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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
https://t.me/med1917
Valve Diseases: TEER, Valve
inValve, andBeyond
TaimurSafder, GloriaAyuba, andVeraH.Rigolin
Abstract
The mitral valve apparatus is a complex structure that requires harmonious interplay of several key components to function properly. As
such, diseases of the mitral valve can present a
signicant challenge for clinicians to diagnose
and manage. Innovation in cardiac imaging
techniques, transcatheter based interventions
and study of clinical outcomes has transformed the care available for patients with
mitral valve disorders. In this chapter, a casebased review of the optimal imaging approach
to patients being evaluated for transcatheter
mitral valve intervention will be presented.
More specically, imaging considerations for
the following interventions will be reviewed:
1. Transcatheter edge to edge repair for mitral
regurgitation
2. Percutaneous balloon mitral valvuloplasty in
mitral stenosis
3. Transcatheter mitral valve in valve
Supplementary InformationThe online version contains
supplementary material available at https://doi.
org/10.1007/978-3-031-50740-3_2.
Keywords
Mitral stenosis · Mitral regurgitation ·
Transcatheter intervention · Mitral valve in
valve · Valvular disease · Valvular intervention · Mitral valve disease · Transcatheter
mitral valve treatment · Mitral valve replacement · Transcatheter edge-to-edge repair ·
Mitral balloon valvuloplasty · Valve-in-valve
· Transcatheter mitral valve replacement ·
Prosthetic stenosis · Cardiac imaging
Abbreviations
ACC American College of Cardiology
AHA American Heart Association
BMI Body mass index
CT Computed tomography
DVI Dimensionless velocity integral
EOA Effective Orice Area
EROA Effective regurgitant orice area
GDMT Goal directed medical therapy
HF Heart failure
LA Left atrium
LAA Left atrial appendage
LV Left ventricle
LVEF Left ventricle ejection fraction
T. Safder · G. Ayuba · V. H. Rigolin (*)
Bluhm Cardiovascular Institute, Northwestern
University Feinberg School of Medicine,
Chicago, IL, USA
e-mail: Vrigolin@nm.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. M. Kelsey et al. (eds.), Cardiac Imaging in Structural Heart Disease Interventions,
https://doi.org/10.1007/978-3-031-50740-3_2
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T. Safder et al.
LVESD Left ventricle end systolic diameter
LVOT Left ventricular outow tract
ME Mid-esophageal
MG Mean gradient
MR Mitral regurgitation
MS Mitral stenosis
MV Mitral valve
MVA Mitral valve area
MViV Mitral valve-in-valve
NYHA New York Heart Association
PASP Pulmonary artery systolic pressure
PBMV Percutaneous balloon mitral
valvuloplasty
PHT Pressure half time
PISA Proximal isovelocity surface area
PLAX Parasternal long axis
PV Pulmonary vein
RF Regurgitant fraction
RV Right ventricle
Rvol Regurgitant volume
RVSP Right ventricular systolic pressure
SLD Single leaet detachment
STS Society of Thoracic Surgeons
TEE Transesophageal echocardiography
TEER Transcatheter edge to edge repair
TMVR Transcatheter mitral valve
replacement
TTE Transthoracic echocardiography
Test your learning and check your under-
standing of this book’s contents: use the
“Springer Nature Flashcards” app to
access questions using ▶ https://sn.pub/
ambACS.
To use the app, please follow the instruc-
tions in the chapter “Transcatheter
Aortic Valve Replacement.”
Learning Objectives
1. Review initial approach and indications for
transcatheter intervention for patients with
signicant mitral regurgitation presenting to
valve clinic for evaluation.
2. Review pre-procedural, procedural and post
3. Review initial approach, indications and ana-
4. Review pre-procedural, procedural and post
5. Be able to diagnose mitral prosthetic valve
6. Understand the preprocedural considerations
7. Understand the role of multimodality imaging
Mitral Regurgitation
andTranscatheter Edge-to-Edge
Repair (TEER)
Mitral regurgitation (MR) is a complex disease
process that can present a signicant challenge
for clinicians to manage. From initial noninvasive evaluation to indications for surgical vs.
transcatheter interventions, the decision tree for
management of MR continues to branch out. As
mitral valve transcatheter interventions become
more widely available, a multidisciplinary team
approach with integration of multimodality imaging will be key in optimizing and standardizing
outcomes across a diverse set of practice settings.
