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CMactroltraqustaing2)terClTEper
CMaging CME Editor Ragaven Baliga, MD, has re-ported that he has
no relationships to disclose.
Frorepo
Ma
J A C C : C A R D I O V A S C U L A R I M A G I N G V O L . 5 ,
N O . 7 , 2 0 1 2
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L O G Y F O U N D A T I O N I S S N 1 9 3 6 - 8 7 8 X / $ 3 6 . 0
0
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CME Term of Approval:Issue Date: July 2012Expiration Date: June
30, 2013ole of Echocardiographyitral Valve Interventions
o L. Cavalcante, MD, L. Leonardo RodrigueMurat Tuzcu, MD,
William J. Stewart, MD
eveland, Ohio
CC: CARDIOVASCULARAGING CME
E Editor: Ragaven Baliga, MD
is article has been selected as this issues CME activity,ilable
online at www.imaging.onlinejacc.org by select-the CME tab on the
top navigation bar.
creditation and Designation Statemente American College of
Cardiology FoundationCCF) is accredited by the Accreditation
Council
Continuing Medical Education (ACCME) tovide continuing medical
education for physicians.The ACCF designates this Journal-based
CMEivity for a maximum of 1 AMA PRA Category 1edit(s). Physicians
should only claim credit com-nsurate with the extent of their
participation inm the Department of Cardiovascular Disease,
Cleveland Clinic Fourted that they have no relationships relevant
to the contents of this p
nuscript received November 27, 2011; revised manuscript received
Ma
g.onlinejacc.org/ on 02/02/2013n Percutaneous
D, Samir Kapadia, MD,
Claim your CME credit and receive your certif-icate
electronically by following the instructionsgiven at the conclusion
of the activity.
E Objective for This Article: At the end of thisivity the reader
should be able to: 1) evaluate thee of transthoracic
echocardiography (TTE) andnsesophageal echocardiography (TEE) in
theantification of mitral stenosis severity, under-nding the
predictors for successful results follow-percutaneous mitral
balloon valvotomy (PMBV);
understand the echocardiographic inclusion cri-ia for
transcatheter edge-to-edge repair (Mitra-ip); and 3) identify the
role of intraproceduralE in patients undergoing transcatheter
closure ofiprosthetic regurgitation (TPPR).
E Editor Disclosure: JACC: Cardiovascular Im-A T E - O F - T H E
- A R T P A P E R
L I S H E D B Y E L S E V I E R I N C . h t t p : / / d x . d o
i . o r g / 1 0 . 1 0 1 6 / j . j c m g . 2 0 1 2 . 0 3 . 0 1
0ndation, Cleveland, Ohio. All authors haveaper to disclose.
rch 15, 2012, accepted March 16, 2012.
-
Ro anIn
Int ad idactic
rev s to to-date
ech he aneous
mi 1) osis; 2)
tra ; an tion. In
ad tra of this
tec y th
Sditesoechanplaof3-protho(3Dpain-
Art Paper by Naqvi (3), published in iJACC a
fewyeaupRTechintpefocba2)misur
PM
PaInles
plirhetiesustoorthe
whsuluseriowhmeextleaap1-to-4 scale (maximum total score 16).
Aninverse relationship exists between the total spl-
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 5
, N O . 7 , 2 0 1 2
J U L Y 2 0 1 2 : 7 3 3 4 6
Cavalcante et al.
Echo in Percutaneous MV Interventions
734
Downloaders ago, by further describing the role of the
most-to-date echocardiographic methods (including3D and
simultaneous biplane transesophagealocardiography [TEE]) in patient
selection and
raprocedural monitoring of patients undergoingrcutaneous mitral
valve interventions. We willus on 3 interventions: 1) percutaneous
mitral
lloon valvuloplasty (PMBV) for mitral stenosis;transcatheter
edge-to-edge repair (TE2E) of
tral valve regurgitation; and 3) transcatheter clo-e of
periprosthetic regurgitation (TPPR).
BV for Mitral Stenosis
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 thele of Echocardiography in
Percutterventions
raprocedural imaging continues to evolve in parallel with
iewuses several illustrationsand rich intraprocedural video
ocardiographic and advanced imaging technologies in t
tral valve interventions. We will focus on 3 interventions:
nscatheteredge-to-edgerepairofmitralvalve regurgitation
dition, we discuss potential pitfalls of 3-dimensional
hnique. (J AmColl Cardiol Img 2012;5:73346) 2012 b
tructural intervention procedures requireclear delineation of
intracardiac anatomy,which is currently not feasible with
fluoros-copy and cineangiography, without the ad-
ion of echocardiography, mostly using trans-phageal methods. The
traditional strengths ofocardiography (spatial and temporal
resolution
d portability) have been supplemented by multi-ne imaging and
more recently the developmentsimultaneous biplane imaging and
real-time
dimensional imaging (RT3D), based on parallelcessing and faster
computing technology. Al-ugh an extensive review of the
3-dimensional) methodology is beyond the scope of this
per, readers can benefit from 2 recent importantdepth reviews
(1,2).This review will build on a worthy State-of-the-tient
selection. Since its introduction in 1984 byoue et al. (4), PMBV
has become a safe, effective,s invasive alternative to surgery,
with low com-
proofhecifi
d From: http://imaging.onlinejacc.org/ on 02/02/2013eous Mitral
Valve
vances in percutaneous mitral valve interventions. This d
furtherdescribeanddemonstrate the roleof themostup-
patient selection and intraprocedural guidance of percut
percutaneous balloon mitral valvuloplasty for mitral sten
d3) transcatheterclosureofperiprostheticmitral regurgita
nsesophageal echocardiography and show examples
e American College of Cardiology Foundation
cation rates, for some patients with symptomaticumatic mitral
stenosis. In properly selected pa-
nts, PMBV obtains excellent immediate andtained hemodynamic
improvement, comparablethe results of surgical procedures,
including openclosed mitral commissurotomy and mitral pros-tic
replacement (5,6).
