 7-8 mmHg with inadequate mitral regurgitation reduction. A single PASCAL ACE device was then implanted orthogonally across the cleft with sequential independent grasping of P2 and P3, successfully reducing mitral regurgitation from Grade IV to mild with a resulting mean gradient of 3 mmHg. At the 90-day follow-up, New York Heart Association class had improved from IV to II, with no hospital readmission and no echocardiographic recurrence of significant mitral regurgitation. Discussion: This case demonstrates the feasibility of PASCAL implantation in complex leaflet cleft anatomy, offering a bridge-to-surgery or definitive therapeutic option in critically ill patients, highlighting the value of individualized procedural strategies and device-specific advantages.