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Blanke P, Dvir D, Cheung A, Ye J, Levine RA, Precious B, Berger A, Stub D, Hague C, Murphy D, Thompson C, Munt B, Moss R, Boone R, Wood D, Pache G, Webb J, Leipsic J. A simplified D-shaped model of the mitral annulus to facilitate CT-based sizing before transcatheter mitral valve implantation. J Cardiovasc Comput Tomogr 2014; 8:459-67. [PMID: 25467833 DOI: 10.1016/j.jcct.2014.09.009] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 08/27/2014] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The nonplanar, saddle-shaped structure of the mitral annulus has been well established through decades of anatomic and echocardiographic study. Its relevance for mitral annular assessment for transcatheter mitral valve implantation is uncertain. OBJECTIVE Our objectives are to define the methodology for CT-based simplified "D-shaped" mitral annular assessment for transcatheter mitral valve implantation and compare these measurements to traditional "saddle-shaped" mitral annular assessment. METHODS The annular contour was manually segmented, and fibrous trigones were identified using electrocardiogram-gated diastolic CT data sets of 28 patients with severe functional mitral regurgitation, yielding annular perimeter, projected area, trigone-to-trigone (TT) distance, and septal-lateral distance. In contrast to the traditional saddle-shaped annulus, the D-shaped annulus was defined as being limited anteriorly by the TT distance, excluding the aortomitral continuity. Hypothetical left ventricular outflow tract (LVOT) clearance was assessed. RESULTS Projected area, perimeter, and septal-lateral distance were found to be significantly smaller for the D-shaped annulus (11.2 ± 2.7 vs 13.0 ± 3.0 cm(2); 124.1 ± 15.1 vs 136.0 ± 15.5 mm; and 32.1 ± 4.0 vs 40.1 ± 4.9 mm, respectively; P < .001). TT distances were identical (32.7 ± 4.1 mm). Hypothetical LVOT clearance was significantly lower for the saddle-shaped annulus than for the D-shaped annulus (10.7 ± 2.2 vs 17.5 ± 3.0 mm; P < .001). CONCLUSION By truncating the anterior horn of the saddle-shaped annular contour at the TT distance, the resulting more planar and smaller D-shaped annulus projects less onto the LVOT, yielding a significantly larger hypothetical LVOT clearance than the saddle-shaped approach. CT-based mitral annular assessment may aid preprocedural sizing, ensuring appropriate patient and device selection.
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Affiliation(s)
- Philipp Blanke
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Danny Dvir
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Anson Cheung
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Jian Ye
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Precious
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Adam Berger
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Dion Stub
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Cameron Hague
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Darra Murphy
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Christopher Thompson
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Brad Munt
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Robert Moss
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Robert Boone
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David Wood
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Gregor Pache
- Section of Cardiovascular Radiology, Department of Radiology, University of Freiburg, Freiburg, Germany
| | - John Webb
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Jonathon Leipsic
- Center for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
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Lancellotti P, Zamorano JL, Vannan MA. Imaging challenges in secondary mitral regurgitation: unsolved issues and perspectives. Circ Cardiovasc Imaging 2014; 7:735-46. [PMID: 25027455 DOI: 10.1161/circimaging.114.000992] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Patrizio Lancellotti
- From the Department of Cardiology, University of Liège Hospital, GIGA Cardiovascular Sciences, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium (P.L.); University Hospital Ramón y Cajal, Madrid, Spain (J.-L.Z.); and Piedmont Heart Institute, Atlanta, GA (M.A.V.).
| | - Jose-Luis Zamorano
- From the Department of Cardiology, University of Liège Hospital, GIGA Cardiovascular Sciences, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium (P.L.); University Hospital Ramón y Cajal, Madrid, Spain (J.-L.Z.); and Piedmont Heart Institute, Atlanta, GA (M.A.V.)
| | - Mani A Vannan
- From the Department of Cardiology, University of Liège Hospital, GIGA Cardiovascular Sciences, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium (P.L.); University Hospital Ramón y Cajal, Madrid, Spain (J.-L.Z.); and Piedmont Heart Institute, Atlanta, GA (M.A.V.)
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Dal-Bianco JP, Beaudoin J, Handschumacher MD, Levine RA. Basic mechanisms of mitral regurgitation. Can J Cardiol 2014; 30:971-81. [PMID: 25151282 DOI: 10.1016/j.cjca.2014.06.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 06/16/2014] [Accepted: 06/22/2014] [Indexed: 12/17/2022] Open
Abstract
Any structural or functional impairment of the mitral valve (MV) apparatus that exhausts MV tissue redundancy available for leaflet coaptation will result in mitral regurgitation (MR). The mechanism responsible for MV malcoaptation and MR can be dysfunction or structural change of the left ventricle, the papillary muscles, the chordae tendineae, the mitral annulus, and the MV leaflets. The rationale for MV treatment depends on the MR mechanism and therefore it is essential to identify and understand normal and abnormal MV and MV apparatus function.
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Affiliation(s)
- Jacob P Dal-Bianco
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Beaudoin
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Department of Cardiology, Québec City, Québec, Canada
| | - Mark D Handschumacher
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert A Levine
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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