# Plug-based bail-out strategy for leaflet tear after mitral transcatheter edge-to-edge repair: a case report

## TL;DR

This case report describes a novel transcatheter bail-out strategy using a plug and additional device to treat a leaflet tear after a heart repair procedure.

## Contribution

A new plug-based bail-out strategy is proposed for leaflet tears following mitral TEER.

## Key findings

- A leaflet tear after TEER was successfully managed using a PASCAL Ace device and an Amplatzer Vascular Plug II.
- The plug-based strategy reduced MR jet to mild without requiring surgery.
- This approach may be considered when additional TEER devices alone are insufficient.

## Abstract

Mitral transcatheter edge-to-edge repair (TEER) is a safe and widespread treatment approach for severe mitral regurgitation (MR). However, rare but serious device-related complications, including single leaflet device attachment, perforation, and leaflet tear, may occur, often requiring surgical correction.

An 82-year-old man with congestive heart failure and ischaemic cardiomyopathy underwent mitral TEER using MitraClip XTW clip for severe functional MR. Two days after the procedure, MR recurrence due to a leaflet tear was observed. Given the patient’s advanced age and reduced left ventricular function, our cardiac team decided to perform a transcatheter bail-out procedure. First, the tear was converted to a hole shape by implanting a PASCAL Ace device (Edwards Lifesciences) lateral to the XTW, as this device has a lower risk of leaflet damage compared to the MitraClip device. Then, Amplatzer Vascular Plug II (AVP II) was deployed into the hole, with its mid-lobe positioned in contact with the devices and leaflets. After releasing the AVP II, the MR jet reduced to mild.

An optimal bail-out strategy for leaflet tears has not yet been established. When it is difficult to sufficiently cover the leaflet tear using only an additional TEER device, the use of a plug with additional TEER devices can be considered a bail-out strategy.