Role of CT in Assessment of MR/MS and Planning for Transcatheter Mitral Repair
TERMINOLOGY
Mitral Valve Disease
Mitral valve apparatus is composed of anterior and posterior leaflet, chordae tendineae, anterolateral and posteromedial papillary muscles and mitral annulus
Mitral regurgitation (MR) is most common disorder involving mitral valve and can be classified as either primary or secondary
Primary MR is intrinsic structural or degenerative abnormality of valve [e.g., mitral valve prolapse (MVP)]
Secondary MR is result of disease process of left ventricle that affects mechanics and function of mitral valve apparatus (e.g., ischemic or nonischemic dilated cardiomyopathy)
Rheumatic fever is most common cause of mitral stenosis (MS)
Degenerative calcific mitral valve disease is largely seen in elderly population
MS can result from leaflet thickening, commissural fusion, and chordal shortening and fusion
Indications for Transcatheter Mitral Valve Repair
Patients deemed high surgical risk following assessment by heart team with one of the following
Primary mitral valve regurgitation: Severe symptomatic mitral regurgitation
Asymptomatic: Left ventricular systolic ejection fraction (LVEF) < 60%, left ventricular end-systolic diameter (LVESD) > 45 mm, atrial fibrillation (AF), systolic pulmonary pressure > 50 mm Hg
Secondary functional MR: Severe MR despite optimal medical therapy and cardiac resynchronization therapy (CRT)
Indications for percutaneous balloon mitral valvuloplasty (PBMV) as therapy for MS
Echocardiography is primary imaging modality for establishing the severity of MR and MS
Severe MR is characterized by regurgitant volume of 60 mL, regurgitant fraction of 50%, and effective orifice area of > 0.4 cm²
Transcatheter Mitral Valve Repair Strategies
Percutaneous mitral valve repair for severe MR includes edge-to-edge repair (MitraClip) and annuloplasty rings (e.g., Cardioband), and PBMV for severe MS
MitraClip (Abbott Vascular, Menlo Park, California): Can be considered for treatment of moderate to severe and severe degenerative and functional MR
Device is delivered to mitral valve via femoral vein following transeptal puncture
Aligned above mitral valve and centered over origin of regurgitant jet, advanced across valve orifice, followed by grasping and coapting of leaflets
EVERST II trial evaluated MitraClip for treatment of degenerative and functional MR, and at 5 years conventional surgery resulted in greater freedom from death, surgery, or moderate/moderate-severe MR compared to MitraClip device
In recently completed COAPT trial of patients with only symptomatic secondary functional MR, device resulted in significant reduction in heart failure hospitalization and all cause mortality at 2 years compared to medical therapy
General exclusion criteria: LVEF < 25%, LVESD > 70 mm, mitral valve orifice area < 4 cm²
Cardioband system (Valtech Cardio, OrYehuda Israel): Traditionally, annuloplasty has been combined with mitral valve repair for degenerative MR to improve leaflet coaptation and long-term durability of repair
Percutaneous annuloplasty can be performed in isolation using Cardioband device in setting of functional MR resulting from left ventricular systolic dysfunction, mitral annular dilatation, and lateral papillary muscle displacement
Surgical-like annuloplasty device that is implanted along posterior mitral annulus
Delivered to left arium following femoral vein access and transeptal puncture
After implantation, device is contracted to remodel annulus and reduce MR
Early evidence for this device in symptomatic patients with secondary functional MR despite optimal medical therapy, has shown feasibility and safety in small sample size (n = 31) of high-risk patients with MR
CT may be used to assess the following in planning for Cardioband device implantation
Location of transeptal puncture, left circumflex coronary artery anatomy in relation to mitral annulus (to minimize risk of injury)
Exclusion criteria: Patients with LVEF < 25% and end-diastolic diameter ≥ 70 mm, primary (organic) lesions of mitral valve and calcification of mitral annulus
Percutaneous balloon mitral valvuloplasty (PBMV): Inoue balloon (Toray industries, Japan) is delivered to mitral valve via femoral vein following transeptal puncture
Balloon catheter is advanced into left ventricle, pulled back with distal portion of balloon inflated; proximal portion and waist are then inflated
Main mechanism of PBMV action is commissural fracture, leading to reduction in transmitral pressure gradient, increasing MV area and cardiac output
Superior to surgical commissurotomy, with lager resulting valve area and better durability
1st-line therapy in absence of contraindications
Inclusion criteria: Severe symptomatic MS (mitral valve area < 1.5 cm²)
Asymptomatic patients: Resting systolic pulmonary arterial pressure > 50 mm Hg, new-onset AF, history of embolism
Echocardiography is used to determine suitability for PBMV, depending on leaflet mobility, thickening, calcification, and subvalvular thickening (Wilkins score)
