Cardioscopically Guided Beating Heart Surgery: Paravalvular Leak Repair Benoit Rosa, PhD, Zurab Machaidze, MD, Margherita Mencattelli, PhD, Sunil Manjila,

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Cardioscopically Guided Beating Heart Surgery: Paravalvular Leak Repair Benoit Rosa, PhD, Zurab Machaidze, MD, Margherita Mencattelli, PhD, Sunil Manjila, MD, Borami Shin, MD, Karl Price, MSc, Michael A. Borger, MD, Vinod Thourani, MD, Pedro del Nido, MD, David W. Brown, MD, Christopher W. Baird, MD, John E. Mayer, MD, Pierre E. Dupont, PhD The Annals of Thoracic Surgery Volume 104, Issue 3, Pages 1074-1079 (September 2017) DOI: 10.1016/j.athoracsur.2017.03.028 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Cardioscope mounted on a handheld catheter for transapical access. (LED = light-emitting diode.) The Annals of Thoracic Surgery 2017 104, 1074-1079DOI: (10.1016/j.athoracsur.2017.03.028) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Paravalvular leak (PVL) model and device deployment. (A) Bioprosthetic valve incorporating three PVLs. (B) Schematic showing PVL locations as viewed from ventricle. (C) Three-lobe occluder (Amplatzer AVP II) shown extended from delivery cannula as deployed from the cardioscope. (D) Delivery process. The Annals of Thoracic Surgery 2017 104, 1074-1079DOI: (10.1016/j.athoracsur.2017.03.028) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Epicardial echocardiography of paravalvular leaks (PVLs). (A) Short-axis view of implanted valve. (B) Long-axis echo color Doppler showing regurgitant jet in right coronary (RC) and noncoronary (NC) sinuses. (C) Long-axis echo color Doppler showing regurgitant jet in the left coronary (LC) sinus. (D) Short-axis view after delivery of closure devices in three PVLs. The Annals of Thoracic Surgery 2017 104, 1074-1079DOI: (10.1016/j.athoracsur.2017.03.028) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Cardioscopic images during paravalvular leak (PVL) closure. (A) View in blood. (B) Localizing PVL by visualization of regurgitation. Inset: Imaged region of valve. Blue fabric appears white in cardioscopic image because of lighting. (C) Device deployment. (D) Device inspection. The Annals of Thoracic Surgery 2017 104, 1074-1079DOI: (10.1016/j.athoracsur.2017.03.028) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Cardioscopic images during device recovery. (A) Positioning device screw connector inside working channel. (B) Forceps grasping screw connector. (C) Device pulled from paravalvular leak. (D) Device removed through apex. The Annals of Thoracic Surgery 2017 104, 1074-1079DOI: (10.1016/j.athoracsur.2017.03.028) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Postoperative assessment of device placement (arrows) viewed from ventricle (anterior mitral leaflet resected). Inset: aortic view. The Annals of Thoracic Surgery 2017 104, 1074-1079DOI: (10.1016/j.athoracsur.2017.03.028) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions