state-of-the-art paper ...mitral stenosis patients, due to la blood stasis and atrial ﬁbrillation....

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S T A T E - O F - T H E - A R T P A P E R

Role of Echocardiography in PercutaneousMitral Valve Interventions

João L. Cavalcante, MD, L. Leonardo Rodriguez, MD, Samir Kapadia, MD,E. Murat Tuzcu, MD, William J. Stewart, MD

Cleveland, Ohio

JACC: CARDIOVASCULARIMAGING CME

CME Editor: Ragaven Baliga, MD

This article has been selected as this issue’s CME activity,available online at www.imaging.onlinejacc.org by select-ing the CME tab on the top navigation bar.

Accreditation and Designation StatementThe American College of Cardiology Foundation(ACCF) is accredited by the Accreditation Councilfor Continuing Medical Education (ACCME) toprovide continuing medical education for physicians.

The ACCF designates this Journal-based CMEctivity for a maximum of 1 AMA PRA Category 1redit(s)™. Physicians should only claim credit com-

mensurate with the extent of their participation inthe activity.

Method of Participation and Receipt of CMECertificateTo obtain credit for this CME activity, you must:1. Be an ACC member or JACC: Cardiovascular

Imaging subscriber.2. Carefully read the CME-designated article avail-

able online and in this issue of the journal.3. Answer the post-test questions. At least 2 out of

the 3 questions provided must be answered cor-rectly to obtain CME credit.

Manuscript received November 27, 2011; revised manuscript received

5. Claim your CME credit and receive your certif-icate electronically by following the instructionsgiven at the conclusion of the activity.

CME Objective for This Article: At the end of thisactivity the reader should be able to: 1) evaluate therole of transthoracic echocardiography (TTE) andtransesophageal echocardiography (TEE) in thequantification of mitral stenosis severity, under-standing the predictors for successful results follow-ing percutaneous mitral balloon valvotomy (PMBV);2) understand the echocardiographic inclusion cri-teria for transcatheter edge-to-edge repair (Mitra-Clip); and 3) identify the role of intraproceduralTEE in patients undergoing transcatheter closure ofperiprosthetic regurgitation (TPPR).

CME Editor Disclosure: JACC: Cardiovascular Im-aging CME Editor Ragaven Baliga, MD, has re-ported that he has no relationships to disclose.

Author Disclosure: All authors have reported thatthey have no relationships relevant to the contents ofthis paper to disclose.

Medium of Participation: Print (article only); on-line (article and quiz).

CME Term of Approval:Issue Date: July 2012

4. Complete a brief evaluation. Expiration Date: June 30, 2013

From the Department of Cardiovascular Disease, Cleveland Clinic Foundation, Cleveland, Ohio. All authors havereported that they have no relationships relevant to the contents of this paper to disclose.

March 15, 2012, accepted March 16, 2012.

http://dx.doi.org/10.1016/j.jcmg.2012.03.010

http://www.imaging.onlinejacc.org

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Echo in Percutaneous MV Interventions

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Role of Echocardiography in Percutaneous Mitral ValveInterventions

Intraprocedural imaging continues to evolve in parallel with advances in percutaneous mitral valve interventions. This didactic

review uses several illustrations and rich intraprocedural videos to further describe and demonstrate the role of the most up-to-date

echocardiographic and advanced imaging technologies in the patient selection and intraprocedural guidance of percutaneous

mitral valve interventions. We will focus on 3 interventions: 1) percutaneous balloon mitral valvuloplasty for mitral stenosis; 2)

transcatheter edge-to-edge repair of mitral valve regurgitation; and 3) transcatheter closure of periprosthetic mitral regurgitation. In

addition, we discuss potential pitfalls of 3-dimensional transesophageal echocardiography and show examples of this

technique. (J Am Coll Cardiol Img 2012;5:733–46) © 2012 by the American College of Cardiology Foundation

tructural intervention procedures requireclear delineation of intracardiac anatomy,which is currently not feasible with fluoros-copy and cineangiography, without the ad-

dition of echocardiography, mostly using trans-esophageal methods. The traditional strengths ofechocardiography (spatial and temporal resolutionand portability) have been supplemented by multi-plane imaging and more recently the developmentof simultaneous biplane imaging and real-time3-dimensional imaging (RT3D), based on parallelprocessing and faster computing technology. Al-though an extensive review of the 3-dimensional(3D) methodology is beyond the scope of thispaper, readers can benefit from 2 recent importantin-depth reviews (1,2).

This review will build on a worthy State-of-the-Art Paper by Naqvi (3), published in iJACC a fewyears ago, by further describing the role of the mostup-to-date echocardiographic methods (includingRT3D and simultaneous biplane transesophagealechocardiography [TEE]) in patient selection andintraprocedural monitoring of patients undergoingpercutaneous mitral valve interventions. We willfocus on 3 interventions: 1) percutaneous mitralballoon valvuloplasty (PMBV) for mitral stenosis;2) transcatheter edge-to-edge repair (TE2E) ofmitral valve regurgitation; and 3) transcatheter clo-sure of periprosthetic regurgitation (TPPR).

