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Mitral Valve Devices

  • Christine JellisEmail author

Abstract

The MitraClip (Fig. 6.1) is a percutaneous mitral valve repair system from Abbott Vascular. The device incorporates a steerable guide catheter that traverses the interatrial septum and enables accurate positioning and trajectory of the clip (Fig. 6.2).

Keywords

MitraClip Occluder devices Paravalvular leak Transcutaneous valve replacement 

Supplementary material

Video 6.1

Transesophageal echo (TEE) biplane view at 125° and 11°, demonstrating excessive motion and flail of the A2 segment of the anterior mitral valve leaflet (AVI 3872 kb)

Video 6.2

TEE biplane view at 125° and 11°, demonstrating severe posterolaterally directed mitral regurgitation (AVI 1180 kb)

Video 6.3

Tenting of the interatrial septum to confirm the position prior to septostomy (AVI 7690 kb)

Video 6.4

The guide catheter is then advanced across the interatrial septum to gain access to the left atrium (AVI 4432 kb)

Video 6.5

The device is positioned in the left atrium to ensure appropriate medial-lateral and anterior-posterior alignment with the mitral valve (AVI 6117 kb)

Video 6.6

The device can be seen approaching the valve, using 3D imaging (AVI 2332 kb)

Video 6.7

3D imaging can be used to visualize the MitraClip crossing the mitral valve (AVI 1962 kb)

Video 6.8

When both clip arms are adequately aligned, the clip is positioned perpendicular to the line of leaflet coaptation. Both leaflet tips must be fully inserted on both sides of the device between the grippers and clip arms to ensure stability of attachment (AVI 4108 kb)

Video 6.9

After deployment on an initial MitraClip across the medial aspects of A2 and P2, there is good leaflet opposition with moderate (2+) residual MR (AVI 4226 kb)

Video 6.10

3D zoom imaging is used to visualize the MitraClip from the left atrium. The clip is well positioned, with good attachment to both leaflets, and creates a double-orifice valve appearance (AVI 2359 kb)

Video 6.11

The same double-orifice view can be appreciated in 3D from the left ventricular aspect of the mitral valve (AVI 2311 kb)

Video 6.12

If there is residual MR, a second MitraClip is often deployed to improve leaflet coaptation. Care must be taken not to disrupt the first clip and to ensure that the valve orifice does not become stenotic. There is also increased risk of snaring the second clip in the subvalvular apparatus, as the chordae are now more centrally positioned after deployment of the first clip. In this example, deployment of a second clip is seen immediately adjacent to the first clip on the lateral aspect of the A2 and P2 scallops (biplane view) (AVI 4300 kb)

Video 6.13

An excellent final result is achieved, with only trivial MR seen on this bicommissural view with simultaneous gray-scale and color Doppler images (AVI 5098 kb)

Video 6.14

Trivial MR is confirmed on a long-axis view with simultaneous gray-scale and color Doppler images (AVI 5190 kb)

Video 6.15

The adjacent MitraClips create a double orifice mitral valve, which can be visualized in 3D from both the left ventricular (left image) and left atrial (right image) aspects (AVI 2534 kb)

Video 6.16

An expected trivial to mild residual left-to-right interatrial shunt was noted at the septostomy site on color Doppler imaging (AVI 5364 kb)

Video 6.17

TEE 120° view shows the mitral valve with two MitraClips deployed side-by-side on the central and medial aspects of the valve, with good leaflet coaptation (AVI 10853 kb)

Video 6.18

TEE 120° view demonstrates mild (1+) residual central MR (AVI 2617 kb)

Video 6.19

Biplane view of the mitral valve in long-axis (125°) and off-axis (17°) four-chamber views, again showing the MitraClips (AVI 5001 kb)

Video 6.20

Biplane view of the mitral valve in long-axis (125°) and off-axis 4 chamber views (17°) with the MitraClips in situ and mild (1+) residual MR (AVI 1003 kb)

