Name: a simplified stepwise approach to echo guidance during percutaneous mitral valve repair
Uploaded: 2021-10-16T13:00:00.000+00:00
Duration: 8 min 31 s
Description: Watch this Scientific Journal Video about A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair at JoVE.com

We thank Ms. Dorothea Scheurlen for technical video support.

The protocol follows the guidelines of our&#39;s institution&#39;s human research ethics committee.
1. Evaluation before intervention
<ol>
	<li>Exclude pericardial effusion before transseptal puncture. If a small pericardial effusion is present, measure the maximal end-diastolic echolucent space in a four-chamber (4Ch) view with a focus on the right ventricle (RV), a mid-oesophageal right ventricular inflow-outflow view, and a long-axis (LAX) view.</li>
	<li>Evaluate the pulmonary venous flow pattern with pulse wave doppler (PW) in the left upper pulmonary vein (LUPV) and exclude thrombus formation in the left atrial appendage (LAA). Show the short axis (SAX) view with focus on the LAA, sweep then at 40-60&#176; and rotate the probe anti-clockwise to show the LUPV. Assess the flow in the right upper pulmonary vein (RUPV) by sweeping at 90-110&#176; (Figure 1 and Supplementary Figure 1).</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/62053/62053fig01.jpg" /> 
Figure 1: Modified SAX view: PW flow in the left upper pulmonary vein <a href="https://www.jove.com/files/ftp_upload/62053/62053fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="3">
	<li>Ensure hemodynamic state is the same during pre- and post-procedural evaluation. 
	&#8203;NOTE: AS MR is a dynamic valve disease, regurgitation may seem less severe under general anaesthesia. In this case, consult the operator and increase the afterload and/or the preload.</li>
	<li>Find the best intercommissural view (50-70&#176;). Take a perpendicular view (X-plane) in the three segments with and without color doppler and measure the length of the posterior mitral leaflet (PML). Then, check the leaflet morphology again (Figure 2 and Supplementary Figure 2).</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/62053/62053fig02.jpg" /> 
Figure 2: 2D biplanar view of the MV with color doppler: medial insufficiency jet <a href="https://www.jove.com/files/ftp_upload/62053/62053fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="5">
	<li>Assess the transmitral pressure gradient with continuous wave doppler (CW) in the long axis view (120-140&#176;). 
	&#8203;NOTE: A mean pressure gradient (MPG) &#62; 5 mmHg is a relative contraindication for PMVR.</li>
	<li>Take a 3D dataset with color doppler or a wide-sector zoom image with color and measure the 3D-vena contracta (3D-VCA) (Figure 3).</li>
</ol>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/62053/62053fig03.jpg" /> 
Figure 3: Multiplanar reconstruction of the 3D dataset with color doppler: 3D-Vena contracta <a href="https://www.jove.com/files/ftp_upload/62053/62053fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="7">
	<li>Without color, use the 3D volume to measure the mitral valve area (MVA) (Supplementary Figure 3). 
	NOTE: An area &#60; 4 cm2 is a relative contraindication, an area &#60; 3 cm2 an absolute contraindication to perform the procedure. Otherwise assess the MVA in the transgastric basal SAX view.</li>
	<li>Show the 3D en-face surgical atrial view (aortic valve at 12 o&#39;clock) of the mitral valve. 
	NOTE: The segments of the valve are named &#34;lateral&#34; for the segments 1 and &#34;medial&#34; for the segments 3. The sequence of the segments in the en-face surgical view, is inverse to the sequence in the commissural view. Perform a 180&#176; clockwise rotation into the 3D en-face surgical view (aortic valve at 6 o&#39;clock), that will result in an equal sequence of segments in both views (Figure 4 and Figure 5).</li>
</ol>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/62053/62053fig4v2.jpg" /> 
Figure 4: Wide sector zoom image: 3D en-face surgical atrial view (aortic valve at 12 o&#39;clock) <a href="https://www.jove.com/files/ftp_upload/62053/62053fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/62053/62053fig5v2.jpg" /> 
Figure 5: Wide sector zoom image: 3D en-face atrial view (aortic valve at 6 o&#39;clock) <a href="https://www.jove.com/files/ftp_upload/62053/62053fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="9">
	<li>Finally, take a bicaval view (90-110&#176;) with X-plane, to show the aortic valve (AV), for the transseptal puncture.</li>
</ol>
2. Strategy
<ol>
	<li>Discuss the strategy with the operator before inserting the steerable guide catheter (SGC) and the clip delivery system (CDS) into the left atrium.
	<ol>