PMBV for Mitral Stenosis

Patient selection. Since its introduction in 1984 byInoue et al. (4), PMBV has become a safe, effective,
less invasive alternative to surgery, with low com-
plication rates, for some patients with symptomaticrheumatic mitral stenosis. In properly selected pa-tients, PMBV obtains excellent immediate andsustained hemodynamic improvement, comparableto the results of surgical procedures, including openor closed mitral commissurotomy and mitral pros-thetic replacement (5,6).

Proper patient selection is of major importancewhen predicting the immediate and long-term re-sults of PMBV. The most validated and commonlyused transthoracic echocardiographic (TTE) crite-rion is the one originated by Wilkins et al. (7),which we call the “splitability score.” This assess-ment by TTE takes into account the severity andextent of leaflet calcification, leaflet thickening,leaflet mobility, and involvement of the subvalvularapparatus (Table 1), each graded qualitatively on a1-to-4 scale (maximum total score � 16). Aninverse relationship exists between the total spl-itability score and PMBV success, with the cutpointof �8 reflecting best short- and long-term results.Of note, Wilkins score alone does not appear to bea good predictor of post-PMBV mitral regurgita-tion (MR), but rather the degree of commissuralopening (8,9). In addition, it is important to care-fully quantify the severity of underlying MR beforepercutaneous valvotomy (Online Video 1A and 1B,Figs. 1A to 1C). MR that is �2� has beendemonstrated by Palacios et al. (9) to be associatedwith worse outcome. Recent technological advancessuch as RT3D echocardiography with multiplanarreformatting have allowed more precise measure-ment of the mitral valve (MV) area before theprocedure (Fig. 1D). 3D TEE allows interrogationof the commissures more directly, which is veryhelpful to understanding asymmetric fusion or cal-
cification of commissures. These asymmetric defor-
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mations of mitral orifice may increase the risk ofMR with balloon valvuloplasty. Further, alterationin shape of mitral orifice in 3D is the consequenceof subvalvular, valvular, and leaflet scarring, all ofwhich are important determinants for the success ofballoon valvuloplasty (10,11).

TEE before PMBV is useful to screen for leftatrial (LA) or LA appendage thrombus or densespontaneous echo contrast, which are common inmitral stenosis patients, due to LA blood stasis andatrial fibrillation.

A small single-center study of 23 patients evalu-ated the role of multiphase cine cardiac computedtomography (CT)–derived Wilkins score to predictMV area changes after PMBV. Cardiac CT-derived score was more predictive of MV areaincrease after PMBV than echocardiographic-basedWilkins score was. In particular, increased posteriorleaflet mobility, decreased leaflet thickness, andabsence of subvalvular disease were all associatedwith MV area improvement following PMBV (12).To this date, cardiac magnetic resonance imaginghas not been used in patient selection or proceduralguidance in PMBV.Intraprocedural monitoring. After obtaining venousnd arterial access, TEE is typically performednder conscious sedation in the catheterizationaboratory. Adequate anesthesia of the posteriorharynx and suctioning is the key to success foratient comfort. Prior to septal puncture, the atrialppendage and LA are carefully assessed to rule outhrombus. Thrombus can develop in the appendageery rapidly, especially when anticoagulation isithheld for the procedure. Reassessment of MR

nd gradients at this time can serve as an importantaseline to compare after balloon inflations to judgedequacy of the procedure.

Although the transseptal puncture can be per-ormed primarily by fluoroscopic guidance, ultra-ound imaging with TEE or intracardiac echocar-iography can be useful, improving visualization ofhe contiguous structures and mainly avoiding aor-ic puncture. The specific location of the transseptaluncture may be customized to meet the needs ofhe specific procedure. Crossing at the level of theossa ovalis in the posterior inferior part is best forost PMBV. The transseptal puncture site can be

hosen using the visualization by TEE of tentingf the atrial septum by the catheter before ad-ancing the needle. Figure 2 shows TEE guid-nce, using multiple planes/views. For example,he bicaval view secures the proper height,
hereas the proper distance from the aorta is best a
ppreciated in the short-axis view. This becomesarticularly important in patients with previouseptal surgeries or punctures, excessively mobileeptum, and in patients with very large atria oristorted anatomy as seen in patients with scoli-sis or pneumonectomy.Although fluoroscopy has an important role,

EE is very helpful to optimize balloon positioncross the MV leaflets and avoid entrapment in theubvalvular apparatus. TEE imaging with 2 simul-aneous orthogonal planes is helpful to visualize theest position for Inoue balloon placement betweenhe MV leaflets and guide during its quick inflationOnline Video 2A and 2B). TEE use is critical todentify and prevent complications such as pericar-ial effusion and aortic puncture.Immediately following PMBV, the TEE exam

hould be targeted to answer quickly 4mportant questions:

. How severe is the MR and does itemerge from a commissural location?(Online Video 3A and 3B, Figs. 3Aand 3B)

. What are the post-PMBV MV areaand the peak/mean MV gradients?(Figs. 3C and 3D)

. Is there good commissural opening? Is itbilateral or unicommissural? (Fig. 3D)

. Is there any increase in pericardial effu-sion? If so, what is the size, and what arethe hemodynamic consequences?

RT3D with multiplanar reformattingmmediately after PMBV provides supe-ior estimation of MV area comparedith conventional TEE (Fig. 3D) (13).

ntraprocedural RT3D immediately after balloon in-ation can diagnose the presence and extent of leafletears better than TTE, 2-dimensional (2D) TEE, orntracardiac echocardiography can (14).

