Accurate planning relies on 3D transesophageal echocardiography and coronary CT-scan with multiplanar, 3D, and 4D reconstructions. Shape, size, and location of the defect must precisely be evaluated, as well as relationships between heart structures and chambers and between the heart itself and the thoracic wall. Intra-operative guidance is performed by both 3D echocardiography and fluoroscopy (Figure 5). Mitral leak closure can be accomplished both through a venous transfemoral Inhibitors,research,lifescience,medical transseptal route and by a transapical access.49 Figure 5 Perivalvular Leak Closure with the

Amplatzer AVPIII Device. MITRAL VALVE IMPLANTATION Although repair is currently the leading method to treat mitral valve regurgitation in surgical practice, replacement is associated with a number of potential advantages, particularly suitable for a transcatheter approach: the procedure can be more reproducible; it can be applied to the majority of patients, and may provide more Inhibitors,research,lifescience,medical predictable results. However, mitral valve anatomy brings unique and complex features that make transcatheter valve implantation much more Inhibitors,research,lifescience,medical challenging than in the aortic position. The mitral annulus is asymmetrical, non-tubular, and frequently not calcified, so that the main problem for any kind of mitral prosthesis remains anchoring, since radial force would not be effective and could cause serious complications. Left-ventricle outflow tract obstruction

and aortic valve deformation (that could derive from a large and rigid mitral stent) are also major concerns. Inhibitors,research,lifescience,medical Moreover, leaks in the mitral position would be poorly tolerated, both hemodynamically and in terms of hemolysis because of the elevated pressure gradients. Mitral valve implantation is not yet routinely available in the clinical setting, but several KRX-0401 in vivo devices are currently under development. The CardiAQ (CardiAQ Valve Technologies, Inc., Winchester, MA, USA) prosthesis has been the first to reach human implantation Inhibitors,research,lifescience,medical in 2012, although only one case has been reported so far (Sondergaard L. Transcatheter Mitral

Valve Implantation: CardiAQ, TCT Meeting, Miami 2012). It is transseptally delivered and self-anchoring without the need of radial force. The first patient showed early good implantation and hemodynamic result, but died after 3 days due to multi-organ failure. Autopsy did not reveal any prosthesis issue. The Lutter prosthesis (Tendyne Medical, Inc., Baltimore, Fossariinae MD, US) has been successfully implanted transapically in numerous porcine models. The latest version of the prosthesis is made of a flat ring (atrial fixation system) connected at a 45° angle to the tubular stent that accommodates a 28-mm trileaflet bovine pericardial valve; between the base of the stent and the apex, neo-chordae act as ventricular fixation system. A waterproof membrane is sutured in the atrial ring and over the ventricular component to guarantee sealing, minimize paravalvular leakage, and allow easier repositioning.