Transcatheter Edge-to-Edge Repair in Adult Congenital Heart Disease: Anatomic Challenges, Device Adaptations, and Emerging Evidence

Atrioventricular valvular regurgitation (AVVR) is a principal determinant of morbidity and mortality in adults with congenital heart disease (ACHD), and surgical management carries substantial operative risk owing to prior sternotomies, distorted intracardiac anatomy, impaired ventricular function, and lesion-specific hemodynamic fragility. Transcatheter edge-to-edge repair (TEER)-using MitraClip or TriClip (Abbott) or PASCAL/PASCAL ACE (Edwards Lifesciences)-has emerged as a compelling alternative in high-surgical-risk acquired valvular disease and is rapidly expanding into ACHD. We review the anatomic substrate, device-specific technical considerations, preprocedural imaging requirements, and clinical evidence supporting TEER across the principal ACHD substrates: congenitally corrected transposition of the great arteries (TGA) with systemic tricuspid regurgitation, atrial switch repairs for dextro-TGA, atrioventricular septal defects, and single-ventricle Fontan circulations. We also address procedural challenges unique to ACHD, including venous access anomalies, altered transseptal geometry, absent conventional echocardiographic windows, and iatrogenic stenosis risk in morphologically abnormal valves. Multidisciplinary selection integrating ACHD structural expertise, advanced imaging, and procedural TEER experience is requisite for safe outcomes.