Both the MitraClip and PASCAL systems offer transcatheter edge-to-edge repair (TEER) solutions for mitral regurgitation. Evidence indicates a lower technical success rate for TEER in complex degenerative mitral regurgitation (DMR) cases. We conducted a retrospective analysis of patients who underwent transcatheter edge-to-edge therapy for primary mitral regurgitation with advanced anatomy, defined as mitral regurgitation effective regurgitant orifice area (MR-EROA) ≥0.40 cm² or large flail gap (≥5 mm) or width (≥7 mm) or Barlow’s disease, that completed follow-up after 1 year. Our criteria were met by 27 patients treated with PASCAL and 18 with MitraClip. All patients exhibited a significant, equivalent short-term reduction in MR-EROA, mitral regurgitation vena contracta diameter (MR-VCD), regurgitant volume, and clinical status. At 1 year follow-up, reductions in MR-VCD, regurgitant volume, and MR-EROA remained significant for both groups without significant differences between groups. MR-Grade ≤ 1+ was achieved in 18 (66.7%) and 10 (55.6%) patients, respectively. At follow-up, no difference in hospitalization for cardiac decompensation was observed. Overall death was similar in both groups. Our study suggests that both the PASCAL and MitraClip systems significantly reduce mitral regurgitation even in advanced degenerative diseases. Within our limited data, we found no evidence of inferior performance of the PASCAL system.

Zusammenfassung: Die Trikuspidalklappeninsuffizienz (TI) ist eine häufige Herzklappenerkrankung mit erheblichen Auswirkungen auf die Patientenmorbidität und -letalität. In den letzten Jahren wurde die Klassifikation der TI durch die Einführung neuer Formen und 5 Schweregrade verfeinert. Dabei spielt die dreidimensionale Echokardiografie eine zunehmende Rolle in der TI-Beurteilung und -Graduierung sowie in der Bewertung der rechtsventrikulären Funktion. Bei relevanter TI sollte eine Überweisung in ein spezialisiertes Zentrum erfolgen.

Transcatheter edge-to-edge repair (TEER) is the most widely used approach for tricuspid regurgitation in patients with prohibitive surgical risk. However, TEER might not be feasible in advanced tricuspid regurgitation. In such cases, a stepwise approach with initial annuloplasty and subsequent TEER can be a worthwhile alternative, which is reported in this series. (Level of Difficulty: Intermediate.)

Background/Objectives: The objective of this study was to characterize echocardiographic characteristics comparing patients accepted or deemed unsuitable for transcatheter mitral valve interventions. Methods: We performed a retrospective analysis of 293 patients with severe mitral regurgitation evaluated for mitral transcatheter edge-to-edge repair (M-TEER) or transcatheter mitral valve replacement (TMVR), if patients were primarily identified as unsuitable candidates for M-TEER, at our institution between 2018 and 2023. All patients underwent transthoracic and transesophageal echocardiography, and mitral valve quantification (MVQ) analysis was performed. Feasibility was determined by an interdisciplinary Heart Team based on quantitative data and semi-quantitative echocardiographic parameters, including mean pressure gradient, regurgitation volumes, and morphological aspects alongside clinical assessment. Patient characteristics were evaluated using clinical records and echocardiographic data. Results: We screened 195 patients for M-TEER, 168 of which were accepted for the procedure. M-TEER-rejected patients presented with higher regurgitation volumes and higher transmitral pressure gradients than those accepted to undergo M-TEER. We then screened 104 patients for TMVR, and 27 were approved for the procedure. Patients rejected for TMVR presented with lower tenting volume, area, and height and had smaller ventricular diameters. Further, mitral valve area appears to be an important parameter in determining MR treatment strategy. Conclusions: The majority of MR patients screened for transcatheter intervention were suitable for M-TEER. However, elevated MPG and more pronounced billowing were the main factors associated with M-TEER exclusion. Conversely, the only morphological parameter associated with TMVR refusal was small left ventricular size. Importantly, the multimorbidity of patients and level of critical illness did not prohibit TMVR.