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This protocol presents in detail how to perform real-time echocardiographic guidance during transcatheter mitral valve repair. The fundamental views and the necessary measurements are described for each stage of the procedure.
Percutaneous transcatheter edge-to-edge reconstruction of the mitral valve is a safe and well-established therapy for severe symptomatic mitral regurgitation in patients with high surgical risk. Echocardiographic guidance in addition to fluoroscopy is the gold standard and should be performed using a standardized technique.
This article lays out our reproducible step by step echocardiographic guide including views, measurements as well as highlighting possible difficulties that may arise during the procedure.
This article provides detailed and chronological echocardiographic views for each step of the procedure, especially preferences between 2D and 3D imaging. If needed, pulse wave, continuous wave and color doppler measurements are described. Furthermore, as there are no official recommendations for the quantification of mitral regurgitation during the percutaneous edge-to-edge-repair procedure, advice is also included for echocardiographic quantification after grasping the mitral leaflets and after device deployment. In addition, the article deals with important echocardiographic views to prevent and deal with possible complications during the procedure.
Echocardiographic guidance during transcatheter mitral valve repair is mandatory. A structured approach improves the collaboration between interventionist and imager and is indispensable for a safe and effective procedure.
Mitral regurgitation (MR) is the second-most frequent indication for valve surgery in Europe1. Untreated, it may lead to severe heart failure and reduced quality of life2,3,4. The percutaneous mitral valve repair (PMVR) is a catheter-based technique, which mimics the Alfieri stitch surgical method to mitral repair by connecting the A2 and P2 scallops5. For patients with high surgical risk, this technique offers a minimally invasive approach for the treatment of severe MR. Data from several registries and trials has shown that the MitraClip procedure, a transcatheter mitral valve repair therapy, is an effective and safe method6,7,8,9. In 2019, a similar device, the PASCAL transcatheter valve repair system, was introduced to the market. It has shown feasibility and acceptable safety in the treatment of patients with severe MR10. The duration and success of the PMVR are dependent on the individual operator's skill and experience11. In contrast to other percutaneous techniques, like the percutaneous transvalvular replacement (TAVR), which can be done with fluoroscopy only, PMVR requires echocardiographic guidance12,13.
This article describes step by step the echocardiographic approach during PMVR, including measurements, suggestions for intraprocedural quantification of the MR and important views to prevent periprocedural complications.
The protocol follows the guidelines of our's institution's human research ethics committee.
1. Evaluation before intervention
Figure 1: Modified SAX view: PW flow in the left upper pulmonary vein Please click here to view a larger version of this figure.
Figure 2: 2D biplanar view of the MV with color doppler: medial insufficiency jet Please click here to view a larger version of this figure.
Figure 3: Multiplanar reconstruction of the 3D dataset with color doppler: 3D-Vena contracta Please click here to view a larger version of this figure.
Figure 4: Wide sector zoom image: 3D en-face surgical atrial view (aortic valve at 12 o'clock) Please click here to view a larger version of this figure.
Figure 5: Wide sector zoom image: 3D en-face atrial view (aortic valve at 6 o'clock) Please click here to view a larger version of this figure.
2. Strategy
3. Transseptal puncture
Figure 6: 2D biplanar view: transseptal puncture Please click here to view a larger version of this figure.
4. Introduction of the SGC into the LA
5. Advancement of the CDS into the LA
Figure 7: Wide sector zoom image: SGC in the LA including the interatrial septum, the left lateral ridge and the MV Please click here to view a larger version of this figure.
6. Orientation of the device above and below the MV
Figure 8: 2D biplanar view of the MV: positioning of the device over the mitral valve Please click here to view a larger version of this figure.
Figure 9: Wide sector zoom image: positioning of the device over the mitral valve Please click here to view a larger version of this figure.
NOTE: The clip arms are visible only in the LAX view.
7. Grasping of the mitral leaflets and assessment of MR before and after clip deployment
Figure 10: Wide sector zoom image: double orifice of the MV after device deployment Please click here to view a larger version of this figure.
8. Final MR assessment
9. Implantation of additional devices
Percutaneous edge-to-edge valve repair is an alternative to surgical valve repair or replacement in patients not eligible for surgery with symptomatic severe MR. The first clinical application of the MitraClip was investigated in the Endovascular Valve Edge-to-Edge Repair Study I (EVEREST I)14 trial. Many other trials have proven the effectiveness of the procedure with an improvement of symptoms as well as low rates of hospital mortality and adverse events (ACCESS EU, TRAMI, EVEREST II)
Echo-guidance for the PMVR is a safe method. Complications due to echocardiography may occur but rarely lead to significant damage. Nevertheless, esophageal lesions are possible after performing transesophageal echocardiography. This incidence is reduced with a shorter duration of the intervention34. On the contrary, several complications associated with the transcatheter edge-to-edge mitral valve repair are described35,36. Major bleeding ...
The authors have nothing to disclose.
We thank Ms. Dorothea Scheurlen for technical video support.
Name | Company | Catalog Number | Comments |
EPIQ 7 Ultrasound System | Philips | US218B0542 | Cardiac Ultrasound Machine |
X8-2t xMATRIX 3D-TEE probe | Philips | B34YYK | TEE-probe |
Sheath 6F 25 cm | Merit Medical | B60N25AQ | Sheath |
Dilator 16 F | Abbott | 405544 | Dilator |
BRK-1 transseptal needle 71 cm | St. Jude Medical | ABVA407201 | Transseptal Needle |
Swartz Lamp 90° | St. Jude Medical | 407356 | Transseptal Guiding Introducer Sheath |
Amplatz super stiff | Kook Medical | 46509 | Wire |
Steerable Guide Catheter | Abbott | SGC0302 | Steerable Guide Catheter |
MitraClip NTR Delivery System | Abbott | CDS0602-NTR | Clip Delivery System |
MitraClip NTR Bundle | Abbott | MSK0602-NTR | Device |
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