RT3D also provides improved ability to deter-ine the degree of commissure opening afterMBV, which is an important prognosticator of

he clinical procedural success in addition to theraditional measurement of MV area and gradi-nts (15). Immediate post-procedure measure-ents of valve area and gradients might obtain

ifferent results than measurements performedater after LA remodeling and changes in wallompliance. Furthermore, changes in heart rateay also have an impact on mitral gradients,

otentially misleading interpretation of compar-

A B B

A N D

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R E V I A T I O N S

A C R O N YM S

left atrial

mitral regurgitation

mitral valve

R � paravalvular

gitation

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n valvuloplasty

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area; P2 � middle pos

MV � mitral valve.


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TE2E Repair of MV Regurgitation

This percutaneous mitral clip technique mimics thesurgical mitral repair procedure introduced in 1991by the Italian surgeon Ottavio Alfieri who success-fully treated a patient with anterior leaflet prolapse.Using a pledgeted stitch to approximate the edgesof the middle portions of the anterior and posteriormitral valve leaflets, Alfieri created a double orifice(“figure of 8”) (16). In the largest surgical series

ral Assessment of a Stenotic MV by TEE

chocardiography (TEE) at mid-esophageal level at 0° (“4-chamberbileaflet thickening involving the mid-distal segments of thereduced opening. (B) Simultaneous biplane imaging of the MV atvel at 0° and 90° (right) with color Doppler showing mild mitralt baseline. (C) Continuous-wave Doppler indicating increasedD) Real-time 3-dimensional imaging with multiplanar reformattingnotic MV with important commissural fusion (MVA � 0.84 cm2).scallop; LA � left atrium; LV � left ventricle; MVA � mitral valve

of MV Anatomy According to the Wilkins Score

Mobility Thickening

ile valve with only leaflet tips Leaflets near normal in thicknes(4–5 mm)

and base portions have normal Mid-leaflets normal, considerabthickening of margins(5–8 mm)

ues to move forward in diastole,om the base

Thickening extending throughthe entire leaflet (5–8 mm)

al forward movement of thediastole

Considerable thickening of allleaflet tissue (�8–10 mm)

is the sum of the 4 items and ranges between 4 and 16.

terior scallop; PMBV � percutaneous mitral balloon valvuloplasty.

from this same group, including 260 patients whounderwent such repair, 80% of the cohort hadadditional MV annuloplasty that was associatedwith reduced reoperation at a mean follow-up of 5years (17).

TE2E implants a clip that grasps the free edgesof the middle portions of the MV, to reduce thedegree of MR. For example, a portion of 1 leafletthat is prolapsing or flail can be supported byattaching it via the clip to the opposite leaflet thathas intact chordae.

Several other devices designed to mimic a surgi-cal annuloplasty are under development and/orearlier stages of clinical trials. However, as docu-mented by CT (18), the method of coronary sinusimplantation has some dangers of affecting thecircumflex artery and missing the desired annuluslocation.

The MitraClip system (Evalve Inc., Menlo Park,California) has been the most studied device cur-rently available for transcatheter treatment of MR.The EVEREST I (Endovascular Valve Edge-to-Edge Repair Study) established the safety, feasibil-ity, and hemodynamic improvements in patientswith moderate to severe (3�) to severe (4�) MR.The morbidity and mortality were low, and the MRwas reduced to �2� in the majority of patients,along with sustained freedom from death (19).Recently, the results of the EVEREST II trial werereported, which randomized patients with 3 to 4�MR to either percutaneous repair or surgical repair/replacement. Percutaneous repair was less effectiveat reducing MR than conventional surgery was(approximately 23% patients were left with �3�MR), but the procedural risk of TE2E was low.The surgical and the TE2E groups with successfultreatment showed similar improvements in reduc-

Calcification Subvalvular Thickening

A single area of increasedecho brightness

Minimal thickening just belowthe mitral leaflets

Scattered areas of brightnessconfined to leaflet margins

Thickening of chordalstructures extending toone-third of the chordallength

Brightness extending into themid portions of the leaflets

Thickening extended to distalthird of the chords

Extensive brightnessthroughout much of theleaflet tissue

Extensive thickening andshortening of all chordalstructures extending downto the papillary muscles

Figure 1. Pre-Procedu

(A) Transesophageal eview”). Note moderatemitral valve (MV) withthe mid-esophageal leregurgitation (arrow) atransmitral gradients. (showing a severely steA2 � middle anterior

Table 1. Assessment

Grade

1 Highly mobrestricted

s

2 Leaflet midmobility

le

3 Valve continmainly fr

4 No or minimleaflets in

The total Wilkins score (3)

tion in LV size as assessed by echocardiography and

mtp


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similar clinical improvement in symptoms and ex-ercise capacity (20). The high-risk registry datarecently showed improvement in MR in a majorityof patients, resulting in improvement in clinical

Figure 2. Transseptal Puncture Under TEE Guidance

Note tenting of the fossa ovalis by the catheter before advancingthe needle. RA � right atrium; other abbreviations as in Figure 1.

