USE OF ECHOCARDIOGRAPHY IN INTERVENTIONS. PBMV PMVL MITRA CLIP TAMI

1. Echocardiography during
Mitral Valve
Percutaneous Interventions
Dr.Praveen Nagula

2. Introduction
• TEE is routinely used to guide Percutaneous interventions involving
the Mitral valve.
MC percutaneous procedures are
• 1.PBMV (Percutaneous Balloon Mitral Valvuloplasty) for Rheumatic
Mitral stenosis.
• 2.Edge to edge repair with the Mitra clip for MR.
• 3.Closure of Prosthetic ParaValvular Mitral Leakages (PVML).
• 4.TAMI

3. PBMV
• Commissural fusion is the requisite lesion for PBMV to be effective.
• Not effective for degenerative calcific MS, where mitral annular
calcification is the main lesion.

4. Preprocedural assessment
• Assessment of valve area
• The mean doppler gradients
• Pulmonary artery pressure.

5. • 2Dplanimetry - PSxA where the maximal diastolic orifice present.
• Entire MV orifice should be seen.
• Avoid high gain settings – underestimation of MVA
• Correlates with anatomic valve area as assessed on explanted valves.
• Planimetry by 3D echo is more accurate and reproducible than 2D
echocardiography.

6. • Mitral maximal and mean doppler gradients are also calculated.
• Maximal gradient, derived from peak mitral velocity, is influenced
by LA compliance and LV diastolic function.
• Mean MV gradient more accurately reflects the MS severity.
• CW doppler measurements across MV have good correlation with
invasive measurements using Transspetal catheterization.
• Highly rate and flow dependent, as gradient is a function of the
square of the transvalvular flow.
• HR and CO significantly affect the transmitral diastolic gradient.

7. Assessment of valve anatomy and suitability
for PBMV
1.Wilkins score
• 2D echo valve assess morphologic leaflet mobility , flexibility,
thickness, calcification, subvalvular fusion,commissural fusion,
calcification.
• A score greater than 8 suggests the valve may not be suitable for
PBMV.
2.Assessment of commissural calcium - each half commissure with
detection of high intensity bright echoes score of 1.
• Significant predictor of achieving an MVA post PBMV greater than
1.5cm² without creating significant MR.
• Does not add predictive value to score more than 8 in Wilkins score.
• Commissural calcification grade0/1 had large valve areas and better
improvement of symptoms than patients with grade 2/3.

8. 3.Echocardiographic grouping - based on the echocardiographic and
fluoroscopic calcification assessment of the following characteristics:
valve mobility,
fusion of the subvalvular apparatus,and
the amount of leaflet calcification.

9. 4.Real time 3D echocardiographic score - evaluates both mitral
leaflets and sub valvular apparatus.
• Highly reproducible with good interobserver and intraobserver
agreement in the assessment of MV morphology in patients with
MS.
• Superior for detection of calcification and commissural splitting.
• High calcification RT TT3DE –post procedural MR.

10. • No scoring system has been proved to be superior.
• They should be used in conjunction with one another as part of a
comprehensive echocardiogrpahic assessment of the valve
pathology.

11. C/I to PBMV
• MVA >1.5 cm²
• LA thrombus
• More than mild MR
• Severe or bicommissural calcification
• Absence of commissural fusion
• Severe concomitant aortic valve disease or severe combined TS and
TR.
• Concomitant CAD requiring CABG

12. Intraprocedural guidance
• Single balloon (Lock and colleagues)
• Double balloon (Al Zaibag and colleagues)
• Inoue balloon (MC used)
• Low intraprocedurral and periprocedural mortality and a success rate
of 95% or more.
• MVA increases to 1.9-2.0 cm² and NYHA function improves to class
I-II in 90% of cases.
• TEE should be done to exclude an LA thrombus and to reassess
contraindications to PBMV.
• LA thrombus – postpone (can be attempted in certain situations)
• Nonresolving thrombus – Surgery > PBMV

15. • Preferred Transeptal puncture site is in the posterior, a more
inferior region of the fossa ovalis.
• TEE or Intracardiac echo guidance is helpful, especially in
Pts with dilated atria or unusual morphology of the interatrial septum
(IAS) such as large atrial septal aneurysm, prior IAS surgery, or
distortion of the IAS from the scoliosis or prior pneumectomy.
• Tip of the needle for TS puncture can be identified by a tent like
indentation of the IAS on TEE.
• Height above the valve is best appreciated in the 4chamber view (0),
AP orientation is obtained using a short axis view at the base(30-45),
superior inferior orientation is seen on long axis view (90-100)
• X plane shows simultaneous AP,SI orientations.
• Inflation of the balloon in the subvalvular region should be avoided,
as this may lead to valvular, chordal or papillary muscle rupture.
• Hemodynamic deterioration during balloon inflation.

16. • Close monitoring of hemodynamic parameters is mandatory during
balloon inflation.
• Dilation of the MV Orifice due to splitting of the commissures in
evident by echo and fluoroscopy – the constriction of the balloon,
visible at its waist at the level of the mitral leaflets, suddenly
disappears.

17. Post procedure
• Severity and location of MR (newly developed MR emerging from the
commissures indicate a rupture of the valve lealflets (1.4-9.4%
develop significant MR)
• Mitral valve leaflet mobility
• Post PBMV MVA using mean doppler gradients,2D,3D MV
planimetry.
• Commissural opening
• Pericardial effusion
• L-R shunt through ASD secondary to TS puncture.

18. Why not PHT ?
Atrial compliance
A newly created ASD
Changes in hemodynamics

19. Successful PBMV
• As an MVA 1.5 cm² or more
• MR 2+
• Absence of complications

21. MITRAL REGURGITATION

24. Edge to Edge repair with the Mitraclip for
Mitral Regurgitation
• Alfieri – surgical technique of suturing the free edges of the mid
portions of the Anterior(A2) and Posterior (P2) mitral valve scallops
to create a double mitral valve orifice to treat MR.
• St Goar developed the Mitra Clip as a catheter based approach to
create a double MV orifice and thereby reduce MR.

25. Mitraclip system
• Only percutaneous method available to alter the mitral valve
morphology and annulus diameter and reduce MR.
• Transeptal approach
• 2 arms that form a clip when closed.
• Clip arms are opened in LV – during a pullback into LA, the central
portions of AML,PML are entrapped.
• Double orifice reduces MR.

27. Echocardiographic parameters essential for evaluation
before, during and after Mitraclip implantation
• Quantification of mitral valve morphology and MR severity.
• Guidance of the MitraClip system during the procedure.
• Assessing the intraprocedural results.
• Identification of complications during the procedure.
• Assessment of final results post Clip implantation in regard to MR
severity and diastolic gradient.
• Follow up regarding MR severity, residual shunting through the atrial
septum at the site of transseptal puncture, and pulmonary artery
systolic pressure.

28. Patient selection
• Impaired LV function
• LVEF <40%
• Mitraclip implantation can be safely performed with good results even
in patients with LVEF <20% - Franzen and colleagues.
• Moderate to severe MR (>3+ to 4+).

29. Morphological characterization for
Mitraclip eligibility
EVEREST criteria
• Coaptation length of 2mm
• Depth of <11mm
• Flail gap <10 mm
• Flail width < 15 mm

33. Imaging of Mitral valve
TEE – valve morphology
• 0 – (upper esophagus) A1 and P1 segments,A2 and P2 –
midesophagus,A3 and P3 distal esophagus.
• 60 – intercommissural views – P1,A2,P3 –along the plane.
• Clockwise rotation – A1-A3 are seen
• Counterclockwise – P1-P3 are seen
• LVOT view – A2 and P2 segment
• Transgastric short axis views – all segments of both leaflets.
• X plane imaging – valve segments and commissures
• Enface views of the mitral valve -3D echo
• Submitral apparatus view from LV

34. • Posterior leaflet prolapses are best visualized from the LA view
• Anterior leaflet is well seen from the LV.
• Anterior prolapse assessment is more difficult.(scallops are less
pronounced)
• More accurate than the 2D echo.
• High temporal and spatial resolution

35. Guiding of the Mitraclip procedure
• 3D TEE > 2D TEE – regarding position of the
catheters,wires,devices,target structures in a single view.
• TS puncture
• Steering of the delivery catheter
• Proper mitraclip procedure perpendicular to the line of coaptation in
the middle segments of the mitral valve.
• 30% reduction in the procedural time compared with 2DTEE and
fluoroscopy.

36. Mitraclip procedure

37. Additional Mitraclip implantation
• Fluoroscopy is helpful in positioning of a second mitral
clip,as it should be alligned as parallel as possible to fisrt
clip.
• Entrapment between 2 mitraclips to be avoided –
uncorrectable residual MR.

40. Assessment of complications

44. Paravalvular Mitral Leaks
• Frequent causes for reoperation.
• Dehisced suture or a complication of infective endocarditis.
• 60% occur in the first year after surgery.
• Subsequent risk decreasing to between 0.06 %- 5.4%
• Isolated or multiple
• Assosciated with any valve types
• Small and asymptomatic
• Spontaneous closure by fibrosis of the valve annulus.
• Clinically significant 1-5%
• PVML most frequently in the mitral commissural areas (76%)
• 3D TEE is optimal

45. • First successfully performed PPVL closure was reoprted in 1992 by
Hourhain and colleagues.
• Double umbrella Rashkind occluder device in 7 patients.

46. PVMC
• Assessment
• Intraprocedural guidance
• Post procedural assessment

50. Prosthetic valve evaluation

58. Stress echocardiography

59. Latest …

60. Endovalve Herrmann
Mini thoracotomy
No need of extracorpreal circulation
Bovine Pericardium
Lutter valve
Transapical appproach
Self expanding nitinol stent
Cardia AQ valve
Porcine pericardium
Nitinol self expanding stent
Transseptal appraoch
First percutaaneous valve to be
implanted in native valve
Bovine pericardium
Tiara valve
Self expanding stent
D shaped atrial portion
Ventricular portion outer coating to avoid
leaks
3 anchors
Successful implantation rate -81%

61. TIARA
• Transcatheter Apical Mitral valve Replacement
TAMI
• C:UsersLAPTOPDocumentsTAMI of the Tiara_
FIM Study of a Mitral Bioprosthesis_(360p).mp4