Furthermore, it is becoming increasingly clear
that expertise in non-invasive imaging for evaluation of MR will be the central tenet of any multidisciplinary team hoping to optimize patient
outcomes. In this section, a patient with severe
MR presenting to the valve clinic for evaluation
of candidacy for a transcatheter intervention will
be discussed.
procedural imaging considerations for
patients with signicant MR being evaluated
for transcatheter edge-to-edge repair.
tomic suitability for PBMV in patients with
mitral stenosis.
procedural imaging considerations for
patients undergoing PBMV for mitral
stenosis.
dysfunction.
of transcatheter mitral valve-in-valve intervention including inclusion and exclusion
factors.
in diagnosis, planning and procedural
guidance.
Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
https://t.me/med1917
Background andDenitions
Case Study
A 62year old male with history of severe
MR presents to valve clinic for evaluation.
Patient’s past medical history is signicant
for hypertension, hyperlipidemia, obesity
(BMI 40), chronic kidney disease and
chronic obstructive pulmonary disease and
signicant anxiety/depression. Exam is
signicant for elevated jugular venous
pulse, 3/6 holosystolic murmur best heard
at apex which radiates to axilla, 3+ bilateral
lower extremity edema. The patient was
initially evaluated at an outside hospital for
surgical mitral valve replacement but due
to his overwhelming anxiety to undergoing
surgery, he was referred for transcatheter
edge to edge repair (TEER) evaluation.
The patient was initially diagnosed with
signicant MR 3years ago at which time
transesophageal echocardiography (TEE)
showed normal left ventricular (LV) size
and function [LV ejection fraction (EF)
61%] and ail posterior leaet of the mitral
valve. LV end diastolic volume was 102mL
(indexed 45.1 mL/m2) while LV end systolic volume was 30 mL (indexed 13.3
(mL/m2). At that time, he was recommended to undergo mitral valve surgery but
due to severe anxiety, he declined and was
lost to follow up. The patient now presents
again for evaluation due to worsening
symptoms. He now notes severe dyspnea
on exertion and needs to stop and rest several times when climbing three ights of
stairs in his apartment building. He also
notes lower extremity edema and orthopnea. Symptoms mildly improved with furosemide. Due to the patient’s previous
aversion to surgical intervention leading to
lost to follow up, patient was referred
directly for TEER evaluation.
The initial evaluation of any patient being considered for an intervention starts with the appropriateness of the indication of the procedure.
Once the diagnosis of severe MR has been
agreed upon by the valve team, the most impactful factors that determine the patient’s eligibility
for MR intervention are the etiology of the MR
(primary vs. secondary), the status of left ventricular (LV) size and function and the presence
or absence of symptoms. The 2020 ACC/AHA
practice guideline for patients with valvular
heart disease incorporates these factors into the
recommendations for valve intervention [1]. A
simplied version of these recommendations is
shown in Tables 1 and 2.
TEER is a technique which relies on approximating the edges of MV leaets to reduce the
degree of MR. It is modeled after the surgical
MV repair technique of the Aleri Stich credited
to Dr. Ottavio Aleri [2]. The Everest II trial lent
initial support for TEER as a viable treatment
option for degenerative MR [3]. Currently, no
class I indications exist for TEER for treatment
of severe MR regardless of etiology or symptoms. For primary MR, the 2020 ACC/AHA
practice guideline for valvular heart disease gives
TEER a class 2a recommendation for patients
with favorable anatomy at high or prohibitive
surgical risk (Table 1) [1]. The more recent
COAPT and MITRA-FR trials evaluated TEER
for treatment of secondary MR [4, 5]. While the
former trial showed improved outcomes with
TEER in patients with secondary MR, the latter
did not. Divergent outcomes are largely driven by
differences in the baseline characteristics of the
subjects enrolled in the two trials [6]. The 2020
ACC/AHA practice guideline for valvular heart
disease gives a 2a indication for TEER for
patients with severe secondary MR who have
persistent symptoms (NYHA II or greater), are
on optimal heart failure (HF) guideline directed
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Adapted from ACC/AHA 2020 practice guideline for management of patients with valvular heart disease [1]
Table 1
ACC/AHA chronic primary MR intervention recommendations
Class of
recommendation I IIa IIb
Symptomatic severe
MR, irrespective of
LV function
Asymptomatic severe
MR with LV
dysfunction (LVEF
≤60%, LVESD
≥40mm)
Table 2
Adapted from ACC/AHA 2020 practice guideline for management of patients with valvular heart disease [1]
ACC/AHA chronic secondary MR intervention
recommendations
Class of
recommendation I IIa IIb
N/A TEER for
severe MR,
persistent
symptoms ≥
NYHA II, on
optimal HF
GDMT, LVEF
between
20–50%,
LVESD
≤70mm,
PASP
≤70mmHg
N/A MV surgery
for severe MR
at time of
CABG
Symptomatic (NYHA class III or IV)
severe MR with high/prohibitive surgical
risk, TEER is reasonable if anatomy is
favorable and life expectancy ≥1year
In asymptomatic, severe MR with normal
LV function (LVEF ≥60%, LVESD
≤40mm), MV repair is reasonable when
likelihood of successful and durable
repair without residual MR is >95% and
mortality rate<1%) and when done at a
comprehensive valve center
Diagnosis andPre-procedural
Assessment
Initial Patient Assessment
MV surgery
for severe
MR due to
atrial annular
dilation,
LVEF ≥50%,
NYHA III or
IV symptoms
despite
GDMT for
HF
MV surgery
for severe
MR related to
LVEF ≤50%,
NYHA III or
IV symptoms
despite
GDMT for
HF
The clinical presentation of a patient with severe
MR can be variable. Symptoms can range from
signicant to subtle to lacking entirely [7].