		<li>Evaluate a one device strategy if the orifice is &#60; 1 cm wide and position the clip directly above the regurgitation jet if the orifice is circular.</li>
		<li>Evaluate the implantation of &#8805; 2 clips in case of large elliptic or multiple jets. Implant the device starting medially of the regurgitant orifice, as the positioning of a second device is often easier when the first has been implanted in this way, rather than after starting laterally (Supplementary Figure 4).</li>
	</ol>
	</li>
</ol>
3. Transseptal puncture
<ol>
	<li>Show a bicaval view combined with a SAX view. Ensure the AV is visible, to avoid aortic injury.</li>
	<li>Make sure the puncture site is slightly superior and posterior (Figure 6).</li>
</ol>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/62053/62053fig06.jpg" /> 
Figure 6: 2D biplanar view: transseptal puncture <a href="https://www.jove.com/files/ftp_upload/62053/62053fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol style="margin-left: 40px;">
	<li>Choose a puncture height of 4-5 cm in case of degenerative MR (e.g., prolapse) and of &#62; 3.5 in functional MR. Avoid a patent foramen ovale, as the entry is far too anterior.</li>
</ol>
<ol start="3">
	<li>Once the transseptal needle leads to tenting of the interatrial septum, measure the puncture height in the 4Ch view in mid-systole (Supplementary Figure 5). 
	NOTE: In patients with large atria, if the puncture site is too posterior the tenting cannot be visualized in the 4Ch view. In this case, retroflex and insert the probe deeper into the oesophagus.</li>
	<li>After transseptal puncture, always exclude pericardial effusion in the 4Ch view.</li>
	<li>Show a SAX view with a focus on the LAA and pulmonary vein to visualize the entering of the stiff guidewire into the LUPV.</li>
</ol>
4. Introduction of the SGC into the LA
<ol>
	<li>Visualize the tenting and advancement of the SGC with the dilator in a SAX view with continuous 2D-echocardiography and fluoroscopic guidance to avoid injuries to the left atrial wall. 
	NOTE: The tip of the SGC is defined by a radiopaque and echo bright double ring (Supplementary Figure 6).</li>
	<li>Show the operator the SAX view and the bicaval view (90-120&#176;) to position the SGC in the direction of the left ventricle (LV).</li>
</ol>
5. Advancement of the CDS into the LA
<ol>
	<li>Take a 3D-volume including the interatrial septum, the left lateral ridge and the MV and ensure that the left lateral ridge is visible because protrusion of the CDS is common (Figure 7).</li>
</ol>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/62053/62053fig07.jpg" /> 
Figure 7: Wide sector zoom image: SGC in the LA including the interatrial septum, the left lateral ridge and the MV <a href="https://www.jove.com/files/ftp_upload/62053/62053fig07large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol style="margin-left: 40px;">
	<li>Otherwise choose the SAX view and the LAX view (X-plane) to ensure, the CDS does not have contact with the ridge and the LA-wall. 
	NOTE: The operator may ask the imager to show the interatrial septum and pull back the SGC a few millimetres to bypass the ridge. If the double ring in 3D cannot be visualized, switch to 2D and show the SGC in the SAX view.</li>
</ol>
<ol start="2">
	<li>Check that the CDS is positioned perpendicularly to the coaptation line to guarantee a correct trajectory.
	<ol>
		<li>Show the intercommissural view in 2D at ca. 60&#176; to display the medial - lateral plane and the LAX view at 120-140&#176; to identify the anterior - posterior plane of the MV (Supplementary Figure 7).</li>
		<li>Alternatively optimize the medial, lateral, anterior, and posterior positioning of the CDS in the 3D en-face view (Supplementary Figure 8).</li>
	</ol>
	</li>
</ol>
6. Orientation of the device above and below the MV
<ol>
	<li>Take the 3D en-face view to show a perpendicular positioning of the arms to the coaptation line.
	<ol>
		<li>In the event of poor image quality, show an intercommissural view combined with a LAX view (Figure 8 and Figure 9).</li>
	</ol>
	</li>
</ol>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/62053/62053fig08.jpg" /> 
Figure 8: 2D biplanar view of the MV: positioning of the device over the mitral valve <a href="https://www.jove.com/files/ftp_upload/62053/62053fig08large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/62053/62053fig09.jpg" /> 
Figure 9: Wide sector zoom image: positioning of the device over the mitral valve <a href="https://www.jove.com/files/ftp_upload/62053/62053fig09large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
NOTE: The clip arms are visible only in the LAX view.
<ol start="2" style="margin-left: 40px;">
	<li>Adjust the intercommissural view angle for medially and laterally positioned devices to visualise the complete length of both arms. Sweep at ca. 30-45&#176; for medially positioned devices and ca. 70-90&#176; for laterally positioned devices.</li>
</ol>
<ol start="2">
	<li>Choose the intercommissural view combined with a LAX view to visualize the advancing of the CDS into the LV.</li>
	<li>Ensure the CDS is placed just a few millimetres below the MV.</li>
	<li>Verify in the 3D en-face view that the clip arms are still in the planned position, as a rotation of the clip while crossing the valve is frequent. 
	NOTE: If the position of the clip arms has changed, clockwise or anticlockwise rotation will be performed to obtain symmetric grasping. Be careful during this manoeuvre to minimize chordal and subchordal entanglement.</li>
	<li>If gross reorientation of the device is necessary, show the intercommissural view with X-plane to visualize the inversion of the clip that will be retrieved into the LA.</li>
</ol>
7. Grasping of the mitral leaflets and assessment of MR before and after clip deployment
<ol>
	<li>Record the grasping of the leaflets in the intercommissural view combined with the LAX view (X-plane) or in the LAX view only (Supplementary Figure 9).</li>
	<li>Ask the anaesthesiologist to perform a breath-hold manoeuvre to reduce shifting during ventilation and to facilitate the grasping of the leaflets.</li>
	<li>Ensure continuous visualisation of leaflet insertion to avoid rolling of the leaflets or the chordae. 
	NOTE: Grasping a rolled leaflet or a chorda may result in a partial leaflet detachment and/or an aggravation of the MR.</li>
	<li>Carefully evaluate the regurgitation reduction before clip deployment. Ensure both, operator and imager analyse this crucial step.
	<ol>
		<li>Rotate the TEE probe medially and laterally to the clip or use X-plane with color doppler to find eccentric jets close to the clip (Supplementary Figure 10). 
		NOTE: Due to shadowing artifacts caused by the CDS underestimation of the MR may occur. Insert the probe deeper into the esophagus or show the transgastric view to visualize the residual insufficiency jets without shadowing artifacts.</li>
		<li>Evaluate the PW flow in the pulmonary veins. 
		NOTE: if a previous systolic flow reversal changes into a systolic dominant pattern, a relevant reduction has probably occurred.</li>
		<li>Measure the MPG across the mitral valve. 
		&#8203;NOTE: A gradient &#62; 5 mmHg is a relative contraindication for clip deployment (Supplementary Figure 11 and Supplementary Figure 12).</li>
		<li>Use the 3D en-face view of the MV or a transgastric SAX view of the MV to show the double orifice (Figure 10).</li>
	</ol>
	</li>
</ol>
<img alt="Figure 10" class="xfigimg" src="/files/ftp_upload/62053/62053fig10.jpg" /> 
Figure 10: Wide sector zoom image: double orifice of the MV after device deployment <a href="https://www.jove.com/files/ftp_upload/62053/62053fig10large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol start="5" style="margin-left: 40px;">
	<li>Finally, if the result is satisfactory, check leaflet insertion in 2D.</li>
</ol>
<ol start="5">
	<li>After releasing the clip from the CDS, repeat the last five steps. 
	NOTE: Due to the tension of the system on the MV, the residual insufficiency jets after releasing the device may be aggravated.</li>
	<li>Show when the delivery catheter tip is retrieved from the SGC in the LAX view with X-plane and ensure that the spike avoids contact with the LA (Supplementary Figure 13).</li>
</ol>
8. Final MR assessment
<ol>
	<li>Show the intercommissural view with color doppler in combination with perpendicular X-planes in the residual insufficiency jets if present.</li>
	<li>Calculate the 3D-VCA in a 3D-volume. NOTE: usually the orifices are not in the same plane. In this case measure separated planimetries of each orifice in the appropriate planes (Supplementary Figure 14).</li>
	<li>Evaluate once again the pulmonary vein flow and the mean gradient across the mitral valve. 
	NOTE: continuous LA pressure monitoring may be a useful tool during transcatheter mitral valve repair.</li>
	<li>Finally, show the 3D en-face view of the mitral valve.</li>
</ol>
9. Implantation of additional devices
<ol>
	<li>Ensure MR reduction is sufficient. 
	NOTE: If the result is not satisfactory, evaluate the implantation of additional devices.</li>
	<li>Ensure that the additional device does not contact the implanted device diving into the left ventricle. 
	NOTE: fluoroscopy is essential to show the real distance between the clips.</li>
	<li>Show the 3D en-face view to visualize the commissural line, as it might be deferred after implantation of the first clip.</li>
	<li>Repeat the five steps as explained in point 7.4 to evaluate MR after grasping the leaflets with the additional clip.</li>
</ol>

