Percutaneous Transcatheter Edge-to-Edge MitraClip Technique: A Practical “Step-by- Step” 3-Dimensional Transesophageal Echocardiography Guide  Limor Ilan Bushari, MD, Guy S. Reeder, MD, Mackram F. Eleid, MD, Krishnaswamy Chandrasekaran, MD, Maurice Eriquez-Sarano, MD, Charanjit S. Rihal, MD, Joseph F. Maalouf, MD  Mayo Clinic Proceedings  Volume 94, Issue 1, Pages 89-102 (January 2019) DOI: 10.1016/j.mayocp.2018.10.007 Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 1 A, Three-dimensional (3D) enface left atrial (LA) view. A mitral cleft (yellow arrow) is seen between the P1 and P2 scallops. B, Corresponding 3D full-volume (FV) color flow Doppler (CFD) image from LA view demonstrating the regurgitant jet (yellow arrow) originating from the P1/P2 cleft. C, Three-dimensional FV CFD image from LA view. Posteromedial commissural mitral regurgitation (MR) (yellow arrow) in a patient with flail P2 segment (black arrow). D-G, Collage of FV 3D CFD MR from left ventricular view. Discrete central MR jet (arrow) in a patient with flail P2 segment (D). Wide single central MR jet (arrows) in a patient with severe functional MR (E). Two separate MR jets (yellow arrows) (F). Medial paracommissural MR jet (yellow arrow) (G). Mayo Clinic Proceedings 2019 94, 89-102DOI: (10.1016/j.mayocp.2018.10.007) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 2 A, Three-dimensional mitral valve left atrial (LA) view demonstrating schematic of perpendicular orientation of the clip arms (blue lines) relative to the curvilinear relationship of the anterior and posterior leaflets from medial to lateral (curved double-headed red arrow with the arrowheads pointing to the medial and lateral commissures); yellow arrow points to flail P2. Asterisk marks the interatrial septum (IAS). I = inferior; LAA = left atrial appendage; S = superior. B, Left atrial view of a large flail P3 segment. The double-headed red arrow points to 2 ruptured chordae tendinea. Asterisk marks the IAS. C, Two-dimensional orthogonal planes demonstrating the Brockenbrough transseptal needle (red arrow) in only one plane. The yellow arrow points to fossa ovalis in the anteroposterior plane, and the green arrowheads point to the aortic root. RA = right atrium. D, Three-dimensional zoom dual-layout RA and LA views of fossa ovalis (red arrowheads) in relation to the superior vena cava (SVC), inferior vena cava (IVC), and aortic root. The eustachian ridge is marked by a green asterisk. The coronary sinus is seen in cross section (green arrow). The white arrow points to the mitral valve. E-F, Orthogonal atrial septum planes (E) and corresponding full-volume view (F). White arrow points to the aortic root. Red arrow points to the Mullen assembly. Mayo Clinic Proceedings 2019 94, 89-102DOI: (10.1016/j.mayocp.2018.10.007) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 3 Technique for 3-dimensional full-volume acquisition of the mitral valve (MV) from a 2-dimensional bicaval view. A, The MV is partially seen (white arrowhead). Superior vena cava (SVC) is marked by yellow arrowhead. Green arrow points to atrial septum at level of fossa ovalis. RA = right atrium. B, Leftward (counterclockwise) rotation of the probe toward the MV (red arrow). C-E, Three-dimensional full-volume collage from bicaval window. Slight counterclockwise rotation of probe showing a portion of the MV (white arrowheads) (C). Further counterclockwise rotation exposes the entire MV (D). A = anterior mitral leaflet; P = posterior mitral leaflet. Z rotatation (E): the aortic valve is anterior. The ostium of the left atrial appendage (LAA) is partially seen (red arrow). F-H, Left atrial appendage and left superior pulmonary vein (LSPV) anatomy. Left atrial (LA) view of MV (F) is the same as in part E. Green arrow points to aortic valve. Ostium of LAA (red arrow) superior to plane of the MV is seen with leftward (usually counterclockwise) rotation of probe (G). The aortic valve is seen anteriorly (green arrow). Enface views of ostia of LAA and LSPV (H). Mayo Clinic Proceedings 2019 94, 89-102DOI: (10.1016/j.mayocp.2018.10.007) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 4 Mitral valve (MV) and interatrial septum (IAS) anatomy with rightward (clockwise) rotation of the probe. A-C, With progressive clockwise rotation of the probe from MV view obtained from the bicaval window (A, same as Figure 3, E; green arrow points to aortic valve), the entire wall of the atrial septum is exposed (B) and there is corresponding counterclockwise rotation in position of the aortic valve (C, green arrow). The white arrows in B and C point to the MV. D, Position of the fossa ovalis (red arrows) relative to MV plane (white arrow) as viewed on clockwise rotation