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Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond

https://t.me/med1917

Fig. 6 PISA measurement with color Doppler baseline shift seen on (a) (1.6 cm) with angle of correction consideration due to constrained jet (b). Reversal of PV ow with PW Doppler seen on (c) (arrow)

https://t.me/med1917

Our patient’s echo measures and MR severity

Table 6

calculations

Echo measures PISA 1.6cm MR Vmax

4.2m/s MR VTI 96cm Va 0.39m/s Angle of correction=135°

Va aliasing velocity, Q regurgitant ow, MR VTI MR jet velocity time integral, Vmax maximal MR jet velocity

Fig. 8 TEE 3D.MV enface view with AV at 12 o’clock position (asterisk). Increase in the wall lter setting allowing for simultaneous visualization of MV anatomy and the jet of MR (arrow)

With angle correction

Q=2∏ (1.6) 39 × (135/180) EROA=1.1cm Rvol=105mL

Without angle correction

Q=2∏ (1.6) 39

EROA=1.5cm Rvol=144mL

T. Safder et al.

Fig. 7 Flail width measurement of 23mm on MV enface 3D view

Heart Team Decision

The ACC/AHA 2020 practice guideline on valvular heart disease provides a framework for decision making for MV surgical vs. transcatheter approach primarily based on mechanism of MR (Tables 1 and 2) [1]. Surgical MV repair is considered the gold standard for primary MR due to the ability to provide a more complete repair when compared to TEER.Thus, TEER for primary MR is suitable only when the patient is demonstrated to be high surgical risk or a poor candidate for surgical repair due to other factors (i.e. anatomical). Despite our patient’s anxiety over surgical repair, a formal cardiothoracic surgery evaluation is required and was ordered to

assess for eligibility for TEER.Due to patient’s comorbidities, he was determined to be of high surgical risk for surgical MV repair with a calculated STS score of 9.5%. With a designation of high surgical risk, our patient can now be considered for TEER if his anatomy proves favorable.

Several anatomical factors need to be reviewed when deciding this patient’s suitability for TEER (Table3). The central location of leaet pathology is favorable for TEER due to ease of access of the A2–P2 location for the TEER system. Lack of any degree of mitral stenosis and minimal leaet calcication also favor a TEER approach in this patient. Furthermore, adequate posterior leaet length measurements also assure us of good grasping zones. But a signicant ail width (Fig.7) and ail gap (Fig.5b) are less favorable features. A large

Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond

https://t.me/med1917

Our patients MV characteristics as it pertains to

and/or highly mobile ail segment can lead to an unstable clip attachment and a poor TEER result.

Further discussion within the heart team led to the decision to move forward with TEER. The favorable features that allowed for a successful TEER were thought to outweigh the less favorable

Table 7

TEER

Favorable Less favorable Middle location of pathology Flail width>15mm Minimal leaet calcication Flail gap of 9.7mm No signicant mitral stenosis Large grasping zone

ones (Table 7). Additionally, as experience is gained, it is recognized that placement of multiple MV clips during TEER can allow for stabilization of larger more mobile ail leaets. But this is undertaken at the risk of procedural complications,

Intraprocedural Imaging Modalities andMeasurements

such as MV clip single leaet detachment (SLD).

Crucial procedural steps Imaging highlights Optimal TEE views

Transseptal puncture

Delivery system guidance Clip arm positioning above the valve

Clip arm positioning below the valve

Grasping of leaets

Clip closure

Evaluation post deployment

Delivery system withdrawal

– The transeptal puncture must be at least >3.5cm

(ideally >4cm) above the MV annular plane (as shown measured in Fig.9b)

– Optimal position of transeptal puncture in

midposterior fossa with inferior and posterior positioning

– Adequate atrial septal tenting is needed to assess

catheter positioning (Video 9 and Fig.9b) – Conrm crossing of tip of catheter into LA – Guide delivery system and clip into the left atrium

as it advances to clear surrounding anatomy – Aid in positioning of the clip perpendicularly

above the known regurgitant orice based on

pre-procedural imaging – Partial opening of clip arms with movement of

grasping mechanism to identify clip arm orientation – Conrm clip position above regurgitant orice by

use of color Doppler – Conrm orientation of clip arms has not changed

after passing through the MV (reducing 2D/3D

gain until MV leaets are not visible is needed to

visualize clip below the MV) – The 2 clip arms must be visualized as clearly as

possible as the clip is retracted towards the MV in

an attempt to capture both leaets in their

appropriate anterior and posterior grippers – Verify each leaet capture (release and re-capture

if necessary due to poor capture, Video 13) – Close clip with concomitant color Doppler

evaluation as to note the reduction in MR in real time – Residual MR location and severity evaluation by

color Doppler – PV ow reversal and transmitral peak and mean

gradient evaluation – Assess need for additional clip

– Continuously image the distal end of delivery

catheter to assure clearance of any adjacent

anatomy as it is withdrawn – Evaluate shunt ow from resulting iatrogenic

interatrial defect

– 2D ME bicaval view for superior-inferior

positioning with biplane which allows for anterior-posterior positioning (Video 8 and Fig.9a)