The authors have nothing to disclose.

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 ...

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&#39;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.

<table><tbody><tr><td>EPIQ 7 Ultrasound System</td><td>Philips</td><td>US218B0542</td><td>Cardiac Ultrasound Machine</td></tr><tr><td>X8-2t xMATRIX 3D-TEE probe</td><td>Philips</td><td>B34YYK</td><td>TEE-probe</td></tr><tr><td>Sheath 6F 25 cm</td><td>Merit Medical</td><td>B60N25AQ</td><td>Sheath</td></tr><tr><td>Dilator 16 F</td><td>Abbott</td><td>405544</td><td>Dilator</td></tr><tr><td>BRK-1 transseptal needle 71 cm</td><td>St. Jude Medical</td><td>ABVA407201</td><td>Transseptal Needle</td></tr><tr><td>Swartz Lamp 90&amp;deg;</td><td>St. Jude Medical</td><td>407356</td><td>Transseptal Guiding Introducer Sheath</td></tr><tr><td>Amplatz super stiff</td><td>Kook Medical</td><td>46509</td><td>Wire</td></tr><tr><td>Steerable Guide Catheter</td><td>Abbott</td><td>SGC0302</td><td>Steerable Guide Catheter</td></tr><tr><td>MitraClip NTR Delivery System</td><td>Abbott</td><td>CDS0602-NTR</td><td>Clip Delivery System</td></tr><tr><td>MitraClip NTR Bundle</td><td>Abbott</td><td>MSK0602-NTR</td><td>Device</td></tr></tbody></table>

a simplified stepwise approach to echo guidance during percutaneous mitral valve repair

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.

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)<sup class=...

Watch this Scientific Journal Video about A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair at JoVE.com

A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair

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 ...

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3.8K Views.  BG Klinikum Unfallkrankenhaus Berlin. 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. 

Video: A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair

Echocardiographic Approaches and Protocols for Comprehensive Phenotypic Characterization of Valvular Heart Disease in Mice

The aim of this manuscript and accompanying video is to provide an overview of the methods and approaches used for imaging heart valve function in rodents, with detailed descriptions of the appropriate methods for anesthesia, the echocardiographic windows used, the imaging planes and probe orientations for image acquisition, the methods for data analysis, and the limitations of emerging technologies for the evaluation of cardiac and valvular function. Importantly, we also highlight several future areas of research in cardiac and heart valve imaging that may be leveraged to gain insights into the pathogenesis of valve disease in preclinical animal models. We propose that using a systematic approach to evaluating cardiac and heart valve function in mice can result in more robust and reproducible data, as well as facilitate the discovery of previously underappreciated phenotypes in genetically-altered and/or physiologically-stressed mice.

This protocol provides a detailed description of the echocardiographic approach for comprehensive phenotyping of heart and heart valve function in mice.

The aim of this manuscript and accompanying video is to provide an overview of the methods and approaches used for imaging heart valve function in ...

