PMC5568623_01
Images of transesophageal echocardiography (TEE) and fluoroscopy during percutaneous edge-to-edge mitral valve repair (PMVR). (a) The biplane intercommissural and left ventricular outflow tract (LVOT) view in TEE showing a severe prolapse and flail of the posterior mitral leaflet (PML; P2 segment). (b) The biplane intercommissural and LVOT view in TEE with color Doppler demonstrating eccentric severe mitral regurgitation (MR). (c) Fluoroscopy showing balloon dilatation of the interatrial septum over a transseptal guidewire. (d) Digital substraction angiography (DSA): a mechanical obstruction in this area with a tortuous right common iliac vein precluded advancement of the MitraClip system (the depicted arrow may indicate a venous valve). (e) Fluoroscopy showing an unsuccessful attempt to dilate the right iliac vein with a dilator. (f) Unsuccessful attempt to advance the guide through the iliac vein (the arrow indicates an obstruction at the curve of the right common iliac vein). (g) Dilatation of the right iliac vein with increasing sizes of percutaneous transluminal angioplasty (PTA) balloons (up to 10 mm). (h) Successful positioning of the MitraClip delivery system and the clip within the left atrium. (i) Clip deployment. (j) Significant reduction of MR after clip deployment as demonstrated by intraprocedural TEE.
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An eccentric jet was caused by a flail of the posterior leaflet (PML) in segment P2 (Figures 1(a) and 1(b)). SafeSept wire (Figure 1(c); Supplemental Movie 1 in Supplementary Material available online at https://doi.org/10.1155/2017/3652413). Subsequently, we experienced another obstacle, as the dilator of the MitraClip steerable sheath system (Abbott Vascular) could not be advanced to the inferior vena cava over the placed ultrastiff wire (Amplatz, Cook Medical, Bloomington, IN), even when using a second superstiff buddy wire (Amplatz, Boston Scientific Corporation, San Jose, CA) (Figures 1(d), 1(e), and 1(f); Supplemental Movie 2). Thus, we carried out successive balloon dilatations of the right common iliac vein with gradually increasing balloon sizes up to 10 mm (Figure 1(g); Supplemental Movie 3). Deployment of the clip (Figures 1(h) and 1(i)) in the central segment of the mitral leaflets (A2/P2) resulted in a significant MR reduction (Figure 1(j)).