Figure 3. Post-PMBV Assessment of the MV by TEE

(A) Post-PMBV TEE, from the same patient illustrated in Figure 1, showis observed after PMBV with integrity of the mitral leaflets and subvalvnificant improvement of transmitral gradients. (D) Post-PMBV real-timeimprovement in the MVA (from 0.84 to 1.74 cm2), and commissural op
differences before and after PMBV with Figure 1D. MR � mitral regurgitati
symptoms and significant left ventricular reverseremodeling over 12 months (21).Patient selection. TE2E has been successful in re-ducing MR in 2 groups of patients: those withexcessive leaflet motion (myxomatous degenerationwith prolapse or flail); or those with functional MR(apical tethering of normal leaflets), including pa-tients with left ventricular enlargement from isch-emic heart disease. TE2E is not applicable topatients with MR due to restricted leaflet motion(rheumatic MR) and those with flail or prolapsethat does not involve the middle portion of theanterior or posterior mitral leaflets, the “graspingarea” for the TE2E procedure, or in whom that areais calcified (22).

A key TTE inclusion criterion for the MitraCliprequires a regurgitant jet origin associated with theA2 to P2 segments of the MV and not at the commis-sures. For patients with functional MR, the coapta-tion length must be at least 2 mm, and the coaptationdepth less than 11 mm. For patients with flail leaflet,the flail gap must be �10 mm and the flail width �15

m (19) (Fig. 4). Calcification of the grasping area ofhe leaflets is also a contraindication because ofotential risk of embolization. A critical goal of the

proved mobility of both MV leaflets (still diastolic frame). (B) Mild MRapparatus. (C) Continuous-wave Doppler across the MV reveals sig-imensional imaging with multiplanar reformatting shows significantg (arrows) making planimetry a less valid parameter. Compare MVA

s imular3-denin

on; other abbreviations as in Figure 1.

Edge-to-Ed


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pre-procedural echo imaging study is the determi-nation of the MR mechanism and severity (OnlineVideo 4A and 4B, Figs. 5A to 5D). Which leaflet is

Anatomic Eligibility Criteria for MitraClip (EVEREST Trial)

tional MR, the primary mechanisms are mitral annular dilationrestriction secondary to LV remodeling. The posterior mitral leaf-commonly involved from scarring of the inferior wall and pos-

l papillary muscle. These processes lead to apical tethering withtion of the MV leaflets as shown. The coaptation length must bem, and coaptation depth must be �11 mm so that there is

e the clip can grasp. (B) In degenerative MR with MV prolapsel, measurements such as flail depth �11 mm and a flail width on�15 mm are important anatomic features associated withMitraClip procedural success. EVEREST � Endovascular Valvege Repair Study; other abbreviations as in Figures 1 and 3.

Figure 5. TEE Assessment of MV Morphology, Regurgitation Me

(A) Two-dimensional TEE at mid-esophageal level 0° using real-timeMV annular dilation and leaflet tethering leading to central malcoaat 95° of the MV with color Doppler showing systolic frame represeconvergence zone with large radius (1.0 cm). (C) Pulse-wave Dopplmarked systolic blunting (S) indicative of elevated LA pressures. (D)
dense holosystolic regurgitant jet with high peak velocity. All these fea
moving abnormally is determined using long-axisviews. Which portion of the leaflet is movingabnormally is determined from 2D short-axis views,2D intercommissural long-axis views, or RT3D;this has improved the complete visualization of MVscallops (23,24) (Online Video 5, Fig. 6).

The potential role of cardiac CT (25,26) andcardiac magnetic resonance (25) in the assessmentof a patient’s eligibility and intraprocedural guid-ance for percutaneous MV procedures has beenreviewed elsewhere (25). The feasibility and trueclinical utility of these techniques remain untestedin a large-scale cohort of patients.

Another important goal of the pre-proceduralecho is to quantitate carefully the severity of MRusing American Society of Echocardiographyguidelines. For this, important images are zoommid-esophageal long-axis or 4-chamber views ofthe flow convergence, for measurement of thealiasing radius (to calculate regurgitant orifice area)and the diameter of the vena contracta, although forMR jets that are eccentric, not holosystolic, or haveproximal constraint, the assumptions of thesecalculations may be misleading. Additional usefulviews include a pulsed Doppler assessment of the

nism, and Quantification

lane imaging with orthogonal planes showing functional MR withion between A2 and P2 scallops. (B) Mid-esophageal zoomed viewg severe central mitral regurgitation jet. Note the proximal flowterrogation of the right upper pulmonary vein flow showingtinuous-wave Doppler through the MV, which demonstrates a

Figure 4.

(A) In funcand leafletlet is moreteromediamalcoaptaat least 2 msome tissuand/or flaishort axisincreased

cha

bipptatntiner inCon

tures are consistent with severe MR. Abbreviations as in Figure 1.





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pattern of systolic reversal of flow in 1 or morepulmonary veins (Fig. 5C) and the density ofcontinuous wave Doppler recordings through themitral orifice (Fig. 5D). These assessments pro-vide an important baseline for comparison after re-pair, although the flow convergence methods are verydifficult or nearly impossible once the MitraClip is inplace, mostly due to the multiplicity of residual regur-gitant jets after clip deployment.Intraprocedural monitoring. The success in deliveringthe MitraClip under real-time echocardiographic guid-

Figure 6. RT3D TEE With En Face View of the MV (Systolic Fram

Marked myxomatous changes of the MV leaflets, with particularly sarea (ROA) created by the malcoaptation of the prolapse scallops (Dadding detailed information about the anatomy of MV scallops andaortic valve (AV) is, and the left atrial appendage (LAA) is to the lefother abbreviations as in Figure 1.