Percutaneous Contrast Echocardiography-guided Intramyocardial Injection and Cell Delivery in a Large Preclinical Model

Cell and gene therapy are exciting and promising strategies for the purpose of cardiac regeneration in the setting of heart failure with reduced ejection fraction (HFrEF). Before they can be considered for use, and implemented in humans, extensive preclinical studies are required in large animal models to evaluate the safety, efficacy, and fate of the injectate (e.g., stem cells) once delivered into the myocardium. Small rodent models offer advantages (e.g., cost effectiveness, amenability for genetic manipulation); however, given inherent limitations of these models, the findings in these rarely translate into the clinic. Conversely, large animal models such as rabbits, have advantages (e.g., similar cardiac electrophysiology compared to humans and other large animals), whilst retaining a good cost-effective balance. Here, we demonstrate how to perform a percutaneous contrast echocardiography-guided intramyocardial injection (IMI) technique, which is minimally invasive, safe, well tolerated, and very effective in the targeted delivery of injectates, including cells, into several locations within the myocardium of a rabbit model. For the implementation of this technique, we also have taken advantage of a widely available clinical echocardiography system. After putting in practice the protocol described here, a researcher with basic ultrasound knowledge will become competent in the performance of this versatile and minimally invasive technique for routine use in experiments, aimed at hypothesis testing of the capabilities of cardiac regenerative therapeutics in the rabbit model. Once competency is achieved, the whole procedure can be performed within 25 min after anaesthetizing the rabbit.

Novel therapeutic strategies in cardiac regenerative medicine require extensive and detailed studies in large preclinical animal models before they can be considered for use in humans. Here, we demonstrate a percutaneous contrast echocardiography-guided intramyocardial injection technique in rabbits, which is valuable for hypothesis testing the efficacy of such novel therapies.

Cell and gene therapy are exciting and promising strategies for the purpose of cardiac regeneration in the setting of heart failure with reduced ejection ...

Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed.
In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients.
Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively.
Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Valve-sparing aortic root replacement has the advantage of preserving the patient&#39;s own aortic valve. The complexity of the reported techniques to date restricts their use to a limited number of cardiac surgeons. This protocol describes step-by-step a standardized technique reproducible by a greater number of cardiac surgeons.

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures ...

An Image Guided Transapical Mitral Valve Leaflet Puncture Model of Controlled Volume Overload from Mitral Regurgitation in the Rat

Mitral regurgitation (MR) is a widely prevalent heart valve lesion, which causes cardiac remodeling and leads to congestive heart failure. Though the risks of uncorrected MR and its poor prognosis are known, the longitudinal changes in cardiac function, structure and remodeling are incompletely understood. This knowledge gap has limited our understanding of the optimal timing for MR correction, and the benefit that early versus late MR correction may have on the left ventricle. To investigate the molecular mechanisms that underlie left ventricular remodeling in the setting of MR, animal models are necessary. Traditionally, the aorto-caval fistula model has been used to induce volume overload, which differs from clinically relevant lesions such as MR. MR represents a low-pressure volume overload hemodynamic stressor, which requires animal models that mimic this condition. Herein, we describe a rodent model of severe MR in which the anterior leaflet of the rat mitral valve is perforated with a 23G needle, in a beating heart, with echocardiographic image guidance. The severity of MR is assessed and confirmed with echocardiography, and the reproducibility of the model is reported.&#160;&#160;

A rodent model of left heart volume overload from mitral regurgitation is reported. Mitral regurgitation of controlled severity is induced by advancing a needle of defined dimensions into the anterior leaflet of the mitral valve, in a beating heart, with ultrasound guidance.&#160;

Mitral regurgitation (MR) is a widely prevalent heart valve lesion, which causes cardiac remodeling and leads to congestive heart failure. Though the ...

Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale (PFO) detection, for patient selection for transcatheter ASD/PFO closure,&#160;for intraoperative guidance and for long-term follow-up. The size, shape, location and the number of the atrial communications schould be determined. The accuracy of PFO detection can be improved by using agitated saline together with maneuvers to transiently increase the right atrial (RA) pressure. The appearance of microbubbles in the left atrium (LA) within 3 cardiac cycles after opacification of the RA is considered positive for the presence of an intracardiac shunt. Three dimensional TEE identifies further septal fenestrations and describes the dynamic morphology of ASD/PFO and atrial septal aneurysm. Follow-up evaluations with TTE is recommended at 1, 6, and 12 months after the procedure, with a subsequent evaluation every year. Previous studies showed an increased incidence of atrial arrhythmias early after device closure. Speckle tracking analysis may help to understand functional left atrial remodeling following percutaneous closure and its impact on atrial arrhythmias.

