Direct Percutaneous Mitral Annuloplasty in Patients With Functional Mitral Regurgitation: When and How

Figures

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  Figure 1. The saddle-shape configuration of the mitral valve. The nonplanar shape is believed to significantly reduce the mechanical strains on the posterior leaflet during systole and optimize force distribution among mitral apparatus.

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  Figure 2. Transesophageal echocardiography (TTE): (A) intercommissural view focused on MV for intercommissural diameter measurement; (B) mid-esophageal Long-axis view (ME LAX View) for septo-lateral (antero-posterior) annulus measurement.

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  Figure 3. Atrial view of mitral valve. Components of mitral valve apparatus and the adjacent structures. The posterior leaflet of the mitral valve composes ~3/5 of the annular circumference and comprises three individual scallops identified as P1 (anterior or medial scallop), P2 (middle scallop), and P3 (posterior or lateral scallop). The three corresponding segments of the anterior leaflet are A1 (anterior segment), A2 (middle segment), and A3 (posterior segment).

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  Figure 4. Currently available transcatheter direct annuloplasty systems: (A) Cardioband (Edwards Lifesciences); (B) Mitralign (Mitralign Inc.); (C) Millipede (Boston Scientific Corp.). Image Courtesy of Millipede, Inc. www.millipedemedical.com All rights reserved.

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  Figure 5. Long-axis view of the LV and MV apparatus. Coaptation length, height, and tenting area are among key measurements in the preoperative planning and screening.

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  Figure 6. Carpentier type I mitral regurgitation (depending from annular dilatation). Normal leaflet motion. Regurgitation jet directed centrally.

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  Figure 7. Left ventricle and mitral valve—side view (LVOT was not depicted). The restricted leaflet motion and tethering in the course of posterior papillary muscle ischemia predominantly affects the posteromedial leaflet segment (P3).

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  Figure 8. Carpentier type III mitral regurgitation. Restricted leaflet motion. Regurgitation jet directed eccentrically.

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  Figure 9. Phenotypes of tethering. (A) Transthoracic echocardiography (TTE), parasternal LAX view: anterior leaflet (AL) tethering with AL bend; (B) transesophageal echocardiography (TTE), midesophageal 4-CH view focused on MV: less pronounced bend and tip angle of the AL.

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  Figure 10. Transthoracic echocardiography (TTE); apical 4-CH view. Mitral annular calcification (MAC).

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  Figure 11. Integrated intra-procedural guidance for Cardioband: (A,C) real-time 3D transesophageal echocardiography facilitates the navigation and delivery of the first anchor; (B) fluoroscopy: the use of coronary wire may serve as a radiographic marker and a potential railway for bailout strategies. Fusion imaging allows to display an overlap image of the “echo-structures” in the fluoro-images. This could be a valuable tool in the presence of difficult anatomies and in the first phase of the operator's learning curve.

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  Figure 12. Pre- and post-implantation echo and fluoroscopy images. TEE 2-CH and LAX projections demonstrating visibly reduced regurgitation jet. Fluoro images showing the process of deployment and clinching of the annuloplasty ring concluded with a successful implantation.