Transcatheter Tricuspid and Mitral Valve Edge-to-Edge Repair: The Double Double Orifice

Figures

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  Figure 1. Moderate to severe (3+) MR as seen in (A) parasternal long-axis, (B) four-chamber, (C) three-chamber, and (D) two-chamber windows. Except where otherwise specified, the Nyquist range used for all color flow Doppler was ±55–66 cm/sec.

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  Figure 2. Severe (4+) TR as seen in (A,B) four-chamber, (C) basal short-axis, and (D,E) right ventricular inflow views. (F) The vena contracta (v.c.) and aliasing radius of flow convergence measured 0.68 and 0.91 cm, respectively, with calculated EROA of 0.40 cm2, using an aliasing velocity of −28.9 cm/sec. PISA, Proximal isovelocity surface area.

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  Figure 3. Baseline MR and TR as seen in (A,B) four-chamber and (C) three-dimensional views on transesophageal echocardiography. The leaflets of the tricuspid valve can be visualized en face (D) in transgastric short-axis window or (E) by three-dimensional imaging. The pacemaker wire (PPM; white arrowhead) can be seen between the posterior and septal leaflets (D,E) and appears to be discrete from the central TR jet (C,D). A, Anterior; AoV, aortic valve; MV, mitral valve; P, posterior; TV, tricuspid valve; S, septal.

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  Figure 4. MR (A) before and (B,C) after successful MitraClip implantation on A2-P2 scallops. (A) Biplane imaging of the ME (B) bicommissural (approximately 60°) and (C) long-axis views (approximately 150°) are commonly used to visualize the mitral valve leaflet anatomy and successful edge-to-edge grasp of the leaflets. AMVL, Anterior mitral valve leaflet; AoV, aortic valve; LAA, left atrial appendage; PMVL, posterior mitral valve leaflet.

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  Figure 5. (A) The delivery catheter (arrow) in the right atrium is directed toward the tricuspid valve in a modified basal short-axis tricuspid inflow-outflow window (ME 90°, plane represented by the red line in panel B) that visualizes all three leaflets of the tricuspid valve, posterior-septal-anterior from left to right of the image. (B,C) Biplane imaging (yellow line) of the inflow view can visualize two of the leaflets in profile in an inverted four-chamber “grasping” view (ME 180°, plane represented by the green line in panel B). (C) The septal and anterior leaflets are seen here in profile with the clip apparatus (blue arrowhead) being maneuvered out of the delivery catheter toward its intended leaflets. The pacemaker wire (PPM; white arrowhead) can be seen between the posterior and septal leaflets on the inflow view. A, Anterior; AoV, aortic valve; IAS, interatrial septum; LA, left atrium; MC, MitraClip; MV, mitral valve; P, posterior; RA, right atrium; TV, tricuspid valve; S, septal.

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  Figure 6. Biplane imaging of the inflow view identifies the predominant regurgitant jet by color Doppler and visualizes the underlying leaflet anatomy in the perpendicular “grasping” view. The (A) posterior-septal leaflet and (B) septal-anterior leaflet coaptation planes demonstrate the central TR jet seen at both commissures and the pacemaker wire (PPM; white arrowhead) between the posterior-septal commissure. A, Anterior; P, posterior; PPM, pacemaker; S, septal.

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  Figure 7. The clip is opened above the anterior and septal leaflets and oriented perpendicular to the coaptation line as seen in (A) biplane and (B) three-dimensional (3D) images. The pacemaker wire (white arrowhead) can be seen in 3D images moving to one side of the clip and does not appear to be entangled in the clip apparatus. The clip is positioned over the regurgitant jet, seen here in (C) four-chamber and (D) 3D views. (E) Successful grasp of the anterior and septal leaflets is confirmed in the inverted four-chamber view. (F) The presence of a tissue bridge can be visualized in 3D view. The pacemaker wire (white arrowhead) can be seen moving freely adjacent to the clip (blue arrowhead). A, Anterior; AoV, aortic valve; MV, mitral valve; P, posterior; S, septal.

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  Figure 8. (A) One MitraClip was successfully implanted in the tricuspid position between the anterior and septal leaflets with moderate (2+) residual TR. (B) The double-orifice valve with tissue bridge is visualized in three-dimensional images with and without color Doppler flow in systole and diastole, respectively. The pacemaker wire (white arrowhead) is seen in the posterior orifice, unrestricted by the clip (blue arrowhead). (C) Mean transtricuspid gradient of 2.0 mm Hg is acceptable. A, Anterior; P, posterior; S, septal; TV, tricuspid valve.

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  Figure 9. Two double-orifice valves are visualized in three-dimensional images, and clip stability is confirmed in the four-chamber view. The clips (blue arrowheads) can be seen separate from the pacemaker wire (PPM; white arrowhead), which remains within the posterior-septal commissure. A, Anterior; AMVL, anterior mitral valve leaflet; AoV, aortic valve; LAA, left atrial appendage; P, posterior; PMVL, posterior mitral valve leaflet; S, septal.

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  Figure 10. (A) Bidirectional shunting is noted at the interatrial site of transseptal puncture in this patient with long-standing pulmonary hypertension and known right ventricular dysfunction. A Cardioform Septal Occluder successfully closed the iatrogenic atrial septal defect, seen here in (B) three-dimensional view from the left atrial aspect (white arrowhead) and (C) in basal short-axis view with and without color Doppler. AoV, Aortic valve; LA, left atrium; RA, right atrium.