ECHO 2013 / Interventional Echocardiography
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Post-procedure: 3D Echocardiography
Assessing Valve |
Assessing Aortic |
Assessing |
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Position/Shape |
Regurgitation |
Aortic Anatomy |
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Peri-aortic hematoma
Edge-to-Edge
Echocardiography:
Identify mechanism of MR: degenerative flail segment with flail width <1.5 cm vs. ischemic or functional etiology
Ensure origin of regurgitant jet is within central two-thirds of coaptation line (away from
commissures)
Quantitate MR
Guide clip deployment
Assess reduction of MR post-clip and stability of clip placement
Circ Cardiovasc Imaging. 2012;5:748-755
Residual MR |
MVOA |
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At 6 months follow-up, left atrial and left ventricular enddiastolic volumes were significantly more reduced in patients in whom regurgitant vena contracta area was reduced by >50% compared with those with less reduction
Step 1: Trans-septal Puncture
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Too Superior |
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Mid-posterior fossa |
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1.Transseptal puncture and introduction of catheters
1.Locate the position and direction of transseptal catheter puncture
•3.5-4 cm above the annular plane
•Mid-posterior fossa
•Posterior and superior direction of the catheter
2.Position the MitraClip™ guiding catheter so that the tip (doubleechodensity) is across the interatrial septum.
Step 3: Position and Orient Clip
3.Position the clip and orient the clip arms:
1.Based on the pre-procedural anatomic imaging (TEE) of the mitral valve, the clip is positioned over the regurgitant orifice.
2.The clip arms are partially opened to determine orientation
Guide the orientation/rotation of the clip arms to be perpendicular to the leaflets at the site of the regurgitant orifice
Note: although typically the clip is perpendicular to the commissures, maximum reduction in regurgitant volume may require an off-axis orientation of the clip.
Use color Doppler to confirm positioning above the regurgitant jet
Posterior Leaflet Capture
Anterior Leaflet Capture
Step 5: Post-deployment Assessment
5.Post-deployment assessment:
1.Verify mitral regurgitation reduction by multiple methods:
CW Doppler for peak and mean transmitral gradients
Color Doppler for MR jet area and vena contracta
PW Doppler for reversal of pulmonary vein flow Planimetry of the regurgitant orifice using en face
views of 3D color Doppler. 2. Planimetry of the double mitral valve orifice area
3D reconstruction and planimetry may be useful in the setting of nonplanar orifices
3. Decide whether second clip is required
Step 5: Post-deployment Assessment
Planimetry of the regurgitant orifice using en face views of 3D color Doppler
EROA = 0.25 cm2
Decision made to deploy a second clip
Second Clip Deployed
LV Stroke Volume = 76 cc
MVA = 1.86 cm2
EROA (3D) = 0.03 + 0.03 cm2 = 0.06 cm2
MVOA by planimetry = 1.6 + 1.3 cm2
Peak/mean gradients = 5 and 3 mmHg
Percutaneous Transcatheter Repair of
Paravalvular Regurgitation
Kim MS et al. J Am Coll Cardiol Intv 2009;2:81–90
Multiple procedural approaches are currently being
used
Retrograde (through AV)
Antegrade (through the IAS)
Transapical (through the LV apex)