Percutaneous Mitral Valve Repair: Multi-Modality Cardiac Imaging for Patient Selection and Intra-Procedural Guidance

Figures

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  Figure 1. Multi-parametric assessment of mitral regurgitation. In addition to qualitative color Doppler grading, multiple methods of mitral regurgitant quantification should be used. (A) A multiplanar reconstruction of 3-Dimensional echocardiographic color Doppler can be used to directly planimeter vena contracta area. A double-oblique method is used to align long-axis images (upper left and right), and directly planimeter vena contracta area (lower left). (B) Mitral valve inflow stroke volume, which includes mitral regurgitant volume, can be calculated by multiplying mitral annulus area (top panel) by pulsed-wave velocity time integral at the annulus level (middle panel). Left ventricular or right ventricular outflow tract calculated stroke volume, in the absence of aortic or pulmonic insufficiency, can be subtracted from mitral stroke volume to obtain regurgitant volume. Regurgitant volume can be divided by mitral regurgitation continuous-wave Doppler velocity time integral (bottom panel) to calculate quantitative Doppler derived regurgitant orifice area.

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  Figure 2. Pre-Mitraclip mitral valve anatomy characterization. (A) A large, medial regurgitant jet is demonstrated. (B) On bi-plane imaging of the region, medial anterior flail segment is demonstrated. (C) A 3-dimensional echocardiographic surgical view demonstrates A2-A3 scallop flail (yellow arrow) with a ruptured chord (red-dashed line). (D) Leaflet length in planned “grasping view” is measured and appears adequate for insertion into edge-to-edge repair device. (E) 3-Dimensional echocardiographic reconstruction demonstrates adequate baseline mitral valve area of 4.4 cm2, greater than the 4.0 cm2 cutoff.

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  Figure 3. Mitraclip intra-procedural guidance. (A) Transseptal puncture should be performed in a mid-posterior location within the inter-atrial septum, 4.0-4.5 cm basal to the mitral annulus plane. Bi-plane imaging allows simultaneous visualization of the bicaval (typically 90–110°) and the 4-chamber (typically 0 or 180°, or orthogonal view from biplane imaging of bicaval view) view for localization of the puncture. (B) 3-dimensional echocardiographic imaging of needle tenting at the interatrial septum (yellow arrow) confirms trajectory across the mitral commissures (red dashed arch). (C) Extrusion of the mitraclip from the delivery sheath should be visualized to avoid injury from contact with the atrial wall. (D) After straddling the clip delivery system across the mitral commissures, the clip is opened while visualizing the 3D-TEE surgeon's view (left atrial perspective, aortic valve at 12 o'clock position) to check orientation (red-dashed line). In the image shown the clip needs rotation of 90° to achieve appropriate orientation perpendicular to commissures. (E) After clockwise rotation, the clip is oriented in planned clipping direction (red-dashed line) on the surgeon's view for A2-A3…

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  Figure 4. Pre-procedural cardiac computed tomography virtual anchor planning for cardioband. (A) Cubic-spline interpolation of multiple points is used in a semi-automated workflow to calculated projected mitral annulus perimeter excluding the trigone-to-trigone distance, which is used for sizing of Cardioband. (B) Control points of cubic-spline interpolation are visualized and can be adjusted on the short-axis, or long axis views (C). (D) Anchor planning can be performed from trigone to trigone to visualize the trajectory of band. In this image, 14 anchors are planned with a potentially unsuitable location marked as a red anchor. (E) Each virtual anchor can be visualized (blue rectangle), and projected distances from anchor head to mitral annulus (turquoise line), mid-anchor to left ventricle (pink line), and nearby blood vessels such as the left circumflex coronary artery (yellow line) can be measured. (F) Projected fluoroscopic views can be planned.

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  Figure 5. Intra-procedural echocardiographic guidance for cardioband procedure. (A) Severe, functional mitral regurgitation is shown in biplane, color Doppler imaging. (B) After transseptal puncture, the first anchor (red circle) is implanted adjacent to the lateral commissure (red-dashed line). (C) Cardioband implantation continues adjacent to P3 scallop. (D) At each anchor implantation, multiplane 3D imaging is helpful to locate position of anchor insertion within the mitral annulus, with adequate distance from leaflet. (E). Completed Cardioband pre-cinching is shown. (F) After cinching, annuloplasty reduction is achieved. (G) Post-implant mitral regurgitation appears mild by qualitative assessment. 3-dimensional color Doppler multiplanar reconstruction may be used to planimeter vena contracta area. Images courtesy of Dr. Florian Deuschl.