Left Internal Jugular Vein Access for Mitral Transcatheter Edge-to-Edge Repair: A Case Report and Review of Literature for Alternative Venous Access Routes.
This is a single case report describing mitral TEER via left internal jugular vein access using the PASCAL P10 in a 50-year-old with severe functional MR, IVC occlusion, and right IJV occlusion from prior renal transplant history.
Transseptal puncture was performed with the VersaCross radiofrequency system, the septum dilated with a 6 mm balloon, and the device deployed between A2 and P2 with MR reduction from 4+ to 1+ and no complications at 2 months.
One patient, two months of follow-up, and a technically demanding workaround that most centers will never need.
That said, the case is instructive: as TEER indications broaden — ESC 2025 elevated TEER for ventricular secondary MR to Class I based on COAPT and RESHAPE-HF2 — operators will encounter more patients with exhausted venous access from prior transplants, dialysis catheters, or thrombosis.
BACKGROUND: The increasing indications of transcatheter edge-to-edge repair (TEER) have led to its use in more diverse populations, including patients with complex comorbidities where standard transfemoral access may not be feasible. In these cases, utilizing the right internal jugular vein (IJV) access has been reported as a safe and practical alternative route. Herein, we report the first case of mitral TEER via left IJV access, using PASCAL system. CASE PRESENTATION: A 50-year-old woman with long-standing chronic kidney disease and two previously failed renal transplants suffered repeated admissions for acute pulmonary edema. Echocardiography confirmed severe functional mitral regurgitation (MR) and global left ventricular systolic dysfunction. Due to extremely high surgical risk, the multidisciplinary heart team opted for mitral TEER. Unexpectedly, pre-procedural imaging demonstrated complete occlusion of the inferior vena cava with prominent collateral circulation and total occlusion of the right IJV. After extensive team discussion, access via the left IJV was selected. Transseptal puncture (TSP) was performed with the VersaCross radiofrequency system, the septum was dilated using a 6 mm Mustang balloon, and a PASCAL P10 device was successfully implanted between the A2 and P2 segments, resulting in reduction of MR severity from severe (4+) to mild (1+). The procedure concluded without complications and hemostasis was secured. At 2-month follow-up the patient remained stable with no recurrent decompensations. CONCLUSION: Left IJV is a feasible alternative access for mitral-TEER when other venous accesses are not feasible. Proper pre-procedural planning and local expertise is essential to overcome the technical challenges related to TSP and steering the guiding catheter against the complex anatomical orientation of the left innominate vein.
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