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OBJECTIVE: Transcatheter mitral valve (MV) repair using the MitraClip system is of increasing interest. Image guidance for this procedure is dependent on fluoroscopy and echocardiography, which however do have several limitations. We therefore aimed to develop a novel protocol for MV imaging using rotational angiography to depict anatomical landmarks of the MV apparatus to simplify guidance. We herein present our first - in man experience with this new modality.
METHODS: A 74 year old patient presented with dyspnea (NYHA class III) due to severe mitral regurgitation (MR). His logistic EuroScore was >25 and co-morbidities were: COPD, pulmonary hypertension and previous cardiac surgery. Surgery was denied due to the high operative risk.
The procedure was performed under general anaesthesia and respiratory support. A Pigtail catheter was placed in the pulmonary artery and a temporary pacemaker wire in the right ventricle (RV). Dyna-CT was performed with RV-pacing (180bpm) and continuous application of diluted contrast medium (Σ=20ml) at a rate of 10 ml/sec. Siemens Syngo system (Siemens AX, Forchheim, Germany) was used for fully automated segmentation creating a three dimensional (3D) overlay for flouroscopic images. 3D model revealed anatomical landmarks which included the mitral annulus, MV leaflets and as well as the optimal transeptal puncture site.
RESULTS: A clear definition of the MV apparatus with MV annulus, both papillary muscles, both MV leaflets and the left ventricle was achieved. The 3d-overlay into the standard fluoroscopy image enabled superior intracardiac navigation throughout the complete procedure.
CONCLUSIONS: 3D-Rotational angiography supports MitraClip implantation. However, further applications as well as cardiac dynamics need to be investigated.