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Value of Real Time 3D Transesophageal Echocardiography for Transcatheter Mitral Valved Stent Implantation in the Beating Heart
Katharina Huenges1,
Saskia Pokorny1, Telse Bhr1, Matthias Gegenwart1, Gunther Fischer2, Lucian Lozonschi3, Jochen Cremer1, Georg Lutter1.
1University Hospital Schleswig-Holstein, Campus Kiel, Department of Cardiovascular Surgery, Kiel, Germany, 2University Hospital Schleswig-Holstein, Campus Kiel, Department of Pediatric Cardiology, Kiel, Germany, 3University of Wisconsin, School of Medicine and Public Health, Department of Cardiothoracic Surgery, Madison, WI, USA.

OBJECTIVE: In this study we report our experiences with real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) as adequate imaging technique during guidance and evaluation of mitral valved stent implantation in an experimental setting.
METHODS: Implantation of a mitral valved stent was performed in 28 pigs of the german landrace or Edelschwein (49.5±2.94kg) via a transapical approach in the beating heart. The implantation and deployment procedure were guided by 2D and RT-3D-TEE. A full two-dimensional (2D) and RT-3D-TEE evaluation based on a standard protocol was conducted before and 1h after implantation. Focus of the assessment were the global heart function, the valved stent performance and position as well as possible paravalvular leakages (PVL) and central regurgitation (cMR).
RESULTS: The self-expanding valved stents were successfully implanted in 24 pigs at first attempt. Four pigs died during the procedure due to ventricular fibrillation. TEE evaluation showed a slightly decreasing ejection fraction (63.54±5.13% to 56.68±8.83%) and E/A ratio (1.28±0.42 to 1.12±0.33), but still in physiological ranges. Mitral annular plane systolic excursion (MAPSE) as parameter for the longitudinal function slightly decreased after implantation (1.2±0.1cm to 1.0±0.1cm), but remained within a physiological range. Mildly increasing maximal velocities were observed over the mitral valve, the left ventricular outflow tract and the aortic valve (MV:64.78±12.53cm/s to 88.30±21.68, LVOT:67.42±10.01cm/s to 97.29±43.23cm/s, AV: 91.64±14.36cm/s to 102.90±25.41cm/s). The gradients across the mitral valved stent remained low (1.04±0.63mmHg post implantation). RT-3D-TEE provided dependable spatial visualization of the left heart, mitral apparatus, delivery system and the valved stent. By the use of 3D-TEE orientation during deployment and positioning of the valved stent was notably facilitated. 3D showed particular benefit during evaluation of the stent performance and visualization of the stent movement and deformation.
CONCLUSIONS: RT-3D-TEE provided accurate views and allowed assessment of regurgitations as well as the imaging of the stent, it is of explicit value as a guidance method during implantation. Therefore 3D-TEE highly contributed to the successful minimally invasive implantation of this novel valved-stent in the native mitral annulus.

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