fig13

Figure 13. Procedural guidance of the transapical beating heart chordal implantation. A: identification of the LV apex through “finger testing”: the interventionist pushes the apex (white arrow) and the imager checks its position on biplane imaging; B: the system is directed towards the LA on simultaneous biplane LAX and commissural views, avoiding entrapment into subvalvular apparatus. After entering the LA, echocardiographic imaging is switched to 3D surgical view (C), targeting the prolapsing segment (white arrow). After confirmation of leaflet grasping and capture, the device is pulled out from the LV apex and tension is adjusted, until effective MR reduction is shown with color Doppler interrogation (D). LV: left ventricular; LA: left atrium; LAX: long axis; MR: mitral regurgitation