Abstract Body (Do not enter title and authors here): Introduction: Mitral regurgitation is the second most common valvular heart disease, it has a high prevelance in older patients, transcatheter mitral valve edge-to-edge repair has been introduced as an alternative treatment to mitral valve surgery especially in the elderly, MitraClip is used as a standard treatment for transcatheter mitral valve edge-to-edge repair (M-TEER). PASCAL has recently been used with minimal evidence comparing both of them.

Aim: We aimed to compare the outcomes of both device systems on mitral regurgitation residuals and clinical outcomes.

Methods: PubMed, Scopus, WOS, and Cochrane were retrieved from inception until May 2024 for relevant clinical studies that compared PASCAL to MitraClip approaches in M-TEER procedure and reported the primary outcome of interest, which was the grade of MR at follow-up. Other reported outcomes were technical success, Death from any cause, and reintervention, Dichotomous data were analyzed using OR and 95% CI with a fixed-effect model.

Results: Seven studies were included with a total of 1834 patients. MR ≤ 2 at discharge was less with MitraClip (RR, 0.67, 95%CI [0.45 to 1]), and MR ≤ 2 at follow-up was less with MitraClip (RR, 0.84, 95% CI [0.64 to 1.1]), MR ≤ 1 at follow up was significantly less with MitraClip (RR 0.69, [0.56 to 0.85]). However, there were no significant differences in technical success, Death from any cause, or reintervention between the two systems used.

Conclusion: MitraClip and PASCAL are similar in procedural success, with better outcomes for PASCAL regarding Mitral regurgitation grades after the procedure. The guide to proceed with MitraClip or PASCAL should be guided by mitral valve anatomy, the etiology of MR, and device-specific features. Also, Large-volume RCTs are warranted to validate the current findings.