– Rotating of transducer will likely be

needed to locate and follow the catheter

– 2D ME 4Ch and 2Ch views with biplane

(Video 10)

– 3D ME enface view (Video 11)

– Combination of 2D and 3D enface ME

view (Video 12)

– 2D ME long-axis and higher omniplane

(~120°–150°) views (Videos 14 and 15)

– 2D and 3D enface ME views with color

Doppler (Videos 16, 17 and Fig.10)

– 2D ME commissural views for PV PW

and MV CW evaluation (Fig.11a)

– 3D ME enface views (Videos 18, 19 and

Fig.11b)

– TEE imaging views and approach for

second clip similar to rst clip (Videos 20, 21, 22, 23, 24, 25 and 26 and Fig.12)

– 2D ME views with biplane (Video 27

and Fig.13)

– 2D ME bicaval view with color Doppler

and CW (Fig.14)

https://t.me/med1917

T. Safder et al.

Fig. 9 TEE procedure guidance with ME biplane using the bi-caval view. Optimal superior-inferior and anteriorposterior positioning of the catheter for transeptal puncture can be determined in this view (a). Left atrial height should be measured from the coaptation point of the MV

in a straight line to the transeptal puncture site (b). Atrial septal tenting is crucial in locating catheter position (arrow). Inferior vena cava (IVC), superior vena cava (SVC), left atrium (LA), right atrium (RA), aortic valve (AV)

Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond

https://t.me/med1917

Fig. 10 Color ow Doppler evaluation shows presence of a signicant MR jet lateral to the clip with the PISA radius measuring 0.8cm

https://t.me/med1917

Fig. 11 MV gradient with CW Doppler is noted to be 2 mmHg (a). Color ow Doppler demonstrates the signicant MR jet lateral to the clip (b)

T. Safder et al.

Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond

https://t.me/med1917

Fig. 12 TEE procedure guidance. MV gradient with CW Doppler after second MV clip is noted to be 3 mmHg

Fig. 13 The Mitraclip by Abbott delivery system has a sharp tip (arrow) that is uncovered post deployment. This sharp tip must be retracted into the delivery system catheter carefully under direct visualization of 2D echocardiographic imaging

https://t.me/med1917

Fig. 14 TEE procedure guidance. Color Doppler and CW of iatrogenic interatrial defect showing predominantly left to right shunt ow

T. Safder et al.

Follow UpAssessment

identify favorable outcomes such reverse

remodeling of LV and LA.Our patient’s 1 day A comprehensive follow up TTE for patients undergoing TEER is recommended at 1 day, 30 days and again at 6–12 months after their procedure. TTEs at 1 and 30days aid in identifying any possible complications post procedure while TTE at 6–12 months can help in evaluation of effectiveness of procedure and

Modality Clinical application Limitations Transthoracic

echocardiography (TTE)

Transesophageal Echocardiography (tee)

– First line test for assessment of etiology,

mechanism and severity of mitral regurgitation

– Can refer for TEER procedure after initial TTE if

the TTE is of high quality and is able to denitively answer key questions regarding patient’s candidacy for TEER

– Preprocedural evaluation of MR, especially in the

setting of incomplete evaluation or discordant ndings on TTE

– Can obtain more precise information about valve

anatomy and pathology – Intraprocedural imaging guidance – Immediate post procedure evaluation and

evaluation for complications

post procedure TTE showed stable device position and no signicant increase in MR. At 30 days and 6 month follow up, our patient reported signicant symptom improvement. A TTE was scheduled for 1 year post procedure for our patient.

Multimodality imaging comparison

– Lower spatial resolution

compared to TEE

– Body habitus and artifact may

limit adequate assessment of mitral valve

– Some absolute contraindications

include upper GI anatomical considerations, active upper GI

bleeding – Requires sedation – May underestimate MR severity

due to anesthesia and its effect on

loading conditions

Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond

https://t.me/med1917

Modality Clinical application Limitations Exercise stress

echocardiography

Cardiac computed tomography (CT)

Fluoroscopy – Intraprocedural guidance

Cardiac magnetic resonance imaging (CMR)

– Can aid in pre-procedural planning when

discordant ndings between clinical symptoms and echocardiographic ndings

– Can aid in pre-procedural planning if any concern

for atypical anatomy

– Can aid in MV surgery planning if patient is not a

candidate for TEER with evaluation of mediastinal anatomy, cannulation strategy and coronary artery disease

