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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3737_Библиотеки_им_академика_М_И_Перельмана
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Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
https://t.me/med1917
99
Her admission diagnosis was acute
decompensated heart failure for which she
was initiated on IV furosemide diuretic
therapy and an urgent 2D echocardiogram
was ordered for further evaluation.
2D Echocardiogram demonstrated preserved LV systolic function (Videos 39 and
40) with degeneration of the bioprosthetic
valve with restricted leaet excursion
(Fig.27 with corresponding Video 41) and
ow acceleration noted across the bioprosthetic mitral valve on color Doppler
(Fig.28 with corresponding Video 42).
Doppler evaluation of the prosthetic
mitral valve noted a peak velocity of
3.4m/s, mean gradient of 27mmHg at HR
of 84bpm, PHT: 216ms, a calculated EOA
of 0.70cm2 and a DVI of 4.9 (Fig.29a, b).
Findings consistent with severe bioprosthetic stenosis with specic parameters
essential to access mitral prosthesis listed
in Table16 [18]. This was also associated
with secondary ndings of pulmonary
hypertension with RVSP calculated at
65 mmHg and left atrial enlargement as
shown in Fig.30a, b.
Given 2D echo ndings she was also
initiated on metoprolol succinate to reduce
her heart rate and improve her diastolic lling period.
Fig. 25 Electrocardiogram showing sinus rhythm with left bundle branch block and evidence of left atrial
enlargement
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Fig. 26 Posterior-anterior chest X-ray showing perihilar
vascular congestion and interstitial edema
T. Safder et al.
Fig. 28 Color Doppler interrogation shows diastolic ow
acceleration across the bioprosthetic mitral valve as indicated by red arrow
Fig. 27 Zoomed PLAX
view of the bioprosthetic
mitral valve with
degeneration and
restricted leaet
excursion at end diastole
ab
ab
Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
https://t.me/med1917
Fig. 29 (a) Continuous wave Doppler prole across the mitral valve prosthesis. (b) Pulse wave Doppler prole at
LVOT
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Table 16
Adapted from Zoghbi etal. [18]
Spectral Doppler parameters required for evaluation of mitral prosthetic function
Normal Possible stenosis Signicant stenosis
PHT (ms) <130 130–200 >200
Peak velocity (m/s) <1.9 1.9–2.5 >2.5
Mean gradient (mmHg)
prMV
2
)
/VTI
lvot
DI:VTI
EOA (cm
≤5
<2.2 2.2–2.5 >2.5
≥2.0
6–10 >10
1–2 <1
Fig. 30 (a) Continuous wave Doppler prole across the tricuspid valve. (b) 2-CH view of the left atrium showing
enlargement
Background andDenitions
Reoperation of failed bioprosthetic valves is
associated with signicant morbidity and mortality estimated at 3–23% [19–21].
In majority of cases, bioprosthetic mitral valve
dysfunction occurs due to cusp calcication
resulting in leaet thickening and stiffening,
which may result in valve stenosis with or without
concomitant regurgitation. Valve dysfunction can
also occur due to pannus overgrowth or thrombus
with a 15-year reintervention rate of 40% [22].
Mitral valve in valve (MViV) can be per-
formed by transeptal or transapical approaches
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T. Safder et al.
under transesophageal echocardiography (TEE)
and uoroscopic guidance.
The Edwards SAPIEN valve (Edwards
Lifesciences) is the most used valve for MViV
intervention. This is a low-prole, balloonexpandable, bovine pericardial transcatheter
valve mounted on a chromium cobalt frame
designed for transcatheter aortic valve replacement and is currently used on a compassionateuse basis in the mitral position [23, 24].
Recent outcome studies have shown favorable
30-day and 1-year all-cause mortality rate at
5.4% and 16.7% respectively with excellent technical success and sustained improvement in echo
derived mitral valve gradient [24]. Clinical
improvement in heart failure at 1year following
intervention has also been reported but there
remains a paucity of data on long term outcomes
[24, 25].
