Role of imaging in novel mitral technologies—echocardiography and computed tomography

Abstract

As minimally invasive cardiovascular procedures gain popularity, novel transcatheter mitral valve repair devices continue to emerge. The success of these technologies is critically dependent on high quality imaging performed at all stages: patient selection, intervention planning, intraprocedural guidance, monitoring complications and follow-up. We present an overview of specific imaging requirements and challenges applicable to mitral valve interventional techniques. Modern valve imaging is multimodal and primarily combines echocardiography and computed tomography (CT). Echocardiography remains the gold standard for detailed anatomic imaging, complete hemodynamic characterization and real-time guidance and evaluation of procedural success. CT is indispensable for mitral annulus (MA) imaging and in predicting left ventricular outflow tract (LVOT) obstruction post transcutaneous mitral valve replacement (TMVR). 3D modeling, fusion imaging and automated image analysis may further contribute to the evolutionary transformation of valvular heart imaging.

Transapical mitral valve repair with neochordae implantation: FSI analysis of neochordae number and complexity of leaflet prolapse

“…In this context, echo‐based computational models that study MV function and treatment commonly use complementary segmentation and modeling approaches based on optimization methods, parametric modeling using anatomic landmarks points, multiscale image‐based geometry, and generalized anatomical models from literature‐derived data . Fortunately, the field of transcatheter MV therapy is quickly evolving, and as technology improves, the use of multimodality cardiac imaging techniques that combine echo, CT‐based planning, and imaging fusion techniques is expected to play a more dominant role in these minimally invasive procedures …”

“…[41][42][43] Fortunately, the field of transcatheter MV therapy is quickly evolving, and as technology improves, the use of multimodality cardiac imaging techniques that combine echo, CT-based planning, and imaging fusion techniques is expected to play a more dominant role in these minimally invasive procedures. [44][45][46]…”

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2019

“…48,49 Despite these advances, transcatheter mitral valve replacement has a small but important risk of left ventricular outflow tract obstruction that depends on factors such as septal dimensions, annular calcification, and the subannular profile of the selected mitral prosthesis. 50,51 The role of three-dimensional computed tomographic imaging is most valuable in this setting for preoperative calculation of left ventricular outflow tract area, taking into account the planned mitral prosthesis. 50,51 A predicted left ventricular outflow tract volume below 1.7 cm 2 has a 96.2% sensitivity and a 92.3% specificity for prediction of obstruction across the left ventricular outflow tract, defined as an increase in the mean gradient above 10 mmHg.…”

“…50,51 The role of three-dimensional computed tomographic imaging is most valuable in this setting for preoperative calculation of left ventricular outflow tract area, taking into account the planned mitral prosthesis. 50,51 A predicted left ventricular outflow tract volume below 1.7 cm 2 has a 96.2% sensitivity and a 92.3% specificity for prediction of obstruction across the left ventricular outflow tract, defined as an increase in the mean gradient above 10 mmHg. 50,51 This complication has been associated with a significant increase in periprocedural mortality (34.6% v 2.4%: p < 0.001).…”

“…50,51 A predicted left ventricular outflow tract volume below 1.7 cm 2 has a 96.2% sensitivity and a 92.3% specificity for prediction of obstruction across the left ventricular outflow tract, defined as an increase in the mean gradient above 10 mmHg. 50,51 This complication has been associated with a significant increase in periprocedural mortality (34.6% v 2.4%: p < 0.001). 51 To overcome this potential complication, the CardiAQ (Edwards Lifesciences, Irvine, CA) transcatheter mitral valve has anchoring method that employs the native mitral leaflets for positioning with deployment in a supra-annular position.…”