Figure - available from: Frontiers in Cardiovascular Medicine
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Quantification of mitral regurgitation (MR). (A) Calculation of effective regurgitant orifice area (EROA) and regurgitant volume (RVol) by proximal isovelocity surface area (PISA) method. Indicators for severe MR include elevated early diastolic mitral inflow (E wave) velocity (B), dense continuous-wave Doppler signal (C), and systolic reversal of pulmonary vein flow (D). (E) 3D vena contracta area reconciles discrepant linear vena contracta width measurements in an elliptical regurgitant orifice. (F) With cardiac MRI, mitral RVol is calculated as the difference between total left ventricular stroke volume and the aortic flow (forward stroke volume) by phase-contrast imaging.
Source publication
Transcatheter mitral valve interventions are an evolving and growing field in which multimodality cardiac imaging is essential for diagnosis, procedural planning, and intraprocedural guidance. Currently, transcatheter mitral valve-in-valve with a balloon-expandable valve is the only form of transcatheter mitral valve replacement (TMVR) approved by...
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Citations
... There are currently several types of interventional and surgical procedures available for the treatment of mitral regurgitation (MR) (Otto et al 2021). Accurate information on the morphology and dynamics of the mitral valve is critical in order to determine the treatment plan for patients with MR, and medical images such as transesophageal echocardiography (TEE) and contrast-enhanced computed tomography (CT) are often used to obtain morphologic and dynamic information pertaining to the mitral valve (Garcia-Sayan et al 2021). ...
xD; Accurate extraction of mitral valve shape from clinical tomographic images acquired in patients has proven useful for planning surgical and interventional mitral valve treatments. However, manual extraction of the mitral valve shape is laborious, and the existing automatic extraction methods have not been sufficiently accurate. In this paper, we propose a fully automated method of extracting mitral valve shape from computed tomography (CT) images for the all phases of the cardiac cycle.
This method extracts the mitral valve shape based on DenseNet using both the original CT image and the existence probability maps of the mitral valve area inferred by U-Net as input. A total of 1585 CT images from 204 patients with various cardiac diseases including mitral regurgitation (MR) were collected and manually annotated for mitral valve region. The proposed method was trained and evaluated by 10-fold cross validation using the collected data and was compared with the method without the existence probability maps.
The mean error of shape extraction error in the proposed method is 0.88 mm, which is an improvement of 0.32 mm compared with the method without the existence probability maps.
... In recent years, the application of cardiovascular 3-dimensional (3D) printing technology has proven to be highly beneficial in facilitating precise preprocedural assessment and guidance for structural heart interventions [6][7][8][9][10]. We present the first case report of a transcatheter mitral valve-in-ring replacement (TMViR) procedure utilizing the innovative Mi-thos system (NewMed Medical Co., Ltd., Shanghai, China) via the transapical approach. ...
... This method offers a valuable solution to address the limitations of evaluating complex MV, enabling a more comprehensive and precise assessment of anatomical structures. Additionally, 3D printing can guide device selection and evaluate device-bioprosthesis interactions and potential complications [7][8][9]. Mao et al. [8] utilized 3D printing to restore the patient's degenerative mitral bioprosthetic structure, facilitating evaluation and simulation prior to the valve-in-valve procedure. This approach allowed for accurate selection of the appropriate size of the balloon-expandable valve and ensured optimal device positioning, resulting in satisfactory clinical outcomes. ...
... We present a case of a patient who underwent TMViR. A patient-specific, 3D-printed model was utilized to gain valuable insights into the shape of the landing zone, facilitating discussions regarding valve sizing and determining the optimal position for the valve-inring procedure [6][7][8][9][10]. Moreover, the model enabled simulation of the main procedural steps and prediction of potential intraoperative complications, and the utilization of 3D printing technology allows us to thoroughly explore the unique properties of new devices and significantly reduces the learning curve associated with their implementation. ...
Background:
Transcatheter mitral valve-in-ring replacement (TMViR) is an emerging alternative for patients with recurrent mitral regurgitation (MR) after a prior failed annuloplasty ring. However, intraoperative common issues and complications remain to be addressed.
