Screening and Procedural Guidance for Mitral Transcatheter Edge-to-Edge Repair (M-TEER)

Figures

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  Figure 1. (A–C): Primary MR with multiscallop prolapse and diffusely thickened leaflets (Barlow disease). (D–F) Primary MR with P3 prolapse, thin leaflets and chordal rupture (fibroelastic deficiency). LA: left atrium, LV: left ventricle.

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  Figure 2. Severe secondary ventricular MR in a patient with ischemic cardiomyopathy due to akinesia of the inferolateral and lateral wall. LA: left atrium, LV: left ventricle, MR: mitral regurgitation.

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  Figure 3. Ischemic dynamic MR unmasked by exercise echocardiography in a 66 y.o. patient with ischemic cardiomyopathy (LVEF = 25%) due to anterior infarct and exertional dyspnea NYHA III. (A) At rest, MR is mild, whereas (B) at 75 Watts the patient develops dyspnea upon aggravation of MR (EROA = 0.41 cm2, RVol = 39 mL) with significant elevation of pulmonary pressures (TR Vmax = 4.0 m/s, TR PeakPG = 65 mmHg, estimated SPAP = 70 mmHg). LA: left atrium, LV: left ventricle, MR: mitral regurgitation.

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  Figure 4. Segmental assessment of the mitral valve. (A) Mid-esophageal commissural view with biplane imaging allows systematic segmentation from the lateral commissure (noted by the left atrial appendage). (B–D) Biplane cuts demonstrate sequential leaflet scallops: A1–P1 (red line, (B)), A2–P2 (yellow line, (C)), and A3–P3 (green line, (D)). (E) Three-dimensional “en face” view of the mitral valve from the left atrial perspective provides a comprehensive anatomical context and spatial orientation of scallops. LA: left atrium, LV: left ventricle, LAA: left atrial appendage, AoV: aortic valve.

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  Figure 5. (A) Posterior leaflet length measurement using 2D and (B) multiplanar reconstruction (MPR) at grasping zone. LA: left atrium, LV: left ventricle, AoV: aortic valve.

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  Figure 6. (A) Mitral valve area measurement using MPR. (B) Baseline mean mitral valve gradient using CW Doppler. MVA: mitral valve area.

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  Figure 7. (A,B) Measurement of flail width in primary MR (red line). (C,D) Measurement of flail gap (red line). MV: mitral valve, AoV: aortic valve.

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  Figure 8. (A) Measurement of coaptation depth (or tenting height) in secondary MR (red line). (B) Measurement of coaptation length (red line). (C) Measurement of coaptation gap (red line). MV mitral valve, AoV: aortic valve.

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  Figure 9. Three-dimensional “en face” mitral valve shows cleft-like indentation at the junction of the P2 and the P3 segment. (A) Atrial view or surgeon’s view and (B) ventricular view. LAA: left atrial appendage, AoV: aortic valve.

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  Figure 10. (A) Comparative assessment of posterior leaflet motion in (A) systolic and (B) diastolic phases. The posterior leaflet, indicated by a red arrow in both images, demonstrates a complete lack of movement throughout the cardiac cycle. LA: left atrium, LV: left ventricle, AML: anterior mitral leaflet, PML: posterior mitral leaflet.

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  Figure 11. (A) The posterior annulus (green arrow) is calcified and extended into the posterior leaflet, resulting in a shorter effective posterior leaflet for grasping in 2D image and (B) in 3D with multiplanar reconstruction. LA: left atrium, LV: left ventricle, AML: anterior mitral leaflet, PML: posterior mitral leaflet, LAA: left atrial appendage, AoV: aortic valve.

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  Figure 12. (A) The circle represents optimal transseptal puncture site (superior and posterior). (B) The short axis view guides anterior (towards the aorta) or posterior position, (C) the bi-caval view guides superior or inferior position, (D) the 4-chamber view is used for measurement of puncture height from the level of annulus and, (E) when the puncture site is positioned more superiorly than typically expected and the four-chamber view fails to adequately delineate both the puncture site and the annulus, a modified 135–150° view is employed to optimize alignment, thereby enabling precise visualization and measurement. LA: left atrium, LV: left ventricle, RA: right atrium, RV: right ventricle, AoV: aortic valve.