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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
109
Heart Team Decision
Given improvement in the projected neo-LVOT
area, the decision was made by the multidisciplinary heart team to proceed with a MViV procedure 2 months following her alcohol septal
ablation.
Intraprocedural Imaging
andAssessment
Patient was placed under general anesthesia and
baseline intraprocedural TEE showed no signicant changes in her prosthetic valve anatomy
compared to her prior echo with a mean gradient
measured at 22mmHg at a heart rate of 69bpm.
Vascular access was obtained in bilateral femoral veins and a 5-F pacing catheter was advanced
into the right ventricle via the left femoral vein
for rapid pacing during valve deployment. A 14
French sheath was then placed in the right femoral vein over a stiff wire without difculty.
Unfractionated heparin (200U/kg) was administered to ensure adequate systemic anticoagulation, and the activated clotting time was monitored
regularly to maintain a level>300s.
Under TEE and uoroscopic guidance, a transeptal puncture was made at the mid fossa using
a BRK needle within an SL 1 dilator/sheath with
a transeptal height measured at 3.42 cm to the
bioprosthetic mitral valve (Fig.44a) and a guide-
wire was advanced to the left upper pulmonary
vein (Fig.44b).
The SL 1 dilator/sheath was then exchanged
for an NXT small curl steerable guide sheath
(Abbott, Chicago, Illinois). A stiff Safari 2 wire
(Boston Scientic, Marlborough, Massachusetts)
was directed into the left ventricle apex under
TEE and uoroscopic guidance and the atrial
septum was sequentially dilated with a 14 mm
Mustang (Boston Scientic, Marlborough,
Massachusetts) balloon (Fig.45 with corresponding Video 50).
Following septal dilation, a 26mm Edwards
Sapien 3 Ultra valve was advanced through the
interatrial septum and into the 25mm Edwards
Magna bioprosthetic valve.
Fig. 45 Fluoroscopic image showing balloon dilation of
the interatrial septum
a
Fig. 44 (a) TEE showing point of transeptal puncture with measured distance to mitral valve prosthesis. (b) TEE image
showing guidewire parked in left upper pulmonary vein
b
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a
Fig. 46 Fluoroscopic images depicting deployment of the Sapien 3 valve under rapid pacing
Following adequate valve alignment under
uoroscopic imaging, the Sapien 3 valve was
successfully deployed under rapid pacing
(Fig. 46a, b with corresponding uoroscopic
(Video 51) and TEE (Video 52) videos).
b
Following the procedure on our patient, the gradient assessment of the LVOT revealed no evidence of obstruction with a peak gradient of
9mmHg and mean gradient of 4mmHg (Fig.49).
There was signicant reduction in the mean
gradient across the prosthetic mitral valve from
22mmHg at HR of 69bpm to 3mmHg at 71bpm
Post procedural Assessment
with normal diastolic excursion of the valve leaflets post procedure (Fig.50).
Post procedural evaluation following valve
deployment include:
Color Doppler evaluation on 2D and 3D imaging showed trivial transvalvular regurgitation and
no paravalvular regurgitation (Fig. 51 with cor-
• Evaluation of the LVOT gradient by TEE from
the deep transgastric view.
• 2D evaluation of the prosthesis to ensure the
valve is wall seated and leaets show normal
excursion.
• Color Doppler assessment with 2D and 3D
imaging for evaluation of transvalvular and
perivalvular regurgitation. 3D imaging helps in
the localization of the origin of paravalvular
regurgitation that can occur following MViV
intervention (Fig.47 with corresponding Video
53) and is useful in guiding transcatheter based
closure (Fig.48 with corresponding Video 54).
• Spectral Doppler evaluation across the prosthesis for assessment of MV gradient.
responding Videos 55, 56).
Spectral Doppler evaluation of the iatrogenic
atrial septal defect showed left to right shunting
(Fig.52) which was not closed.
30 days post intervention, a follow up 2D
echocardiogram was obtained with noted preserved biventricular systolic function, a valve-invalve prosthesis that appears well seated with
(Fig.53 with corresponding Video 57).
There is no valvular regurgitation noted on
color Doppler assessment (Video 58) and mean
gradient across MV prosthesis was measured at
7.6mmHg at heart rate of 74bpm with no LVOT
obstruction (Fig.54a, b) (Table16).
Multimodality imaging comparison
Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
https://t.me/med1917
Fig. 47 3D color Doppler image depicting a moderate perivalvular leak lateral to a prosthesis following MViV (red
arrow)
111
Fig. 48 3D color Doppler image following successful paravalvular leak closure with Amplatzer plugs with trace residual regurgitation
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Fig. 49 Pulse wave Doppler prole of the LVOT shows no elevated gradient
Fig. 50 Continuous wave Doppler across the mitral valve prosthesis pre and post intervention
Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
https://t.me/med1917
Fig. 51 Color Doppler evaluation on 2D and 3D imaging showing trivial transvalvular regurgitation and no paravalvular regurgitation
113
Fig. 52 Continuous wave Doppler across the iatrogenic atrial septal defect with noted left to right shunt
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Fig. 53 4-CH view with well seated bioprosthetic mitral valve
a
Fig. 54 Continuous wave Doppler prole across mitral valve in valve prosthesis (a) and across aortic valve (b)
b
Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
https://t.me/med1917
Modality Clinical application Limitations
Transthoracic
echocardiography
(TTE)
Transesophageal
Echocardiography
(tee)
Cardiac computed
tomography
(CT)
Fluoroscopy – Intraprocedural guidance of transeptal
– Preprocedural etiology and mechanism
of prosthetic valve dysfunction
– Assessment of cardiac remodeling and
hemodynamic impact of prosthetic
dysfunction
– Preprocedural evaluation of etiology and
mechanism of prosthetic valve dysfunction
– Assessment of cardiac remodeling and
hemodynamic impact of prosthetic
dysfunction
– Exclude left atrial appendage thrombus
– Intraprocedural imaging guidance
– Immediate post procedure evaluation
and evaluation for complications
– Pre procedural prosthetic implant sizing
– Prediction of risk of LVOT obstruction
(neo-LVOT area, septal-mitral distance,
aorto-mitral angle)
puncture
– Intraprocedural valve alignment
assessment
– Lower spatial resolution compared
to TEE
– Shadow artifact may limit adequate
assessment of perivalvular
regurgitation
– Absolute contraindicated in
patients with esophageal stricture,
tumor, active upper GI bleed etc.