Case summary:
We describe the case of a 67-year-old male patient who underwent surgical mitral concomitant tricuspid annuloplasty repair 7 years ago who developed recurrent severe MR (New York Heart Association functional class IV). To avoid a high-risk surgical reoperation, we chose to perform a TMViR using an innovative dedicated device-the Mi-thos system-via a transapical approach. A patient-specific, 3-dimensional printed model was used to guide the procedure to avoid potential challenges. The procedure was performed successfully, and the patient exhibited symptomatic improvement.
Conclusions:
This case report highlights the first use of the innovative Mi-thos system in a TMViR procedure. The findings demonstrate the feasibility and safety of utilizing the Mi-thos system, guided by 3-dimensional printing technology, for patients who have experienced recurrent mitral regurgitation MR following a failed annuloplasty ring.
... There are currently several types of interventional and surgical procedures available for the treatment of MR [2]. Accurate information on the morphology and dynamics of the mitral valve is critical in order to determine the treatment plan for patients with MR, and medical images such as transesophageal echocardiography (TEE) and contrast-enhanced computed tomography (CT) are often used to obtain morphologic and dynamic information pertaining to the mitral valve [3]. ...
Accurate extraction of mitral valve shape from clinical tomographic images acquired in patients has proven useful for planning surgical and interventional mitral valve treatments. However, manual extraction of the mitral valve shape is laborious, and the existing automatic extraction methods have not been sufficiently accurate. In this paper, we propose a fully automated method of extracting mitral valve shape from computed tomography (CT) images for the all phases of the cardiac cycle. This method extracts the mitral valve shape based on DenseNet using both the original CT image and the existence probability maps of the mitral valve area inferred by U-Net as input. A total of 1585 CT images from 204 patients with various cardiac diseases including mitral regurgitation (MR) were collected and manually annotated for mitral valve region. The proposed method was trained and evaluated by 10-fold cross validation using the collected data and was compared with the method without the existence probability maps. The mean error of shape extraction error in the proposed method is 0.88 mm, which is an improvement of 0.32 mm compared with the method without the existence probability maps.
... Catheter-based treatments of structural heart diseases have been impressively expanding. [1][2][3][4][5][6][7] This growth has been possible thanks to the developments of new percutaneous devices but also due to the innovations in imaging techniques. Mitral regurgitation (MR) treatment is still a challenge in the clinical arena. ...
... Mitral valve (MV) surgery plays a primary role on indications for intervention; however, transcatheter procedures have emerged as an alternative to treat inoperable and high-risk surgical patients. [1][2][3][4][5][6][7] In patients with suitable anatomy, the transcatheter edge-to-edge mitral leaflet repair (TEER) is the most frequently applied procedure. [1] Transcatheter native mitral valve replacement (TMVR) is a novel procedure that has the potential to overcome some of the current limitations associated with TEER. ...
... [1] Transcatheter native mitral valve replacement (TMVR) is a novel procedure that has the potential to overcome some of the current limitations associated with TEER. [2][3][4][5][6][7] Nowadays, there is a wide range of TMVR devices at various stages of development. [6,7] The TMVR device that is most used for native anatomy is the Tendyne system (Abbott, Menlo Park, CA). ...
Transcatheter native mitral valve replacement (TMVR) is a novel procedure that has the potential to overcome some of the current limitations associated with the transcatheter edge-to-edge mitral valve (MV) repair technique. The aim of this study was to describe the key steps in periprocedural echocardiographic guidance of TMVR with the Tendyne system, emphasizing potential caveats and areas of difficulty. The imaging pathway can be schematized in four fundamental steps: baseline evaluation of mitral regurgitation (MR), preprocedural screening and planning, intraprocedural guidance, and follow-up. Baseline evaluation of MR in TMVR includes the guidelines-recommended imaging pathway of MR assessment. A dedicated preprocedure cardiac multimodality imaging screening and planning for TMVR is able to determine patient eligibility according to the anatomic characteristics and measurements, provide information for appropriate valve sizing, and detect features that can predispose to potential hazard or complications. Cardiac computed tomography and two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) are the main actors in this phase. The road map for intraprocedural TMVR guidance includes the following: (1) apical access assessment: 2D TEE assessment of the site for optimal left ventricular apical access as planned by the preprocedural computed tomography; (2) support for catheter and sheath localization, trajectory, and positioning; and (3) valve positioning and radial orientation. Thereafter, the prosthesis is withdrawn toward the left ventricle and deployed intra-annularly. Post-deployment includes assessment for correct clocking and hemodynamics, perivalvular leakage, and left ventricular outflow tract obstruction. Two-dimensional and 3D TEE and fluoroscopy provide intraprocedural guidance. The follow-up of the Tendyne device includes the guidelines-recommended imaging pathway of bioprosthesis. Knowledge of multimodality imaging use is key for the interventional imagers and crucial in the success of the procedure.