Inclusion Criteria forMViV
Intervention
• Failed bioprosthetic mitral valve disease with
mitral stenosis or mitral regurgitation at high
or prohibitive risk for redo-operation on eval-
uation by a cardiovascular surgeon.
• Absence of contraindications to anticoagula-
tion given need for anticoagulation with war-
farin post valve implantation.
• Absence of contraindication to transesopha-
geal imaging needed to guide the procedure.
• Not at risk of LVOT obstruction.
Diagnosis andPre-procedural
Evaluation
Pre-procedural evaluation of MViV intervention
includes a detailed evaluation of the mechanism
of prosthetic valve dysfunction with TTE and
TEE. Cardiac computed tomography plays an
important role for evaluation of implant valve
sizing, optimal uoroscopic angles, and risk of
LVOT obstruction.
The mitral valve anatomy is complex and is
near the left ventricular outow tract (LVOT)
which makes preprocedural evaluation crucial.
CT allows for evaluation of the spatial relationship between the aortic and mitral valves to allow
appropriate valve and predict whether MViV will
result in obstruction of the left ventricular outow track [26].
The presence of LVOT obstruction is associated with a 34.6% mortality rate and a 19.2% rate
of conversion to surgery. Historically, up to 50%
of cases rejected for MViV are due to the risk of
LVOT obstruction [26–28].
Recent studies have evaluated the risk and predictors of LVOT obstruction in transcatheter
mitral valve replacement with use of preprocedural cardiac CT to identify a threshold of
neo-LVOT area to discriminate the risk for LVOT
obstruction. The cutoff values of 170–189 mm2
predict LVOT obstruction with a sensitivity of
96.2–100% respectively in observational studies
[27, 29]. The predicted neo-LVOT area is derived
using a simulated balloon-expandable transcatheter heart valve in the failed bioprosthetic valve on
CT cross sectional imaging at end systole [30].
Other anatomical and device related factors
may predispose patients to narrowing of the neoLVOT dimension including greater device protrusion into the left ventricle, device aring at its left
ventricular outow tract and a smaller mitral annulus to interventricular septum distance <17.8mm
due to a more pronounced septal bulge [27, 30].
Given ndings of severe bioprosthetic mitral
valve stenosis on our patient, a TEE was performed for a more detailed evaluation of the
mitral valve prosthesis and to evaluate the mechanism of the mitral stenosis and rule out a left
atrial appendage thrombus.
On the 4-CH transesophageal view (Fig.31,
Video 43), there is thickening and calcication of
the prosthetic valve leaets with associated
restricted diastolic excursion (red arrow) and
associated spontaneous echo contrast visualized
in the left atrium (yellow arrow).
This restricted diastolic excursion of the
leaets and calcication is also appreciated on
3D imaging (Fig.32) with no evidence of tissue
overgrowth/pannus resulting in obstruction
from the atrial or ventricular view as seen in
Fig. 33a, b respectively with corresponding
Videos 44 and 45.
On color Doppler interrogation, there is ow
acceleration noted across the bioprosthetic mitral
Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
https://t.me/med1917
Fig. 31 TEE 4-CH
view showing thickening
and calcication of the
prosthetic valve leaet
and spontaneous echo
contrast visualized in the
left atrium
Fig. 32 3D image of
the mitral valve
prosthesis with restricted
diastolic excursion of
the leaets and
calcication
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valve (Fig. 34) with mild mitral regurgitation
noted (Video 46). Spectral Doppler assessment
showed a mean gradient of 18mmHg at a heart
rate of 72 bpm (Fig. 35). Flow in the left ventricular outow tract (LVOT) was assessed from
the deep gastric view and was noted to be normal.
The mean gradient was 1mmHg and peak gradient was 4mmHg (Fig.36).
Evaluation of the left atrial appendage showed
no evidence of thrombus (Fig.37).
Given TEE confirmation of structural
degeneration of the prosthesis resulting in
mitral stenosis, the heart valve team was
consulted.
On recommendation by the heart valve team,
she underwent a right and left heart catheterization. Angiography showed 40% stenosis of the
mid LAD (Fig.38, yellow arrow) and 70% ostial
diagonal branch stenosis (Fig. 38, red arrow)
with no signicant stenosis seen in the right coronary circulation as seen in Fig. 39 with corresponding Video 48.
