Intracardiac Echocardiography as the Sole Imaging Modality for Guidance of a Challenging Commissural Mitral Valve Transcatheter Edge-to-Edge Repair

Figure 1. Two-dimensional transthoracic echocardiography (performed preprocedure) without (A and C) and with (B and D) color flow Doppler in the apical four-chamber (top) and apical two-chamber (bottom) systolic views demonstrates severe primary degenerative MR with two regurgitant jets originating from the posterior leaflet, with likely P1 prolapse and flail segment (arrow), resulting in an anteriorly directed jet with wall impingement (arrow). LA, Left atrium; LV, left ventricle.

Figure 2. (A) Three-dimensional (3D) ICE, volume-rendered reconstruction en face systolic view of the MV (top), demonstrates extensive P1 prolapse and flail segment (arrow) with blunted left upper pulmonary vein systolic flow detected by ICE pulsed-wave Doppler (bottom). (B) Three-dimensional multiplane reconstruction ICE, quad display with simultaneous orthogonal commissural, long-axis (top), short-axis, and 3D volume-rendered reconstruction en face views (bottom), demonstrates P1 prolapse and flail segment (arrows). (C) Three-dimensional ICE, volume-rendered reconstruction en face systolic view of the MV with color flow Doppler, demonstrates the severe eccentric MR originating laterally and directed medially. (D) Two-dimensional ICE, simultaneous orthogonal long-axis systolic views with color flow Doppler, demonstrates eccentric MR originating from P1 and directed medially. Ant, Anterior; AV, aortic valve; D, diastole; L, lateral; LA, left atrium; LV, left ventricle; M, medial; Post, posterior; S, systole.

Figure 3. (A) Three-dimensional (3D) ICE, volume-rendered reconstruction, en face systolic view of the MV, demonstrates the orientation of the delivery system in the lateral commissure. (B) Three-dimensional multiplane reconstruction ICE, quad display with simultaneous orthogonal commissural, long-axis (top), short-axis, and 3D volume-rendered reconstruction en face views (bottom), demonstrates the lateral commissural position of the first M-TEER device grasping A1-P1. (C) Two-dimensional ICE, simultaneous orthogonal long-axis systolic displays from the commissural view with color flow Doppler, demonstrates residual moderate MR after the first M-TEER device. (D) Two-dimensional ICE, simultaneous long-axis systolic display from the commissural view, demonstrates positioning of the second device grasping just medial to the first device. Ant, Anterior; L, lateral; LA, left atrium; LV, left ventricle; M, medial; Post, posterior.

Figure 4. (A) Two-dimensional ICE, simultaneous orthogonal long-axis systolic displays from the commissural view with color flow Doppler, demonstrates the two adjacent devices deployed between A1 and P2 scallops (arrows) with a single MV orifice and trace MR after two devices were placed. (B) Two-dimensional ICE-guided pulsed-wave Doppler interrogation of the upper left pulmonary vein demonstrates normal anterograde systolic and diastolic spectral profile display after M-TEER. (C and D) Three-dimensional ICE volume-rendered reconstruction, en face diastolic view without (C) and with (D) color flow Doppler, demonstrates the two devices deployed between the A1 and P2 scallops. Ant, Anterior; D, diastole; L, lateral; LA, left atrium; LV, left ventricle; M, medial; Post, posterior; S, systole.

Figure 5. (A) Fluoroscopic left anterior oblique view demonstrates the positions of the device and intracardiac echocardiography catheter within the left atrium (top) and a schematic illustrating intracardiac echocardiography catheter positioning and field of view during M-TEER (bottom). (B) Three-dimensional ICE, volume-rendered en face systolic view of the MV with representative simultaneous orthogonal displays (inserted illustrations) representing −45° (red arrow; TEE approximate 60°-65° midesophageal view) and +45° (blue arrow; TEE approximate 130°-135° midesophageal view). Ant, Anterior; L, lateral; M, medial; Post, posterior.