... Therefore, individualized preoperative simulation using a personalized 3D printed model is of great significance to accurately predict the procedural results and the possible locations of the PVLs and to help surgeons improve operative strategies. Eleid et al. [65] first reported in 2016 that a patient-specific 3D printed model was successfully used to predict PVL and LVOT obstruction after TMVR [66][67][68][69]. They found that the preoperative evaluation results based on the 3D printed models accurately reflected the locations and the size of the PVLs, and enabled the surgeon to directly evaluate the rationality of the LVOT and the selection of the stent [65]. ...
Mitral valve (MV) disease is one of the most common valvular diseases that endangers health status. A variety of catheter-based interventions have been developed to treat MV disease. The special anatomical structures of the MV complex increase the difficulty of interventional surgery, and the incidence of perioperative complications remains high. With the continuous development of cardiovascular 3-dimensional (3D) printing technology and of multidisciplinary cooperation, 3D printing for transcatheter mitral valve interventions (TMVI) has become a revolutionary technology to promote innovation and improve the success rate. Patient-specific 3D printed models have been used in measuring sizes and predicting perioperative complications before TMVI. By simulating a bench test and using multi-material printing, surgeons may learn how the device interacts with the specific anatomical structures of the MV. This review summarizes relevant cutting-edge publications in this field and illustrates the application of 3D printing in TMVI with examples. In addition, we discuss the limitations and future directions of 3D printing in TMVI. Clinical Trial Registration: ClinicalTrials.gov Protocol Registration System (NCT02917980).
... Multimodality imaging with echocardiography and MDCT is used for obtaining this information. [33][34][35] Echocardiography is used predominantly for assessing the mechanism and severity of valve dysfunction, ruling out contraindications such as left atrial clot, and evaluating the interatrial septal anatomy. In comparison, MDCT is the primary modality used for valve sizing, predicting neo-LVOT size and the risk of LVOT obstruction, and for the assessment of vascular access routes. ...
... The TMViVR procedure is done under combined fluoroscopic and TEE guidance. [33][34][35]40,41] Once the TEE probe is inserted after induction of general anesthesia, a quick reassessment of the preprocedure findings should be done. The mitral PHV structure and function, IAS anatomy, LV size and systolic function, the status of LVOT and the baseline LVOT gradient, RV systolic function, pulmonary pressures, etc., should be checked. ...
... Conversely, deployment more toward the LA minimizes the risk of LVOT obstruction but increases the risk of PVL and device embolization into the LA. [34,35] Once the proper device positioning is confirmed, the valve is deployed using slow balloon inflation under rapid ventricular pacing with ventilation briefly paused. The deployment is done under fluoroscopic and real-time TEE guidance. ...
The recent technical advances have revolutionized the field of percutaneous structural heart disease interventions. Multimodality imaging is pivotal to the success of these procedures and echocardiography is an integral part of this imaging. Echocardiography is essential for preprocedural evaluation as well as postprocedure assessment and follow-up of all such patients. In addition, for mitral valve interventions, echocardiography is also indispensable for intra-procedural guidance, although its role in guiding transcatheter aortic valve replacement (TAVR) has diminished lately. A thorough understanding of echocardiography, especially for valvular assessment, and a high level of expertise in intraprocedural imaging are necessary for facilitating these procedures. This review describes the role of echocardiography in guiding TAVR and transcatheter mitral valve-in-valve replacement- the two most commonly performed percutaneous valve replacement procedures at present.