Proper patient selection is of major importanceen predicting the
immediate and long-term re-ts of PMBV. The most validated and
commonlyd transthoracic echocardiographic (TTE) crite-n is the one
originated by Wilkins et al. (7),ich we call the splitability
score. This assess-nt by TTE takes into account the severity andent
of leaflet calcification, leaflet thickening,flet mobility, and
involvement of the subvalvularparatus (Table 1), each graded
qualitatively on acedure (Fig. 1D). 3D TEE allows interrogationthe
commissures more directly, which is very
lpful to understanding asymmetric fusion or cal-cation of
commissures. These asymmetric defor-
-
maMinofwhba
atrspomiatr
atetomMdeincWleaabwiTohaguIntanunlabphpaapthrverwianbaad
forsoudiotheticputhefosmochofvananthwh
appasepsepdisosi
TEacrsubtanbethe(Oidedia
shoim
1.
2.
3.
4.
imriowiIntflateaint
miPMthetraenmediflat
air
nsesophageal
iography
ranscatheter closure of
hetic regurgitation
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 5
, N O . 7 , 2 0 1 2
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Cavalcante et al.
Echo in Percutaneous MV Interventions
735
Downloadetions of mitral orifice may increase the risk ofR with
balloon valvuloplasty. Further, alterationshape of mitral orifice
in 3D is the consequencesubvalvular, valvular, and leaflet
scarring, all ofich are important determinants for the success
of
lloon valvuloplasty (10,11).TEE before PMBV is useful to screen
for leftial (LA) or LA appendage thrombus or densentaneous echo
contrast, which are common in
tral stenosis patients, due to LA blood stasis andial
fibrillation.A small single-center study of 23 patients evalu-d the
role of multiphase cine cardiac computedography (CT)derived Wilkins
score to predict
V area changes after PMBV. Cardiac CT-rived score was more
predictive of MV arearease after PMBV than
echocardiographic-basedilkins score was. In particular, increased
posteriorflet mobility, decreased leaflet thickness, andsence of
subvalvular disease were all associatedth MV area improvement
following PMBV (12).
this date, cardiac magnetic resonance imagings not been used in
patient selection or proceduralidance in PMBV.raprocedural
monitoring. After obtaining venousd arterial access, TEE is
typically performedder conscious sedation in the
catheterizationoratory. Adequate anesthesia of the posteriorarynx
and suctioning is the key to success fortient comfort. Prior to
septal puncture, the atrialpendage and LA are carefully assessed to
rule outombus. Thrombus can develop in the appendagey rapidly,
especially when anticoagulation isthheld for the procedure.
Reassessment of MRd gradients at this time can serve as an
importantseline to compare after balloon inflations to judgeequacy
of the procedure.Although the transseptal puncture can be per-med
primarily by fluoroscopic guidance, ultra-nd imaging with TEE or
intracardiac echocar-graphy can be useful, improving visualization
ofcontiguous structures and mainly avoiding aor-
puncture. The specific location of the transseptalncture may be
customized to meet the needs of
specific procedure. Crossing at the level of thesa ovalis in the
posterior inferior part is best forst PMBV. The transseptal
puncture site can be
osen using the visualization by TEE of tentingthe atrial septum
by the catheter before ad-
cing the needle. Figure 2 shows TEE guid-
ce, using multiple planes/views. For example,e bicaval view
secures the proper height,ereas the proper distance from the aorta
is best
comapoati
d From: http://imaging.onlinejacc.org/ on 02/02/2013preciated in
the short-axis view. This becomesrticularly important in patients
with previoustal surgeries or punctures, excessively mobiletum, and
in patients with very large atria ortorted anatomy as seen in
patients with scoli-s or pneumonectomy.Although fluoroscopy has an
important role,E is very helpful to optimize balloon positionoss
the MV leaflets and avoid entrapment in thevalvular apparatus. TEE
imaging with 2 simul-eous orthogonal planes is helpful to visualize
the
st position for Inoue balloon placement betweenMV leaflets and
guide during its quick inflation
nline Video 2A and 2B). TEE use is critical tontify and prevent
complications such as pericar-l effusion and aortic
puncture.Immediately following PMBV, the TEE examuld be targeted to
answer quickly 4
portant 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 reformattingmediately after PMBV provides
supe-r estimation of MV area comparedth conventional TEE (Fig. 3D)
(13).raprocedural RT3D immediately after balloon in-tion can
diagnose the presence and extent of leafletrs better than TTE,
2-dimensional (2D) TEE, orracardiac echocardiography can (14).RT3D
also provides improved ability to deter-ne the degree of commissure
opening after
BV, which is an important prognosticator ofclinical procedural
success in addition to the
ditional measurement of MV area and gradi-ts (15). Immediate
post-procedure measure-nts of valve area and gradients might
obtainferent results than measurements performeder after LA
remodeling and changes in wall
A B B R
A N D A
LA left
MRmit
MVmi
ParaVR
regurgita
PMBV
balloon v
RT3D r
imaging
TE2E t
edge rep
TEE tra
echocard
TPPR t
periprostmpliance. Furthermore, changes in hearty also have an
impact on mitral gradietentially misleading interpretation of
compve readings.E V I A T I O N S
C R O N YM S
atrial
ral regurgitation
tral valve
paravalvular
tion
percutaneous mitral
alvuloplasty
eal-time 3-dimensional
ranscatheter edge-to-ratents,ar-
-
mi(fi
frounadwiyea
ofdethaattha
calearmeimcirloc
Ca
F
(Avmthretransmitral gradients. (D)showing a severely stenoA2
middle anterior scaarea; P2 middle poster
T
G
A
S
B
E
Th
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 5
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J U L Y 2 0 1 2 : 7 3 3 4 6
Cavalcante et al.