Furthermore, the patient may underestimate their
functional capacity or subtly decrease their activity level as they adjust to their symptoms slowly
over time. Physical exam ndings, such as presence and severity of murmur, have been shown to
be predictive of severe MR [8]. For these reasons,
a comprehensive history and physical exam is
crucial in gaining clinical context for the noninvasive ndings when assessing patients with
MR for the rst time.
Our patient has given us a history of symptoms that are typically seen with progression of
severity of MR.He reports worsening exertional
dyspnea, orthopnea and new lower extremity
edema, which are suggestive of uid overload
Asymptomatic, severe MR
with normal LV function but
with progressive increase in
LV size or decrease in
function (on ≥3 serially done
imaging studies)
and heart failure. While the patient’s symptoms
are somewhat difcult to attribute solely to his
medical therapy (GDMT), have an LV EF
between 20 and 50%, have an LV end systolic
dimension (LVESD) <70 mm, and pulmonary
artery systolic pressure (PASP) <70 mmHg [1].
These criteria are based on the positive results
from the COAPT trial population and the lessons
learned from the negative results of the
MITRA-FR trial.
MR in the context of BMI of 40, the overall worsening of symptoms (while the weight has stayed
stable) gives us more condence that the MR is a
signicant factor in his symptomatology. Exam
ndings of elevated JVP and bilateral lower
extremity edema support our concerns about
uid overload and HF and further support a diagnosis of severe MR. The holosystolic murmur
T. Safder et al.
Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
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73
radiating to the axilla may suggest a posterolateral direction of the MR jet. This information
helps to form a clinical picture of our patient and
will later be helpful when reviewing our patient’s
imaging studies.
Non-invasive Imaging
Transthoracic Echocardiography
Transthoracic echocardiography (TTE) is the
gateway imaging modality for the diagnosis and
evaluation of MR.TTE can help inform on several important characteristics of the mitral valve
pathology that can aid in determining the appropriate management plan.
The rst step in the echocardiographic evaluation of MR is to determine the mechanism of the
regurgitation. When assessing mechanism, it is
important to evaluate the entire mitral valve anatomy including the leaets, annulus, subvalvular
apparatus and the surrounding myocardium. A
careful assessment of the anatomy provides not
only structural information but also assists in procedural planning. Specic ndings, such as leaflet calcication or perforation, may limit a TEER
as a treatment option (Table 3). The Carpentier
classication is a frequently used classication
scheme that groups the etiology of MR into 4
subtypes. Type 1 is MR due to a dilated annulus
Table 3 Unfavorable echocardiographic characteristics
for TEER
Unfavorable echo features
Location of
pathology
Calcication If severe and at site of grasping zone
MV gradient,
M VA
Grasping leaet
length
Primary MR Flail width>15mm
Secondary MR LVESD >70mm
Adapted from Badhwar V, JACC 2020: 2236–70 [8]
Within body of leaet (i.e.,
perforation, cleft)
Mitral stenosis (≥5mmHg), MVA
2
<4cm
<7mm
Flail gap >10mm
LVESD >55mm
Highly mobile ail leaet
Severely thickened and redundant
leaet (i.e., Barlow’s type valve)
Coaptation depth>11mm
or perforated leaet. Type 2 is MR due to excessive leaet motion. Type 3a is MR due to leaet
restriction in systole and diastole. Type 3b is MR
due to leaet restriction in systole only [8].
The initial TTE for this patient was challenging due to patient’s body habitus. Despite this,
primary mitral valve disease due to a ail posterior MV leaet ail was identied (Videos 1, 3
and Fig.1). Because of the technically challenging nature of the TTE, other important MV structural information could not be assessed (Table4).
MV vegetations, calcication and perforation are
just a few characteristics that, if present, would
have a signicant impact on the patient’s candidacy for TEER.