– Requires sedation
– No hemodynamic assessment
– Limited anatomic assessment
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Clinical Controversies andClinical
Pearls
• Transcatheter valve-in-valve therapy is an
excellent strategy for the management of
patients with failed bioprosthetic mitral valve
disease who are at high or prohibitive risk for
redo mitral surgery.
• Echocardiography plays an important role in
the diagnosis and intervention of prosthetic
valve dysfunction.
• Cardiac CT angiography is important for preprocedural planning given its use in determining implant valve sizing, optimal uoroscopic
angles, and risk of LVOT obstruction.
• Preemptive alcohol septal ablation has been
shown to be useful in reducing the risk of
LVOT obstruction in patients who are at elevated risk.
• In appropriately selected patients, transcatheter MViV intervention show favorable shortterm outcomes including clinical improvement
and sustained prosthetic gradient reduction
although there remains a paucity of data on
long term outcomes.
Key Points
– Transcatheter valve-in-valve therapy is an
excellent strategy for the management of
patients with failed bioprosthetic mitral valve
disease who are at high or prohibitive risk for
redo mitral surgery.
– Echocardiography plays an important role in
the diagnosis and intervention of prosthetic
valve dysfunction.
– Cardiac CT angiography is important for
pre- procedural planning given its use in determining implant valve sizing, optimal uoroscopic angles, and risk of LVOT obstruction.
– Preemptive alcohol septal ablation has been
shown to be useful in reducing the risk of
LVOT obstruction in patients who are at elevated risk.
– In appropriately selected patients, transcathe-
ter MViV intervention show favorable shortterm outcomes including clinical improvement
and sustained prosthetic gradient reduction
although there remains a paucity of data on
long term outcomes.
Disclosures There are no conicts of interest to disclose.
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Chapter Review Questions
1. Which of the following features is unfavor-
able for a MV transcatheter edge-to-edge
repair (TEER)?
A. Flail width 10mm
B. Flail gap 6mm
C. Coaptation depth 7mm
D. Large leaet cleft
Answer: D. Location of MR pathology being
present in the leaet body is an unfavorable
characteristic and such a patient is unlikely to
benet from MV TEER.The other choices are
all favorable characteristics.
2. What condition must be met prior to a patient
qualifying for a MV transcatheter edge-toedge repair (TEER)?
A. MR must be primary in nature
B. MR must be secondary in nature
C. Patient must be classied as high surgical
risk
D. LVEF <40%
Answer: C. The current ACC/AHA Practice
Guideline for Patients with Valvular Heart
Disease recommends MV TEER only for
patients at high surgical risk. The other conditions listed are not required for MV TEER
eligibility.
3. Which of the following is not a contraindica-
tion to percutaneous balloon mitral valvuloplasty (PBMV)?
A. Signicant commissural calcication
B. Commissural fusion
C. Left atrial appendage thrombus
D. Severe MR
4. What is one key characteristic that can help
differentiate rheumatic mitral stenosis from
non-rheumatic?
A. Commissural fusion without signicant
calcication
B. More common in women
C. Presents in elderly
D. Valvular calcication
Answer: A. While rheumatic MS can present
with valvular calcications, the hallmark of
rheumatic MS is commissural fusion without
signicant valvular calcication which is
what differentiates it from non-rheumatic
disease.
5. True or False?
MViV intervention is indicated for the management of patients with failed bioprosthetic
mitral valve disease with only mitral stenosis
at low risk for redo-operation on evaluation
by a cardiovascular surgeon.
Answer: False. Currently transcatheter MViV
intervention should only be considered in the
management of failed bioprosthetic mitral
valve disease with mitral stenosis or mitral
regurgitation at high or prohibitive risk for
redo-operation on evaluation by a multidisciplinary heart team.
6. Which of the following factors have been
shown to be associated with an increased risk
of LVOT obstruction following mitral valvein- valve intervention?
A. Neo-LVOT area of 150mm
2
B. Large annulus to interventricular septum
distance
C. Neo-LVOT area of 300mm
2
D. Large dilated left ventricle
Answer: B. Commissural fusion without calci-
cation is the ideal pathology for which PBMV
can be very effective. All other choices are
contraindications.
Answer: A. Pre-procedural cardiac CT identify a
threshold of neo-LVOT area to discriminate
the risk for LVOT obstruction with cutoff values of 170–189 mm2 predicting LVOT
Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
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obstruction with a sensitivity of 96.2–100%
respectively in 2 different observational
studies.
Other device related factors that may predispose patients to narrowing of the neo-LVOT
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
<17.8 mm due to a more pronounced septal
bulge.
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