# Electrosurgical-laceration and stabilization of two PASCAL devices using artificial intelligence-based procedural planning: a case report

## TL;DR

A new technique combining electrosurgical laceration and AI-based planning was used to treat recurrent mitral regurgitation in a patient who had previously undergone a mitral valve repair procedure.

## Contribution

The paper introduces the ELASTA technique combined with AI-driven CT imaging for treating recurrent mitral regurgitation after prior transcatheter repair.

## Key findings

- ELASTA combined with transapical TMVI successfully treated recurrent MR in a patient with prior M-TEER.
- AI-based CT analysis improved procedural planning for complex mitral valve interventions.
- Recurrent MR after M-TEER is a growing clinical challenge requiring innovative solutions.

## Abstract

Mitral transcatheter edge-to-edge repair (M-TEER) has been established as a treatment for severe mitral regurgitation (MR). However, recurrent MR may occur after successful primary M-TEER. Repeat M-TEER procedures are challenging or even anatomically unfeasible. Therefore, novel techniques like electrosurgical laceration from the anterior leaflet and stabilization (ELASTA) of M-TEER devices are important.

An 85-year-old male presented with recurrent cardiac decompensations and relevant dyspnoea [New York Heart Association (NYHA) functional Class III–IV] caused by severe MR and heart failure. Four years earlier, the patient underwent M-TEER with two PASCAL devices due to severe primary MR. Echocardiography revealed two significant regurgitation jets, representing severe recurrent MR. Repeated M-TEER was prohibitive due to an elevated mean transvalvular gradient (6.2 mmHg) and surgery was deemed unfeasible. A computed tomography (CT) was performed using software based on artificial intelligence (AI) for automatic analysis of the mitral valve anatomy. The heart team then decided to perform an ELASTA of the two PASCAL devices with subsequent transapical transcatheter mitral valve implantation (TMVI). The procedure was performed without complications and achieved optimal haemodynamic outcomes.

The frequency of M-TEER procedures will rise, leading to a corresponding increase of recurrent MR requiring treatment. However, additional edge-to-edge repair is often not feasible due to space limitations, elevated inflow gradients, or progressive calcification of valve leaflets. Emerging electrosurgical techniques, such as ELASTA, combined with subsequent TMVI, offer promising solutions for recurrent MR. Computed tomography imaging plays a critical role in procedural planning, and AI-driven programs have the potential to significantly improve and optimize these analyses.