Complex mitral valve anatomy continues to challenge even the most experienced TEER operators. In this month's SWAC conference, Dr. Sergio Garcia, Dr. Tom Waggoner, Dr. Mark Bieniarz, and Dr. Aidan Raney walk through how to approach PASCAL therapy in anatomies where leaflet length, clefts, stenosis, and calcification make decision-making difficult.

Using multiple real patient examples, they break down:

• How PASCAL’s separatable clasps change strategy in short posterior leaflets

• When to choose PASCAL vs Pascal Ace based on anatomy

• Managing posterior leaflet restriction, clefts, and deep scallop gaps

• How clasping technique differs from MitraClip

• Imaging keys for procedural success on transesophageal echo

• When to attempt independent clasping—and when not to

• Avoiding iatrogenic mitral stenosis

• What to do when coaptation depth is low or leaflet mobility is asymmetric

• Real-world case outcomes, lessons, and clinical pearls from each scenario

A must-watch for operators training in PASCAL or managing anatomies that push TEER beyond standard degenerative or functional mitral regurgitation.

Chapters:

00:00 – Introduction: Why complex mitral anatomy requires a different strategy

01:00 – Case review overview and PASCAL system fundamentals

01:40 – Leaflet length, calcium, clefts: deciding if TEER is feasible

02:20 – When to choose PASCAL vs Pascal Ace

03:00 – Understanding PASCAL’s independent clasping advantage

03:40 – Case 1: Short posterior leaflet and how to secure a durable grasp

04:20 – Using TEE to confirm leaflet insertion and avoid chordal entanglement

04:50 – Maneuvering around a cleft and choosing the correct landing zone

05:20 – Case 2: Posterior leaflet restriction and reduced mobility

05:50 – Why independent clasping helps unequal coaptation

06:20 – Residual MR strategies: reposition, reclasp, or add a second device

06:50 – Case 3: When coaptation depth is too shallow for a central grasp

07:20 – Recognizing when stenosis risk outweighs TEER benefit

07:45 – Procedural adjustments when leaflet tissue is limited

08:10 – Case 4: Complex functional MR with tenting and asymmetric jets

08:45 – TEE markers for good versus poor grasping zones

09:10 – Post-grasp evaluation: gradients, residual jets, and stability

09:40 – Final thoughts: how PASCAL expands TEER into anatomies once avoided

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