High-quality live imaging assessment of cardiac valves and cardiac anatomy is crucial for the success of percutaneous catheter-based mitral valve (MV) repair techniques. We examined the use of intracardiac echocardiography (ICE) in providing online ICE images necessary for successful perctunaneous MV repair by Alfieri stitch technique–based percutaneous edge-to-edge device in a swine model.

ICE was performed in 20 healthy adult pigs (90 ± 8 kg, mean ± SEM). A 10F ICE catheter was advanced through the left femoral vein and the right jugular vein. Images were obtained from the right atrium, left atrium, right ventricle, and pulmonary artery. Fluoroscopy was used to locate the position of ICE catheter tip in different imaging windows.

An echocardiographic protocol was developed for focused visualization of target cardiac structures during the process of percutaneous MV repair. This included visualization of interatrial septum to guide transeptal puncture; to confirm transit of guidewire into the left atrium, across the MV into the left ventricle and across the aortic valve into the aorta; to assist in central positioning of guide catheter in the left atrium above and then across MV leaflets; and to visualize middle scallops of anterior and posterior MV leaflets in short- and long-axis views. Finally, location and orientation of the orifice of the therapy catheter against each MV leaflet was visualized to enable successful capture of MV leaflets, to confirm successful deployment of suture and double orifice (figure of 8” appearance of MV, and finally to confirm central deployment of clip at the site of suture.

An ICE protocol was developed to visualize serial cardiac structures to guide deployment of suture into the A₂-P₂ scallops of the MV and to confirm final result before release of clip.