Adjunctive Intracardiac Echocardiography Imaging From the Left Ventricle to Guide Percutaneous Mitral Valve Repair With the MitraClip in Patients With Failed Prior Surgical Rings Mike Saji, 1,2 MD, Ann M. Rossi, 1 DNP NP , Gorav Ailawadi, 3 MD, John Dent, 1 MD, Michael Ragosta, 1 MD, and D. Scott Lim, 1 * MD Objectives: We evaluated intracardiac echocardiography (ICE) for adjunctively guiding the MitraClip procedure in patients with prior surgical rings. Background: Transesoph- ageal echocardiography (TEE) is the standard imaging modality used to guide the MitraClip procedure (Abbott Vascular, CA). However, in patients with post-surgical anatomy, clear imaging of the mitral valve leaflets may be complex because of shad- owing from the surgical ring. In these patients, TEE may be suboptimal for guiding the procedure, even using three-dimensional imaging. Methods: This retrospective analy- sis included data from 121 consecutive patients with mitral regurgitation who under- went MitraClip procedures at the University of Virginia. ICE was used adjunctively when there was difficulty with TEE, particularly for assessing the insertion of the pos- terior leaflet into the MitraClip’s arms. The ICE catheter was introduced transarterially into the left ventricle and flexed to obtain the short-axis view. Results: Six patients had prior surgical rings, and in five, we used adjunctive ICE. The etiology of the mitral regurgitation was prolapse of the posterior leaflet in one patient and restriction of the posterior leaflet due to ischemic tethering in the remainder. All images were obtained from the left ventricle, and were adequate for assessing posterior leaflet insertion and the perpendicularity of the MitraClip arms. The procedural success rate was 80%. There was no adverse event related to the ICE procedure. Conclusions: Mitral valve repair with the MitraClip system assisted by ICE is feasible in patients with prior surgical rings, achieving an excellent risk profile and satisfactory proce- dural success. V C 2015 Wiley Periodicals, Inc. Key words: mitral regurgitation; MR; ICE; shadowing; annuloplasty; artifact; adjunctive INTRODUCTION Transesophageal echocardiography (TEE) is the standard imaging modality used to guide the MitraClip procedure (Abbott Vascular, Menlo Park, CA). After early clinical experience proved promising [1–3], it has now been performed in more than 16,000 patients worldwide as a less invasive treatment than surgery. However, in patients with post-surgical anatomy, clear imaging of the mitral valve leaflets may be complicated by shadowing from the surgical annulo- plasty ring. In these cases, even using three- dimensional imaging, TEE may be suboptimal for guiding the procedure, particularly in assessing the adequacy of posterior leaflet insertion into the Mitra- Clip’s arms [4]. 1 Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Virginia 2 Department of Cardiology, Sakakibara Heart Institute, Tokyo 3 Advanced Cardiac Valve Center, Department of Surgery, Division of Cardiothoracic Surgery, University of Virginia, Vir- ginia Conflict of interest: Scott Lim is a consultant to Abbott Vascular and a proctor of MitraClip. Gorav Ailawadi is a consultant to Abbott Vascular. John M Dent is a consultant of Abbott Vascular. *Correspondence to: D. Scott Lim, Advanced Cardiac Valve Center, Department of Medicine, University of Virginia 1215 Lee Street, Hospital Expansion, Room 4033, Charlottesville, VA, 22908. E-mail: SL9PC@virginia.edu Additional Supporting Information may be found in the online version of this article. Received 31 October 2014; Revision accepted 4 April 2015 DOI: 10.1002/ccd.25981 Published online 23 June 2015 in Wiley Online Library (wileyonlinelibrary.com) V C 2015 Wiley Periodicals, Inc. Catheterization and Cardiovascular Interventions 87:E75–E82 (2016)