Video 6.21

3D zoom view of the mitral valve from the left atrial perspective. The Mitraclips can be seen side-by-side, apposing the anterior and posterior leaflets (AVI 1076 kb)

Video 6.22

Use of Philips 3DQ reconstruction software demonstrates a multiplanar view of the mitral valve with the MitraClips in situ (AVI 1554 kb)

Video 6.23

Color Doppler imaging in a long-axis (120°) view confirmed severe (4+), posteriorly directed mitral regurgitation due to anterior leaflet prolapse and partial flail (AVI 1543 kb)

Video 6.24

3D imaging of the mitral valve from the left atrium confirmed predominant involvement of the A1/A2 scallops (AVI 621 kb)

Video 6.25

Atrial septostomy was performed (AVI 3546 kb)

Video 6.26

The device is aligned with the mitral valve using the steerable guide catheter, which bends at 90° in the left atrium after traversing the interatrial septum (AVI 7462 kb)

Video 6.27

The device is aligned perpendicular to the valve leaflets. The long-axis (120°) view is helpful to visualize both device arms and both mitral valve leaflets simultaneously (AVI 7145 kb)

Video 6.28

Once the MitraClip is adequately positioned with optimal leaflet insertion between the grippers and arms, the clip is deployed (AVI 7453 kb)

Video 6.29

This transgastric TEE view shows a lateral view of the MitraClip with the clip arms perpendicular to the line of leaflet coaptation (AVI 7639 kb)

Video 6.30

Using 3D imaging of the mitral valve from a left atrial view, the clip can be seen apposing the lateral aspects of the leaflets (A1/P1 scallops) (AVI 1149 kb)

Video 6.31

To ensure optimal leaflet coaptation, a second MitraClip was deployed more medially. Residual 1+ MR was noted on color Doppler imaging with TEE (AVI 1679 kb)

Video 6.32

Long-term follow-up with transthoracic echocardiography (TTE) demonstrates a good result, with only trivial residual MR noted on an apical four-chamber view (AVI 2897 kb)

Video 6.33

Color Doppler imaging in a parasternal long-axis view by TTE shows negligible regurgitation (AVI 2190 kb)

Video 6.34

TEE view of the mitral valve at 112°, demonstrating anterior leaflet prolapse (A2 scallop) (AVI 6904 kb)

Video 6.35

Color Doppler imaging demonstrates resultant moderately severe (3+) MR due to failure of leaflet coaptation (AVI 2187 kb)

Video 6.36

Baseline 3D image of the mitral valve viewed from the left atrium (AVI 1482 kb)

Video 6.37

3D image showing the guide catheter in the left atrium approaching the mitral valve. The position and trajectory are adjusted to optimize perpendicular alignment of the MitraClip with the valve leaflets (AVI 979 kb)

Video 6.38

A TEE two dimensional (2D) long-axis view of the mitral valve demonstrates that the MitraClip is well positioned, with stable attachment to both leaflets, and is ready for deployment (AVI 6948 kb)

Video 6.39

(a) After MitraClip deployment, 3D imaging shows the guide catheter retracted into the left atrium (AVI 2360 kb)

Video 6.39

(b) The MitraClip can be seen apposing the valve leaflets centrally across the A2 and P2 scallops to create a double-orifice mitral valve (AVI 1634 kb)

Video 6.40

2D imaging of the mitral valve in long-axis view demonstrates 1+ residual MR (AVI 3942 kb)

Video 6.41

2D TEE image at 90° of the St. Jude bileaflet mitral valve replacement (AVI 6519 kb)

Video 6.42

Color Doppler imaging demonstrates a severe, eccentric, paravalvular leak at the anterolateral aspect of the prosthetic valve annulus (AVI 1893 kb)

Video 6.43

3D imaging of the left atrial aspect of the mitral valve prosthesis. The arrow points to a region of dehiscence from which the paravalvular leak originates (AVI 3399 kb)

Video 6.44

Color 3D imaging demonstrates color flow through the region of dehiscence, representative of the paravalvular leak (AVI 529 kb)

