Multimodality Cardiac Imaging for Procedural Planning and Guidance of Transcatheter Mitral Valve Replacement and Mitral Paravalvular Leak Closure

Abstract

Transcatheter mitral valve interventions are an evolving and growing field in which multimodality cardiac imaging is essential for diagnosis, procedural planning, and intraprocedural guidance. Currently, transcatheter mitral valve-in-valve with a balloon-expandable valve is the only form of transcatheter mitral valve replacement (TMVR) approved by the FDA, but valve-in-ring and valve-in-mitral annular calcification interventions are increasingly being performed. Additionally, there are several devices under investigation for implantation in a native annulus. Paravalvular leak (PVL) is a known complication of surgical or transcatheter valve implantation, where regurgitant flow occurs between the prosthetic sewing ring and the native mitral annulus. We sought to describe the role and applications of multimodality cardiac imaging for TMVR, and PVL closure, including the use of Cardiovascular Computed Tomography Angiography and 3-Dimensional Transesophageal Echocardiography for diagnosis, prosthetic valve evaluation, pre-procedural planning, and intraprocedural guidance, as well as evolving technologies such as fusion imaging and 3D printing.

Unearthing the Tunnel

“…Advanced TEE imaging in conjunction with cardiac CT allowed for robust preprocedural planning and a successful procedural result. 7 …”

Role of computed tomography in transcatheter replacement of ‘other valves’: a comprehensive review of preprocedural imaging

“…13 Echocardiography, CT and MR have a primary role for the identification, quantification of severity and characterization of the underlying cause of mitral valve regurgitation as well as for the assessment of suitability for structural intervention. 15,16 In particular, cardiac CT is becoming the best technique for evaluating anatomic features and predicting consequences of device implantation, especially left ventricular outflow tract (LVOT) obstruction and delayed embolization.…”

Imaging in transcatheter native mitral valve replacement with Tendyne mitral valve system: Echocardiographic pathway for the interventional imager

“…Mitral valve (MV) surgery plays a primary role on indications for intervention, however, transcatheter procedures have emerged as an alternative option to treat inoperable and high-risk surgical patients and have been impressively expanding [3,[4][5][6][7][8][9][10][11][12][13][14][15]. This growth has been possible thanks to the developments and rapid progress of new percutaneous devices but also due to the innovations in imaging techniques [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]. These developments have prompted the need for a new dedicated professional figure with specific competencies in the field of structural heart disease procedures imaging 'the interventional imager' whose collaboration with the implanter team is crucial for the procedural success [22,25,26].…”

“…Imaging is paramount in planning and guide the MV interventional procedure. While the angiography and the fluoroscopy are performed by the implanter team, other multimodality imaging, semi and non-invasive, the so called 'interventional imaging', is performed by the structural heart disease interventional imagers [16][17][18][19][20][21][22]25,26]. A peculiar imaging work-up is essential to select the right patient [16][17][18][19][20][21][22]25,26].…”

“…In this setting, computed tomography (CT), two-(2D) and three-dimensional (3D) transesophageal echocardiography (TEE) have a key role in multimodality imaging and in the interaction between the implanting and imaging teams [17][18][19][20]. As its use is expanding into the clinical arena, a detailed description of the use of different imaging modalities is necessary for the interventional imager and is also advised for the interventional implanter team.…”