Real-Time 3D TEE Allows Optimized Guidance of Percutaneous Edge-to-Edge Repair of the Mitral Valve
percutaneous mitral valve repair using the edge-to-edge technique has been shown to be safe and effective for treatment of mitral regurgitation considering specific indications (1). Two-dimensional (2D) transesophageal echocardiography (TEE) has been described for guidance of the procedure (2,3). The complex spatial structure of the mitral valve, as well as the complex interaction of the interventional device with parts of the beating heart, requires optimal real-time (RT) spatial visualization. RT 3-dimensional (3D) TEE allows the acquisition of pyramidal datasets which can be used to visualize the size, shape, and motion of cardiac structures from multiple perspectives.
The following 2D TEE and RT 3D TEE images demonstrate the superior guidance of percutaneous edge-to-edge mitral valve repair using RT 3D TEE. In a series of 26 patients, RT 3D TEE provided important additional imaging information compared to 2D TEE in several critical steps of the procedure. In particular, safe guidance of the clip delivery system through the left atrium towards the mitral valve (Fig. 1), precise positioning of the clip delivery system in the middle of the intercommissural line as well as at the center of the regurgitant jet (Fig. 2), accurate alignment of the clip arms perpendicular to the intercommissural line in the left atrium as well as the left ventricle (Fig. 3), confirmation of correct grasping location in the middle of anterior and posterior mitral leaflet resulting in a symmetric split of the mitral orifice (Fig. 4), and adequate positioning of a second clip relative to the first clip if required by remaining mitral regurgitation (Fig. 5) were strongly supported with RT 3D TEE. While 2D TEE required several views to determine the precise clip position with the need to change also the transducer position, RT 3D TEE provided even more information within one transducer position.
In the complex interventional edge-to-edge repair with the MitraClip device (Abbott Vascular Structural Heart, Menlo Park, California) requiring optimal spatial information RT 3D TEE allowed improved guidance of the procedure. RT 3D TEE guidance resulted in great operator confidence to adequately perform the procedure. It is likely to reduce time requirements to perform individual procedural steps, and increase safety in the performance of procedural steps.
1. : "Percutaneous mitral valve repair using the edge-to-edge technique". J Am Coll Cardiol 2005; 46: 2134.
2. : "Echocardiographic guidance and assessment of percutaneous repair for mitral regurgitation with the Evalve MitraClip: lessons learned from EVEREST I". J Am Soc Echocardiogr 2007; 20: 1131.
3. : "Echocardiography in percutaneous valve therapy". J Am Coll Cardiol Img 2009; 2: 1226.
The authors have reported that they have no relationships to disclose.