Mitral transcatheter edge-to-edge repair with inverse leaflet grasping in the setting of prior atrial septal defect closure: a case report

Abstract Background According to the 2025 ESC/EACTS guidelines, transcatheter edge-to-edge repair has a class IIa recommendation in patients with primary mitral regurgitation at high surgical risk following Heart Team evaluation. Procedural complexity may be increased by prior septal closure devices and challenging leaflet anatomy. We describe a modified technical approach that enabled successful treatment in this setting. Case Summary A 75-year-old woman with a history of atrial septal defect closure presented with advanced heart failure symptoms due to severe primary mitral regurgitation from posterior leaflet prolapse. Because of frailty and comorbidities, surgical repair was not feasible and an interventional approach was recommended. Transseptal puncture was technically challenging due to an Amplatzer occluder and required a posterior–superior puncture site. Conventional leaflet capturing with the PASCAL Ace device was unsuccessful because of pronounced prolapse and localized chordal restriction. A modified sequence, called inverse leaflet grasping, was employed: clasps were fixed in a horizontal position while the paddles remained elongated during posterior leaflet engagement, followed by paddle closure. This maneuver allowed secure capture and effective reduction of regurgitation after the first device, followed by implantation of a second device using conventional technique. The patient improved clinically and remained stable at six-month follow-up with mild residual mitral regurgitation. Discussion This case illustrates that mitral transcatheter edge-to-edge repair is feasible even in anatomically complex scenarios. Inverse leaflet grasping may serve as a bailout technique when conventional leaflet capturing fails. The report underlines the importance of tailored interventional strategies in line with current ESC guidelines.