PMC7640598_01
(A) Mid-oesophageal four-chamber view with and without colour showed that severe mitral regurgitation (MR) started at the level of mitral valve (MV) leaflets and passed to the left atrium (LA) beside the MV ring. (B) Mid-oesophageal two-chamber view showed the vena-contracta 0.7 cm at MV leaflets and 0.96 cm at the para-ring hole. (C) Live 3D frame from the LA in surgical view showed the oval-shaped hole beside the C-shaped MV repair ring at 5'o clock (arrow). (D) 3D full volume with colour showed the severe MR.
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A transesophageal echocardiogram (TOE) was performed and revealed the following: mid-oesophageal four-chamber view (Fig. 1A) and mid-oesophageal two-chamber view (Fig. 1B) showed that severe MR started at the level of MV leaflets with vena-contracta 0.7 cm and then passed to the left atrium (LA) beside the MV ring with vena-contracta 0.96 cm (see online Supplementary Videos 1 and 2). Live 3D frame from the LA in surgical view (Fig. 1C and online Supplementary Video 3) and 3D full volume with colour (Fig. 1D and online Supplementary Video 4) showed the severe MR coming through the oval-shaped hole beside the C-shaped MV repair ring at 5o'clock in the surgical view, no MR passes the ring itself.
(A) The clip was directed to be perpendicular to the mitral valve (MV) at A2P2 with lateral movement to target the mitral regurgitation (MR) jet. (B) The clip was completely closed, showing residual trace MR. (C) No MR through the para-ring hole. (D) Transgastric view showed the clip dividing the MV to nearly equal orifices.
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The catheter depth was measured, and the clip was directed toward the MV at A2P2 with little lateral movement to target the MR jet (Fig. 2A). The two leaflets were grasped successfully; the clip was fully closed, only trace MR remained at the MV leaflets (Fig. 2B) with no more flow to the para-ring hole (Fig. 2C and online Supplementary Video 5), the MV orifice was divided into two nearly equal orifices as showed in transgastric short axis view on the MV (Fig. 2D and online Supplementary Video 6).
(A) The systolic reversal in the left upper pulmonary vein before the clip. (B) The improvement of the pulmonary venous flow immediately after the clip. (C) The mean pressure gradient on the mitral valve after the clip was 2 mmHg. (D) Follow-up after 6 months, trace residual MR.
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Live 3D frame from the LA in surgical view (Fig. 1C and online Supplementary Video 3) and 3D full volume with colour (Fig. 1D and online Supplementary Video 4) showed the severe MR coming through the oval-shaped hole beside the C-shaped MV repair ring at 5o'clock in the surgical view, no MR passes the ring itself. The systolic reversal in the left pulmonary vein before the clip and the improvement of the pulmonary venous flow immediately after the clip is shown in Fig. 3A and B. The mean pressure gradient on the MV was 2 mmHg (Fig. 3C). Follow-up transthoracic echocardiography after 6 months showed the clip in place, trace residual MR, and EF remained at 15% (Fig. 3D).
Fluoroscopy showed the MV C-shaped ring and the clip after release.
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The clip was released and the procedure was successful (Fig. 4). The patient was extubated after 12 hours; she was clinically stable with acceptable laboratory results.