Technical Recommendations for Real-Time Echocardiography and Fluoroscopy Imaging Fusion in Catheter-Based Mitral Valve Paravalvular Leak and Other Procedures

Figures

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  Figure 1. Schematic description of different EFF scenarios. (A) “Side view of the TEE probe” scenario. (B) “Front view of the TEE probe” scenario. The figure presents standard echocardiography planes (green and purple contour) and three-dimensional imaging volume (3D) with X-ray directions depending on different C-arm projections and mitral and aortic annuli with the segmentation of the mitral valve according to Carpentier [12]. 4C and 2C—four- and two-chamber echocardiography planes, 3D—three-dimensional imaging volume. Positions of the C-arm: Cran—cranial, Caud—caudal, RAO—right anterior oblique, LAO—left anterior oblique, AP—antero-posterior.

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  Figure 2. An example of EFF scenario A “Side view of the TEE probe”. The position of the C-arm at 26° Cran, and 20° RAO, TEE probe is seen obliquely—from the side and the top. The automatic recognition of the TEE probe by EchoNavigator®-system software is highlighted by the green contouring. (A,B) preprocedural and postprocedural 3D and 3D Color Doppler TEE images of the biological prosthesis from the surgical perspective. I and II—paravalvular regurgitant jets show the location of two PVLs at 8 and 10 o’clock (A). Black stars mark PVL occluders with a small residual regurgitant jet near the first occluder (B). (C,D) intraprocedural EFF images for the closure of the I and II PVLs. Two X-plain (perpendicular to each other) 2D TEE views with Color Doppler cross the I and the II PVLs and regurgitant jets on the left. 2D TEE views planes seen on EFF images tilted in space. In addition, the X-plain views used to construct the markers transferred onto the EFF images (on the right). Green circle—sewing ring of X-ray negative biological valve prosthesis, small red ring (yellow arrows) placed at the PVLs.

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  Figure 3. EFF scenario “Front view of the TEE probe”. (A) panel—Preprocedural 3D TEE images of the biological mitral prosthesis from the surgical perspective (left). Four (I, II, III, and IV) regurgitant jets through the PVLs seen from 4 to 8 o’clock (right). (B) panel—Postprocedural 3D TEE images. The occluders are marked by three black stars (left). Trace residual regurgitant jet thru the third (III) PVL is seen on 3D Color Doppler (right). (C–E) panels—intraprocedural merged 3D TEE and fluoroscopy images with wire passage thru the I (C panel), II (D panel) and IV (E panel) PVLs. The position of the C-arm is at 3° Caud and 5° RAO, producing a front view of the TEE probe. (C) panel—EFF with reduced brightness of the 3D TEE for the optimal view of the wire on the fluoroscopy. (D) panel—application of 3D Color Doppler for the second (II) and the fourth (IV) defects. The arrows point to the anatomical markers (red circle) applied at the locations of the first (I) and fourth (IV) PVLs (C,E).

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  Figure 4. EFF scenario “Free view of the TEE probe”. This figure represents the closure of the two defects in the native anterior mitral valve leaflet (AML). C-arm positioned at 17° Caud and 21° RAO. (A,B) panels—pre- and postprocedural views of the mitral valve in the long axis (LAX) TEE view with Color Doppler (top). 3D TEE “surgical view” (middle). 3D Color Doppler TEE (bottom). I and II—two defects in the AML. White arrows point to the defects. Black stars—the occluders in the AML. (C) panel (top)—long axis view (LAX) and commissural views (Com) perpendicular to each other. Software use labeled mitral annulus with anatomical marker—yellow circle and location of the defects—small red circle. Yellow arrows point to the defects. (C) panel, bottom—anatomical markers transferred by EFF software onto fluoroscopy screen.