Author + information
- Francesco Faletra, MD⁎,⁎ (, )
- Antonio Grimaldi, MD†,
- Elena Pasotti, MD⁎,
- Julija Klimusina, MD⁎,
- Antonietta Evangelista, MD⁎,
- Ottavio Alfieri, MD†,
- Tiziano Moccetti, MD⁎ and
- Giovanni Pedrazzini, MD⁎
Address for correspondence:
Dr. Francesco F. Faletra, Division of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland
a new percutaneous edge-to-edge mitral valve repair (PMVR) has been developed over the past few years. The clip is deliverable using the transseptal approach. Combined fluoroscopic and echocardiographic guidance have been used to properly monitor the device position in the left atrium so that it can be placed at the center of the mitral valve orifice over the regurgitant jet. In particular, 2-dimensional transesophageal echocardiography (2D TEE) has been shown to be a valuable tool for transseptal puncture guidance, for optimal clip positioning, and for assessment of the severity of mitral regurgitation before and after final deployment of the clip. However, the location of an intracardiac catheter relative to the surrounding structures requires acquisition of 2D TEE multiple planes and frequent image adjustments. Real-time 3-dimensional transesophageal echocardiography (RT3D TEE) provides detailed anatomical data of the different scallops of mitral leaflets and precise relationships of surrounding anatomical structures from different perspectives. Furthermore, its ability to visualize the entire length of the intracardiac catheter including the tip, makes RT3D TEE the ideal tool for monitoring PMVR. The insertion of a single clip usually leads to a significant reduction of mitral regurgitation in a significant proportion of patients, however, in some cases, a residual unacceptable mitral regurgitation may require the insertion of a second clip.
The following 2D TEE and RT3D TEE images demonstrate the successful insertion of 2 clips and highlight the importance of imaging in guiding the procedure and determining the final outcome.
A severe mitral regurgitation due to ruptured cordae of the anterior leaflet associated to a slight tethering of posterior leaflet (Fig. 1A), was treated by insertion of a percutaneous clip (Figs. 1C to 1F). The clip was inserted exactly over the regurgitant lesion which was located very close to the medial commissure (Fig. 1B). An unexpected, new, severe mitral regurgitation emerged from the central area of coaptation line (Figs. 2A and 2B). We speculated that this new regurgitation was due to the latent tethering already present in the baseline condition and exacerbated by the deployment of the first clip. A second clip was then inserted laterally to the first one, with a nearly complete abolition of regurgitation (Figs. 2C to 2F). Because of its large baseline mitral orifice area due to annular enlargement, no significant gradient was observed with the unusual creation of 3 smaller orifices (Fig. 2D) as opposed to standard “double orifice.”
While the role of 2D TEE in monitoring PMVR has been established, the role of RT3D TEE is still evolving and the comparative strength between 2D and RT3D TEE for this purpose is still unclear. Nevertheless, we found that some steps of the procedure would benefit from RT3D TEE. In our case, because the lesion was very close to the medial commissure, the precise location size and site of the flail leaflet was better defined with RT3D TEE rather than with the standard 2D TEE (Figs. 1A and 1B). Although the precise site of transseptal puncture was also identified through recognition of tenting by 2D TEE, both puncture of the septum as well as the position of the tip into left atrium, were easily monitored in a single 3D image from left atrial perspective (Figs. 1C to 1E and 2C). The alignment of the clip arms perpendicular to the coaptation line over the regurgitant orifices was definitely better visualized from an atrial perspective (Figs. 1E and 2C) rather than from the transgastric short-axis view. On the other hand, because of its superior temporal and axial resolution, other steps of the procedure, such as small iterations for the perfect axial alignment of the system, leaflets grasping, and leaflets capture inside the clip arms, were better evaluated by 2D TEE rather than RT3D TEE.
- American College of Cardiology Foundation