Table 2. Role of Transesophageal Echocardiography inEdge-to-Edge MV Repair Technique (MitraClip)

Assessing the mechanism of MR

Quantitating the severity of MR

Guiding transseptal crossing

Aligning the delivery system perpendicular to the mitral planeat the location of the MR jet

Alignment of clip’s arms perpendicular to MV coaptation line

Determining success of grasping both leaflets

Verification of clip stability after release from delivery system

Reassessing MR severity

Locating of persistent leak(s)

MR � mitral regurgitation; MV � mitral valve.

ance is a result of the unique collaboration betweeninterventionalists and echocardiographers. The TE2Eprocedure entails a standard sequence of maneuvers,all of which are monitored and guided by echocardi-ography (Table 2).

e P2 prolapse and mild A2 prolapse. Note the regurgitant orificeost-processing software allows multiplanar reconstruction (B,C,E,F)tionship with other structures. Anterior is to the top, where thethe figure. RT3D � real-time 3-dimensional; SAX � short axis;

Figure 7. TEE Bicaval View With Simultaneous BiplaneImaging Showing IAS Dilation by the Guiding Sheath

Arrows indicate the interatrial septum (IAS) dilation by the guid-ing sheath. SVC � superior vena cava; other abbreviations as in

e)

ever). Prelat of

Figures 1 and 2.

as in Figur


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Supervision of transseptal puncture and crossingis the first goal of TEE imaging. As mentionedbefore, TEE or intracardiac echocardiography canvisualize the location where the catheter indents theatrial septum, allowing the interventionalist to ad-just the location of septal crossing, aiming farenough superiorly and posteriorly to allow the arc ofthe catheter to easily reach the middle of the mitralorifice. A mid-esophageal aortic valve short-axis

TEE at Mid-Esophageal Level With Simultaneous Biplanehowing the Guide Sheath Transversing the Interatrial Septumhe LA

sheath (arrow) into the LA at a safe superior distance from theibicaval view showing the guide sheath tip pointing away from

lls. (C) Live 3-dimensional (3D) view from the LA perspective, look-the RA. (D) Components of the MitraClip shown by 3D echo:th, delivery catheter, and MitraClip at the distal tip. Abbreviationses 1, 2, 6, and 7.

Figure 9. Advancing the MitraClip Into the LV

(A) RT3D of the mitral valve in the en face/surgeon’s view using prview using simultaneous biplane imaging showing the MitraClip bethe correct position where the MR jet is. Although the image frame
it intermittently to aid in the fluoroscopic guidance for the intervention
view (multiplane angle of approximately 30° to 60°)and the bicaval view at 90° to 100° are useful duringthe transseptal puncture to visualize all the adjacentstructures avoiding device-endocardial contact. Thetransverse 4-chamber (0°) imaging plane can assessthe height of proposed septal puncture above thevalve plane (22).

Once the interatrial septum is crossed, the nextstep is to dilate the interatrial septum to allow thepassage of the delivery system and clip toward theregurgitant MV (Fig. 7). During advancement ofthe super stiff wire, monitoring with TEE can helpto avoid puncture of the LA appendage or LA wallto avoid pericardial tamponade. The catheter tip isechodense and should be imaged during mostmanipulations to avoid contact with the posteriorand lateral structures such as the lateral LA wall andLA appendage (Online Video 6, Fig. 8). Then thedelivery catheter is turned inferiorly and alignedparallel to the antegrade mitral flow. For this, the enface RT3D of the MV “surgeon’s view” from theLA perspective (23) (Fig. 9A) is helpful. Weparticularly use the biplane real-time imaging with1 plane in the intercommissural orientation (atmultiplane angles of about 45° to 70°), and theother in a long-axis orientation (Fig. 9B). The clipshould be positioned where the largest mitral re-gurgitant jet is located by color Doppler mapping,such that it splits the jet and is pointed parallel tothe direction of mitral antegrade flow (OnlineVideo 7).

Once the tip of the delivery catheter is poised inthe LA just above the MV, the arms of the clipdevice are then opened. It is important to rotate the

perpendicular alignment of the MitraClip. (B) Mid-esophagealadvanced into the MV. Color Doppler mapping is used to guidee decreases due to increased processing demand, we tend to use

Figure 8.Imaging Sand Into t

(A) GuideAV. (B) Semthe LA waing towardguide shea

operingrat

al cardiologist. Abbreviations as in Figures 1, 3, and 6.





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clip arms so that they are perpendicular to themitral coaptation line, primarily using the RT3Dsurgeon’s view; when it is unavailable, the transgas-tric 2D short-axis view of the MV should be used,although it is difficult to obtain in about one-thirdof patients (Online Video 8, Figs. 10A and 10B).