Video 6.45

A 3D view of the mitral valve from the anterolateral aspect demonstrates the region of dehiscence (AVI 466 kb)

Video 6.46

3D image of the bileaflet mitral valve prosthesis with the occluder device in situ, adjacent to the anterolateral aspect of the valve (AVI 438 kb)

Video 6.47

Biplane color Doppler TEE image at 130° and 11°, showing a bileaflet prosthetic mitral valve with moderate (2–3+) anterolateral paravalvular leak (AVI 1150 kb)

310450_1_En_6_MOESM49_ESM.avi (134 kb)
Video 6.48 Color 3D reconstruction image of the paravalvular jet of mitral regurgitation (AVI 134 kb)
Video 6.49

3D image of the mitral valve from a left atrial view, showing a guide catheter through the anterolateral region of valve dehiscence (2 o’clock position) (AVI 567 kb)

Video 6.50

3D reconstruction of the mitral valve from the left atrial view. The paravalvular leak was successfully closed using 10-mm and 12-mm Amplatzer Vascular Plug II devices at the 2 and 3 o’clock positions (AVI 754 kb)

310450_1_En_6_MOESM52_ESM.avi (501 kb)
Video 6.51 Biplane color Doppler TEE image at 125° and 14° after deployment of the occluder in the anterolateral region of valve dehiscence. The Amplatzer occluder devices can be seen adjacent to the valve replacement, with only a trivial residual paravalvular leak (AVI 501 kb)
Video 6.52

TEE image at 61° demonstrating a normally functioning bileaflet St. Jude prosthetic mitral valve (AVI 4737 kb)

Video 6.53

TEE image at 61° demonstrating the mild to moderate paravalvular leak (AVI 1882 kb)

Video 6.54

Valve dehiscence is not evident on 3D reconstruction (Philips 3DQ) of the mitral valve replacement from a left atrial view, owing to the small size of the orifice of the leak (AVI 1249 kb)

Video 6.55

Magnified view of the 3D mitral valve reconstruction from Fig. 6.64 (AVI 929 kb)

Video 6.56

Transesophageal 91° view demonstrating a trivial residual paravalvular leak after deployment of the occluder device (AVI 1646 kb)

Video 6.57

3D zoom view of the mitral valve, showing the 12-mm Amplatzer Vascular Plug II device deployed inferoposteriorly (AVI 3809 kb)

Video 6.58

TTE parasternal long-axis view with simultaneous 2D and color Doppler imaging demonstrating the occluder device in situ adjacent to the posterior aspect of the valve ring. No significant residual mitral regurgitation is visible (AVI 4244 kb)

Video 6.59

Transthoracic parasternal short-axis view just apical to the true mitral valve annulus with simultaneous 2D and color Doppler imaging. The ventricular aspect of the occluder device can be seen inferoposteriorly (AVI 6442 kb)

Video 6.60

Transesophageal 0° view demonstrating the Carpentier-Edwards prosthetic mitral valve in situ, with calcification and immobility of the posteromedial leaflet (AVI 5076 kb)

Video 6.61

3D zoom of the bioprosthetic mitral valve from the left atrium, demonstrating thickening and immobility of the posteromedial prosthetic leaflet (AVI 996 kb)

Video 6.62

3D imaging of the guidewire across the mitral valve (AVI 1835 kb)

Video 6.63

3D imaging of the mitral valve prosthesis being fed along the guide wire into position (AVI 862 kb)

310450_1_En_6_MOESM65_ESM.avi (506 kb)
Video 6.64 3D imaging during balloon inflation and deployment of the new 26-mm Edwards Sapien bioprosthetic valve prosthesis (AVI 505 kb)
Video 6.65

3D imaging after deployment of the fully expanded and normally functioning mitral valve prosthesis; the guidewire is still in situ (AVI 1006 kb)

Video 6.66

3D imaging after removal of the guidewire demonstrates unrestricted opening of the new transcutaneous “valve in valve” mitral valve replacement (AVI 1933 kb)

