Real-time three-dimensional transoesophageal echocardiography showing sequential events of the percutaneous mitral clip procedure

A surgical technique, called edge-to-edge technique or Alfieri's stitch, approximating the middle scallops of the mitral leaflets to create a double orifice with improved leaflet coaptation was introduced in the early 1990s. Recently, a percutaneous method to create the same type of repair was developed. Real-time 3D transoesophageal echocardiography (RT 3D TEE) is a new technique which allows a consistently fine image quality of mitral valve from a left atrium perspective. We present RT 3D TEE sequential images showing the most relevant steps of this transcutaneous mitral valve repair procedure. Panel A shows a guide-wire passing into the left atrium and in Panel B, the trans-septal apparatus is exchanged for the guide catheter. In Panel C, the clip delivery system is advanced into the left atrial chamber and centred over the mitral orifice. Panel D shows as the arms of the clip are opened and oriented perpendicularly to the long axis of the leaflet edges. Panel E shows the achievement of a double-orifice mitral valve because of leaflet insertion into the closed clip arms. Panel F shows the final result once two clips are sequentially released from the clip delivery system and the delivery system and guide catheter are withdrawn. Real-time 3D TEE colour Doppler images before (Panel G) and after (Panel H) the procedure show a significant improvement in mitral regurgitation severity. Finally, panel I shows a laminar diastolic flow through the two orifices thus indirectly confirming the absence of obstruction.