Once the mechanism of mitral regurgitation is
identied, quantication of MR severity is the
next step. Quantication should not rely solely
on color Doppler imaging. There are multiple
parameters that are useful to determine the severity of MR and each has pros and cons. MR severity must therefore be assessed using a
comprehensive approach. Quantitative parameters such as effective regurgitant orice area
(EROA), regurgitant volume (Rvol) and regurgitant fraction (RF) are particularly useful in
patients being considered for TEER.Secondary
markers of MR severity, such as left atrial (LA)
size and LV chamber size and function, can also
be helpful determining MR severity (Table5).
MR severity in this patient’s TTE was difcult
to assess because of his large body habitus. A signicant color ow Doppler MR jet was not
appreciated and only a partial ow convergence
zone was visualized (Videos 2, 4, Fig. 2). MR
continuous wave (CW) Doppler was also
attempted with and without an echo enhancing
agent and showed a faint and incomplete MR signal with a possible early MR peak velocity
(Figs.3a and b). Clues to the presence of signicant MR included an elevated MV E wave velocity and a dilated LA (Figs.4a and b). An adequate
Doppler signal in the pulmonary veins could not
be obtained. LV chamber size was dilated but
normalized when corrected for his large body
size.
After initial clinical and TTE evaluation, it is
reasonable to refer for a TEER procedure if the
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T. Safder et al.
Fig. 1 TTE PLAX view. A ail posterior segment can be appreciated and is labeled
Table 4 Etiology of primary and secondary MR
Primary MR Secondary MR
Myxomatous changes
(prolapse, ail, ruptured
chordae)
Degenerative changes
(calcification,
thickening)
Infectious (perforations,
vegetations due to
endocarditis)
Inammatory (rheumatic,
radiation, collagen,
vascular)
Congenital (cleft,
parachute MV)
Adapted from Zoghbi WA, etal. J Am Soc Echocardiogr
2017; 30(4): 303–371 [9]
Ischemic MR
Non-ischemic
cardiomyopathy
Annular dilation (atrial
brillation, restrictive
disease)
Table 5
Severe MR criteria
Quantitative criteria Secondary markers
EROA ≥0.4cm
Regurgitant fraction
≥50%
Regurgitant
volume≥60mL
2
Pulmonary vein systolic ow
reversal
LA/LV dilation
Increased MV E velocity and
E/A ratio
following questions have been answered with
condence:
1. Indication for procedure (Tables 1 and 2)
2. Severity and mechanism for MR (Tables 4
and 5)
3. Anatomy unfavorable for TEER (Table3)
ab
Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
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Fig. 2 A baseline shifted color Doppler image
is seen with a partial ow convergence (FC) signal
75
Fig. 3 TTE CW MR Doppler. An incomplete MR CW
Doppler signal is seen due to an eccentric jet before (a)
and after (b) administration of an echo enhancing agent.
If any of those questions remain unanswered
then further testing is warranted.
Symptomatic severe MR is a Class I indication for MV surgery. For our patient to be eligible
for a commercial TEER (Class IIa), a surgical
The signal appears to be consistent with an early MR peak
velocity
evaluation with a designation of high surgical
risk is needed. The TTE shows evidence for a
ail posterior leaet, a specic marker for severe
MR, but color ow Doppler and quantication
measures are unable to conrm severity of
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Fig. 4 MR secondary measures. (a) With MV PW Doppler showing increased E velocity of 1.23 m/s and (b) with
biplane method measurement of left atrium showing enlarged LA with an index volume of 41.6 mL/m
MR.Some secondary markers also suggest presence of signicant MR.The MV leaet morphology is also poorly seen so questions regarding
favorable anatomy for TEER remain unanswered
in our patient.
ing. The dynamic nature of MR due to alterations in loading conditions can make it difcult
to fully appreciate its severity under resting conditions [10]. Hemodynamic stress testing may
show worsening of MR with exercise along with
2
other ndings such as increased pulmonary
artery systolic pressure, failure of left or right
Additional Testing
ventricle function to augment properly, and failure of appropriate augmentation of LV systolic
When important questions regarding severity,
function.
mechanism of MR and morphology of the MV
are not fully answered, further imaging should be
undertaken. There are several different imaging
modalities that may serve as an appropriate next
step depending on the specic situation.