After passage of the clip into the left ventricle,and final verification of its position and orientation,the open device is pulled up to grasp the leafletsfrom their underside. Both RT3D and simultane-ous biplane imaging are crucial at this point todetermine the success of grasping both leaflets(Figs. 11A and 11B). Once both leaflets aregrasped, the arms of the clip are closed and anassessment is made of the new severity of the MR(Online Video 9, Fig. 11C). If the MR has not beensubstantially reduced, the clip is everted andbrought back into the LA, and a repeat placementof the same clip is attempted. If the MR has beensubstantially reduced, the clip arms are tightenedand the delivery system is detached. After verifica-tion of the stability of the clip, the suture attachedto the clip is pulled through to remove the finaltether of the clip (Online Video 10, Fig. 11D).Finally, repeat assessment of the severity of theresidual MR and the mitral gradient, before andduring afterload manipulation with phenyleph-rine, helps to determine whether a second clipshould be placed, which is indicated usually ifmoderate or greater (�2�) MR is present. Ifneeded, the second clip should be positionedwhere the flow convergence and vena contractaare largest. Before a second clip is deployed, it isimportant to search for any significant increase intransmitral gradients resulting from the first clip.This routine practice is probably the explanationwhy no cases have been reported of acute mitralstenosis with this procedure. Finally, in patientswith hypotension, it may be useful to manipulateafterload and pre-load to evaluate the severity ofMR under hemodynamics more comparable toambulatory conditions.

This TE2E procedure can be lengthy and verydemanding on both the echocardiographer andinterventionalist. Both RT3D and simultaneousbiplane imaging provide substantial value oversingle-plane 2D TEE by reducing the need to flipthe image back and forth between the intercom-missural and long-axis views. Frequent monitor-ing of the pericardial space allows early detectionof growing effusions before hemodynamic com-promise develops. As mentioned previously, good
communication between the echocardiographer
and the interventionalist, using standardized vo-cabulary and anatomical landmarks, is essential todecrease maneuvering error and to increase pro-cedural efficiency. With the advent of 3D echo-cardiography, there is also a need for propertraining of the interventional cardiologist on thebasic 3D views. This is of critical importance if

Figure 10. Transgastric View With Retroflexion Showing the LVShort-Axis View With the MitraClip Straddling the MV Leaflets

(A) Note that the MitraClip (arrow) is not orientated perpendicularMV coaptation line (dashed blue line). (B) MitraClip position is corrwith 30° of clockwise rotation of the delivery catheter. Lat � lateramedial; other abbreviations as in Figure 1.

Figure 11. Sequence of Events in the Deployment of Edge-to-EdRepair Technique (MitraClip)

(A) Simultaneous biplane imaging at 60° and 150° demonstrates thlocation of the MitraClip within the MV structure. Once the positionfirmed, grasping of the MV leaflet occurs. (B) Live 3D zoomed viewdelivery catheter and MitraClip grasping the A2 and P2 scallops of(C) Similar to A, simultaneous biplane imaging at 60° and 150° demstrates trivial to mild (1�) MR after MitraClip grasps the MV leafletsMitraClip system is finally released from the delivery system and se(arrow) in the center of the new “figure-of-8” MV. Ant � anterior; P

in

to theectedl; Med �

ge MV

e exactis con-of thethe MV.on-. (D)enost �

posterior; other abbreviations as in Figures 1, 3, 8, and 10.




ahrid4(aatT

gitcmevamcFigures 1,


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this technique is used for real-time navigation.Orientation in the 3D domain can be particularlyconfusing the absence of internal anatomicallandmarks. A recent document from the Euro-pean Association of Echocardiography and theAmerican Society of Echocardiography providesan important practical guide on the image acqui-sition, interpretation, as well as current andpotential clinical applications of 3D echocardiog-raphy (2).

. TEE Baseline Assessment of ParaVR

imensional (2D) TEE at mid-esophageal 4-chamber view (0°)aravalvular regurgitation (ParaVR) (arrow) outside the anteriorthe MV bioprosthesis annulus. Also note the flow convergencewhead), which suggests significant regurgitant flow. (B) Atn from another angle, is the severe anterior paravalvular leak) RT3D of the MV bioprosthesis demonstrating the paravalvu-rrow). Note the AV is on the top. (D) RT3D with color Dopplerlarge anterior paravalvular leak (arrow). Abbreviations as in

Table 3. Role of TEE in TPPR

Assessing the severity of ParaVR

Identification of the location and number of holes

Guiding atrial septal puncture or LV apical puncture (in patientswith the combination of prosthetic aortic and mitral valves orissues of crossing the aortic valve)

Guiding placement of the veno-arterial rail

Assessing reduction in ParaVR during balloon inflation

Assisting with placing the disk in the defect

Monitoring the effects of the device on prosthetic leaflet(occluder) motion

Reassessing the severity of ParaVR

LV � left ventricular; ParaVR � paravalvular regurgitation; TEE � transesoph-ageal echocardiography; TPPR � transcatheter closure of periprostheticregurgitation.

f6, and 11.

TPPR

Patient and device selection. Paravalvular regurgita-tion (ParaVR) is common, but most cases are smalland asymptomatic. Clinically important ones, oc-curring in as many as 5% of patients who haveundergone valve replacement, tend to present withcongestive heart failure, hemolytic anemia, or ar-rhythmias. This may result from suture dehiscencedue to infection (endocarditis), annular calcifica-tion, technical problems, and/or a combination ofall of those.

