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

https://t.me/med1917

considerably depending on valve anatomy and mechanism of disease (i.e. rheumatic versus non-rheumatic).

Patients with rheumatic disease may qualify

for one of several possible treatment options. One

Table 10 Common MS hemodynamic parameters used to assess severity

Advantages Disadvantages

Planimetry (by 2D or 3D)

Pressure half-time (PHT)

Mean gradient (MG)

Systolic pulmonary artery pressure

PISA

Adapted from Baumgartner etal. [12]

LA left atrium, LV left ventricle, AI aortic insufciency, RA right atrium, MVA mitral valve area, PHT pressure

half-time, PISA proximal isovelocity surface area

– Direct

measurement

– Independent

from other cardiac factors

– Easy to obtain – Can help derive

M VA

– Easy to obtain – Can be affected

– Readily available

in most studies

– Independent of

ow conditions

– Not always

feasible due to imaging quality or calcications

– User experience

dependent

– Can be affected

by other cardiac factors (i.e. AI, LA/LV compliance)

by other cardiac factors (i.e. HR, forward ow)

– Indirect estimate

of RA pressure

– No estimation of

pulmonary vascular resistance

– Technically

difcult

– User experience

dependent

such option is percutaneous mitral balloon valvuloplasty (PBMV). When compared to surgical techniques, PBMV has shown to be safe and effective with comparable long term outcomes and as such has become the preferable treatment option [13]. The decision regarding PBMV versus surgery is predominantly decided by anatomical suitability.

The most widely used parameter to assess anatomic suitability is the Wilkins score rst proposed by Dr. Wilkins in 1988 (Table11) [14]. It allows for grading of MV leaet calcication, thickening, mobility as well as subvalvular thickening. Generally, a score of ≤8 with no more than moderate MR is thought to be the ideal candidate for PBMV [15]. Patients with higher scores should be considered for surgical interventions if surgical risk is not prohibitive. One notable limitation of the Wilkins score is the lack of inclusion of information regarding commissural fusion or calcication. If the restrictive pathology lies more in the MV leaets without signicant commissural fusion or if there is presence of signicant commissural calcications, the effectiveness of PBMV is likely to be limited and may potentially be harmful.

Patients with non-rheumatic disease generally have signicant annular and valvular calcication and thus make poor candidates for PBMV or surgery. Intervention is only recommended as a last resort and after extensive discussions with patient and family regarding high procedural risk.

Table 11

Wilkins score adapted from Wilkins etal. [14]

Grade Leaet mobility Leaet calcication Leaet thickness Subvalvular thickening 0 Normal None Normal None 1 Highly mobile leaets

with only leaet tips restricted

2 Leaet mid- and basal

portions have normal mobility

3 Valve continues to

move in diastole, mainly from the base

4 No or minimal

forward leaet motion in diastole

Single area of increased echo brightness Scattered areas of brightness limited to leaet margins Brightness extending into mid leaets

Extensive brightness throughout the leaet tissue

Leaets near-normal thickness (4–5mm)

Midleaets normal, considerable leaet tip thickening (5–8mm) Extension of thickening through entire leaet (5–8mm) Signicant thickening of entire leaet (>8–10mm)

Minimal thickening just below leaets (i.e. mild chordal thickening) Thickening of chordal structures extending to one-third of chordal length Thickening of chordal structures extending to the distal third of chordae Extensive chordal thickening and shortening extending down to the papillary muscles

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T. Safder et al.

Diagnosis andPre-procedural Assessment

When assessing any patient for possible intervention for their MS, their indication as well as anatomical suitability for intervention must be thoroughly investigated. The ACC/AHA practice guideline for patients with valvular heart disease recommendations for intervention for severe MS can be seen in Fig.15.

The evaluation process starts with conrming the diagnosis and severity of MS.On review of the most recent TTE of our patient, we can appreciate thickened MV leaets with restricted opening on both the PLAX and apical four chamber view but without signicant annular or valvular calcications (Videos 28 and 29). The classic “hockey stick” appearance seen in rheumatic MS is noted on the PLAX view (Fig.16). Color Doppler evaluation shows ow acceleration through the MV as well as ow convergence zone where a PISA can be measured even without baseline shifting the color Doppler scale (Fig. 17). These ndings strongly suggest signicant MS along with a likely rheumatic etiology.

