Three-Dimensional Real-Time Multiplanar Reconstruction for Intraprocedural Guidance of Challenging Mitral Transcatheter Edge-to-Edge Repair

Figures

• 

  Figure 1. Anteroposterior chest radiography demonstrates pulmonary congestion and bilateral pleural effusions.

• 

  Figure 2. (A) Three-dimensional TEE, midesophageal, RT-MPR simultaneous orthogonal long-axis (top) and short-axis (bottom) 2D and volume-rendered reconstruction en face MV views, demonstrates extensive P2/P3 prolapse and isolated flail segment (arrows). (B) Three-dimensional TEE, midesophageal, volume-rendered reconstruction en face MV view with color flow Doppler, demonstrates severe anteriorly directed MR.

• 

  Figure 3. Insertion of first M-TEER device. Three-dimensional TEE, midesophageal, volume-rendered reconstruction en face MV view, demonstrates optimal orientation of the device over central A2P2(A) and confirms a broad tissue bridge after release (C). (B) Two-dimensional TEE, simultaneous long-axis display from the bicommissural view, demonstrates optimal grasping view with ideal grasping position of the device. (D) Three-dimensional TEE, midesophageal, volume-rendered reconstruction en face MV view with color flow Doppler, demonstrates residual severe MR medial to the device.

• 

  Figure 4. Three-dimensional TEE, midesophageal, RT-MPR simultaneous orthogonal long-axis (top) and short-axis (bottom) 2D and volume-rendered reconstruction en face MV systolic views after deployment of the first device, demonstrates the detailed valve anatomy at the specific point of the residual MR (red and green planes aligned next to the initial device) and confirms the flail segment (arrows) medial to the device.

• 

  Figure 5. Unsuccessful first attempt at placement of a medial second device. Three-dimensional TEE, midesophageal, RT-MPR simultaneous orthogonal long-axis views (A) and short-axis volume-rendered reconstruction en face MV (B) and 2D bicommissural (70°) view with color flow Doppler (C), demonstrates optimal grasping view, near parallel alignment of the devices (red lines), and residual MR (arrow) despite good grasp (note proximal flow acceleration despite a normal Nyquist limit).

• 

  Figure 6. A-frame plan of the second device, second attempt. Three-dimensional TEE, midesophageal, RT-MPR simultaneous orthogonal long-axis (top) and short-axis (bottom) 2D and volume-rendered reconstruction en face MV views, demonstrate a strategy for simultaneous assessment of an atypical device alignment, while able to better compensate for shadow generated from the first device.

• 

  Figure 7. Three-dimensional TEE, midesophageal, RT-MPR simultaneous orthogonal long-axis and short-axis, 2D and volume-rendered reconstruction en face MV views after deployment of the final device, demonstrates how the smaller views on the left can be enlarged as necessary to enhance visualization (note that the red plane is enlarged on the right and confirms adequate leaflet grasping).