Surgical intervention is usually recommended topatients with symptomatic ParaVR, especially if it isassociated with infection, although increased mor-bidity and mortality associated with reoperationhave stimulated the development of other optionsto address this complex problem. TPPR appears asan attractive, albeit challenging, alternative. Mostpublished evidence comes from single-center expe-rience with case reports predominantly involvingParaVR of the MV prosthesis. More recently,technical success has ranged from 63% to 100%(27–30). In this new field of work, the design ofspecific “plugging” devices is in its early phase (31).Most reports of TPPR have entailed off-label use ofdevices designed to close congenital septal defectsor vascular plugs.Goals of imaging in TPPR and description of theprocedure. Transprocedural echocardiographic im-ging in TPPR is critically important because it canelp the interventionalist to: 1) locate the optimalegion for transseptal puncture; 2) guide the cross-ng of the hole that leads to ParaVR; 3) monitor theecrease in ParaVR during balloon inflation;) monitor the onset of possible complicationspericardial effusion, iatrogenic post-proceduretrial septal defect or prosthetic leaflet entrapment);nd 5) assess the final result of the device implan-ation. Table 3 summarizes the important aspects ofEE for this particular procedure.The role of transesophageal echo in TPPR be-

ins with assessing the severity of the ParaVR. Thiss difficult in mitral ParaVR because the left ven-ricular side of the mitral prosthesis, where the flowonvergence would ideally be measured, is com-only shadowed by the prosthesis itself. The pres-

nce of a mitral prosthesis also shields the leftentricular outflow tract where the periprostheticortic regurgitation would be observed. Further-ore, wall constraint often prevents the flow

onvergence from forming hemispheric isovelocity

Figure 12

(A) Two-dshowing paspect ofzone (arro150°, show(arrow). (Clar hole (ashows the

orms, so quantitation of the MR is often difficult.


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Probably the most important role of TEE inTPPR is identification of the location and numberof holes that are present. Single-plane and biplane2D TEE with color Doppler imaging is the main-stay tool for this purpose (Figs. 12A and 12B). Useof RT3D with color Doppler imaging appears to beuseful (27,32,33) (Figs. 12C and 12D), althoughlow temporal resolution, lack of standardized an-gles, and potential motion creating “stitching arti-facts” are current limitations of this imaging tech-nique. Nonetheless, for mitral prosthetic regurgitation,the RT3D TEE with en face/surgeon’s view fromthe LA is most helpful. Although necessitatinganother step, the best convention should be torotate the image so the aortic valve is at the top ofthe image (Figs. 11D and 12C). Multiple simulta-neous biplane 2D views also are useful for charac-terization of anatomic relationships. Note should bemade of which TEE imaging plane/angle bestvisualizes the regurgitant jet.

We also frequently use a fluoroscopic overlaytechnique with CT scanning produced by rotatingthe C-arm at high speed around the patient (SyngoDynaCT Cardiac, Siemens, Erlangen, Germany).Several hundred images are acquired and recon-structed as 3D volumes. Anatomic details of inter-est are marked on the pre-procedural CT angiog-raphy, which is coregistered to an intraproceduralCT acquired in the catheterization laboratory.The CT-CT registration is then fused to thereal-time fluoroscopic image, allowing better pro-cedural navigation with fluoroscopy and with lessuse of a contrast medium (34). Furthermore,

Figure 13. Fusion/Overlay of the ParaVR Information by TEE WiRotating the C-Arm at High Speed Around the Patient

This technique allows better procedural navigation with fluoroscoptionist drawings indicating the site of transseptal puncture (1), theParaVR (blue circles) (not well-seen in this projection but correspo(CT)/fluoroscopy imaging overlay demonstrating the prosthetic M
according to appropriate en face TEE. Abbreviations as in Figures 1,
guidance in the optimum site for transseptalpuncture (Fig. 13A) and overlaying the ParaVRlocation, defined by TEE, on the fluoroscopy areother important strengths of this new imagingtechnique (Fig. 13B).

Access to the defect may be either antegrade viaa venous transseptal approach or retrograde in thedirection of the regurgitation from arterial access(coming across the aortic valve or transapical). Thesite of transseptal puncture in TPPR is highlyvariable and dependent on the location of theParaVR. For example, lateral defects are betterapproached with transseptal access in the posteriorpart of the fossa via the inferior vena cava, whereasmedial defects adjacent to the septum require evenlower and posterior puncture (35). Therefore, im-aging guidance of atrial septal puncture either byintracardiac or TEE or with the CT/fluoroscopyoverlay as aforementioned is important in TPPR.

The objective is to pass a wire through from theright atrium to the LA. The venous wire is thensnared using another wire introduced through thefemoral artery. In patients who have both aortic andmitral valve replacements in place, the echo canhelp guide LV apical puncture for downstreamaccess (27). The first (venous) wire is pulledthrough and its tip exteriorized, which can thusbe called a veno-arterial rail (36). This allowsbetter support for the delivery catheter in situa-tions where numerous defects and/or acute anglesare encountered thereby making transit of thedelivery catheter difficult across the ParaVR orcreating excessive kinking on it. Hence, TEE has

luoroscopic Overlay Technique With CT Scanning Produced by

) Fluoroscopic right anterior oblique projection with the interven-thetic MV (2), aortic valve (“t3-leaf-clover”) (3), and the 2 sites ofng to the sites on the next panel). (B) Computed tomographynd the 2 sites of ParaVR (pentagon and square shapes)

th F

y. (AprosndiV a

6, and 12.

al MV leaflet functioning. Abbreviations as in Figures 1, 6, 8, and 12.