For further evaluation of severity of MS, quantitative evaluation is needed (Fig.18). Some measures of MS severity for our patient are noted in Table12 and demonstrate a signicantly abnormal MG, PHT and MVA.These ndings classify our patient as stage D (Table9). The morphology of the valve seen on TTE ts with the severity

Fig. 16 Classic “hockey stick” appearance of the anterior leaet (arrow) of the rheumatic MV during valve opening

Fig. 15 Indication for intervention for rheumatic MS adapted from the 2020 ACC/AHA practice guideline for valvular guidelines [1]

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

https://t.me/med1917

markers measured on TTE and furthermore, these ndings provide a reasonable explanation of our patients worsening symptoms. The next step after conrmation of severe, symptomatic MS due to a rheumatic etiology is to refer our patient to a multi-disciplinary valve team for further evaluation for suitability of intervention.

If a patient with MS presents with discrepancies between clinical symptoms and echocardiographic ndings, an exercise stress echo with hemodynamic assessment should be considered (class I, level of evidence C-LD) [1]. Exercise testing may unmask signicant MS with increased cardiac workload.

Fig. 17 Zoom view of the apical 4C demonstrating a ow convergence zone at the MV even without baseline shift in Doppler scale

Table 12

graphic ndings for our patient

Transthoracic echocardiogram parameter Patient’s ndings

Mean gradient 15mmHg (at HR

PHT 173ms MVA by planimetry (TEE) 0.86cm Wilkins score 6/16 Mitral regurgitation Mild

PHT pressure half-time, MVA mitral valve area

Relevant pre-procedural MV Echocardio-

85)

Fig. 18 CW Doppler evaluation through the MV showing MG 15 mmHg at HR 85. PHT is noted to be 173 ms which would lead to a calculated MVA of 1.3cm2. All these criteria classify this patient in the severe MS range

https://t.me/med1917

T. Safder et al.

Heart Team Approach andDiscussion

With a diagnosis of severe symptomatic MS, our patient has a class I recommendation for undergoing PBMV if her MV is anatomically favorable and she is without any contraindications to the procedure [1]. Our patient’s Wilkins score was 6/16 with commissural fusion and without signicant commissural calcications. She was noted to have mild MR and was without any other signicant valvular lesions.

A TEE is needed prior to a patient proceeding to a PBMV to assure there is no thrombus in the LA and LAA.A TEE can also help further dene MV morphology and anatomic suitability as well

as evaluating MS severity (Videos 30 and 31 and Figs.19a, b and 20). A TEE in our patient con- rmed the TTE ndings of severe MS and ruled out presence of LA or LAA thrombus (Fig.19c).

Selection of an appropriate balloon size is a critical factor during procedure planning. Balloon size has been shown to be predictive of both post procedure MR severity as well as MS gradient reduction [16]. Some literature has advocated sizing based on height or body surface area. Another approach is to measure the MV annular diameter and use it as a reference for the maximal balloon size for the procedure [15]. For our patient, the MV annular size was measured ~27mm and so the decision was made to use a 26mm balloon (Fig.21a and b).

Fig. 19 Figure demonstrates key images from our patient’s TEE. Severe MS is conrmed by pressure half time (a) and mean mitral valve gradient (b). It is important

to note the hemodynamic measures can be underestimated during TEE in the presence of anesthesia. (c) Shows no thrombus in the LAA

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

https://t.me/med1917

Fig. 20 3D multi-planar reconstruction of MV with TEE demonstrates MVA of 0.712cm2 by planimetry

Fig. 21 MV annular size measured at 27mm on both the PLAX view (a) and a zoomed in apical 4C (b)

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T. Safder et al.