Transthoracic (TTE) and transesophageal (TEE) echocardiography represent the basic imaging tools for interatrial septum examination. Three dimensional (3D) TEE provides incremental information in the assessment of the interatrial septum. Further advanced echocardiography techniques using speckle tracking echocardiography are applied for sensitive volumetric and functional assessment of the heart chambers.&#160;

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale ...

A Novel Right Ventricular Volume and Pressure Loaded Piglet Heart Model for the Study of Tricuspid Valve Function.

Heart conditions in which the tricuspid valve (TV) faces either increased volume or pressure stressors are associated with premature valve failure. Mechanistic studies to improve our&#160;understanding of the underlying pathophysiology responsible for the development of premature TV failure are lacking. Due to the inability to conduct these studies in humans, an animal model is required. In this manuscript, we describe the protocols for a novel chronic recovery infant piglet heart model for the study of changes in the TV when placed under combined volume and pressure stress. In this model, volume loading of the right ventricle&#160;and the TV is achieved through the disruption of the pulmonary valve. Then pressure loading is accomplished through the placement of a pulmonary artery band. The success of this model is assessed at four weeks post intervention surgery through echocardiography, intracardiac pressure measurement, and pathologic examination of the heart specimens.

A novel recovery piglet heart model with combined pressure and volume overload on the right ventricle is described for the study of tricuspid valve function.

Heart conditions in which the tricuspid valve (TV) faces either increased volume or pressure stressors are associated with premature valve failure. ...

Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices (PVADs) are used for the treatment of cardiogenic shock in an effort to improve hemodynamics. Impella is currently the most common PVAD and actively pumps blood from the left ventricle into the aorta. PVADs unload the left ventricle, increase cardiac output and improve coronary perfusion. PVADs are typically placed in the cardiac catheterization laboratory under fluoroscopic guidance via the femoral artery when feasible. In cases of severe peripheral arterial disease, PVADs can be implanted through an alternative access. In this article, we summarize the mechanism of action of PVAD and the data supporting their use in the treatment of cardiogenic shock.

Percutaneous ventricular assist devices are increasingly being utilized in patients with acute myocardial infarction and cardiogenic shock. Herein, we discuss the mechanism of action and hemodynamic effects of such devices. We also review algorithms and best practices for the implantation, management and weaning of these complex devices.

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices ...

The Use of 3D Echocardiography in Surgical Planning of the Mitral Valve in Pediatric Cardiology

Mitral valve disease in pediatric cardiology is complex and can involve a combination of annular, leaflet, chordae tendineae and papillary muscle abnormalities. Transthoracic two-dimensional echocardiography (2DE) remains the primary diagnostic imaging technique utilized in pediatric surgical planning. However, given that the mitral valve is a three-dimensional (3D) structure, the addition of 3D echocardiography (3DE) to better define the mechanisms of stenosis and/or regurgitation is advantageous. Transthoracic 3DE technology has improved with advances in probe technology and ultrasound scanners, producing images with good spatial resolution and adequate temporal resolution. Specifically, the addition of pediatric 3D transducers with higher frequencies and a smaller footprint provides better 3DE imaging in children. Improved efficiency of 3DE acquisition and analysis allow 3D assessment of the mitral valve to be more easily integrated by the sonographer, the cardiologist and the surgeon in mitral valve assessment. This improvement was also made possible by the postprocessing software optimization.
In this method paper, we aim to describe the transthoracic 3DE assessment of the mitral valve in children and its use in the surgical planning of pediatric mitral valve disease. Firstly, the 3DE assessment begins by selecting the correct probe and by obtaining a view of the mitral valve. Then, the appropriate data acquisition method should be selected based on the individual patient. Next, optimization of the data set is critical in order to properly balance spatial and temporal resolution. During live scanning or following acquisition, the data set can be cropped using innovative tools that allow the user to quickly obtain an infinite number of cut planes or volumetric reconstructions. The cardiologist and surgeon can view the mitral valve en face; thus, accurately reconstructing its morphology in order to support medical or surgical planning. Finally, a review of some clinical applications is proposed, showing examples in pediatric mitral valve managements.

