Mitral Transcatheter Edge-to-Edge Repair Using Novel Augmented Imaging Software

Figures

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  Figure 1. DeviceGuide Modes Three DeviceGuide-specific modes were used to guide the procedure: (A) Default Mode allows the imager to work in the 3D MPR view, and it is used to reorient the target or image the anatomy without colored overlays. (B) Device Mode continuously centers the coregistered implant (PASCAL Ace) in a dedicated 2D view (yellow box plane), eliminating out-of-plane imaging. (C) Target Mode focuses on the anatomic target designated by the imager in Default Mode by continuously imaging the target on the 3D en face view (red [anteroposterior] and green [commissural] lines), creating 2D MPR views corresponding to these target lines (red and green box planes), while also continuously imaging the perfectly aligned device paddles (yellow box plane). 2D = 2-dimensional; 3D = 3-dimensional; MPR = multiplanar reconstruction.

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  Figure 2. Procedure Flow After Setting the Anatomic Target in Default Mode (A) First, Device Mode was used to image the formation of the closed device (see also Video 1) and (B) guide it toward the mitral annulus while continuously imaging the tissue surrounding the device and ensuring safe movement within the left atrium. (C) Target Mode was used once the device was opened to continuously image the trajectory (yellow dotted lines), orientation (blue icon on the 3D short-axis view), and position relative to the target (see also Video 2). (D) Because the severe prolapse/flail was in the medial commissure, the device was closed to cross the annular plane (see also Video 3) and (E) was then opened below the leaflets; notably, the blue device icon can easily be recognized on the 3D image despite moving below the leaflets. (F) The device was closed with a reduction in mitral regurgitation, however a significant jet remained lateral to the first device. 3D = three-dimensional.

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  Figure 3. Final 2-Device Result for Case 1 (A) The MVOA of the 2 orifices measured 3.06 cm2 and 0.28 cm2 (total MVOA: 3.34 cm2). (B) The 3 small residual regurgitant jets with (C) 3D vena contracta area measuring 10 mm2 and regurgitant volume of 19 mL, consistent with mild residual mitral regurgitation. (D) Pulmonary vein systolic reversal at baseline now showed systolic forward flow, (E) with a mean gradient of 5 mm Hg at a heart rate of 81 beats/min. See also Video 4. 3D = three-dimensional; EROA = effective regurgitant orifice area; Grad = gradient; MR = mitral regurgitation; MVOA = mitral valve orifice area; PV = pulmonary vein.

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  Figure 4. Case 2, Example of a Medial A3 to P3 Prolapse: Baseline (A) Baseline 3D TEE showed severe prolapse of both the A3 and P3 leaflets (red circle). (B) Standard color Doppler views showed a large mitral regurgitant jet arising from the medial commissure, with a lateral trajectory (yellow arrow) and a regurgitant orifice of 55 mm2, regurgitant volume of 70 mL, and regurgitant fraction of 60%. 3D TEE = three-dimensional transesophageal echocardiography; A = anterior; A-P = anteroposterior; L = lateral; LA = left atrium; LV = left ventricle; M = medial; MR = mitral regurgitation; P = posterior.

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  Figure 5. Case 2, Example of a Medial A3 to P3 Prolapse: DeviceGuide (A) The A3-to-P3 target was set (red double arrow) and the device was introduced, positioned, and oriented in the left atrium. Given the commissural position of the target, the device was closed for advancing safely into the left atrium; DeviceGuide followed the closed device orientation (B) and allowed real-time alignment to the target (yellow and red double arrows, and yellow and red planes aligned). (C) The device was then opened, and the initial trajectory (yellow dashed lines) was not aligned in the red plane. (D) After the trajectory was corrected, the leaflets were grasped. See also Videos 5 and 6. CW = clockwise; CCW = counter clockwise.

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  Figure 6. Utility of AI-Assisted Imaging Software The described AI-enhanced imaging software has the potential for improving M-TEER procedural guidance given the enhanced device detection, AI-driven navigation optimization, and continuous imaging of the device throughout the procedure. By improving visualization, navigation, and device positioning in both routine and anatomically complex cases, this technology has the potential to reduce procedural time, minimize complications, and enhance operator confidence. 3D TEE = three-dimensional transesophageal echocardiography; AI = artificial intelligence; MPR = multiplanar reconstruction; M-TEER = mitral transcatheter edge-to-edge repair.