... The most common method to evaluate mitral annular dimensions on dedicated CT software is a cubic spline interpolation technique where several seed points are placed along the mitral annulus over 360° [18,23]. This generates a 3D perimeter of the saddle-shaped annulus and The trigones are defined as the point where the LVOT is no longer seen on short-axis images. ...
... While this absolute cut-off may be excessively conservative for a relatively dynamic structure, factors such as loading conditions and volume status need to be considered at the time of procedure. Small predicted neo-LVOT areas are not necessarily prohibitive as several interventional techniques exist that may help in cases where LVOTo is a significant concern -such as the LAMPOON procedure (intentional laceration of the AML) and preemptive alcohol septal ablation [23]. ...
... Transeptal access is an attractive alternative when feasible, which preserves the apical myocardium (and associated scar), achieved through femoral vein puncture. CT planning may involve delayed or venous phase imaging to help delineate caliber, tortuosity, and occasional obstruction [23]. Some right-sided contrast opacification is useful to facilitate the best transeptal puncture location which would ideally be to achieve the most coaxial position of the transcatheter valve relative to the mitral annular plane (Fig. 16). ...
Purpose of Review
Transcatheter mitral valve replacement (TMVR) is an evolving and rapidly expanding field within structural interventions, offering renewed treatment options for patients with high-risk mitral valve disease. We aim to highlight and illustrate the importance of cardiac CT in the planning of TMVR.
Recent Findings
As TMVR has evolved, so has the specific nuances of cardiac CT planning, we now understand the importance of accurate annular sizing and valve simulation to predict complications such as neo-LVOT obstruction and paravalvular leak (PVL). More so than any other modality, cardiac CT remains instrumental in accurately planning TVMR from feasibility, device sizing, access, and fluoroscopic angles.
Summary
Cardiac CT remains the key modality in TMVR evaluation, often the first step in determining patient eligibility through comprehensive procedural planning as well as informing potential outcomes and prognosis. In this review, we discuss the critical role of cardiac computed tomography (CT) and the specific considerations involved in TMVR.
... 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]. Cardiac computed tomography scan on the other hand as higher isotopic spatial resolution with excellent calcification definition [36]. ...
Determining the severity of stenosis in degenerative mitral stenosis (DMS) is fraught with challenges. Neither a high trans-mitral gradient nor a small valve area calculation is sufficiently diagnostic for DMS due to variable left atrial and left ventricular compliance in the setting of diastolic dysfunction, and the variable flow seen in patients with chronic kidney disease (i.e., high flow state) and elderly women (low flow state). Three-dimensional measurement of mitral valve area may be underestimated due to shadowing from basal calcium, and mitral valve annulus (MVA) by continuity equation (CEQ) or dimensionless mitral valve index can be erroneous in the presence of significant regurgitation of left-sided valves. The proposed dimensionless mitral stenosis index (DMSI) can be an easy echocardiographic tool to use in daily practice but needs further validation and is limited in the setting of significant regurgitation of left sided valves. Mean trans-mitral gradients >8 mmHg and pulmonary artery pressure >50 mmHg are independent predictors of mortality in those with MVA <1.5 cm2 derived by CEQ. In patients who have symptoms that are out of proportion to the degree of stenosis reported, exercise stress testing may help determine the physiologic effects of the stenotic valve. A combination of MVA by CEQ or DMSI and mean transmitral gradient at a given left ventricle stroke volume (flow) should be evaluated in larger studies.
... This growth has been possible thanks to the developments and rapid progress of new percutaneous devices but also due to the innovations in imaging techniques [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]. These developments have prompted the need for a new dedicated professional figure with specific competencies in the field of structural heart disease procedures imaging 'the interventional imager' whose collaboration with the implanter team is crucial for the procedural success [22,25,26]. ...
