Transcatheter Mitral Valve Intervention: Current and Future Role of Multimodality Imaging for Device Selection and Periprocedural Guidance

Figures

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  Figure 1. Carpentier’s classification of MR. Ischemic: papillary muscle displacement/dysfunction, asynchrony. Non-ischemic: dilated cardiomyopathy, asynchrony. LVOT, left ventricular outflow tract; SAM, systolic anterior movement.

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  Figure 2. Currently approved device for TMVI. Type I, II, and III refer to the Carpentier classifications of mitral regurgitation. MA, mitral annulus; CS, coronary sinus; MAC, mitral annulus calcification; LA, left atrium; LV, left ventricle; TMVR, transcatheter mitral valve replacement; LVOTO, left ventricular outflow tract obstruction. * For a more detailed discussion of the challenging anatomic criteria refer to the Section 4.1.

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  Figure 3. Evolution of the MitraClip System through different device generations.

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  Figure 4. Tendyne valve seen from lateral (left) and overhead perspective (right). The black dark line corresponds to the valvular plane. The red line corresponds to the sealing portion of the device. Courtesy of Abbott.

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  Figure 5. 3D Color transillumination rendering of the LAX ME view of MR and vena contracta (red line). Abbreviations are as in the text.

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  Figure 6. Volume experience (green hyperbola) and increasing anatomical difficulties (from white to purple box) determine the best therapeutic strategy. Easier anatomies suitable for repair can be treated even in centers with limited experience, but more difficult anatomies might require replacement strategies and complex repairs that should be performed in high-volume centers. PL, posterior leaflet length; FG, flail gap; FW, flail width, MVA, mitral valve area; MAC, mitral annulus calcification; TH, tenting height; TMVr, transcatheter mitral valve repair; TMVR, transcatheter mitral valve replacement; RMVD, rheumatic mitral valve disease.

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  Figure 7. (Left) LAI; yellow line is the PL length, the green line is the AL length, and the orange dotted line is the AP diameter. (Right) Gap ratio; the red line is the PL length and the blue line the gap size. Abbreviations are as in the text.

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  Figure 8. Straddling maneuver. Image on the left shows a focused representation of SGC and CDS, highlighting the radiopaque markers (adapted from Abbott). Image on the right enlightens the same markers on a fluoroscopic real-time view. (a, b, c, and d) are radiopaque markers on the distal portion of CDS. (e) is the radiopaque marker on the SGC. Abbreviations are as in the text.

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  Figure 9. Steering step (left and central panel) consists of the descent of the device towards the MV plane. The orientation (right panel) is important to ensure a perpendicular alignment with the coaptation line. Abbreviations are as in the text.

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  Figure 10. 3D-zoomed view of the MV post-clip implantation. The images are visualized from lateral (left), en-face LA side (central), and LV side (right) views, using transillumination tools, with decreasing transparency for lower values. Abbreviations are as in the text.

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  Figure 11. CS venography with sizing measurements (left, courtesy of Cardiac Dimensions) and Carillon XE2 sizing chart (right). Note that the distal anchor must be placed in a target zone with a minimum diameter of 3.5 mm, whereas the proximal anchor is in a target zone with a maximum diameter of 13.5 mm. Abbreviations are as in the text.

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  Figure 12. Relationship of imaging methods during the procedural steps of TMVI.