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an important role in guiding placement of thewire. Once the wire is in place, the intervention-alist can move and approach placement of theoccluder device from either direction. Some op-erators use balloon inflation within the defectwith TEE to see if the regurgitation is reduced bythis temporary occlusion of the defect. If balloonocclusion reduces the regurgitation substantially,TEE guides placement of the occluder devicewithin the defect. After the device is expanded,TEE monitors for changes in the motion ofmechanical disks or other adverse effects on theheart (Online Video 11, Fig. 14).

Reassessment of the ParaVR severity by TEEenables a decision whether a second occluder deviceis needed. This reassessment of the severity ofregurgitation again is problematic because oftenthere are unusual anatomy and perivalvular tractsthat are eccentric and shielded by a prosthetic valveand the interventional device. Therefore, assess-ment of the aliasing radius for calculation of theregurgitant orifice area is problematic; other means

Figure 14. Percutaneous Closure of ParaVR From a Dehisced M

(A) There are 2 separate ParaVR jets (anterior and lateral) that are mdehiscence. (B) Under fluoroscopic and TEE guidance, transseptal pdeployment of first Amplatzer device (St. Jude Medical, St. Paul, Mimoderate residual anterior ParaVR. (D) The anterior ParaVR is now aOnce position is confirmed, transient balloon inflation within the PaParaVR) for subsequent deployment of the second Amplatzer devicdevices in close proximity to each other and, more important, norm

itral Bioprosthesis

oderate (2 to 3�) in severity and arising from the area of annularuncture allows the venous wire to cross the lateral defect. (C) Post-nnesota). Note resolution of lateral ParaVR and close proximity ofpproached with the venous wire crossing of the ParaVR defect. (E)raVR defect allows confirmation of adequate position (no significante. (F) Live 3D view of the mitral bioprosthesis shows the 2 Amplatzer

of regurgitation assessment, including spatial color

Figure 15. Post-Procedural Complication in a Patient WhoUnderwent TPPR and RT3D Artifacts

Aside from the iatrogenic atrial septal defect created (arrow), also note2 common artifacts seen with the use of 3D TEE: 1) “stitch” artifact dueto irregular cardiac rhythm, probe, and/or patient (respiratory) move-ments during the image acquisition, creating clear artificial lines thatdivide/fragment the structure being imaged; and 2) near-field artifactdue to improperly high gain-settings in the near field creating a “darkzone” over the area of interest. SBP � systolic blood pressure; TPPR �

transcatheter closure of periprosthetic regurgitation; other abbrevia-
tions as in Figures 1, 6, 7, and 8.

al


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Doppler mapping and pulmonary vein flow profiles,are required.

In summary, TEE is useful in guiding transcath-eter closure of ParaVR by guiding access to the areafrom the arterial and venous side, placement of theoccluder device, and assessment of the amount ofreduction of regurgitation.

Future Directions

Intraprocedural imaging (RT3D TEE, biplane im-aging, CT/fluoroscopy overlay, etc.) will continueto evolve in parallel with advances in percutaneousMV interventions. In terms of TE2E, better patientselection along with further refinements on thedevice technology addressing the annulus compo-nent in addition to the leaflet problem would becrucial for the long-term success. In TPPR, betterdesign with low-profile devices could avoid compli-cations such as inflow/outflow obstruction or leafletimpingement.

Although 3D TEE is a powerful tool with severaladvantages for use in percutaneous interventions,improvements, in particular, the frame rate whenusing simultaneous RT3D with color Doppler areneeded. Furthermore, during acquisition of fullvolume 3D dataset, stitch artifacts can occur due toirregular heart rhythm, patient’s respiratory motion,or fine probe movements, making interpretation

compared with open surgical commis- plasty variables th

with device shadowing can also reduce the qualityof both 2D and 3D TEE, creating dropout ornear-field artifacts and potentially leading to incor-rect diagnosis (Online Video 12, Fig. 15). For thesepercutaneous procedures, we more frequently usethe live 3D option.

Finally, an experienced team composed by aninterventional cardiologist, an interventional echo-cardiographer, a cardiothoracic surgeon, a cardiacanesthesiologist, and nurses that are able to performboth catheterization lab and operating room dutiesis needed. Due to the overlap of domains ofknowledge, it is key that all parties, in particular theechocardiologist and interventionalist, use not onlythe same vocabulary, but also share crossed trainingskills (e.g., training of the interventionalist on basicechocardiographic views critical for the procedure,and possession of unique interventional imagingskill by the echocardiologist) (3,37).

AcknowledgmentsThe authors acknowledge Marion Tomasko for themedical illustration (Fig. 4) and Dr. Amar Krish-naswamy for his valuable comments in the CT/fluoroscopy overlay technology and for providingFigure 13.

Reprint requests and correspondence: Dr. William J. Stew-rt, Department of Cardiovascular Disease, J1-5, Cleve-and Clinic Foundation, 9500 Euclid Avenue, Cleveland,

more difficult. Improper gain adjustments along Ohio 44195. E-mail: [email protected].

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Key Words: balloonvalvuloplasty y mitralregurgitation y mitral valve y3-dimensional echocardiographyy transcatheter repair yransesophageal echocardiography.

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