Interventional Echocardiography-Guided Transcatheter Edge-to-Edge Interscallop Repair of the Mitral Valve

Figures

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  Figure 1. (A) Midesophageal 2D TEE and color-flow Doppler views of the MV at 60° (commissural view) in systole. The medial (P3) scallop of the posterior MV leaflet is flail, associated with severe eccentric MR. The Nyquist limit was shifted to demonstrate the proximal isovelocity surface area of the MR jet. A2 scallop = middle scallop of the anterior MV leaflet; P1 scallop = lateral scallop of the posterior MV leaflet. (B) Continuous-wave Doppler of the MV shows a peak E-wave velocity of 1.45 m/sec and mean pressure gradient of 2 mm Hg. (C) Pulsed-wave Doppler of the right upper pulmonary vein shows late systolic flow reversal (arrows).

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  Figure 2. Live 3D en face view of the MV obtained from the midesophagus using 3D TEE. The MV is oriented in the surgeon’s view from the left atrial side. The aortic valve is at 12 o’clock, the medial aspect of the MV is on the right, and the lateral aspect is on the left. The flail P3 scallop due to torn chordae at its lateral edge and the deep interscallop defect between the P2 and P3 scallops can be appreciated.

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  Figure 3. Live 3D color-flow Doppler image of the MV, obtained from the midesophagus using 3D TEE. The flail P3 scallop is seen at 3 o’clock, and the origin of the MR jet (arrows) is located at the base of the posterior leaflet between the P2 and P3 scallops, showing that the interscallop defect between those 2 scallops is deep and extends to the annulus of the valve.

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  Figure 4. Three-dimensional ICE, images obtained from the left atrium in midsystole. Using MPR, 2 orthogonal long-axis (A and B), a short-axis (C), and a volume-rendered, “surgeon's perspective” (D) display are shown. The aortic valve is at 11 o’clock, the medial aspect of the MV is on the right, and the lateral aspect is on the left. The flail P3 scallop due to torn chordae at its lateral edge and the deep interscallop defect between the P2 and P3 scallops can be appreciated. The green MPR plane (A) is the commissural view of the MV, and the red MPR plane (B) is the long-axis view of the MV.

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  Figure 5. Midesophageal 3D TEE images using MPR during midsystole; 2 orthogonal long-axis (A and B), a short-axis (C), and a volume-rendered (D) display are shown. The 3D en face view (D) of the MV is oriented in the surgeon's view from the left atrial side. The aortic valve is at 12 o'clock, the medial aspect of the MV is on the right, and the lateral aspect is on the left. This view shows the open arms of the TEER device oriented perpendicular to the interscallop defect between the P2 and P3 scallops. The red MPR plane (red line in C and D) was aligned parallel to the open arms of the device. The red MPR image (B) therefore shows the device with its open arms in the left atrium above the P2 (right leaflet) and P3 (left leaflet) scallops of the MV.

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  Figure 6. Three-dimensional TEE using biplane imaging during diastole. The commissural view (60°) on the left shows the device is on the P3 scallop of the MV, with a free lateral (P1) scallop. The orthogonal long-axis view (150°) on the right shows the device is on the posterior leaflet of the MV, with a free anterior leaflet. Biplane imaging cannot demonstrate the leaflet edges that the device has captured.

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  Figure 7. Midesophageal 3D TEE using MPR during diastole; 2 orthogonal long-axis (A and B), a short-axis (C), and a volume-rendered, surgeon’s perspective (D) display are shown. The blue MPR plane (C), which is the z axis or en face view of the MV, and the 3D en face view of the MV (D) show an open MV in this diastolic frame. The device is attached to the medial aspect of the posterior MV leaflet, between the P2 and P3 scallops. The red MPR plane (red line in panelsC and D) is parallel to the device, and the red MPR image (B) demonstrates that both P2 and P3 scallops are captured within the closed device. The 3D image shows that the interscallop defect has been successfully “bridged” by the device.

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  Figure 8. Midesophageal 2D TEE and color-flow Doppler views of the MV at 60° (commissural view) showing mild residual MR at the conclusion of the procedure (A). Continuous-wave Doppler of the MV shows a peak E-wave velocity of 0.75 m/sec and mean pressure gradient of 1 mm Hg (B). Pulsed-wave Doppler of the right upper pulmonary vein shows forward systolic flows (C, arrows).