Sequential Venous Percutaneous Transluminal Angioplasty and Balloon Dilatation of the Interatrial Septum during Percutaneous Edge-to-Edge Mitral Valve Repair

Figure 1

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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