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Review
. 2016 Apr;6(2):144-59.
doi: 10.21037/cdt.2016.02.04.

Peri-procedural imaging for transcatheter mitral valve replacement

Navin Natarajan  1 , Parag Patel  1 , Thomas Bartel  1 , Samir Kapadia  1 , Jose Navia  1 , William Stewart  1 , E Murat Tuzcu  1 , Paul Schoenhagen  1
Affiliations
Review

Peri-procedural imaging for transcatheter mitral valve replacement

Navin Natarajan et al. Cardiovasc Diagn Ther. 2016 Apr.

Abstract

Mitral regurgitation (MR) has a high prevalence in older patient populations of industrialized nations. Common etiologies are structural, degenerative MR and functional MR secondary to myocardial remodeling. Because of co-morbidities and associated high surgical risk, open surgical mitral repair/replacement is deferred in a significant percentage of patients. For these patients transcatheter repair/replacement are emerging as treatment options. Because of the lack of direct visualization, pre- and intra-procedural imaging is critical for these procedures. In this review, we summarize mitral valve anatomy, trans-catheter mitral valve replacement (TMVR) options, and imaging in the context of TMVR.

Keywords: Trans-catheter mitral valve replacement (TMVR); angiography; computed tomography; echocardiography; imaging; magnetic resonance imaging (MRI); mitral regurgitation (MR).

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Conflict of interest statement

Conflicts of Interest: Jose Navia—Chairman of the Scientific Medical Board of NaviGate Cardiac Structures, Inc.; Thomas Bartel—Consulting Fees/Honoraria/Sponsoring (Edwards Lifescience Biosense, Webster/Johnson & Johnson, Actelion, Siemens, Abbott); Paul Schoenhagen—Editor-In-Chief Cardiovascular Diagnosis and Therapy. The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Mitral valve complex. The mitral valve complex includes the valve itself (annulus and two leaflets), the chordae tendineae, and the papillary muscles.
Figure 2
Figure 2
Mitral leaflets. The three portions of the posterior mitral leaflet, named from lateral to medial are P1, P2 and P3. The anterior leaflet similarly is divided into three portions named A1, A2 and A3, from lateral to medial. The fibrous continuity of the anterior mitral valve leaflet with the non-coronary and left-coronary leaflet of the aortic valve is known as the aortic mitral curtain.
Figure 3
Figure 3
Apical long axis echocardiogram. Apical long axis view is utilized for measuring the AP diameter of mitral annulus.
Figure 4
Figure 4
Apical two chamber view echocardiogram. Apical 2 chamber view is utilized for measuring intercommissural length of mitral annulus.
Figure 5
Figure 5
3D-TEE of the mitral valve. Enface view shows the mitral valve segmental prolapse from the left atrial perspective. AML, anterior mitral leaflet; LAA, left atrial appendage; P2 is the central segment of the posterior leaflet.
Figure 6
Figure 6
Mitral valve anatomy. A 68-year-old female with degenerative mitral valve disease, was evaluated for surgical mitral valve repair. There was severe (4+) mitral valve regurgitation due to anterior leaflet prolapse and flail likely related to myxomatous degenerative disease. This figure shows the valvular and subvalvular structures, including the papillary muscles (2-chamber view left upper; 3-chamber view right upper; two short-axis views in the lower panels, located at the level of the papillary muscles (left) and leaflets (right).
Figure 7
Figure 7
Mitral valve anatomy. This figure shows ‘Volume rendered images’ (VRI) of the same patient in Figure 6 in a 4-chamber projection (upper panels) and 3-chamber projection (right lower panel).
Figure 8
Figure 8
Mitral valve anatomy. Planimetry of the CT images for the same patient in Figure 6 (acquired in diastole) allowed confirmation of LV dilatation (right lower panel) and left atrial dilatation (left upper and lower panels).
Figure 9
Figure 9
Evaluation of the mitral annulus. A 65-year-old male with a longstanding cardiomyopathy with severely dilated LV (LVEDD 8 cm) and severe LV dysfunction had severe functional MR with NYHA III symptoms of DOE and fatigue. No obstructive CAD. This figure shows images reconstructed at the mitral annular plane. Diameter and are measurements of chambers are shown. MR, mitral regurgitation.
Figure 10
Figure 10
Evaluation of the mitral annulus. This figure shows the coronary vessels in relationship to the annular plane. The left lower panel shows the proximal LCX passing along the anterior aspect of the mitral annulus. The great cardiac vein crosses the LCX at the center of the crosshair. The right lower panel shows the coronary sinus with the LV pacing lead.
Figure 11
Figure 11
Fusion non-contrast CT and non-contrast MRI. An 80-year-old male with polyvalvular disease (severe TR, mod-severe MR), CAD (s/p CABG '09), and chronic kidney disease (CKD, baseline creatinine: 2.4–2.6) and recent hospital admissions heart failure was evaluated. He was deemed not to be an operable candidate. Non-contrast CT and MRI images were fused. The left and right upper panels images show a bright blood MRI and a CT image at the mitral annulus, respectively. The left and right lower panels show fused images (left lower 50CT-50 MRI; right lower 75MRI-25CT). Moderate mitral annular calcification is better seen with CT. MRI, magnetic resonance imaging.
Figure 12
Figure 12
Assessment of leaflet coaptation length via echocardiogram.
Figure 13
Figure 13
Evaluation of parameters prior to mitral intervention. Coaptation length and depth (demonstrated in upper 2 panels) relative to the annular plane are also important to evaluate and a coaptation length <2 mm has been found to be insufficient to allow grasping by a valve repair device. Flail gap and width (demonstrated in lower panels) is also important to assess as it can complicate device placement.
Figure 14
Figure 14
Biplane Imaging view of interatrial septum. This biplane view is useful during the transeptal puncture step of device placement.
See this image and copyright information in PMC

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