State-of-the-art intra-procedural imaging for the mitral and tricuspid PASCAL Repair System

Figure 1. The PASCAL Repair System. There are features unique to the PASCAL repair system including a central spacer and adjacent paddles and clasps that attach the implant to the native leaflets to reduce regurgitation. (Note: all dimensions are in millimeters).

Figure 2. Primary imaging views for the mitral and tricuspid valve. The primary imaging views used for pre-procedural planning and intra-procedural guidance are shown in this figure.

Figure 3. Three-dimensional imaging of the mitral and tricuspid valves. Standardized imaging display for the en face view of the MV with both lateral and Z-plane rotation (A) and without Z-plane rotation (B); ruptured P2 chordae are seen (asterisk). A real-time 3D en-face view of the TV without Z-plane rotation, results in leaflet orientation similar to the transgastric view (C). Creating multi-beat colour Doppler 3D volumes of the systolic regurgitant jet, allows planimetry of the MR VCA post-device (D). MR, mitral regurgitation; MV, mitral valve; TV, tricuspid valve; VCA, vena contracta area.

Figure 4. Biplane imaging from the MV commissural view. Using simultaneous biplane imaging with the mid-oesophageal MV commissural view as the primary image, a sweep of the entire commissure can be performed. (A) The position of the orthogonal image (white arrow) at the lateral commissure (A1-P1 scallops). (B) The position of the orthogonal image at the midline (A2-P2 scallops) where a small flail posterior scallop is imaged (yellow arrow). (C) The position of the orthogonal image at the medial commissure (A3-P3 scallops). MV, mitral valve.

Figure 5. Four levels of imaging for the tricuspid valve. The path of the oesophagus allows for the generation of four imaging levels for the tricuspid valve: mid oesophageal level, deep oesophageal level , transgastric and deep transgastric. A, anterior leaflet; Ao, aorta; LA, left atrium; LV, left ventricle; P, posterior leaflet; RA, right atrium; RV, right ventricle; S, septal leaflet.

Figure 6. Biplane imaging from the TV commissural view. The mid-oesophageal right ventricular inflow-outflow view (at ∼50–80°) is considered the TV ‘commissural’ view with the anterior (blue line) and posterior (green line) leaflets imaged and the septal leaflet (yellow line) behind the imaging plane. Moving the orthogonal biplane cursor towards the posterior wall (A) images the posterior and septal leaflets. Moving the orthogonal biplane cursor towards the aorta (B) images the anterior leaflet near the aorta and the septal leaflet. TV, tricuspid valve.

Figure 7. Post-device orifice area. Three-dimensional imaging is used to directly planimeter the MV orifice areas separately since the medial and lateral orifices are not typically in the same horizontal plane. Aligning the short-axis plane at the tips of leaflet in diastole (blue lines) allows the lateral orifice area (A) to be planimetered from the short-axis view (blue box). Realigning the short-axis plane for the medial orifice is shown in (B). MV, mitral valve.

Figure 8. Procedural steps for PASCAL mitral device implantation. (A) The imaging requires for transseptal puncture, advancing the delivery system (2D and 3D guidance) and implant orientation. (B) The next procedural steps of positioning and orientating the device below the leaflets, clasping the leaflets and pre-delivery assessment. (C) The imaging necessary for post-implant assessment of mitral valve function as well as haemodynamic benefit, and safe removal of the delivery catheter.

Figure 8. Continued.

Figure 8. Continued.

Figure 8. Continued.

Figure 9. Procedural steps for PASCAL tricuspid device implantation. (A) The imaging requires for pre-device assessment, advancing the delivery system (2D and 3D guidance) and positioning and orientating the device below the leaflets. (B) The next steps of clasping the leaflets and pre-delivery assessment. (C) The imaging necessary for post-implant assessment of tricuspid valve function as well as haemodynamic benefit.