Echo in Percutaneous MV Interventions
736
Downloaded From: http://imagin2E Repair of MV Regurgitation
is percutaneous mitral clip technique mimics thegical mitral
repair procedure introduced in 1991the Italian surgeon Ottavio
Alfieri who success-ly treated a patient with anterior leaflet
prolapse.ing a pledgeted stitch to approximate the edgesthe middle
portions of the anterior and posteriortral valve leaflets, Alfieri
created a double orificegure of 8) (16). In the largest surgical
series
l Assessment of a Stenotic MV by TEE
cardiography (TEE) at mid-esophageal level at 0 (4-chamberleaet
thickening involving the mid-distal segments of theuced opening.
(B) Simultaneous biplane imaging of the MV atat 0 and 90 (right)
with color Doppler showing mild mitralaseline. (C) Continuous-wave
Doppler indicating increased
MV Anatomy According to the Wilkins Score
Mobility Thickening
valve with only leaet tips Leaets near normal in thickness(45
mm)
d base portions have normal Mid-leaets normal,
considerablethickening of margins(58 mm)
s to move forward in diastole,the base
Thickening extending throughthe entire leaet (58 mm)
forward movement of theiastole
Considerable thickening of allleaet tissue (810 mm)
he sum of the 4 items and ranges between 4 and 16.MThtretio
Real-time 3-dimensional imaging with multiplanar reformattingtic
MV with important commissural fusion (MVA 0.84 cm2).llop; LA left
atrium; LV left ventricle; MVA mitral valveior scallop; PMBV
percutaneous mitral balloon valvuloplasty.
g.onlinejacc.org/ on 02/02/2013m this same group, including 260
patients whoderwent such repair, 80% of the cohort hadditional MV
annuloplasty that was associatedth reduced reoperation at a mean
follow-up of 5rs (17).
TE2E implants a clip that grasps the free edgesthe middle
portions of the MV, to reduce the
gree of MR. For example, a portion of 1 leaflett is prolapsing
or flail can be supported byaching it via the clip to the opposite
leaflet thats intact chordae.Several other devices designed to
mimic a surgi-
annuloplasty are under development and/orlier stages of clinical
trials. However, as docu-nted by CT (18), the method of coronary
sinusplantation has some dangers of affecting thecumflex artery and
missing the desired annulusation.The MitraClip system (Evalve Inc.,
Menlo Park,lifornia) has been the most studied device cur-tly
available for transcatheter treatment of MR.e EVEREST I
(Endovascular Valve Edge-to-ge Repair Study) established the
safety, feasibil-, and hemodynamic improvements in patientsth
moderate to severe (3) to severe (4) MR.e morbidity and mortality
were low, and the MRs reduced to 2 in the majority of patients,ng
with sustained freedom from death (19).cently, the results of the
EVEREST II trial wereorted, which randomized patients with 3 to
4
R to either percutaneous repair or surgical repair/lacement.
Percutaneous repair was less effectivereducing MR than conventional
surgery wasproximately 23% patients were left with 3
Calcication Subvalvular Thickening
single area of increasedecho brightness
Minimal thickening just belowthe mitral leaets
cattered areas of brightnessconned to leaet margins
Thickening of chordalstructures extending toone-third of the
chordallength
rightness extending into themid portions of the leaets
Thickening extended to distalthird of the chords
xtensive brightnessthroughout much of theleaet tissue
Extensive thickening andshortening of all chordalstructures
extending downto the papillary musclesTE
ThsurbyfulUsof
able 1. Assessment of
rade
1 Highly mobilerestricted
2 Leaet mid anmobility
3 Valve continuemainly from
4 No or minimalleaets in d
e total Wilkins score (3) is tMV mitral
valve.renThEditywiThwaaloRerepMrepat(ap
igure 1. Pre-Procedura
) Transesophageal echoiew). Note moderate biitral valve (MV)
with rede mid-esophageal levelgurgitation (arrow) at bR), but the
procedural risk of TE2E was low.e surgical and the TE2E groups with
successfulatment showed similar improvements in reduc-n in LV size
as assessed by echocardiography and
-
simercrecof
mmthepo
F
Nth
F
(A proisnimd
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 5
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Cavalcante et al.