... Imaging is paramount in planning and guide the MV interventional procedure. While the angiography and the fluoroscopy are performed by the implanter team, other multimodality imaging, semi and non-invasive, the so called 'interventional imaging', is performed by the structural heart disease interventional imagers [16][17][18][19][20][21][22]25,26]. A peculiar imaging work-up is essential to select the right patient [16][17][18][19][20][21][22]25,26]. ...
... While the angiography and the fluoroscopy are performed by the implanter team, other multimodality imaging, semi and non-invasive, the so called 'interventional imaging', is performed by the structural heart disease interventional imagers [16][17][18][19][20][21][22]25,26]. A peculiar imaging work-up is essential to select the right patient [16][17][18][19][20][21][22]25,26]. ...
The interaction between the implanter team and the imager team is critical to the success of transcatheter native mitral valve replacement (TMVR), a novel interventional procedure in the therapeutic arsenal for mitral regurgitation. This imaging scenario necessitates the addition of a new dedicated professional figure, dubbed "the interventional imager," with specific expertise in structural heart disease procedures. As its clinical application grows, knowledge of the various imaging modalities used in the TMVR procedure is required for the interventional imager and beneficial for the interventional implanter team. The purpose of this review is to describe the key steps of the procedural imaging pathway in TMVR using the Tendyne mitral valve system, with an emphasis on echocardiography. Pre-procedure cardiac multimodality imaging screening and planning for TMVR can determine patient eligibility based on anatomic features and measurements, provide measurements for appropriate valve sizing, plan/simulate the access site, catheter/sheath trajectory, and prosthesis positioning/orientation for correct deployment, and predict the risks of potential procedural complications and their likelihood of success. Step-by-step echocardiographic TMVR intraoperative guidance includes: apical access assessment; support for catheter/sheath localization, trajectory and positioning, valve positioning and clocking; post deployment: correct clocking; hemodynamic assessment; detection of perivalvular leakage; obstruction of the left ventricular outlet tract; complications. Knowledge of the multimodality imaging pathway is essential for interventional imagers and critical to the procedure's success.
... Cardiovascular imaging has become a key player in diagnosis, pre-procedural planning, procedural guidance, and follow-up in TMVR therapies. Moreover, a patient-centered structural intervention team with the interventional and the imaging parties well familiarized with each other's tools, skills, language, and procedures are essential for a successful intervention [10]. ...
... TEE has the superiority of temporal resolution, hence, is the method of choice for mitral valve function and leaflet characterization. On the other hand, CCT is a non-invasive imaging technique with high isotropic spatial resolution and excellent calcification definition, offering ideal capabilities for a higher accuracy for 3D sizing and procedural simulation [10]. This multimodality imaging approach is, at the time, the gold standard for TMVR [15]. ...
... It includes characterization of the valvular disease mechanism, grading, as well as its impact on heart size and function. Moreover, evaluation of right heart cavities and pulmonary hypertension are important prognostic factors that should be noted [10]. Potential contraindications should also be sought, such as active endocarditis, intracardiac thrombus, or severe patient-prosthesis mismatch [16]. ...
Mitral regurgitation is the second-most frequent valvular heart disease in Europe and it is associated with high morbidity and mortality. Recognition of MR should encourage the assessment of its etiology, severity, and mechanism in order to determine the best therapeutic approach. Mitral valve surgery constitutes the first-line therapy; however, transcatheter procedures have emerged as an alternative option to treat inoperable and high-risk surgical patients. In patients with suitable anatomy, the transcatheter edge-to-edge mitral leaflet repair is the most frequently applied procedure. In non-reparable patients, transcatheter mitral valve replacement (TMVR) has appeared as a promising intervention. Thus, currently TMVR represents a new treatment option for inoperable or high-risk patients with degenerated or failed bioprosthetic valves (valve-in-valve); failed repairs, (valve-in-ring); inoperable or high-risk patients with native mitral valve anatomy, or those with severe annular calcifications, or valve-in-mitral annular calcification. The patient selection requires multimodality imaging pre-procedural planning to select the best approach and device, study the anatomical landing zone and assess the risk of left ventricular outflow tract obstruction. In the present review, we aimed to highlight the main considerations for TMVR planning from an imaging perspective; before, during, and after TMVR.
