PASCAL device implantation for severe mitral regurgitation with acute chordae rupture and small calcified mitral valve annulus

Excerpt

An 88-year-old woman with a history of rheumatoid arthritis was hospitalized for acute heart failure (HF). Transthoracic echocardiography revealed severe mitral regurgitation (MR) due to P2 prolapse, and acute chordae rupture was suspected. The mitral valve annulus was severely calcified, and the mitral valve area was 2.62 cm² by 2D planimetry. HF management was difficult despite the administration of high doses of dobutamine and diuretics. Transcatheter edge-to-edge repair was considered because of the high surgical risk. Transesophageal echocardiography (TEE) confirmed severe MR with chordae rupture of P2 (Fig. 1A, B). The posterior leaflet length at the grasping zone was 8.2 mm. Mitral annular calcification was concentric at the basal posterior leaflet (Fig. 1C). Because the MitraClip device (Abbott Vascular Inc., CA) has a rigid cobalt–chrome clip, leading to a risk of leaflet tear and mitral stenosis, a PASCAL Ace device (Edwards Lifesciences, CA) with a flexible nitinol implant and spacer was selected expecting minimal tension against the leaflets. After transseptal puncture, the posterior leaflet was grasped using the PASCAL implant while avoiding the calcified annulus (Fig. 1D); however, MR did not reduce after implant closure (Fig. 1E). The implant’s position was then adjusted to cover the entire posterior leaflet with the calcified annulus, and the posterior clasp was dropped down after grasping the anterior leaflet (Fig. 1F). After implant closure, TEE showed mild MR from lateral indentation (Fig. 1G) and the acceptable transmitral mean pressure gradient (TMPG) of 5 mmHg. The paddles were moving with the heartbeat (Video). After releasing the device, MR did not change, with TMPG of 3 mmHg (Fig. 1H, I). A small calcified mitral valve is unsuitable for TEER. The PASCAL device helps minimize leaflet stress and preserve the valve area [1]. In addition, the PASCAL Ace implant can engage the leaflets with minimal interaction with dense chordae structure. This case suggests the potential advantage of the PASCAL Ace device to avoid mitral stenosis and valve injury in severe MR with a small calcified valve.

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