Echo in Percutaneous MV Interventions
737
Downloadeilar clinical improvement in symptoms and ex-ise
capacity (20). The high-risk registry dataently showed improvement
in MR in a majoritypatients, resulting in improvement in
clinical
igure 2. Transseptal Puncture Under TEE Guidance
ote tenting of the fossa ovalis by the catheter before
advancinge needle. RA right atrium; other abbreviations as in
Figure 1.
igure 3. Post-PMBV Assessment of the MV by TEE
) Post-PMBV TEE, from the same patient illustrated in Figure 1,
shows im
observed after PMBV with integrity of the mitral leaets and
subvalvular apicant improvement of transmitral gradients. (D)
Post-PMBV real-time 3-dimeprovement in the MVA (from 0.84 to 1.74
cm2), and commissural opening (ifferences before and after PMBV
with Figure 1D. MR mitral regurgitation;
d From: http://imaging.onlinejacc.org/ on 02/02/2013ptoms and
significant left ventricular reverseodeling over 12 months
(21).
tient selection. TE2E has been successful in re-cing MR in 2
groups of patients: those withessive leaflet motion (myxomatous
degeneration
th prolapse or flail); or those with functional MRical tethering
of normal leaflets), including pa-
nts with left ventricular enlargement from isch-ic heart
disease. TE2E is not applicable to
tients with MR due to restricted leaflet motioneumatic MR) and
those with flail or prolapset does not involve the middle portion
of the
terior or posterior mitral leaflets, the graspinga for the TE2E
procedure, or in whom that areacalcified (22).A key TTE inclusion
criterion for the MitraClipuires a regurgitant jet origin
associated with theto P2 segments of the MV and not at the
commis-
es. For patients with functional MR, the coapta-n length must be
at least 2 mm, and the coaptationth less than 11 mm. For patients
with flail leaflet,flail gap must be 10 mm and the flail width
15(19) (Fig. 4). Calcification of the grasping area ofleaflets is
also a contraindication because of
tential risk of embolization. A critical goal of the
ved mobility of both MV leaets (still diastolic frame). (B) Mild
MRsymremPaduexcwi(aptieempa(rhthaanareis
reqA2surtiodeptheparatus. (C) Continuous-wave Doppler across the
MV reveals sig-nsional imaging with multiplanar reformatting shows
signicantarrows) making planimetry a less valid parameter. Compare
MVAother abbreviations as in Figure 1.
-
prenaVi
calvie
Figure 4. An
(A) In functioand leaet relet is more coteromedial
pamalcoaptationat least 2 mmsome tissue tand/or ail, mshort axis
1increased MitEdge-to-Edge
anis
plantion
acmd
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 5
, N O . 7 , 2 0 1 2
J U L Y 2 0 1 2 : 7 3 3 4 6
Cavalcante et al.
Echo in Percutaneous MV Interventions
738
Downloaded From: http://imagin-procedural echo imaging study is
the determi-tion of the MR mechanism and severity (Onlinedeo 4A and
4B, Figs. 5A to 5D). Which leaflet is
atomic Eligibility Criteria for MitraClip (EVEREST Trial)
nal MR, the primary mechanisms are mitral annular
dilationstriction secondary to LV remodeling. The posterior mitral
leaf-mmonly involved from scarring of the inferior wall and
pos-pillary muscle. These processes lead to apical tethering withof
the MV leaets as shown. The coaptation length must be, and
coaptation depth must be 11 mm so that there ishe clip can grasp.
(B) In degenerative MR with MV prolapseeasurements such as ail
depth 11 mm and a ail width on5 mm are important anatomic features
associated withraClip procedural success. EVEREST Endovascular
ValveRepair Study; other abbreviations as in Figures 1 and 3.
igure 5. TEE Assessment of MV Morphology, Regurgitation Mech
) Two-dimensional TEE at mid-esophageal level 0 using real-time
biV annular dilation and leaet tethering leading to central
malcoapta
t 95 of the MV with color Doppler showing systolic frame
representing sonvergence zone with large radius (1.0 cm). (C)
Pulse-wave Doppler interarked systolic blunting (S) indicative of
elevated LA pressures. (D) Continense holosystolic regurgitant jet
with high peak velocity. All these featur
g.onlinejacc.org/ on 02/02/2013ving abnormally is determined
using long-axisws. Which portion of the leaflet is movingnormally
is determined from 2D short-axis views,
intercommissural long-axis views, or RT3D;s has improved the
complete visualization of MVllops (23,24) (Online Video 5, Fig.
6).The potential role of cardiac CT (25,26) anddiac magnetic
resonance (25) in the assessmenta patients eligibility and
intraprocedural guid-
ce for percutaneous MV procedures has beeniewed elsewhere (25).
The feasibility and true
nical utility of these techniques remain untesteda large-scale
cohort of patients.Another important goal of the pre-proceduralo is
to quantitate carefully the severity of MR
ing American Society of Echocardiographyidelines. For this,
important images are zoomd-esophageal long-axis or 4-chamber views
of
flow convergence, for measurement of theasing radius (to
calculate regurgitant orifice area)d the diameter of the vena
contracta, although forR jets that are eccentric, not holosystolic,
or haveximal constraint, the assumptions of these
culations may be misleading. Additional usefulws include a
pulsed Doppler assessment of the
m, and Quantication
e imaging with orthogonal planes showing functional MR
withbetween A2 and P2 scallops. (B) Mid-esophageal zoomed viewF
(AMmovieab2Dthisca
carofanrevcliin
echusgumithealianMproevere central mitral regurgitation jet.
Note the proximal owrogation of the right upper pulmonary vein ow
showinguous-wave Doppler through the MV, which demonstrates aes are
consistent with severe MR. Abbreviations as in Figure 1.
-
papucomividpadifplagitIntthe
F
M re Pa Postaao
TE
A
Q
G
A
A
D
V
R
L
M
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 5
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J U L Y 2 0 1 2 : 7 3 3 4 6
Cavalcante et al.
