2023 Volume 87 Issue 6 Pages 854-
A 77-year-old man presented to hospital with severe mitral regurgitation (MR). Transthoracic echocardiography showed P2 prolapse, and a partial prolapse of P3 was also suspected. Transesophageal echocardiography (TEE) for detailed evaluation was attempted but abandoned because of difficulty of insertion into the esophagus. Alternatively, ECG-gated enhanced computed tomography (CT) scan was performed. CT images after motion artifact correction with SnapShot Freeze 2 (GE Healthcare, Milwaukee, WI, USA) in mid-systole (20% of the R-R interval) showed a severe prolapse of the P2 lateral portion with flail leaflet and a mild prolapse of the P2 medial portion (Figure A), and also revealed prominent chordae in the P2 medial portion, which could affect intervention for the leaflets (Figure B–D). Considering the patient’s reduced pulmonary function, we opted to perform transcatheter edge-to-edge mitral valve repair (TEER) using the MitraClip system (Abbott Vascular, Lake Bluff, ILL, USA). Intraprocedural TEE showed the MR jet mainly originated from the major prolapse of the P2 lateral portion with flail leaflet, which corresponded with the CT findings. A single XTW clip was successfully implanted at the lateral portion of A2-P2, resulting in residual mild MR (Figure E,F).
(A,B) Three-dimensional and (C,D) cross-sectional two-dimensional computed tomographic images showing severe prolapse of the P2 lateral portion (yellow arrow) and mild prolapse of the P2 medial portion (orange arrow) with 6-mm flail gap and 18-mm flail width. (E) Intraprocedural transesophageal echocardiography (TEE) showing severe mitral regurgitation (MR) caused by a wide prolapse of the P2 segment. The MR jet mainly originated from the prolapse of the P2 lateral portion. (F) TEE following XTW deployment at the lateral half of the A2-P2 portion, demonstrating reduction of MR to mild. AV, aortic valve; LAA, left atrial appendage.
ECG-gated enhanced CT may be useful for preprocedural planning of TEER strategy in cases of inability to perform preprocedural TEE.
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