Feasibility and reliability of comprehensive three-dimensional transoesophageal echocardiography screening process for transcatheter mitral valve replacement

Abstract

Aims The procedural planning of transcatheter mitral valve replacement (TMVR) requires a specific imaging assessment to establish patient eligibility. Computed tomography (CT) is considered the reference method. In this setting, data regarding the role of transoesophageal echocardiography (TOE) are lacking. We evaluated the feasibility and reliability of a comprehensive 3D-TOE screening in TMVR candidates. Methods and results We performed a retrospective observational study including 72 consecutive patients who underwent a pre-procedural CT and 3D-TOE for TMVR evaluation. The measurements of mitral annulus (MA), length of anterior mitral leaflet (AML), native left ventricular outflow tract (LVOT), and predicted neo-LVOT acquired with CT and 3D-TOE were compared using a novel semi-automated software for post processing analysis (3 mensio Structural Heart 10.1—3mSH, Pie Medical Imaging, Bilthoven, Netherlands). The final suitability decision was given by the valve manufacturer based on CT measurements and clinical conditions. Among 72 patients screened, all patients had adequate image quality for 3D-TOE analysis. 3D-TOE and CT measurements for AML length (r = 0.97), MA area (r = 0.90), perimeter (r = 0.68), anteroposterior (r = 0.88), and posteromedial-anterolateral (r = 0.74) diameters were found highly correlated, as well as for native LVOT (r = 0.86) and predicted neo-LVOT areas (r = 0.96) (all P-values <0.0001). An almost perfect agreement between CT and 3DTOE was found in assessing the eligibility for TMVR implantation (Cohen kappa 0.83, P < 0.001). Conclusion 3D-TOE appraisements showed good correlations with CT measurements and high accuracy to predict TMVR screening success.

Standardization and validation of neoLVOT assessment using three‐dimensional trans‐esophageal echocardiography before trans‐catheter mitral valve replacement

“…As regard to screening candidates of TMVR at potential risk of LVOT obstruction, our results showed excellent correlation between both methods in NeoLVOT area assessment after virtual implantation of same valve size in both data sets (r = .96) (p-value < .0001) and this came in agreement with Piroli et al 1 results which also showed almost perfect agreement between CT and 3DTEE in assessment of mitral annulus and neoLVOT area using 3mensio software in 56 patients evaluated for native valve TMVR (p-value < .001), despite this high correlation between the two methods, they also confirmed the slight tendency of echocardiography to underestimate measurements compared to CT, which in turn may overestimate the risk of LVOTO and/or lead to improper exclusion of the patient for ineligibility. However, it appears reasonable, if the difference between the echocardiography derived annulus and/or neoLVOT dimensions and the manufacturer's cut-off dimension (LVOT of 1.7 cm 2 ) 28 are few mm, a complementary CT evaluation is recommended to confirm the screening results in order to not improperly exclude patients whose anatomical features are judged as unsuitable with echocardiography.…”

“…CT assessment is considered as the gold standard imaging modality for screening candidates for TMVR 1,32 . CT based analysis can detect patients at potential risk of Iatrogenic LVOT obstruction after TMVR, by assessment of LVOT area, aortomitral angle and projected NeoLVOT area after virtual implantation of the new valve in the CT data set 28,30 .…”

“…CT assessment is considered as the gold standard imaging modality for screening candidates for TMVR. 1,32 CT based analysis can detect patients at potential risk of Iatrogenic LVOT obstruction after TMVR, by assessment of LVOT area, aortomitral angle and projected NeoLVOT area after virtual implantation of the new valve in the CT data set. 28,30 Introducing a reliable 3DTEE based software provides a special edge over CT in reduction of radiation exposure and screening candidates who cannot have CT scan for any clinical contraindication, however its accuracy is still investigated.…”

“…Trans-catheter mitral valve replacement (TMVR) procedures had emerged as an alternative solution for patients who have prohibitive surgical risk for mitral valve surgery. 1 One of the main challenges faced during the percutaneous approach is the degree of left ventricular outflow tract (LVOT) narrowing after implanting the new transcatheter mitral prosthesis. Cardiac computed tomography (CT) assessment is considered the gold standard for preprocedural planning and risk stratification in TMVR patients.…”

“…Cardiac computed tomography (CT) assessment is considered the gold standard for preprocedural planning and risk stratification in TMVR patients 2 . This assessment can be done using a commercially available CT‐based analysis software that allows the insertion of a virtual valve within the CT dataset within the native annulus and/or the degenerated bioproshesis to measure the remaining LVOT area (NeoLVOT) using the multiplanar reconstruction (MPR) mode 1–3 . However, there is no full agreement on which phase in systole that shows the narrowest neoLVOT.…”