Contemporary Review of Transcatheter Mitral Valve Interventions for Mitral Regurgitation

Figures

• 

  Figure 1. (A–C) depicts 3D en face imaging of the mitral valve. There is severe primary MR in the context of P2 prolapse and flail (A,B). The black star in (A) shows the site of pathology. AoV denotes the aortic valve for anatomic orientation. (C) shows color Doppler interrogation in 3D MPR revealing a significant anterolaterally directed regurgitant jet at the site of pathology.

• 

  Figure 2. (A–E) shows the critical steps in mitral transcatheter edge-to-edge repair. A desirable transeptal puncture (TSP) tends to be at the posterior and superior to mid aspect of the fossa ovalis, though this is highly dependent on interatrial septal anatomy, the SVC/IVC trajectory and the relationship of the fossa ovalis to the mitral valve. The TSP shown in (A) is at the mid/superior portion of the fossa ovalis. A height of >4.0 cm above the medial commissure of the mitral valve is typically necessary. (B) shows the clip trajectory, as well as orientation prior to bringing the clip to the ventricular side of the mitral valve. (C) shows clip orientation as well as the grasping view in the green box (upper left, within (C)). In (D), the anterior and posterior mitral leaflets were captured with the clip arms, and the clip was subsequently closed (E). (F) is a 3D color Doppler interrogation of the mitral valve after deployment of one clip with trace residual MR.

• 

  Figure 3. (A,B): Carillon® Device RAO (A) and LAO (B) fluoroscopic views of the Carillon® Mitral Contour System™ device implanted in the coronary sinus. The arrows delineate the position of the Carillon device®.

• 

  Figure 4. (A–D) depict multiplanar reconstruction (MPR) of a 4D CT scan (no dose modulation) performed for valve-in-valve transcatheter mitral valve replacement (ViV TMVR) procedural planning. The patient had severe MR due to bioprosthetic mitral valve degeneration. Images were reconstructed in an early systolic phase with dedicated software to simulate implantation of a 29 mm bioprosthesis off-set to match the length of the anterior mitral valve leaflet. (A,B) show the simulated bioprosthesis in the CT equivalent of 2-chamber and short-axis views, respectively. (C,D) were reconstructed to measure the neo-LVOT, measured at 2.3 cm2, in this example, which was deemed suitable for ViV-TMVR without the need for leaflet modification.

• 

  Figure 5. Shows fluoroscopic images LAO (A) and RAO (B) of ViV TMVR with a 29 Sapien S3 prosthesis. In this case, the iatrogenic ASD was closed due to intermittent right-to-left shunting that was seen on intraprocedural intracardiac ultrasound. The red arrows mark the ViV TMVR, the blue arrows mark the aortic bioprosthesis and the white arrows mark the atrial septal occluder device.

• 

  Figure 6. (A–C) shows postprocedural transthoracic echocardiographic images following ViV TMVR. (A) shows a 2-chamber color-compare image in early diastole with mild flow acceleration across the transcatheter mitral valve. (B) shows a 3-chamber color-compare image in early systole without significant MR or LVOT flow acceleration appreciated. (C) shows a mean transmitral gradient of 6 mmHg at a heart rate of 87 beats per minute.

• 

  Figure 7. Three-dimensional transesophageal echocardiography with evaluation and guidance of paravalvular leak closure. (A,B) show preprocedural evaluation with and without color Doppler, identifying severe paravalvular leak on the posterolateral aspect of the bioprosthetic mitral valve (arrows). (C) shows during procedure after one vascular plug is deployed, the wire crossing the defect below the prior plug in anticipation for the second plug to be deployed localized with live multiplanar reconstruction imaging (arrow). (D) shows the final result after 5 vascular plugs were deployed for the paravalvular leak with color Doppler showing trivial residual regurgitation (arrow).