Transcatheter Edge-to-Edge Repair After Patent Foramen Ovale and Atrial Septal Defect Closure

Figures

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  Figure 1. Images After Implantation of Septal Closure Devices (A) Fluoroscopic image showing patent foramen ovale closure using a Gore Cardioform occluder. (B) Fluoroscopic image demonstrating additional atrial septal defect closure with an Amplatzer Cribriform device using the sandwich technique.

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  Figure 2. Echocardiographic Assessment of Mitral Regurgitation (A) TTE image in the parasternal long-axis view demonstrating P1 leaflet prolapse. (B) Color Doppler TTE in the parasternal long-axis view showing severe MR. (C) Three-dimensional TEE en face view of the mitral valve illustrating the P1 prolapse. (D) Three-dimensional TEE in the commissural view showing severe MR. MR = mitral regurgitation; TEE = transesophageal echocardiography; TTE = transthoracic echocardiography.

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  Figure 3. Comparison of Interatrial Septum and Left Atrial Enlargement Between the Prior and Current Procedures (A) TEE in the bicaval view immediately after septal device implantation, showing the interatrial septum almost entirely occupied by the closure devices. (B) TEE in the bicaval view at the time of transcatheter edge-to-edge repair, demonstrating stretching of the interatrial septum. (C) CT imaging obtained at the time of septal closure, showing normal left atrial dimensions. (D) CT imaging 1 year later, demonstrating marked left atrial enlargement and stretching of the interatrial septum. CT = computed tomography; TEE = transesophageal echocardiography.

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  Figure 4. Images Demonstrating Transseptal Puncture and Device Passage (A) TEE bicaval view showing effective tenting of the inferoposterior interatrial septum with the SL-0 sheath. (B) Fluoroscopic image demonstrating successful passage of the SL-0 sheath across the interatrial septum following puncture. (C) Fluoroscopic image showing passage of the PASCAL Ace delivery system through the interatrial septum. (D) Three-dimensional TEE image showing the PASCAL Ace guiding sheath (red arrow) crossing the interatrial septum, with 2 previously implanted septal closure devices also visualized (yellow arrows). TEE = transesophageal echocardiography.

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  Figure 5. Echocardiographic Findings After Transcatheter Edge-to-Edge Repair (A) TEE image showing mild residual mitral regurgitation after transcatheter edge-to-edge repair. (B) TEE image confirming the absence of residual iatrogenic atrial septal defect following removal of the guide catheter. TEE = transesophageal echocardiography.

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  Visual Summary. Key Imaging Findings in TEER After Prior Septal Closure (A) Fluoroscopic image from 1 year earlier showing transcatheter closure of the patent foramen ovale and atrial septal defect using 2 occluder devices. (B) Transthoracic echocardiography on day 1 demonstrating severe degenerative MR due to P1 prolapse with ruptured chordae. (C) TEE in the bicaval view at the time of TEER, demonstrating stretching of the interatrial septum. (D) Fluoroscopic image showing passage of the PASCAL Ace delivery system through the interatrial septum. (E) Three-dimensional TEE image showing the PASCAL Ace guiding sheath (red arrow) crossing the interatrial septum, with 2 previously implanted septal closure devices also visualized (yellow arrows). (F) TEE image showing mild residual mitral regurgitation after transcatheter edge-to-edge repair. MR = mitral regurgitation; TEE = transesophageal echocardiography; TEER = transcatheter edge-to-edge repair.