Right heart Cath performed showed PCWP
26, PA 72/30, RV 70/12, RA 10, PA sat 67%, Ao
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Fig. 33 (a) 3D image of the mitral valve prosthesis from the left atrial perspective. (b) 3D image of the mitral valve
prosthesis from the left ventricular perspective
T. Safder et al.
Fig. 34 TEE mid esophageal view with color ow Doppler across the mitral valve prosthesis
sat 89%, cardiac output 5.3L/min ndings consistent with severe post capillary pulmonary
hypertension.
She was evaluated by cardiothoracic surgery
for redo mitral valve operation but was considered
high risk given calculated STS mortality risk
score of 15.9% based on the presence of very
severe mitral stenosis, acute decompensated heart
failure, severe pulmonary hypertension, and history of CVA with residual right sided weakness.
Given her high risk for re-do mitral valve surgery she was evaluated for a transcatheter mitral
valve-in-valve intervention and underwent a
gated cardiac CT performed for evaluating candidature for TMVR.
CT ndings as shown in Fig.40 depicts a Neo-
LVOT area of 180mm2, septal-mitral distance of
4.9mm and an aorto-mitral angle of 58.20°. She
was determined to be at high risk for LVOT
obstruction given the neo-LVOT area<189mm2.
Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
https://t.me/med1917
105
Fig. 35 Continuous wave Doppler prole across the mitral valve prosthesis
Fig. 36 TEE transgastric view with pulse wave Doppler prole at LVOT
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Fig. 37 TEE biplane
image of the left atrial
appendage shows no
evidence of thrombus
T. Safder et al.
Fig. 38 Coronary angiogram of the left coronary artery
with moderate stenosis of the LAD (yellow arrow) and
severe stenosis of the ostial diagonal branch (red arrow)
Fig. 40 (a) Cardiac CT derived neo-LVOT area. (b) 3-CH view showing septal-mitral distance. (c) 3D volume ren-
dered CT image showing aorto-mitral angle
Fig. 39 Coronary angiogram of the right coronary artery
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Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
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Heart Team Approach
andDiscussion
Given the elevated risk for LVOT obstruction and
re-do mitral valve surgery, discussions were had
about how best to reduce the risk of obstruction
to allow for a successful MViV procedure.
There are two current strategies to reduce the
risk of LVOT obstruction prior to TMVR and this
includes the Lampoon procedure which is a
transcatheter based radiofrequency laceration of
the anterior leaet of the mitral valve via transfemoral retrograde approach as demonstrated
allowing blood ow through the open cells of the
alloy frame of the prosthesis [31].
Alcohol septal ablation (ASA) has been used
as a preemptive strategy to reduce the risk of
LVOT obstruction by increasing the neo-LVOT
area prior to TMVR or as a bail out strategy in
a
b
treating LVOT obstruction that occurred following TMVR [32, 33].
The heart team determined that ASA before
MViV would be the safest approach for our
patient. ASA was performed with selective ablation of the rst septal perforator branch as shown
in Fig. 41a with corresponding Video 49 with
localized septal target region visualized with
intracoronary contrast administration as seen in
Fig. 41b with no outow tract obstruction on
spectral Doppler evaluation at baseline as seen in
Fig.42.
Procedure was complicated by complete heart
block, and she underwent a dual chamber permanent pacemaker placement.
A repeat cardiac CT performed 1month following alcohol septal ablation showed signicant
increase in the neo-LVOT area measured at
255mm2 as shown in Fig.43.
Fig. 41 (a) Selective ablation of the rst septal perforator branch (red arrow). (b) 2D echo showing septal target region
visualized with intracoronary contrast administration (yellow arrow)
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Fig. 42 Continuous
wave Doppler prole
across the aortic valve
shows no evidence of
obstruction
Fig. 43 Cardiac CT
derived neo-LVOT area
1 month following
alcohol septal ablation
T. Safder et al.
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