Transesophageal echocardiography (TEE) is essential for guiding transcatheter mitral valve (MV) therapy, such as MitraClip (Abbott Vascular, Santa Clara, CA). A–F, Imaging guidance for the transseptal puncture (arrowheads). A, Bicaval view showing superior and inferior trajectory of the puncture. B, Short-axis view of the aortic valve and atrial septum, showing anterior-posterior trajectory. The puncture site is posteriorly located. C, Four-chamber view for measurement of distance or height of the puncture to the mitral annular plane. D, Reverse four-chamber view for confirmatory check of the puncture height. E and F, Using TEE, 3-dimensional views of the fossa (F) and mitral annular plane confirm the trajectory and puncture location relative to the medial commissure. G–I, The clip arms must be oriented perpendicular to the mitral coaptation plane. G, 3-D view showing orientation of the clip arms (arrowhead) to be perpendicular relative to the mitral coaptation plane when positioned in the left atrium above the MV. H, Following advancement of the clip into the left ventricle, 3-D viewing with a decrease in the gain allows imaging of the clip arms, and indicates their orientation (arrowhead) without the need for transgastric viewing. On this image, the clip arms (arrowhead) are incorrectly rotated. I, With clockwise rotation, the clip arms (arrowhead) are correctly rotated to be perpendicular to the mitral coaptation plane. J, X-plane imaging confirms the clips are equally viewed in the left ventricular outflow tract view (right panel) and appropriately not visible on the orthogonal, commissural view (left panel). K–N, “Aortic hugger” imaging. K, In situations where the transseptal puncture is too low or too anterior, the trajectory of the clip delivery system (arrowhead) will pose challenges for grasping the anterior and posterior leaflets together or equally. L, This unfavorable trajectory can be seen easily with 3-D, side-imaging of the clip delivery system relative to the MV plane (arrow). M, Following addition of “plus” on the guide and “A” on the steerable sleeve, the aortic hugger is corrected and the imaging confirms a more appropriate trajectory (arrow). N, This correction and the more favorable trajectory is also seen on 2-dimensional imaging (arrow).
Ao, Ascending aorta; IAS, interatrial septum; LA, left atrium; LV, left ventricle; MV mitral valve; RA, right atrium; RV, right ventricle; SVC, superior vena cava.