Safety and Efficacy of Novel Morphology Classification-Guided Mitral Valve Transcatheter Edge-to-Edge Repair for Patients With Commissural Degenerative Mitral Regurgitation: Design and Rationale of the TEER-CD Trial

Figures

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  Fig. 1.. Definition of commissural degenerative mitral regurgitation. (A) Commissures, where anterior and posterior mitral leaflets converge during systole, typically form a Y-shaped structure by joining three segments (e.g., A1-anterolateral commissure-P1 or A3-posteromedial commissure-P3), distinguished by fanlike chordae tendineae stemming from anterolateral and posteromedial papillary muscles. Given the difficulty in distinguishing individual chordae on transesophageal echocardiography, the cleavage segment that separates the anterior leaflet from the posterior leaflet is used as imaging for anterolateral and posteromedial commissure approximation of true anatomic commissures. (B) The protrusion of the commissural segment into the left atrium during systole or (C) the rupture of commissural chordae tendineae characterizes commissural prolapse or flail [13]. AV, aortic valve.

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  Fig. 2.. Imaging protocol for mitral valve commissural disease. (A) Illustration of the mitral valve (MV), surgeon’s view in the “clock-face plane” with the aortic valve (AV) at the 12 o’clock. Transesophageal echocardiography is used to identify mitral commissural (bicommisural) view anatomically optimized the MV plane (~50°–70°, the red dash line), and long axis (LAX) view best clarified MV coaptation plane, such as ~120°–150° for central segments (the green dash line), >~150° for lateral segments (the yellow dash line), and <~130° for medial segments (the blue dash line). (B) Simultaneous biplane imaging permits the use of a dual screen to display two real-time two-dimensional images simultaneously. The first (primary) image of the MV commissure view can be used as the reference view, with the second view, LAX view rotated from 0° to 180° from the primary view to sweep the interrogation of the MV coaptation (central, lateral, and medial tilts). (C) Example of biplane imaging with (D) color Doppler simultaneously displays bicommissural view (~50°–70°) and modified LAX view to identify the posteromedial commissural lesions. (E) Example of biplane imaging with (F) color Doppler…

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  Fig. 3.. Flowchart of the novel morphology classification-guided M-TEER strategy for commissural degenerative mitral regurgitation. A, anterior leaflet; C, commissure leaflet; DMR, degenerative mitral regurgitation; M-TEER, mitral transcatheter edge-to-edge repair; MV, mitral valve; P, posterior leaflet; TEE, transesophageal echocardiography; TEER, transcatheter edge-to-edge repair; TTE, transthoracic echocardiography; MR, mitral regurgitation; TEER-CD, Mitral Valve Transcatheter Edge-to-Edge Repair for Patients with Commissural Degenerative Mitral Regurgitation.

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  Fig. 4.. Patient flow for screening, enrollment and follow up in the TEER-CD trial. DMR, degenerative mitral regurgitation; I/E, inclusion and exclusion criteria; MR, mitral regurgitation; TEE, transesophageal echocardiography; TEER, transcatheter edge-to-edge repair; TTE, transthoracic echocardiography.