Heart Team Decision

gery is a Class I recommendation for patients with severe symptomatic MS with unfavorable

Having a Wilkins score ≤8, commissural fusion without signicant calcication along with mild MR makes our patient an ideal candidate for PBMV.She has no contraindications for PBMV (Table 13). MV replacement sur-

Table 13 Contraindications to PBMV

Contraindications to PBMV Signicant valvular or commissural calcication MS without commissural fusion Another indication for cardiothoracic surgery (i.e.

severe CAD) Greater than moderate MR LA or LAA thrombus Concomitant signicant AV or TV disease

Key procedural steps Key imaging highlights Correlated video/gure Transeptal puncture

Delivery system guidance

Device positioning

Balloon ination – Once proper positioning is conrmed, the balloon is

Delivery system withdrawal

Immediate post procedure evaluation

– Optimal position of transeptal puncture is the center

of fossa ovalis

– Adequate atrial septal tenting is needed to assess

catheter positioning – Conrm crossing of tip of catheter into LA – Aid in guidewire positioning in to the LA followed

by advancing of delivery system over the wire and

into the LA – Aid in placing the balloon across the MV where the

distal half of the balloon rests in the LV

inated across the MV for a few seconds only and

then deated – Multiple balloon inations can be attempted until a

successful outcome is achieved as long as there is no

worsening of MR.For each subsequent attempt, the

balloon is repositioned across the MV with imaging

guidance, and generally inated to a larger size

(typically in increments of 1mm) – Careful MV TEE evaluation is needed after every

balloon ination. A successful outcome is when

>50% reduction in the MV gradient or MVA >1.5cm

is achieved without signicant worsening of MR – For our patient, the balloon was inated to 24mm

(maximum 26mm). No further inations were

performed since there was >50% reduction in the

mean gradient and MR appeared to worsen (Videos

36, 37 and 38, Fig.24a and b) – Under echocardiographic guidance, conrm slow

withdrawal of the device across the septum into the

RA – Once in the RA, the device can be fully removed – The residual atrial septal shunt with left to right ow

should be evaluated and documented – Pericardial space should be evaluated for any effusion

anatomic features for PBMV and who are not at prohibitive surgical risk (Class I recommendation). The same recommendation applies for patients who have failed prior PBMV or have an another indication for cardiac surgery [1].

Intraprocedural Imaging Modalities andMeasurements

Intraprocedural imaging guidance can be provided using TEE or intracardiac echocardiography (ICE). In our patient, TEE was used for intraprocedural guidance. Below are the key steps and imaging highlights of a typical PBMV procedure.

– 2D ME bicaval view for

superior- inferior positioning with biplane which allows for

anterior- posterior positioning – Figure 22a and b – 2D ME 4Ch and 2Ch views with

biplane

– 3D ME enface view and ME 2C

with biplane can also be utilized – Videos 32, 33 and 34 – 3D ME enface view and ME 2C

with biplane can also be utilized.

Fluoroscopy imaging can also be

helpful in visualizing balloon

expansion – Videos 32, 33, 34, 35, 36, 37

and 38 – Figures 23a–c and 24a–c

– 2D ME 4Ch and 2Ch views with

biplane

– 2D ME bicaval view is best

utilized for CW measurement

through the septal defect – Figure 24c

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

https://t.me/med1917

Fig. 22 (a) Shows TEE imaging during transeptal puncture positioning (arrow) and imaging conrmation of catheter crossing into the LA (b)

Fig. 23 MS severity measures immediately after rst balloon ination. Both MG and PHT (a and b) show a signicant (>50%) improvement. MVA has also improved signicantly to 1.39cm

(c)

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T. Safder et al.

Fig. 24 MR severity measured immediately post balloon ination. MR PISA (a) measurement and CW MR signal (b) is shown. (c) Residual left to right shunt is noted in the atrial septum

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

https://t.me/med1917

Post procedural Assessment

A TTE is often repeated the next day, typically prior to discharge, to re-assess the MV and to evaluate for any post procedural complications (Table 14). Our patient received her 1 day post procedure TTE which showed a MG of 7mmHg (HR 72) and a MVA of 1.62cm2 along with moderate MR (Table15). At 1 month follow up clinic visit, she reported symptomatic improvement as she was able to do more activity without signicant dyspnea. TTE should be repeated annually or sooner based on clinical symptoms. At 1 year follow up, our patient continued to do well clinically and TTE ndings remained unchanged.

