A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair

Summary

This protocol presents in detail how to perform real-time echocardiographic guidance during transcatheter mitral valve repair. The fundamental views and the necessary measurements are described for each stage of the procedure.

Abstract

Percutaneous transcatheter edge-to-edge reconstruction of the mitral valve is a safe and well-established therapy for severe symptomatic mitral regurgitation in patients with high surgical risk. Echocardiographic guidance in addition to fluoroscopy is the gold standard and should be performed using a standardized technique.

This article lays out our reproducible step by step echocardiographic guide including views, measurements as well as highlighting possible difficulties that may arise during the procedure.

This article provides detailed and chronological echocardiographic views for each step of the procedure, especially preferences between 2D and 3D imaging. If needed, pulse wave, continuous wave and color doppler measurements are described. Furthermore, as there are no official recommendations for the quantification of mitral regurgitation during the percutaneous edge-to-edge-repair procedure, advice is also included for echocardiographic quantification after grasping the mitral leaflets and after device deployment. In addition, the article deals with important echocardiographic views to prevent and deal with possible complications during the procedure.

Echocardiographic guidance during transcatheter mitral valve repair is mandatory. A structured approach improves the collaboration between interventionist and imager and is indispensable for a safe and effective procedure.

Introduction

Mitral regurgitation (MR) is the second-most frequent indication for valve surgery in Europe¹. Untreated, it may lead to severe heart failure and reduced quality of life^2,3,4. The percutaneous mitral valve repair (PMVR) is a catheter-based technique, which mimics the Alfieri stitch surgical method to mitral repair by connecting the A2 and P2 scallops⁵. For patients with high surgical risk, this technique offers a minimally invasive approach for the treatment of severe MR. Data from several registries and trials has shown that th....

Protocol

The protocol follows the guidelines of our's institution's human research ethics committee.

1. Evaluation before intervention

1. Exclude pericardial effusion before transseptal puncture. If a small pericardial effusion is present, measure the maximal end-diastolic echolucent space in a four-chamber (4Ch) view with a focus on the right ventricle (RV), a mid-oesophageal right ventricular inflow-outflow view, and a long-axis (LAX) view.
2. Evaluate the pulmonary venous flow pattern with pulse wave doppler (PW) in the left upper pulmonary vein (LUPV) and exclude thrombus formation in the left atrial appendage (LAA). Show the sho....

Results

Percutaneous edge-to-edge valve repair is an alternative to surgical valve repair or replacement in patients not eligible for surgery with symptomatic severe MR. The first clinical application of the MitraClip was investigated in the Endovascular Valve Edge-to-Edge Repair Study I (EVEREST I)¹⁴ trial. Many other trials have proven the effectiveness of the procedure with an improvement of symptoms as well as low rates of hospital mortality and adverse events (ACCESS EU, TRAMI, EVEREST II)

Discussion

Echo-guidance for the PMVR is a safe method. Complications due to echocardiography may occur but rarely lead to significant damage. Nevertheless, esophageal lesions are possible after performing transesophageal echocardiography. This incidence is reduced with a shorter duration of the intervention³⁴. On the contrary, several complications associated with the transcatheter edge-to-edge mitral valve repair are described^35,36. Major bleeding .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
EPIQ 7 Ultrasound System	Philips	US218B0542	Cardiac Ultrasound Machine
X8-2t xMATRIX 3D-TEE probe	Philips	B34YYK	TEE-probe
Sheath 6F 25 cm	Merit Medical	B60N25AQ	Sheath
Dilator 16 F	Abbott	405544	Dilator
BRK-1 transseptal needle 71 cm	St. Jude Medical	ABVA407201	Transseptal Needle
Swartz Lamp 90°	St. Jude Medical	407356	Transseptal Guiding Introducer Sheath
Amplatz super stiff	Kook Medical	46509	Wire
Steerable Guide Catheter	Abbott	SGC0302	Steerable Guide Catheter
MitraClip NTR Delivery System	Abbott	CDS0602-NTR	Clip Delivery System
MitraClip NTR Bundle	Abbott	MSK0602-NTR	Device