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. 2024 Dec;32(12):442-454.
doi: 10.1007/s12471-024-01893-5. Epub 2024 Sep 16.

Impact and limitations of 3D computational modelling in transcatheter mitral valve replacement-a two-centre Dutch experience

Mark M P van den Dorpel  1 , Mauricio Felippi de Sá Marchi  1   2 , Zouhair Rahhab  1   3 , Joris F Ooms  1 , Rik Adrichem  1 , Sarah Verhemel  1 , Claire Ben Ren  1 , Rutger-Jan Nuis  1 , Joost Daemen  1 , Alexander Hirsch  1   4 , Ben J L Van den Branden  3 , Nicolas M Van Mieghem  5
Affiliations

Impact and limitations of 3D computational modelling in transcatheter mitral valve replacement-a two-centre Dutch experience

Mark M P van den Dorpel et al. Neth Heart J. 2024 Dec.

Abstract

Background: Transcatheter mitral valve replacement (TMVR) has emerged as a minimally invasive alternative to mitral valve surgery for patients at high or prohibitive operative risk. Prospective studies reported favourable outcomes in patients with annulus calcification (valve-in-mitral annulus calcification; ViMAC), failed annuloplasty ring (mitral valve-in-ring; MViR), and bioprosthetic mitral valve dysfunction (mitral valve-in-valve; MViV). Multi-slice computed tomography (MSCT)-derived 3D-modelling and simulations may provide complementary anatomical perspectives for TMVR planning.

Aims: We aimed to illustrate the implementation of MSCT-derived modelling and simulations in the workup of TMVR for ViMAC, MViR, and MViV.

Methods: For this retrospective study, we included all consecutive patients screened for TMVR and compared MSCT data, echocardiographic outcomes and clinical outcomes.

Results: Sixteen out of 41 patients were treated with TMVR (ViMAC n = 9, MViR n = 3, MViV n = 4). Eleven patients were excluded for inappropriate sizing, 4 for anchoring issues and 10 for an unacceptable risk of left ventricular outflow tract obstruction (LVOTO) based on 3D modelling. There were 3 procedure-related deaths and 1 non-procedure-related cardiovascular death during 30 days of follow-up. LVOTO occurred in 3 ViMAC patients and 1 MViR patient, due to deeper valve implantation than planned in 3 patients, and anterior mitral leaflet displacement with recurrent basal septum thickening in 1 patient. TMVR significantly reduced mitral mean gradients as compared with baseline measurements (median mean gradient 9.5 (9.0-11.5) mm Hg before TMVR versus 5.0 (4.5-6.0) mm Hg after TMVR, p = 0.03). There was no residual mitral regurgitation at 30 days.

Conclusion: MSCT-derived 3D modelling and simulation provide valuable anatomical insights for TMVR with transcatheter balloon expandable valves in ViMAC, MViR and MViV. Further planning iterations should target the persistent risk for neo-LVOTO.

Keywords: Computational modelling; Left ventricular outflow tract obstruction; Multi-slice computed tomography; Transcatheter mitral valve replacement.

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Conflict of interest statement

Conflict of interest: N.M. Van Mieghem: Grants or contracts: Abbott, Boston Scientific, Biotronic, Edwards Lifesciences, Medtronic, Pulsecath BV, Abiomed, Daiichi Sankyo. Consulting Fees: Jenavalve, Daiichi Sankyo, Abbott, Boston Scientific, Medtronic. Payment or honoraria for lectures, presentations, speakers, manuscripts and educational events: Abiomed, Amgen, Jenavalve. J. Daemen: Grants or contracts: Astra Zeneca, Abbott Vascular, Boston Scientific, ACIST Medical, Medtronic, Microport, Pie Medical, and ReCor medical. Consultancy and speaker fees: Abbott Vascular, Abiomed, ACIST medical, Boston Scientific, Cardialysis BV, CardiacBooster, Kaminari Medical, ReCor Medical, PulseCath, Pie Medical, Sanofi, Siemens and Medtronic. A. Hirsch: Grants, consultancy fees: GE Healthcare. Speaker fees: GE Healthcare and Bayer. He is also a member of the medical advisory board of Medis Medical Imaging Systems. Alexander Hirsch is an Editor for the Netherlands Heart Journal. M.M.P. van den Dorpel, M.F. de Sá Marchi, Z. Rahhab, J.F. Ooms, R. Adrichem, S. Verhemel, C.B. Ren, R.-J. Nuis and B.J.L. Van den Branden declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Infographic: Clinical implementation of 3D computational modelling in the workup of transcatheter mitral valve replacement
Fig. 2
Fig. 2
Transcatheter mitral valve replacement simulation flowchart. a, b 2D images were converted into a 3D model using computational modelling. c Annulus indication using 2D-planimetry. d Annulus indication using the 3D model. e Close-up of annulus indication in the presence of extensive annulus calcification. f Examination of different THV sizes within the virtual annulus (i.e. S23, S26 or S29). g Neo-left ventricular outflow tract (neo-LVOT). h Manual neo-LVOT area calculation using cross-sectional planimetry. i, j Automatic neo-LVOT area calculations based on the 3D model. Lower transcatheter heart valve implantation depth results in a smaller neo-LVOT area. TMVR transcatheter mitral valve replacement, LVOT left ventricular outflow tract, THV transcatheter heart valve
Fig. 3
Fig. 3
Transcatheter mitral valve replacement procedure. a, b Trans-septal puncture. c Trans-septal dilatation. d Balloon expandable transcatheter heart valve is deployed in mitral valve position. e, f Transoesophageal echocardiographic imaging confirms proper valve position and mild residual mitral regurgitation
Fig. 4
Fig. 4
Pre-and post-procedural simulations in 3 patients who developed left ventricular outflow tract obstruction. a Left: Preprocedural simulation (ViMAC, SAPIEN3 26 mm THV, A:V 30:70) shows suitable neo-LVOT area. Yellow structures represent calcification. Middle: Postprocedural simulation displaying deeper (A:V 15:85) implantation and smaller neo-LVOT area. Right: Post hoc simulation using actual implantation depth (A:V 15:85) reproduces neo-LVOTO. b Left: Preprocedural simulation (ViMAC, SAPIEN3 2 6 mm THV, A:V 30:70) shows suitable neo-LVOT area. Middle: Postprocedural simulation displaying deeper (A:V 12:88) implantation and smaller neo-LVOT area. Right: Post hoc simulation using actual implantation depth (A:V 12:88) reproduces neo-LVOTO. c Left: Preprocedural 3‑chamber MSCT view shows suitable neo-LVOT area after ASA. Yellow bars indicate virtual THV implant position. Right: Postprocedural MSCT shows recurrent basal septum thickness and displacement of the anterior mitral leaflet (white circle), resulting in neo-LVOTO. LVOT left ventricular outflow tract, neo-LVOTO neo left ventricular outflow tract obstruction, ASA alcohol septal ablation, THV transcatheter heart valve, MSCT multi-slice computed tomography
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