Contraindications: Mitral valve area >1.5 cm², left atrial thrombus, > mild MR, severe bicommissural calcification, severe CAD requiring bypass
IMAGING ANATOMY
Role of CT in Assessment of MR/MS and Planning for Transcatheter Mitral Repair
Selected References
Stone GW et al: Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. ePub, 2018
Baumgartner H et al: 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 38(36):2739-91, 2017
Maisano F et al: Cardioband, a transcatheter surgical-like direct mitral valve annuloplasty system: early results of the feasibility trial. Eur Heart J. 37(10):817-25, 2016
Nishimura RA et al: Mitral valve disease--current management and future challenges. Lancet. 387(10025):1324-34, 2016
Feldman T et al: Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-year results of EVEREST II. J Am Coll Cardiol. 66(25):2844-54, 2015
Feldman T et al: Percutaneous approaches to valve repair for mitral regurgitation. J Am Coll Cardiol. 63(20):2057-68, 2014
Bolen MA et al: Prospective ECG-triggered, axial 4-D imaging of the aortic root, valvular, and left ventricular structures: a lower radiation dose option for preprocedural TAVR imaging. J Cardiovasc Comput Tomogr. 6(6):393-8, 2012
Ewe SH et al: Role of computed tomography imaging for transcatheter valvular repair/insertion. Int J Cardiovasc Imaging. 27(8):1179-93, 2011
Feuchtner GM et al: Cardiac CT angiography for the diagnosis of mitral valve prolapse: comparison with echocardiography1. Radiology. 254(2):374-83, 2010
Alkadhi H et al: Mitral annular shape, size, and motion in normals and in patients with cardiomyopathy: evaluation with computed tomography. Invest Radiol. 44(4):218-25, 2009
Delgado V et al: Assessment of mitral valve anatomy and geometry with multislice computed tomography. JACC Cardiovasc Imaging. 2(5):556-65, 2009
Feldman T et al: Percutaneous mitral repair with the MitraClip system: safety and midterm durability in the initial EVEREST (Endovascular Valve Edge-to-Edge REpair Study) cohort. J Am Coll Cardiol. 54(8):686-94, 2009
Guo YK et al: Isolated mitral regurgitation: quantitative assessment with 64-section multidetector CT--comparison with MR imaging and echocardiography. Radiology. 252(2):369-76, 2009
Nobuyoshi M et al: Percutaneous balloon mitral valvuloplasty: a review. Circulation. 119(8):e211-9, 2009
Related Anatomy
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Related Differential Diagnoses
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References
Tables
Tables
KEY FACTS
Mitral Valve Disease
Indications for Transcatheter Mitral Valve Repair
Transcatheter Mitral Valve Repair Strategies
Role of CT in Assessment of MR/MS and Planning for Transcatheter Mitral Repair
TERMINOLOGY
Mitral Valve Disease
Mitral valve apparatus is composed of anterior and posterior leaflet, chordae tendineae, anterolateral and posteromedial papillary muscles and mitral annulus
Mitral regurgitation (MR) is most common disorder involving mitral valve and can be classified as either primary or secondary
Primary MR is intrinsic structural or degenerative abnormality of valve [e.g., mitral valve prolapse (MVP)]
Secondary MR is result of disease process of left ventricle that affects mechanics and function of mitral valve apparatus (e.g., ischemic or nonischemic dilated cardiomyopathy)
Rheumatic fever is most common cause of mitral stenosis (MS)
Degenerative calcific mitral valve disease is largely seen in elderly population
MS can result from leaflet thickening, commissural fusion, and chordal shortening and fusion
Indications for Transcatheter Mitral Valve Repair
Patients deemed high surgical risk following assessment by heart team with one of the following
Primary mitral valve regurgitation: Severe symptomatic mitral regurgitation
Asymptomatic: Left ventricular systolic ejection fraction (LVEF) < 60%, left ventricular end-systolic diameter (LVESD) > 45 mm, atrial fibrillation (AF), systolic pulmonary pressure > 50 mm Hg
Secondary functional MR: Severe MR despite optimal medical therapy and cardiac resynchronization therapy (CRT)
Indications for percutaneous balloon mitral valvuloplasty (PBMV) as therapy for MS
Echocardiography is primary imaging modality for establishing the severity of MR and MS
Severe MR is characterized by regurgitant volume of 60 mL, regurgitant fraction of 50%, and effective orifice area of > 0.4 cm²
Transcatheter Mitral Valve Repair Strategies
Percutaneous mitral valve repair for severe MR includes edge-to-edge repair (MitraClip) and annuloplasty rings (e.g., Cardioband), and PBMV for severe MS
MitraClip (Abbott Vascular, Menlo Park, California): Can be considered for treatment of moderate to severe and severe degenerative and functional MR
Device is delivered to mitral valve via femoral vein following transeptal puncture
Aligned above mitral valve and centered over origin of regurgitant jet, advanced across valve orifice, followed by grasping and coapting of leaflets
