Fig. 13.1
Two-dimensional TEE images showing the presence of a severe mitral regurgitation due to deep symmetric tethering with a central jet (a) and two commissural jets (b)
Fig. 13.2
Three-dimensional TEE images showing the presence of a deep cleft in the P2 region of the posterior mitral valve leaflet from the atrial (a) and ventricular (b) view
In particular, the central jet did not arise from inside the cleft in the posterior leaflet, but rather from its free edge.
13.3 Procedure Description
From the beginning, we planned to deploy two clips both for the increased annulus diameters (SL: 38 mm; IC: 37 mm) with borderline coaptation and for the presence of a deep cleft in the P2 region of the posterior mitral valve leaflet. As no jet was coming from the indentation of the cleft, we decided to position the clips on both sides of mitral cleft and perpendicular to the rim to avoid any distortion of the leaflet and the consequent risk of increased regurgitation (Fig. 13.3). The presence of a jet inside the cleft could favor a “reverse V” shape of the two clips.
Fig 13.3
Image showing the two clips implanted on both sides of the mitral cleft and perpendicular to the mitral rim
The procedure was performed under general anesthesia and was guided by TEE (two- and three-dimensional) and fluoroscopy (Figs. 13.4 and 13.5). At the end of procedure, TEE demonstrated mild residual mitral regurgitation with the two clips placed on both sides of the mitral cleft (Fig. 13.6).
Fig. 13.4
Three-dimensional TEE image showing implantation of the first clip at the P2/P3 region (a). Two-dimensional TEE image showing the origin of a moderate residual jet lateral to the first clip (b)
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