Video 6.67

Transesophageal 2D biplane view (0° and 90°) demonstrating the new transcutaneous mitral valve replacement opening normally (AVI 4148 kb)

Video 6.68

Transesophageal biplane view (0° and 90°) with color Doppler imaging demonstrating mild residual valvular mitral regurgitation and a trace anterior paravalvular leak (AVI 912 kb)

310450_1_En_6_MOESM70_ESM.mpg (504 kb)
Video 6.69 Transesophageal four-chamber (0°) view demonstrating moderate to severe thickening of both leaflet tips and restriction of leaflet mobility (posterior > anterior) (MPG 503 kb)
310450_1_En_6_MOESM71_ESM.mpg (504 kb)
Video 6.70 Transesophageal view of the mitral valve at 60°, demonstrating moderate bileaflet thickening with restriction of posterior leaflet movement (P1) but relative preservation of anterior leaflet excursion (A1 and A2 scallops) (MPG 504 kb)
310450_1_En_6_MOESM72_ESM.mpg (499 kb)
Video 6.71 Transesophageal view of the mitral valve at 60° with color Doppler imaging, demonstrating turbulent diastolic forward flow associated with the stenosis but minimal regurgitation (MPG 498 kb)
310450_1_En_6_MOESM73_ESM.mpg (540 kb)
Video 6.72 Transesophageal imaging of the mitral valve at 108° during balloon valvuloplasty (MPG 539 kb)
Video 6.73

Transesophageal four-chamber (−5°) view of the mitral valve after balloon valvuloplasty demonstrates improved anterior leaflet excursion (MPG 1080 kb)

310450_1_En_6_MOESM75_ESM.mpg (415 kb)
Video 6.74 After valvuloplasty, a transesophageal view of the mitral valve at 20° with color Doppler imaging demonstrates reduced turbulence of the diastolic forward flow and only trivial to mild regurgitation (MPG 414 kb)
Video 6.75

Apical long-axis image with color Doppler imaging demonstrates a severely dilated left ventricle with extensive regional wall motion abnormalities consistent with multivessel coronary artery disease. An aneurysmal basal inferior wall is noted. There is severe (3–4+) central mitral regurgitation secondary to apical tethering and leaflet restriction (AVI 10546 kb)

Video 6.76

Apical long-axis 2 chamber (B) image with color Doppler imaging demonstrate a severely dilated left ventricle with extensive regional wall motion abnormalities consistent with multivessel coronary artery disease. An aneurysmal basal inferior wall is noted. There is severe (3–4+) central mitral regurgitation secondary to apical tethering and leaflet restriction (AVI 5689 kb)

Video 6.77

Apical long-axis 3 chamber image with color Doppler imaging demonstrate a severely dilated left ventricle with extensive regional wall motion abnormalities consistent with multivessel coronary artery disease. There is severe (3–4+) central mitral regurgitation secondary to apical tethering and leaflet restriction (AVI 7420 kb)

310450_1_En_6_MOESM79_ESM.avi (3.1 mb)
Video 6.78 After 6 months of cardiac resynchronization therapy, a marked decrease in left ventricular size, improvement in left ventricular function, and reduction in mitral regurgitation severity to mild to moderate (1–2+) were observed (AVI 3127 kb)

References

  1. 1.
    Mauri L, Foster E, Glower DD, Apruzzese P, Massaro JM, Herrmann HC, et al. 4-year results of a randomized controlled trial of percutaneous repair versus surgery for mitral regurgitation. J Am Coll Cardiol. 2013;62:317–28.PubMedCrossRefGoogle Scholar
  2. 2.
    Krishnaswamy A, Kapadia SR, Tuzcu EM. Percutaneous paravalvular leak closure– imaging, techniques and outcomes. Circ J. 2013;77:19–27.PubMedCrossRefGoogle Scholar
  3. 3.
    Wilkins GT, Weyman AE, Abascal VM, Block PT, Palacios IF. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to the outcome and mechanism of dilatation. Br Heart J. 1988;60:299–308.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.Department of Cardiovascular MedicineCleveland ClinicClevelandUSA

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