3D echocardiography of the mitral valve in pediatric cardiology produces full anatomic reconstructions that contribute to improved surgical management. Here, we outline a protocol for 3D acquisition and post-processing of the mitral valve in pediatric cardiology.

Mitral valve disease in pediatric cardiology is complex and can involve a combination of annular, leaflet, chordae tendineae and papillary muscle ...

Cox-Maze IV Procedure Concomitant with Valvular Surgery In Situs Inversus Dextrocardia: A Single-Center Experience in China

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The use of ablation technologies made the Cox-Maze IV procedure (CMP-IV) technically easier, faster, becoming the gold standard for the surgical treatment of AF. However, the efficacy and safety of CMP-IV in situs inversus dextrocardia are largely unknown. This paper summarizes the CMP-IV procedure performed concomitantly with valvular surgery in patients with situs inversus dextrocardia at this institution.
From February 2016 to September 2020, three dextrocardia patients with persistent AF and valvular diseases were referred to this institution for valvular and CMP-IV surgery. CMP-IV was performed using either cryoablation with a nitrous oxide (N2O)-based cryoprobe or a bipolar radiofrequency clamp and bipolar radiofrequency pen. Mechanical valve replacement or mitral vavuloplasty was performed in another patient in addition to tricuspid annuloplasty. Transmurality of the ablated atrial tissues was evaluated by electron microscopy. Heart function was assessed by transthoracic echocardiography. Cardiac rhythm was monitored by 24 h Holter at 3, 6, 12, 18, 24, and 48 months follow-up. 
All the AF was successfully eliminated in the ablation procedure without recurrence or other complications during hospitalization. The mean bypass and crossclamp times were similar in all the patients. The postoperative ventilator support time, the duration of stay in the ICU, and postoperative residence time were also not significantly different among the patients. Transmural atrial necrosis was detected in the ablated atrial tissues. Sinus rhythm maintenance was achieved at 3, 6, 12, 18, 24, and 48 months follow-up in all the patients. All valve protheses switched freely; no tricuspid regurgitation was observed. The results of the present study demonstrate that the CMP-IV is safe and effective in eliminating AF in dextrocardia patients concomitant with valvular surgery.

We summarize the Cox-Maze IV procedure concomitant with valvular surgery performed in patients with situs inversus dextrocardia at this institution.

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The use of ablation technologies made the Cox-Maze IV procedure (CMP-IV) technically ...

Transcatheter Pulmonary Valve Replacement from Autologous Pericardium with a Self-Expandable Nitinol Stent in an Adult Sheep Model

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow tract or bioprosthetic valve dysfunction, with excellent early and late clinical outcomes. However, clinical challenges such as stented heart valve deterioration, coronary occlusion, endocarditis, and other complications must be addressed for lifetime application, particularly in pediatric patients. To facilitate the development of a lifelong solution for patients, transcatheter autologous pulmonary valve replacement was performed in an adult sheep model. The autologous pericardium was harvested from the sheep via left anterolateral minithoracotomy under general anesthesia with ventilation. The pericardium was placed on a 3D shaping heart valve model for non-toxic cross-linking for 2 days and 21 h. Intracardiac echocardiography (ICE) and angiography were performed to assess the position, morphology, function, and dimensions of the native pulmonary valve (NPV). After trimming, the crosslinked pericardium was sewn onto a self-expandable Nitinol stent and crimped into a self-designed delivery system. The autologous pulmonary valve (APV) was implanted at the NPV position via left jugular vein catheterization. ICE and angiography were repeated to evaluate the position, morphology, function, and dimensions of the APV. An APV was successfully implanted in&#160;sheep J. In this paper, sheep J was selected to obtain representative results. A 30 mm APV with a Nitinol stent was accurately implanted at the NPV position without any significant hemodynamic change. There was no paravalvular leak, no new pulmonary valve insufficiency, or stented pulmonary valve migration. This study demonstrated the feasibility and safety, in a long-time follow-up, of developing an APV for implantation at the NPV position with a self-expandable Nitinol stent via jugular vein catheterization in an adult sheep model.

This study demonstrates the feasibility and safety of developing an autologous pulmonary valve for implantation at the native pulmonary valve position by using a self-expandable Nitinol stent in an adult sheep model. This is a step toward developing transcatheter pulmonary valve replacement for patients with right ventricular outflow tract dysfunction.

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow ...

A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair

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