Anatomy-Driven Transcatheter Edge-to-Edge Repair of the Systemic Atrioventricular Valve in Complex Transposition Anatomy.

Systemic atrioventricular valve (SAVV) regurgitation contributes importantly to systemic right ventricular deterioration in adults with congenitally corrected transposition of the great arteries (ccTGA) and dextro-transposition of the great arteries (d-TGA) after atrial-switch repair. Transcatheter edge-to-edge repair (TEER) has emerged as an option for selected patients at high or prohibitive surgical risk, and prior congenital series have established the feasibility of transseptal, transbaffle, and alternative access strategies. However, procedural execution remains highly anatomy-dependent because systemic venous pathways, atrial baffles, ventricular topology, cardiac orientation, and access-to-valve geometry can substantially alter guide-catheter support and device coaxiality. We report a single-center Interventional Rounds experience of four consecutive high-risk adults undergoing SAVV-TEER across four distinct transposition anatomies: ccTGA with dextrocardia, d-TGA after Mustard atrial-switch repair, Mustard anatomy with severe iliofemoral tortuosity, and ccTGA with interrupted inferior vena cava and azygos continuation. Transfemoral access was used in two patients, and right internal jugular access in two. Three procedures were performed with PASCAL ACE and one with MitraClip. Device implantation was successful in all four patients, with SAVV regurgitation reduced from severe (3+) to mild (1+). Final mean SAVV gradients were 1.5, 2.1, 1.9, and 1.8 mmHg, respectively, and no major acute procedural complications occurred. The principal technical message is that access selection should be guided not only by anatomic patency but by the anticipated mechanical trajectory of the delivery system. Right internal jugular access may be selected prospectively as the preferred primary route when inferior venous anatomy is absent or expected to provide unfavorable curvature, support, or device alignment. Dextrocardia and atrial-switch baffle anatomy may additionally require specific steering and traversal adaptations. These observations represent focused procedural refinements within the evolving congenital TEER experience rather than evidence of comparative efficacy or safety.