EVERST II trial evaluated MitraClip for treatment of degenerative and functional MR, and at 5 years conventional surgery resulted in greater freedom from death, surgery, or moderate/moderate-severe MR compared to MitraClip device
In recently completed COAPT trial of patients with only symptomatic secondary functional MR, device resulted in significant reduction in heart failure hospitalization and all cause mortality at 2 years compared to medical therapy
General exclusion criteria: LVEF < 25%, LVESD > 70 mm, mitral valve orifice area < 4 cm²
Cardioband system (Valtech Cardio, OrYehuda Israel): Traditionally, annuloplasty has been combined with mitral valve repair for degenerative MR to improve leaflet coaptation and long-term durability of repair
Percutaneous annuloplasty can be performed in isolation using Cardioband device in setting of functional MR resulting from left ventricular systolic dysfunction, mitral annular dilatation, and lateral papillary muscle displacement
Surgical-like annuloplasty device that is implanted along posterior mitral annulus
Delivered to left arium following femoral vein access and transeptal puncture
After implantation, device is contracted to remodel annulus and reduce MR
Early evidence for this device in symptomatic patients with secondary functional MR despite optimal medical therapy, has shown feasibility and safety in small sample size (n = 31) of high-risk patients with MR
CT may be used to assess the following in planning for Cardioband device implantation
Location of transeptal puncture, left circumflex coronary artery anatomy in relation to mitral annulus (to minimize risk of injury)
Exclusion criteria: Patients with LVEF < 25% and end-diastolic diameter ≥ 70 mm, primary (organic) lesions of mitral valve and calcification of mitral annulus
Percutaneous balloon mitral valvuloplasty (PBMV): Inoue balloon (Toray industries, Japan) is delivered to mitral valve via femoral vein following transeptal puncture
Balloon catheter is advanced into left ventricle, pulled back with distal portion of balloon inflated; proximal portion and waist are then inflated
Main mechanism of PBMV action is commissural fracture, leading to reduction in transmitral pressure gradient, increasing MV area and cardiac output
Superior to surgical commissurotomy, with lager resulting valve area and better durability
1st-line therapy in absence of contraindications
Inclusion criteria: Severe symptomatic MS (mitral valve area < 1.5 cm²)
Asymptomatic patients: Resting systolic pulmonary arterial pressure > 50 mm Hg, new-onset AF, history of embolism
Echocardiography is used to determine suitability for PBMV, depending on leaflet mobility, thickening, calcification, and subvalvular thickening (Wilkins score)
Contraindications: Mitral valve area >1.5 cm², left atrial thrombus, > mild MR, severe bicommissural calcification, severe CAD requiring bypass
IMAGING ANATOMY
Role of CT in Assessment of MR/MS and Planning for Transcatheter Mitral Repair
Selected References
Stone GW et al: Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. ePub, 2018
Baumgartner H et al: 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 38(36):2739-91, 2017
Maisano F et al: Cardioband, a transcatheter surgical-like direct mitral valve annuloplasty system: early results of the feasibility trial. Eur Heart J. 37(10):817-25, 2016
Nishimura RA et al: Mitral valve disease--current management and future challenges. Lancet. 387(10025):1324-34, 2016
Feldman T et al: Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-year results of EVEREST II. J Am Coll Cardiol. 66(25):2844-54, 2015
Feldman T et al: Percutaneous approaches to valve repair for mitral regurgitation. J Am Coll Cardiol. 63(20):2057-68, 2014
Bolen MA et al: Prospective ECG-triggered, axial 4-D imaging of the aortic root, valvular, and left ventricular structures: a lower radiation dose option for preprocedural TAVR imaging. J Cardiovasc Comput Tomogr. 6(6):393-8, 2012
Ewe SH et al: Role of computed tomography imaging for transcatheter valvular repair/insertion. Int J Cardiovasc Imaging. 27(8):1179-93, 2011
Feuchtner GM et al: Cardiac CT angiography for the diagnosis of mitral valve prolapse: comparison with echocardiography1. Radiology. 254(2):374-83, 2010
Alkadhi H et al: Mitral annular shape, size, and motion in normals and in patients with cardiomyopathy: evaluation with computed tomography. Invest Radiol. 44(4):218-25, 2009
Delgado V et al: Assessment of mitral valve anatomy and geometry with multislice computed tomography. JACC Cardiovasc Imaging. 2(5):556-65, 2009
Feldman T et al: Percutaneous mitral repair with the MitraClip system: safety and midterm durability in the initial EVEREST (Endovascular Valve Edge-to-Edge REpair Study) cohort. J Am Coll Cardiol. 54(8):686-94, 2009
Guo YK et al: Isolated mitral regurgitation: quantitative assessment with 64-section multidetector CT--comparison with MR imaging and echocardiography. Radiology. 252(2):369-76, 2009
Nobuyoshi M et al: Percutaneous balloon mitral valvuloplasty: a review. Circulation. 119(8):e211-9, 2009
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