Echo in Percutaneous MV Interventions
739
Downloadettern of systolic reversal of flow in 1 or morelmonary
veins (Fig. 5C) and the density ofntinuous wave Doppler recordings
through thetral orifice (Fig. 5D). These assessments pro-e an
important baseline for comparison after re-
ir, although the flow convergence methods are veryficult or
nearly impossible once the MitraClip is ince, mostly due to the
multiplicity of residual regur-ant jets after clip
deployment.raprocedural monitoring. The success in
deliveringMitraClip under real-time echocardiographic guid-
igure 6. RT3D TEE With En Face View of the MV (Systolic
Frame)
arked myxomatous changes of the MV leaets, with particularly
severea (ROA) created by the malcoaptation of the prolapse scallops
(D).dding detailed information about the anatomy of MV scallops and
reortic valve (AV) is, and the left atrial appendage (LAA) is to
the left other abbreviations as in Figure 1.
able 2. Role of Transesophageal Echocardiography indge-to-Edge
MV Repair Technique (MitraClip)
ssessing the mechanism of MR
uantitating the severity of MR
uiding transseptal crossing
ligning the delivery system perpendicular to the mitral planeat
the location of the MR jet
lignment of clips arms perpendicular to MV coaptation line
etermining success of grasping both leaetsIm
AinF
erication of clip stability after release from delivery
system
eassessing MR severity
ocating of persistent leak(s)
R mitral regurgitation; MV mitral valve.
d From: http://imaging.onlinejacc.org/ on 02/02/2013e is a
result of the unique collaboration betweenerventionalists and
echocardiographers. The TE2Ecedure entails a standard sequence of
maneuvers,of which are monitored and guided by echocardi-
raphy (Table 2).
2 prolapse and mild A2 prolapse. Note the regurgitant
orice-processing software allows multiplanar reconstruction
(B,C,E,F)nship with other structures. Anterior is to the top, where
thegure. RT3D real-time 3-dimensional; SAX short axis;
igure 7. TEE Bicaval View With Simultaneous
Biplaneancintproallog
latiof the
F
aging Showing IAS Dilation by the Guiding Sheath
rrows indicate the interatrial septum (IAS) dilation by the
guid-g sheath. SVC superior vena cava; other abbreviations as
inigures 1 and 2.
-
echmaanLAdepafacLApa1muothshogusuctheVi
thede
Figure 8. TEEImaging Shoand Into the
(A) Guide sheAV. (B) Semibthe LA walls.ing toward thguide
sheath,as in Figures
(Avthit
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 5
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Cavalcante et al.
Echo in Percutaneous MV Interventions
740
Downloaded From: http://imaginSupervision of transseptal
puncture and crossingthe first goal of TEE imaging. As
mentionedfore, TEE or intracardiac echocardiography canualize the
location where the catheter indents theial septum, allowing the
interventionalist to ad-t the location of septal crossing, aiming
farough superiorly and posteriorly to allow the arc of
catheter to easily reach the middle of the mitralfice. A
mid-esophageal aortic valve short-axis
at Mid-Esophageal Level With Simultaneous Biplanewing the Guide
Sheath Transversing the Interatrial SeptumLA
ath (arrow) into the LA at a safe superior distance from
theicaval view showing the guide sheath tip pointing away from(C)
Live 3-dimensional (3D) view from the LA perspective, look-e RA.
(D) Components of the MitraClip shown by 3D echo:delivery catheter,
and MitraClip at the distal tip. Abbreviations1, 2, 6, and 7.
igure 9. Advancing the MitraClip Into the LV) RT3D of the mitral
valve in the en face/surgeons view using proper peiew using
simultaneous biplane imaging showing the MitraClip being adve
correct position where the MR jet is. Although the image frame rate
dintermittently to aid in the uoroscopic guidance for the
interventional
g.onlinejacc.org/ on 02/02/2013w (multiplane angle of
approximately 30 to 60)d the bicaval view at 90 to 100 are useful
during
transseptal puncture to visualize all the adjacentuctures
avoiding device-endocardial contact. Thensverse 4-chamber (0)
imaging plane can assess
height of proposed septal puncture above theve plane (22).Once
the interatrial septum is crossed, the nextp is to dilate the
interatrial septum to allow thessage of the delivery system and
clip toward theurgitant MV (Fig. 7). During advancement ofsuper
stiff wire, monitoring with TEE can help
avoid puncture of the LA appendage or LA wallavoid pericardial
tamponade. The catheter tip isodense and should be imaged during
mostnipulations to avoid contact with the posterior
d lateral structures such as the lateral LA wall andappendage
(Online Video 6, Fig. 8). Then the
livery catheter is turned inferiorly and alignedrallel to the
antegrade mitral flow. For this, the ene RT3D of the MV surgeons
view from the
perspective (23) (Fig. 9A) is helpful. Werticularly use the
biplane real-time imaging withplane in the intercommissural
orientation (atltiplane angles of about 45 to 70), and theer in a
long-axis orientation (Fig. 9B). The clipuld be positioned where
the largest mitral re-
rgitant jet is located by color Doppler mapping,h that it splits
the jet and is pointed parallel to
direction of mitral antegrade flow (Onlinedeo 7).Once the tip of
the delivery catheter is poised in
LA just above the MV, the arms of the clipvice are then opened.
It is important to rotate theisbevisatrjusentheori
Fvieanthestrtratheval
steparegthetotorpendicular alignment of the MitraClip. (B)
Mid-esophagealanced into the MV. Color Doppler mapping is used to
guideecreases due to increased processing demand, we tend to
usecardiologist. Abbreviations as in Figures 1, 3, and 6.