of the probe from a standard mitral view similar to that in A. E, Further clockwise rotation from D exposes the right superior pulmonary vein (yellow asterisk) as it enters the dome of the left atrium. Red arrows point to fossa ovalis. F-G, Three-dimensional zoom dual layout from right atrium (RA) (F) and left atrium (G) views of the atrial septum. Note the transseptal puncture Brockenbrough needle (green arrow) seen in RA posterior and superior to the fossa. White arrow points to superior vena cava (SVC). H-I, Corresponding simultaneous 2-dimensional bicaval view. A = anterior; AoV = aortic valve; I = inferior; IVC = inferior vena cava; P = posterior; S = superior. Mayo Clinic Proceedings 2019 94, 89-102DOI: (10.1016/j.mayocp.2018.10.007) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 5 A, Three-dimensional zoom view of left side of atrial septum. Brockenbrough needle tenting the atrial septum (black arrow) is seen superior to the fossa ovalis (red arrow). Asterisk points to right superior pulmonary vein. B, Three-dimensional full volume showing distance (dashed red line) from site of tenting (black arrow) to plane of mitral valve. C, Three-dimensional zoom dual layout of atrial septum showing actual transseptal puncture (red arrow points to tip of Brockenbrough needle and blue arrowheads point to contrast injected into left atrium [LA]). Yellow arrow points to Brockenbrough needle in right atrium (RA). D, Three-dimensional zoom RA: Mullen assembly (white arrow) is seen posterior to fossa (red arrows). White asterisk marks the Eustachian ridge. A = anterior; I = inferior; P= posterior; S = superior. E, Enface LA view of ostia of left atrial appendage (LAA) and left superior pulmonary vein (LSPV). White arrowheads point to a flail A2 segment. F, Amplatz extra-stiff wire (red arrows) curling at ostium of LAA. G, Amplatz extra-stiff wire (red arrow) parked inside LSPV. H, Amplatz extra-stiff and super-stiff wires in LA (yellow arrows). Mayo Clinic Proceedings 2019 94, 89-102DOI: (10.1016/j.mayocp.2018.10.007) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 6 A, Typical appearance of Inoue dilator (yellow arrow) on wire (red arrow). Green arrow points to a second stiff wire in the left atrium (LA). B, The Inoue dilator (yellow arrow) is advanced over the wire during septal dilatation. C, Enface view of steerable guide catheter (SGC) with distinctive double-ring tip (arrowheads) and multipurpose LA pressure monitoring catheter (yellow arrow). D, Rail-like appearance of SGC (green arrows). E, Steerable guide catheter with characteristic double-ring tip (arrowheads) over an Amplatz extra-stiff wire (yellow arrow) as it enters the LA. F, Steerable guide catheter (red arrow) being advanced into LA. Mayo Clinic Proceedings 2019 94, 89-102DOI: (10.1016/j.mayocp.2018.10.007) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 7 A, Steerable guide catheter (SGC) tip (red arrow) abutting left atrial (LA) free wall anteriorly (green arrowheads). Yellow arrowhead points to site of atrial septal puncture. A = anterior; I = inferior; P = posterior; S = superior. B, Steerable guide catheter tip (red arrow) pulled back toward atrial septum (blue asterisk). C, Enface LA view of the MitraClip showing its arms (yellow arrows) and two grippers (red arrows) in a semiopen position. D, MitraClip (yellow arrow) exiting the SGC. E, Perpendicular alignment of MitraClip arms (red arrows) in a patient with central mitral regurgitation. F, Ensuring perpendicular alignment in same patient as in E when MitraClip is advanced into the left ventricle by lowering overall gain setting. G-H, Clockwise rotation of MitraClip arms (red arrows) from G to H in a patient with flail P2. Mayo Clinic Proceedings 2019 94, 89-102DOI: (10.1016/j.mayocp.2018.10.007) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 8 Post-MitraClip Deployment. A-C, Left atrial views of the mitral valve (MV). A, Initial mitral regurgitation (MR) (red arrows). B, Residual MR (yellow arrow) in same patient as in A. C, Post-MitraClip deployment diastolic frame showing 2 large orifices (red arrowheads) and a smaller orifice (yellow arrowhead). D-I, Three-dimensional collage of post-MitraClip deployment MV orifices. Left atrial views show dual orifice (D) (red arrowheads), triple orifice (E) (red arrowheads), and large single orifice with rudimentary medial orifice (F) (red arrowhead). Left ventricular views show single MitraClip (G) (red arrowhead) and 2 clips (red arrows [H] and red arrowheads [I]). Note that the clips are grasping the free edges and are aligned side-by-side. Mayo Clinic Proceedings 2019 94, 89-102DOI: (10.1016/j.mayocp.2018.10.007) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions