Intraprocedural Online Fusion of Echocardiography and Fluoroscopy During Transapical Mitral Valve-in-Valve Implantation

Transapical mitral valve-in-valve implantation using a 29-mm Edwards SAPIEN 3 bioprosthesis (Edwards Lifesciences, Irvine, CA) was successfully performed in a 70-year-old patient with a degenerated bioprosthesis (3-mm SJM Epic; St Jude Medical, St Paul, MN) and severe mitral regurgitation. The procedure was performed under transesophageal echocardiographic and fluoroscopic guidance using the EchoNavigator system Release II (Philips Healthcare, Andover, MA). This innovative technology enables online fusion of both imaging modalities, allowing for simultaneous display of soft tissue anatomy from echocardiography and device structures from fluoroscopy. The SJM Epic bioprosthesis is delineated fluoroscopically by only a thin ring structure with no visibility of the 3 valve-bearing pillars. Therefore, simultaneous display of echocardiographic and fluoroscopic information enables viewing of the entire complex valve structure, which confines the landing zone for the transcatheter mitral valve implantation. Using the Edwards SAPIEN 3 bioprosthesis with asymmetrical shortening during balloon expansion, visibility of the entire landing zone is desirable.