-
climisurtrialtof
anthefrooude(Fgraass(OsubbroofsubantiototetFiresdurinshmonewhareimtraThwhstewiaftMam
deintbipsinthemiingofproco
ancabdecedcartraba
FS
(AMwm
FR
(Alod(C
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Echo in Percutaneous MV Interventions
741
Downloadep arms so that they are perpendicular to thetral
coaptation line, primarily using the RT3Dgeons view; when it is
unavailable, the transgas-
c 2D short-axis view of the MV should be used,hough it is
difficult to obtain in about one-thirdpatients (Online Video 8,
Figs. 10A and 10B).After passage of the clip into the left
ventricle,d final verification of its position and orientation,
open device is pulled up to grasp the leafletsm their underside.
Both RT3D and simultane-s biplane imaging are crucial at this point
totermine the success of grasping both leafletsigs. 11A and 11B).
Once both leaflets aresped, the arms of the clip are closed and
anessment is made of the new severity of the MRnline Video 9, Fig.
11C). If the MR has not beenstantially reduced, the clip is everted
andught back into the LA, and a repeat placementthe same clip is
attempted. If the MR has beenstantially reduced, the clip arms are
tightened
d the delivery system is detached. After verifica-n of the
stability of the clip, the suture attachedthe clip is pulled
through to remove the finalher of the clip (Online Video 10, Fig.
11D).nally, repeat assessment of the severity of theidual MR and
the mitral gradient, before andring afterload manipulation with
phenyleph-e, helps to determine whether a second clip
ould be placed, which is indicated usually ifderate or greater
(2) MR is present. If
eded, the second clip should be positionedere the flow
convergence and vena contractalargest. Before a second clip is
deployed, it is
portant to search for any significant increase innsmitral
gradients resulting from the first clip.is routine practice is
probably the explanationy no cases have been reported of acute
mitralnosis with this procedure. Finally, in patientsth
hypotension, it may be useful to manipulateerload and pre-load to
evaluate the severity ofR under hemodynamics more comparable
tobulatory conditions.
This TE2E procedure can be lengthy and verymanding on both the
echocardiographer anderventionalist. Both RT3D and simultaneouslane
imaging provide substantial value overgle-plane 2D TEE by reducing
the need to flipimage back and forth between the intercom-
ssural and long-axis views. Frequent monitor-
of the pericardial space allows early detection
growing effusions before hemodynamic com-mise develops. As
mentioned previously, good
mmunication between the echocardiographer
stM(ap
d From: http://imaging.onlinejacc.org/ on 02/02/2013d the
interventionalist, using standardized vo-ulary and anatomical
landmarks, is essential to
crease maneuvering error and to increase pro-ural efficiency.
With the advent of 3D echo-diography, there is also a need for
properining of the interventional cardiologist on thesic 3D views.
This is of critical importance if
igure 10. Transgastric View With Retroexion Showing the LV
inhort-Axis View With the MitraClip Straddling the MV Leaets
) Note that the MitraClip (arrow) is not orientated
perpendicular toV coaptation line (dashed blue line). (B) MitraClip
position is correctith 30 of clockwise rotation of the delivery
catheter. Lat lateral; Medial; other abbreviations as in Figure
1.
igure 11. Sequence of Events in the Deployment of
Edge-to-Edgeepair Technique (MitraClip)
) Simultaneous biplane imaging at 60 and 150 demonstrates the
ecation of the MitraClip within the MV structure. Once the position
isrmed, grasping of the MV leaet occurs. (B) Live 3D zoomed view
ofelivery catheter and MitraClip grasping the A2 and P2 scallops of
the) Similar to A, simultaneous biplane imaging at 60 and 150
demonMV
xactcon-theMV.-theeded rates trivial to mild (1) MR after
MitraClip grasps the MV leaets. (D)itraClip system is nally
released from the delivery system and seenrrow) in the center of
the new gure-of-8 MV. Ant anterior; Post osterior; other
abbreviations as in Figures 1, 3, 8, and 10.
-
Amansitporap
TP
Patioancuuncorhydutioall
paassbidhatoanpuriePatec(27speMdeorGoproagheregingde4)(peatrantatTE
ginistricomoenven
Figure 12. TE
(A) Two-dimeshowing paraaspect of thezone (arrowh150,
shown(arrow). (C) Rlar hole (arroshows the laFigures 1, 6,
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 5
, N O . 7 , 2 0 1 2
J U L Y 2 0 1 2 : 7 3 3 4 6
Cavalcante et al.
Echo in Percutaneous MV Interventions
742
Downloaded From: http://imagins technique is used for real-time
navigation.ientation in the 3D domain can be particularlynfusing
the absence of internal anatomicaldmarks. A recent document from
the Euro-
an Association of Echocardiography and theerican Society of
Echocardiography provides
important practical guide on the image acqui-ion,
interpretation, as well as current andtential clinical applications
of 3D echocardiog-hy (2).
E Baseline Assessment of ParaVR
nsional (2D) TEE at mid-esophageal 4-chamber view (0)valvular
regurgitation (ParaVR) (arrow) outside the anteriorMV bioprosthesis
annulus. Also note the ow convergenceead), which suggests signicant
regurgitant ow. (B) Atfrom another angle, is the severe anterior
paravalvular leak
able 3. Role of TEE in TPPR
ssessing the severity of ParaVR
entication of the location and number of holes
uiding atrial septal puncture or LV apical puncture (in
patientswith the combination of prosthetic aortic and mitral valves
orissues of crossing the aortic valve)
uiding placement of the veno-arterial rail
ssessing reduction in ParaVR during balloon ination
ssisting with placing the disk in the defect
onitoring the effects of the device on prosthetic
leaet(occluder) motion
eassessing the severity of ParaVR
left ventricular; ParaVR paravalvular regurgitation; TEE
transesoph-eal echocardiography; TPPR transcatheter closure of
periprostheticgurgitation.aomocofor
T3D of the MV bioprosthesis demonstrating the paravalvu-w). Note
the AV is on the top. (D) RT3D with color Dopplerrge anterior
paravalvular leak (arrow). Abbreviations as inand 11.
g.onlinejacc.org/ on 02/02/2013PR
tient and device selection. Paravalvular regurgita-n (ParaVR) is
common, but most cases are smalld asymptomatic. Clinically
important ones, oc-rring in as many as 5% of patients who
havedergone valve replacement, tend to present withngestive heart
failure, hemolytic anemia, or ar-thmias. This may result from
suture dehiscence
e to infection (endocarditis), annular calcifica-n, technical
problems, and/or a combination ofof those.
Surgical intervention is usually recommended totients with
symptomatic ParaVR, especially if it isociated with infection,
although increased mor-ity and mortality associated with
reoperation
ve stimulated the development of other optionsaddress this
complex problem. TPPR appears asattractive, albeit challenging,
alternative. Most
blished evidence comes from single-center expe-nce with case
reports predominantly involvingraVR of the MV prosthesis. More
recently,hnical success has ranged from 63% to 100%30). In this new
field of work, the design ofcific plugging devices is in its early
phase (31).
ost reports of TPPR have entailed off-label use ofvices designed
to close congenital septal defectsvascular plugs.als of imaging in
TPPR and description of thecedure. Transprocedural
echocardiographic im-
ing in TPPR is critically important because it canlp the
interventionalist to: 1) locate the optimalion for transseptal
puncture; 2) guide the cross-of the hole that leads to ParaVR; 3)
monitor the
crease in ParaVR during balloon inflation;monitor the onset of
possible complicationsricardial effusion, iatrogenic
post-procedureial septal defect or prosthetic leaflet entrapment);d
5) assess the final result of the device implan-ion. Table 3
summarizes the important aspects ofE for this particular
procedure.
The role of transesophageal echo in TPPR be-s with assessing the
severity of the ParaVR. This
difficult in mitral ParaVR because the left ven-cular side of
the mitral prosthesis, where the flownvergence would ideally be
measured, is com-nly shadowed by the prosthesis itself. The
pres-
ce of a mitral prosthesis also shields the lefttricular outflow
tract where the periprostheticthiOrcolanpe
T
A
Id
G
G
A
A
M
R
LVagrertic regurgitation would be observed. Further-re, wall
constraint often prevents the flow
nvergence from forming hemispheric isovelocityms, so
quantitation of the MR is often difficult.
-
TPof2Dstaofuselowglefacniqthetheanrotthenetermavis
tectheDySestrestrapCTThreacedus
lowagintov
rigsnafemmiheaccthrbebetioaredecre
F FluoR
T A) FtiP(Ca
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Cavalcante et al.
Echo in Percutaneous MV Interventions
743
DownloadeProbably the most important role of TEE inPR is
identification of the location and numberholes that are present.
Single-plane and biplaneTEE with color Doppler imaging is the
main-
y tool for this purpose (Figs. 12A and 12B). UseRT3D with color
Doppler imaging appears to beful (27,32,33) (Figs. 12C and 12D),
although
temporal resolution, lack of standardized an-s, and potential
motion creating stitching arti-ts are current limitations of this
imaging tech-ue. Nonetheless, for mitral prosthetic
regurgitation,RT3D TEE with en face/surgeons view fromLA is most
helpful. Although necessitating
other step, the best convention should be toate the image so the
aortic valve is at the top ofimage (Figs. 11D and 12C). Multiple
simulta-
ous biplane 2D views also are useful for charac-ization of
anatomic relationships. Note should bede of which TEE imaging
plane/angle bestualizes the regurgitant jet.We also frequently use
a fluoroscopic overlayhnique with CT scanning produced by
rotatingC-arm at high speed around the patient (Syngo
naCT Cardiac, Siemens, Erlangen, Germany).veral hundred images
are acquired and recon-ucted as 3D volumes. Anatomic details of
inter-are marked on the pre-procedural CT angiog-hy, which is
coregistered to an intraprocedural
acquired in the catheterization laboratory.e CT-CT registration
is then fused to thel-time fluoroscopic image, allowing better
pro-ural navigation with fluoroscopy and with less
e of a contrast medium (34). Furthermore,
igure 13. Fusion/Overlay of the ParaVR Information by TEE
Withotating the C-Arm at High Speed Around the Patient
his technique allows better procedural navigation with
uoroscopy. (
onist drawings indicating the site of transseptal puncture (1),
the prosthearaVR (blue circles) (not well-seen in this projection
but correspondingT)/uoroscopy imaging overlay demonstrating the
prosthetic MV andccording to appropriate en face TEE. Abbreviations
as in Figures 1, 6,
d From: http://imaging.onlinejacc.org/ on 02/02/2013idance in
the optimum site for transseptalncture (Fig. 13A) and overlaying
the ParaVRation, defined by TEE, on the fluoroscopy areer important
strengths of this new imaginghnique (Fig. 13B).Access to the defect
may be either antegrade viaenous transseptal approach or retrograde
in theection of the regurgitation from arterial accessming across
the aortic valve or transapical). The
e of transseptal puncture in TPPR is highlyiable and dependent
on the location of theraVR. For example, lateral defects are
betterproached with transseptal access in the posteriorrt of the
fossa via the inferior vena cava, whereasdial defects adjacent to
the septum require evener and posterior puncture (35). Therefore,
im-
ing guidance of atrial septal puncture either byracardiac or TEE
or with the CT/fluoroscopyerlay as aforementioned is important in
TPPR.The objective is to pass a wire through from theht atrium to
the LA. The venous wire is thenred using another wire introduced
through theoral artery. In patients who have both aortic and
tral valve replacements in place, the echo canlp guide LV apical
puncture for downstreamess (27). The first (venous) wire is
pulledough and its tip exteriorized, which can thuscalled a
veno-arterial rail (36). This allows
tter support for the delivery catheter in situa-ns where
numerous defects and/or acute angles
encountered thereby making transit of thelivery catheter
difficult across the ParaVR orating excessive kinking on it. Hence,
TEE has
roscopic Overlay Technique With CT Scanning Produced by
luoroscopic right anterior oblique projection with the
interven-gupulocothtec
a vdir(cositvarPaappametic MV (2), aortic valve (t3-leaf-clover)
(3), and the 2 sites ofto the sites on the next panel). (B)
Computed tomographythe 2 sites of ParaVR (pentagon and square
shapes)and 12.
-
anwialiocerawithiocTEwiTEmehe
enisregthethaanmeregof
F
(AddmOPd
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, N O . 7 , 2 0 1 2
J U L Y 2 0 1 2 : 7 3 3 4 6
Cavalcante et al.
Echo in Percutaneous MV Interventions
744
Downloaded From: http://imaginimportant role in guiding
placement of there. Once the wire is in place, the intervention-st
can move and approach placement of thecluder device from either
direction. Some op-tors use balloon inflation within the defect
th TEE to see if the regurgitation is reduced bys temporary
occlusion of the defect. If balloonclusion reduces the
regurgitation substantially,E guides placement of the occluder
device
thin the defect. After the device is expanded,E monitors for
changes in the motion ofchanical disks or other adverse effects on
the
art (Online Video 11, Fig. 14).Reassessment of the ParaVR
severity by TEEables a decision whether a second occluder
deviceneeded. This reassessment of the severity ofurgitation again
is problematic because oftenre are unusual anatomy and perivalvular
tractst are eccentric and shielded by a prosthetic valve
igure 14. Percutaneous Closure of ParaVR From a Dehisced
Mitra
) There are 2 separate ParaVR jets (anterior and lateral) that
are modehiscence. (B) Under uoroscopic and TEE guidance,
transseptal punceployment of rst Amplatzer device (St. Jude
Medical, St. Paul, Minneoderate residual anterior ParaVR. (D) The
anterior ParaVR is now appnce position is conrmed, transient
balloon ination within the ParaVaraVR) for subsequent deployment of
the second Amplatzer device. (evices in close proximity to each
other and, more important, normall Bioprosthesis
erate (2 to 3) in severity and arising from the area of
annularture allows the venous wire to cross the lateral defect. (C)
Post-sota). Note resolution of lateral ParaVR and close proximity
ofroached with the venous wire crossing of the ParaVR defect. (E)R
defect allows conrmation of adequate position (no signicantF) Live
3D view of the mitral bioprosthesis shows the 2 AmplatzerMV leaet
functioning. Abbreviations as in Figures 1, 6, 8, and 12.
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 articial lines thatdivide/fragment the structure being
imaged; and 2) near-eld artifactd the interventional device.
Therefore, assess-nt of the aliasing radius for calculation of
theurgitant orifice area is problematic; other meansregurgitation
assessment, including spatial color
dzotrti
g.onlinejacc.org/ on 02/02/2013ue to improperly high
gain-settings in the near eld creating a darkne over the area of
interest. SBP systolic blood pressure; TPPR anscatheter closure of
periprosthetic regurgitation; other abbrevia-ons as in Figures 1,
6, 7, and 8.
-
Do inare
dinete cefro lacoc thred
Fu
In E,ag ) wto n pM , bsel mde nnne blecrucial for the long-term
success. In TPPR, betterdecatim
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and possession of unique interventional imaging
AcThmenafluFig
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Cavalcante et al.
Echo in Percutaneous MV Interventions
745
Downloadepingement.Although 3D TEE is a powerful tool with
severalvantages for use in percutaneous interventions,provements,
in particular, the frame rate whenng simultaneous RT3D with color
Doppler areeded. Furthermore, during acquisition of fulllume 3D
dataset, stitch artifacts can occur due toegular heart rhythm,
patients respiratory motion,fine probe movements, making
interpretationre difficult. Improper gain adjustments along
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acm the arterial and venous side, pcluder device, and assessment
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ture Directions
traprocedural imaging (RT3D TEing, CT/fluoroscopy overlay,
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ant in addition to the leaflet proflow profiles,
g transcath-ss to the areaement of thee amount of
biplane im-ill continueercutaneousetter patientents on theulus
compo-m would be
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ienced team composed by anlogist, an interventional
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y Words: balloonvuloplasty y mitralurgitation y mitral valve
y
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Role of Echocardiography in Percutaneous Mitral Valve
InterventionsPMBV for Mitral StenosisPatient
selectionIntraprocedural monitoring
TE2E Repair of MV RegurgitationPatient selectionIntraprocedural
monitoring
TPPRPatient and device selectionGoals of imaging in TPPR and
description of the procedure
Future DirectionsAcknowledgmentsReferencesAppendix