Transcatheter mitral valve repair for primary mitral regurgitation

Figures

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  Fig. 1.. Variable etiologies of primary mitral regurgitation. The figure demonstrates the spectrum of mitral valve pathology. The first image is a 3D image of a Barlow’s mitral valve showing billowing of the mitral leaflets. The Second image is 3D image of the mitral valve with a cleft of the anterior mitral leaflet seen at the 12 O’Clock position. The third is image is a 3D echocardiographic representation of a rheumatic mitral valve showing fusion of both medial and lateral commissures. The fourth image is a 2D image of radiation induced mitral valve disease showing severe thickening and calcification of the mitral annulus and mitral valve leaflets with involvement of the aorto-mitral curtain. Lastly the image farthest to the right is a 3D image of the mitral valve showing severe calcification and degeneration.

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  Fig. 2.. Comparison of MitraClip G4 Dimension. The figure on the left shows standard length MitraClip NT and NTW dimensions and the right image shows the MitraClip G4 XT and XTW dimensions demonstrating longer arm length.

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  Fig. 3.. Configuration of the PASCAL and PASCAL Ace devices. The left image shows the PASCAL device with two independent clasps and two paddles that allow leaflet grasping. A central spacer is seen in both devices. The central spacer is intended to fill the regurgitant orifice. The PASCAL Ace device is shown on the right image with similar configuration.

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  Fig. 4.. Transcatheter edge-to-edge repair of a case of a flail posterior leaflet. 3-dimensional imaging (A) demonstrates a flail P2 (*) with significant anteriorly directed MR (B). 2-dimensional baseline TEE imaging demonstrates the flail posterior leaflet with severe anteriorly directed MR (C). Left upper pulmonary venous flow at baseline shows systolic flow reversal, indicative of severe MR (D). The MitraClip device (arrow) is advanced into the left atrium and positioned perpendicular to the line of coaptation of A2-P2 (E). The device is then advanced into the LV and deployed to approximate the A2-P2 leaflets, resulting in a tissue bridge (F). This results in significant reduction in MR (G) with dominant systolic flow in the left upper pulmonary venous flow (H). AV, aortic valve; LAA, left atrial appendage.

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  Fig. 5.. Single leaflet detachment. A case of single leaflet device attachment (SLDA). A patient with previous transcatheter edge-to-edge repair of the mitral valve presents with heart failure symptoms and TEE imaging showing SLDA of the MitraClip device (yellow arrow). The device was attached to the anterior leaflet (A&B) with severe mitral regurgitation (C). A second MitraClip device (red arrow) was deployed medial to the first device, resulting in mild residual MR (D). 3 TEE imaging shows the newly implanted device at A3-P3 in relation to the first device that has detached from the posterior leaflet (E). AV, aortic valve; LAA, left atrial appendage; IAS, interatrial septum.

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  Fig. 6.. Potential complications of transcatheter edge to edge repair of the mitral valve. Visual representation of different potential complications that may be associated with TEER.

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  Fig. 7.. MitraClip in annuloplasty ring. A case of transcatheter edge-to-edge repair (TEER) in a patient with a surgical mitral valve ring (MVr). (A) Transesophageal echocardiography (TEE) showing a prolapsed posterior leaflet within the MVr (red arrow) resulting in severe eccentric MR (B). 3D TEE imaging demonstrating prolapsed posterior leaflet (*) within the MVr (C). The patient underwent TEER with MitraClip device (yellow arrow) implantation at A2-P2 (D) resulting in mild residual MR (E). 3D TEE imaging demonstrating the location of the MitraClip at A2-P2 in relation to the MVr (F). AV, aortic valve; LAA, left atrial appendage; IAS, interatrial septum.