Table 14 Possible procedural complications to PMBV

Procedural complications Cardiac chamber perforation Tamponade Severe MR Thromboembolism Clinically signicant left to right shunt

When anatomically favorable patients undergo PBMV, long term outcomes appear to be good. The recurrence of symptomatic MS after a successful PBMV has previously noted to be between 7 to 21% [17]. This case demonstrates the importance of comprehensive evaluation of patients with MS with a specic focus on anatomical favorability for PBMV which can lead to good outcomes for patients.

Multimodality imaging comparison

Table 15

ings for our patient

PHT pressure half-time, MVA mitral valve area

Relevant 1 day post procedure MV TTE nd-

Transthoracic echocardiogram parameter Patient’s ndings

Mean gradient 7mmHg (at HR 72) PHT 173ms MVA by planimetry (TTE) Mitral regurgitation Moderate (EROA 22m2,

1.62cm

regurgitant volume 36mL)

Modality Clinical application Limitations Transthoracic

echocardiography (TTE)

Transesophageal Echocardiography (tee)

Exercise stress echocardiography

Cardiac computed tomography (CT) Fluoroscopy – Intraprocedural guidance – Limited anatomic assessment

– First line test for assessment of etiology,

mechanism and severity of mitral stenosis

– Post procedural assessment of mitral stenosis

and surveillance of complications

– Can aid in the preprocedural evaluation of MS

if TTE yields incomplete or discordant ndings

– Can obtain more precise information about

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

evaluation for complications – Rule out LAA thrombus – 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

– 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

– Mobility limitations of patient

– No hemodynamic assessment – Radiation exposure

– Invasive – Radiation exposure

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T. Safder et al.

Clinical Controversies andClinical Pearls

• The etiology of mitral stenosis (i.e. rheumatic vs. non-rheumatic disease) is key when assessing for possible treatment options as they differ considerably in relation to etiology.

• In patient with severe mitral stenosis due to rheumatic disease, PBMV has shown to be safe and effective when compared to surgery and as such has become the rst line treatment when anatomically suitable.

• While the Wilkins Score is a great tool in assessing anatomic suitably for PBMV, it is important to understand its limitations, such as information regarding commissural fusion not being part of the score which can have signicant impact on treatment success.

• Exercise stress testing can serve as a valuable tool in assessing patients with MS as it may unmask signicant MS with increased cardiac workload.

Key Points

– Echocardiographic imaging, both TTE and

TEE, play an integral role in the diagnostic evaluation as well as the pre, intra and post procedural phases of patients with mitral stenosis being considered for PBMV.

– Several studies have established the safety and

efcacy of PBMV when compared with surgical techniques and as such PBMV has become the initial procedure of choice in patients with favorable anatomy.

– Clinical and anatomical suitability of

patients with mitral stenosis undergoing PBMV and operator expertise are the two most important factors that determine long term success.

Mitral Valve-in-Valve

Case Study

A 75-year-old woman with a past medical history signicant for mitral valve endocarditis complicated by an embolic cerebrovascular accident with residual right sided hemiplegia s/p mitral valve replacement (25 mm Edwards Magna bioprosthetic valve) 7years prior, hypertrophic obstructive cardiomyopathy (HOCM) s/p septal myectomy, non-obstructive coronary artery disease, hypertension and hyperlipidemia who presented to the hospital with a complaint of progressive shortness of breath × 1week.

Her vital signs were temperature 96.8 °F, heart rate 78 beats/minute, blood pressure 111/63mmHg and respiratory rate of 20 breaths/minute.

On physical exam she appears alert but anxious, bibasilar rales were noted on lung auscultation with 1+ bilateral lower extremity edema, mildly elevated JVD. Heart exam revealed a regular rate and rhythm with a grade 2/6 systolic murmur at left sternal border. Right sided upper and lower extremity weakness was also noted.

Her electrocardiogram (Fig.25) showed sinus rhythm with evidence of left atrial enlargement and a chronic left bundle branch block. Chest X-ray obtained was signicant for perihilar vascular congestion and interstitial edema suggestive of decompensated heart failure (Fig.26).

Initial troponin I was <0.045ng/mL, pro BNP 9626pg/mL, hemoglobin 16.1g/dL, and creatinine 0.9mg/dL.

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