Transesophageal Echocardiography
The role of transesophageal echocardiography
(TEE) in MR evaluation is in the setting of dis-
cordant or incomplete TTE ndings. TEE can
help in obtaining more precise information about
Stress Testing
Stress testing can serve as a valuable tool in the
assessment of MR. In asymptomatic patients,
stress testing can help to identify a truly asymptomatic patient from a patient whose symptoms
are masked by their gradual reduction in physical exertion. Furthermore, in the truly asymptomatic patients with severe MR who may not
yet meet indication for intervention, stress testing can help provide an objective baseline measure of functional capacity that can then be
followed over time. Besides exercise capacity,
stress testing can yield echocardiographic information about a patient’s MR that may not be
appreciated in baseline echocardiography imag-
valve anatomy and function when not well
dened by TTE.It is important to note that TEE
may underestimate MR severity due to proce-
dural anesthesia and its effects on loading condi-
tions. Enface views of the MV (surgeon’s view)
obtained with three-dimensional (3D) TEE can
further help localize and identify MR pathology.
TEE is essential for procedural planning in
patients being considered for TEER.
In our patient, due to incomplete information
regarding MR severity and MV morphology
obtained via TTE images, a decision was made to
order a TEE to make sure the valve team had all
the information needed to make an appropriate
recommendation.
Multimodality Imaging ofMitral Valve Diseases: TEER, Valve inValve, andBeyond
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Cardiac CT andMRI
Cardiac CT may be used in pre-procedural planning depending on type of MV intervention
planned. For transcatheter approach, CT imaging can dene level of aortic calcications (typically in patients >65 years old) or dene
anatomy in the case of any other thoracic aortic
disease. If MV surgery is being considered, CT
imaging is particularly important in high risk
patients as it can dene mediastinal anatomy,
cannulation strategy, and can exclude aberrant
cardiovascular anatomy. CT coronary angiogram can also be used in lieu of left heart catheterization in low risk patients to dene coronary
artery disease [2].
In cases where there is conicting or incomplete information on TTE or TEE, CMR can
help dene LV size/function, MV morphology
and MR severity. It can also be used in patients
with cardiomyopathies to help with risk
assessment.
Other Testing
Invasive hemodynamic testing can be considered
in patients with severe pulmonary hypertension
and to guide medical optimization prior to MV
intervention.
Heart Team Approach
andDiscussion
Prior to case evaluation by the valve team, all
pre-requisite imaging should be completed. The
heart valve team should ideally consist of a cardiac interventionalist, cardiac surgeon, cardiac
imaging specialist as well as supporting staff
including nurse practitioners or physician assistants. Ancillary staff, such as an administrative
team, also play a key role in the function of a successful valve team.
With the addition of TEE images, this patients
MV morphology and MR severity is now clear.
The signicant posterior leaet ail seen on TTE
is conrmed (Fig.5a). Biplane sweep of the 2D
MV commissural view allows for the identication of ail P2 scallop. Furthermore, several
important leaet characteristics are noted.
Signicant leaet calcication is absent, a signicant ail gap is present and the posterior leaflet length is measured (Fig. 5b, c, d, e and f).
Color ow Doppler evaluation demonstrates a
signicant anteriorly directed MR jet but without
any evidence of leaet perforation (Video 5). MR
severity is quantied using the proximal isovelocity surface area (PISA) method (Fig.6a). It is
important to note that PISA can overestimate MR
severity in this patient due to constraint of the
eccentric jet against the posterior wall. Angle of
correction due to constrained PISA should be utilized to get a more accurate estimation of MR
severity (Fig.6b). The resulting MR regurgitation
volume (Rvol) of 105 mL and MR effective
regurgitant orice area (EROA) of 1.1cm2 conrm that the MR in our patient is in the severe
range (Table6). PV ow reversal is also seen further supporting severe MR (Fig.6c).
3D TEE imaging of the MV (best reconstructed from the MV commissural view) can
also aid in conrming MV pathology and morphology. The location of P2 ail in this patient
can be appreciated with and without color
(Videos 6 and 7) as well as the extent of ail
with ail width measurement of 23 mm
(Fig.7). Increasing of the wall lter setting on
3D imaging can allow for simultaneous assessment of the underlying MV anatomy along
with the color Doppler MR jet, (Fig. 8).
Utilizing 2D and 3D echocardiographic imaging to their full extent can help give a complete
picture of MV pathology and aid in procedural
planning.
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T. Safder et al.
ef
Fig. 5 TEE ME view. The four-chamber view visualizes
the ail P2 scallop (arrow, a). The ail gap measures
9.7mm (b) and posterior leaet length measures 15.5mm
(c). ME MV commissural view allows for the identica-
tion of the ail segment as one sweeps the biplane view
from lateral (A1–P1, d) to middle (A2–P2. e) to medial
(A3–P3, f). P3 prolapse is also seen (asterisk, gure f) in
addition to the P2 ail
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