Imaging the mitral valve: a primer for the interventional surgeon

Abstract

Transcatheter mitral valve interventions (TMVI) have evolved over the past decade as alternatives to open surgical repair for the therapeutic management of patients with severe mitral regurgitation (MR). Concurrent with the development of these technologies, quality multi-modality cardiac imaging has become essential in patient selection and procedural guidance. The former involves assessments of the pathophysiologic mechanisms of regurgitation, valvular anatomy and morphology, as well as objective quantification of the severity of MR. Both transthoracic and transesophageal echocardiography (TEE) are crucial and serve as the gateway to diagnosis and management of mitral valvular disease. Along with multi-detector computed tomography (CT) and cardiac magnetic resonance imaging (CMR), echocardiography plays an important role for preprocedural planning and evaluation of the spatial relationships of the mitral valvular complex with the coronary sinus, circumflex coronary artery and left ventricular (LV) outflow tract. Procedures that target mitral leaflets (e.g., MitraClip, PASCAL) or annulus (e.g., Cardioband, Carillon), or provide chordal (e.g., NeoChord, Harpoon) or valvular replacement, tend to be guided by TEE and assisted by fluoroscopy. As newer devices become available and outcomes of TMVI improve, cardiac imaging will undoubtedly continue to play an essential role in the success of percutaneous mitral valve repair (MVr) and replacement. The interventional surgeon of the future must therefore have a thorough understanding of the various imaging modalities while synthesizing and integrating novel concepts (e.g., neo-LV outflow tract) as applicable to assessing valvular function and pathology.

Minimally Invasive Strategy to Repair Mitral Valve after Repeated Coronary Revascularization: A Case Report and Literature Review

“…Percutaneous mitral annuloplasty using the Carillon™ Mitral Contour System™ (Cardiac Dimension Inc., Kirkland, WA, USA) is a procedure that started in Europe in August 2011, which involves the stabilization of the annulus through coronary sinus (CS) in patients with functional mitral regurgitation [37]. However, primary mitral regurgitation is a contraindication to its use [38], and the trials currently available provide a short follow-up period (<12 months).…”

Degenerative Mitral Stenosis—Diagnostic Challenges and Future Directions

“…Although transthoracic echocardiography (TTE) can provide a good estimation of the burden of MAC, in severe MAC, the calcification can create an echocardiographic artifact and creates acoustic shadowing but lacks the echo-lucent center which might obscure the valve assessment and [ 33 ]. Transesophageal echocardiography (TEE) can provide better visualization of the mitral annulus and left ventricle thickness and can accurately assess the extension of MAC to the surrounding structure [ 33 , 34 ]. TEE has the superiority of temporal resolution over TTE, and thus it is the method of choice to further evaluate and characterize the MV function, extent of calcification, and the leaflet characterization [ 35 ].…”

Can Multidetector Computed Tomographic Angiography Replace Transesophageal Echocardiography for Preoperative Transcatheter Edge-to-Edge Mitral Valve Repair Planning Purposes?

“…The strength of MDCT is to evaluate mitral annular dimensions (perimeter and inter-trigonal, inter-commissural and septolateral distances), mitral annular calcification, leaflet length, distance between papillary muscles, left ventricular outflow tract area and the course of the coronary sinus and circumflex coronary artery relative to the annular plane. 7) …”