title: Adjunctive intracardiac echocardiography imaging from the left ventricle to guide percutaneous mitral valve repair with the MitraClip in patients with failed prior surgical rings.
abstract: OBJECTIVE
  We evaluated intracardiac echocardiography (ICE) for adjunctively guiding the MitraClip procedure in patients with prior surgical rings.
  
  
  BACKGROUND
  Transesophageal echocardiography (TEE) is the standard imaging modality used to guide the MitraClip procedure (Abbott Vascular, CA). However, in patients with post-surgical anatomy, clear imaging of the mitral valve leaflets may be complex because of shadowing from the surgical ring. In these patients, TEE may be suboptimal for guiding the procedure, even using three-dimensional imaging.
  
  
  METHODS
  This retrospective analysis included data from 121 consecutive patients with mitral regurgitation who underwent MitraClip procedures at the University of Virginia. ICE was used adjunctively when there was difficulty with TEE, particularly for assessing the insertion of the posterior leaflet into the MitraClip's arms. The ICE catheter was introduced transarterially into the left ventricle and flexed to obtain the short-axis view.
  
  
  RESULTS
  Six patients had prior surgical rings, and in five, we used adjunctive ICE. The etiology of the mitral regurgitation was prolapse of the posterior leaflet in one patient and restriction of the posterior leaflet due to ischemic tethering in the remainder. All images were obtained from the left ventricle, and were adequate for assessing posterior leaflet insertion and the perpendicularity of the MitraClip arms. The procedural success rate was 80%. There was no adverse event related to the ICE procedure.
  
  
  CONCLUSIONS
  Mitral valve repair with the MitraClip system assisted by ICE is feasible in patients with prior surgical rings, achieving an excellent risk profile and satisfactory procedural success.
authors.affiliation: Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Virginia.|Department of Cardiology, Sakakibara Heart Institute, Tokyo.
authors.forename: Mike
authors.initials: M
authors.lastname: Saji
authors.affiliation: Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Virginia.
authors.forename: Ann M
authors.initials: AM
authors.lastname: Rossi
authors.affiliation: Advanced Cardiac Valve Center, Department of Surgery, Division of Cardiothoracic Surgery, University of Virginia, Virginia.
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
authors.affiliation: Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Virginia.
authors.forename: John
authors.initials: J
authors.lastname: Dent
authors.affiliation: Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Virginia.
authors.forename: Michael
authors.initials: M
authors.lastname: Ragosta
authors.affiliation: Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Virginia.
authors.forename: D Scott
authors.initials: DS
authors.lastname: Lim
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D019560:Echocardiography, Three-Dimensional; D017548:Echocardiography, Transesophageal; D005240:Feasibility Studies; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000295:instrumentation; D006352:Heart Ventricles / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D008943:Mitral Valve / Q000000981:diagnostic imaging* / Q000601:surgery; D058386:Mitral Valve Annuloplasty / Q000295:instrumentation; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D011237:Predictive Value of Tests; D019233:Retreatment; D012189:Retrospective Studies; D017211:Treatment Failure; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000009:adverse effects / Q000379:methods*; D014768:Virginia
keywords: ICE; MR; adjunctive; annuloplasty; artifact; mitral regurgitation; shadowing