– Pre-procedural hemodynamic testing can be

considered in patients with pulmonary hypertension to guide medical optimization prior to MV intervention

– Can aid in pre-procedural planning when

discordant ndings on TTE/TEE

– Can assess LV size and function, MV morphology

and MR severity

– Can further aid in assessing underlying

cardiomyopathy, if present

– Mobility limitations of patient

– Unable to fully assess etiology

and mechanism of MR – No hemodynamic assessment – Radiation exposure

– Limited anatomic assessment – Invasive testing – Radiation exposure

– Cost – Patient discomfort

Clinical Controversies andClinical Pearls

• Patient selection, based on both clinical and anatomical features, is key in increasing the odds of a good outcome.

• TEER for primary MR is suitable only when patient is demonstrated to be a high surgical risk, otherwise MV surgical repair is the gold standard.

• Exercise stress testing can serve as a valuable tool to assess asymptomatic patients with MR and can shed light on the dynamic nature of MR in patients with discordant clinical ndings.

• Multi-modality imaging (i.e. cardiac MRI) can be useful if used in the proper context such as discordant ndings on echocardiogram.

Key Points

– Mitral regurgitation is a complex disease pro-

cess and transthoracic echocardiography can

serve as the cornerstone imaging modality to provide the clinician with a comprehensive evaluation of the mitral valve.

– Transesophageal echocardiography may be

needed if TTE ndings are incomplete, discordant with clinical ndings or more precise information is needed about MV anatomy to ascertain eligibility for transcatheter intervention.

– A careful consideration of clinical and ana-

tomical features that pertain to a favorable outcome for patients being considered for TEER should be undertaken in pre-procedural planning.

– Familiarity with the key TEER procedural

steps and experience with TEE image optimization techniques is crucial to a successful TEER.

– Follow up imaging at 1 day, 30 days and at

6–12months is recommended to evaluate for post procedure complications and effectiveness of procedure.

https://t.me/med1917

T. Safder et al.

Percutaneous Balloon Mitral Valvuloplasty forMitral Stenosis

Case Study

Ms. K is a 56year old female who moved from Mexico to the U.S. 20years ago. She has known mitral stenosis (MS) and has followed with cardiology for the last 10 years with intermittent transthoracic echocardiography (TTE) imaging. At the most recent clinic visit, the patient reports worsening exertional dyspnea when climbing the stairs in her home during the last 6months. She also reports worsening dyspnea and fatigue when working around the house doing her household chores. Her past medical history is signicant for hypertension and paroxysmal atrial brillation.

Background andDenitions

While MS remains a signicant cause of valvular heart disease around the world, its incidence remains low in high-income countries and is declining in low and middle-income countries. MS presentation and management can vary depending on rheumatic versus non-rheumatic etiology (Table 8) [11]. For this reason, it is important to delineate MS etiology and anatomy at time of diagnosis.

Complete and accurate evaluation of patients with MS is key in ensuring appropriate patient selection for possible intervention. The 2020 ACC/AHA practice guideline for patients with valvular heart disease provides the most up to date classication for MS (Table9) [1]. As is true with all valvular lesions, no one specic parameter or measurement can assess MS completely. Multiple hemodynamic parameters along with valve anatomy, symptoms and secondary cardiac characteristics must be evaluated to accurately assess the presence and severity of MS.Understanding the limitations of the commonly used hemodynamic MS parameters can also help in reconciling conicting ndings (Table10) [12].

Once a diagnosis of severe MS has been made, the patient should be referred to an experienced center to be evaluated by a multidisciplinary valve team for eligibility for possible intervention. Treatment options may differ

Table 8 Key characteristics of rheumatic vs. nonrheumatic MS

Rheumatic Non-rheumatic Signicantly more

common in women (~80% of cases) Can present at any age Typically presents in

Can have minimal or signicant valvular calcication Commissural fusion often present

More common in women but ratio not as high as rheumatic

elderly Typically with signicant annular and valvular calcication No commissural fusion

Table 9

MS classication, adapted from 2020 ACC/AHA practice guideline for valvular disease [1]

At risk of MS Progressive MS

Asymptomatic severe MS Symptomatic severe MS

MS mitral stenosis, LA left atrium, PASP pulmonary artery systolic pressure, MG mean gradient

At HR 60–70bpm

Valve area Valve hemodynamics Secondary ndings

≥1.5cm ≥1.5cm

≤1.5cm

Normal None

Increased transmitral ow velocities but MG <5 mmHg PHT <150ms

Typically MG >5 mmHg PHT ≥150ms

Mild to moderate LA dilation Normal pulmonary pressures at rest Severe LA dilation PASP >50mmHg Severe LA dilation PASP >50mmHg

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