Multimodality imaging in valvular heart disease: how to use state-of-the-art technology in daily practice

Valvular Heart Disease Care in Pakistan: Impact of the Multidisciplinary Valve Heart Team

Background

Patients with complex valvular heart disease (VHD) should be evaluated by a multidisciplinary heart team (HT). In low- and middle-income countries, referral practices are more variable, permitting any physician to refer patients directly to a cardiac surgeon without prior formal evaluation by a cardiologist with expertise in VHD.

Objectives

The goal of the study was to examine the demographics of VHD patients seen in a large heart valve center in a low- and middle-income country and to assess the impact of the multidisciplinary HT in patients referred for valve surgery.

Methods

Over a 20-month period, all patients with VHD seen in the National Institute of Cardiovascular Diseases (Karachi, Pakistan) outpatient cardiovascular surgery clinic were referred to the heart valve center and assessed by a multidisciplinary HT. The multidisciplinary HT developed individualized plans for each patient.

Results

A total of 2,003 patients (52.8% female, mean age: 43.9 ± 14.4 years) were enrolled. Rheumatic heart disease was identified as the predominant cause of mitral valve disease, whereas bicuspid valve was the most common cause of significant aortic stenosis. All patients had been referred for valve surgery. Based on the HT's evaluation, 1,521 patients (76%) were deemed suitable for surgery, 335 patients (17%) were recommended for medical therapy, and 147 patients (7%) were considered candidates for transcatheter treatments. Notably, the HT reclassified the management strategies for 24% of the patients, all of whom had initially been referred for surgical intervention.

Conclusions

The integration of collaborative decision-making through a multidisciplinary HT led to individualized and tailored treatment strategies, with a significant proportion of patients receiving alternative interventions or medical management instead of surgery.

Contemporary diagnosis and treatment of valvular heart disease in Korea: a nationwide hospital-based registry study

BACKGROUND

This study was designed to determine the current status of diagnosis and treatment of valvular heart disease (VHD) in Korea.

METHODS

A nationwide registry study was conducted in 45 hospitals in Korea involving adult patients with at least moderate VHD as determined by echocardiography carried out between September and October of 2019. Of a total of 4,094 patients with at least moderate VHD, 1,482 had severe VHD (age, 71.3 ± 13.5 years; 49.1% male). Echocardiographic data used for the diagnosis of each case of VHD were analyzed. Experts from each center determined the diagnosis and treatment strategy for VHD based on current guidelines and institutional policy. The clinical outcome was in-hospital mortality.

RESULTS

Each valve underwent surgical or transcatheter intervention in 19.3% cases of severe mitral stenosis, 31.4% cases of severe primary mitral regurgitation (MR), 7.5% cases of severe secondary MR, 43.7% cases of severe aortic stenosis, 27.5% cases of severe aortic regurgitation, and 7.2% cases of severe tricuspid regurgitation. The overall in-hospital mortality rate for patients with severe VHD was 5.4%, and for secondary severe MR and severe tricuspid regurgitation, the rates were 9.0% and 7.5%, respectively, indicating a poor prognosis. In-hospital mortality occurred in 73 of the 1,244 patients (5.9%) who received conservative treatment and in 18 of the 455 patients (4.0%) who received a surgical or transcatheter intervention, which was significantly lower in the intervention group (P = 0.037).

CONCLUSIONS

This study provides important information about the current status of VHD diagnosis and treatment through a nationwide registry in Korea and helps to define future changes.

Evolving capabilities of computed tomography imaging for transcatheter valvular heart interventions - new opportunities for precision medicine

The last decade has witnessed a substantial growth in percutaneous treatment options for heart valve disease. The development in these innovative therapies has been mirrored by advances in multi-detector computed tomography (MDCT). MDCT plays a central role in obtaining detailed pre-procedural anatomical information, helping to inform clinical decisions surrounding procedural planning, improve clinical outcomes and prevent potential complications. Improvements in MDCT image acquisition and processing techniques have led to increased application of advanced analytics in routine clinical care. Workflow implementation of patient-specific computational modeling, fluid dynamics, 3D printing, extended reality, extracellular volume mapping and artificial intelligence are shaping the landscape for delivering patient-specific care. This review will provide an insight of key innovations in the field of MDCT for planning transcatheter heart valve interventions.

Emerging Transcatheter Therapies for Valvular Heart Disease: Focus on Mitral and Tricuspid Valve Procedures

The emergence of percutaneous treatment options provides novel therapeutic alternatives for older and feeble patients who are at high risk for any surgical procedure. The purpose of our review was to offer an up-to-date analysis of the rapidly expanding field of percutaneous technologies for mitral, tricuspid, and pulmonary procedures. Edge-to-edge repair is an established treatment for secondary mitral regurgitation (MR), while transcatheter mitral valve replacement is a potential and expanding option for managing both secondary and primary MR. However, additional advancements are necessary to enhance the safety and feasibility of this procedure. Transcatheter tricuspid intervention is an emerging option that was conceived after the success of transcatheter procedures in aortic and mitral valves, and it is currently still in the early stages of advancement. This can be attributed, at least in part, to the previously overlooked effect of tricuspid regurgitation on patient outcomes. The development of edge-to-edge repair represents the forefront of innovations in transcatheter procedures. There is a scarcity of data about tricuspid annuloplasty and replacement, and further study is necessary. Transcatheter mitral, tricuspid, and pulmonary procedures show prospects for the future, while their role in clinical practice has not been definitively established.

Transcatheter Mitral Valve Repair With the MitraClip Device for Prior Mitral Valve Repair Failure: Insights From the GIOTTO-FAILS Study

BACKGROUND

Minimally invasive mitral valve repair has a favorable risk-benefit profile in patients with significant de novo mitral regurgitation. Its role in patients with prior mitral valve repair is uncertain. We aimed to appraise the outcome of patients undergoing transcatheter edge-to-edge repair (TEER) with prior transcatheter or surgical mitral valve repair (SMVR).

METHODS AND RESULTS

We queried the Italian multicenter registry on TEER with MitraClip, distinguishing naïve patients from those with prior TEER or (SMVR). Inhospital and long-term clinical/echocardiographic outcomes were appraised. The primary outcome was the occurrence of death or rehospitalization for heart failure. A total of 2238 patients were included, with 2169 (96.9%) who were naïve to any mitral intervention, 29 (1.3%) with prior TEER, and 40 (1.8%) with prior SMVR. Several significant differences were found in baseline clinical and imaging features. Respectively, device success was obtained in 2120 (97.7%), 28 (96.6%), and 38 (95.0%, P=0.261) patients; procedural success in 2080 (95.9%), 25 (86.2%), and 38 (95.0%; P=0.047); and inhospital death in 61 (2.8%), 1 (3.5%), and no (P=0.558) patients. Clinical follow-up after a mean of 14 months showed similar rates of death, cardiac death, rehospitalization, rehospitalization for heart failure, and their composite (all P>0.05). Propensity score-adjusted analysis confirmed unadjusted analysis, with lower procedural success for the prior TEER group (odds ratio, 0.28 [95% CI, 0.09-0.81]; P=0.019) but similar odds ratios and hazard ratios for all other outcomes in the naïve, TEER, and SMVR groups (all P>0.05).

CONCLUSIONS

In carefully selected patients, TEER can be performed using the MitraClip device even after prior TEER or SMVR.

The myth of aortic valve annulus changes in aortic valve disease

Background

The characteristics of aortic annulus changes in aortic regurgitation (AR) patients are poorly understood, and predictive factors among aortic valve disease are yet to be established.

Objective

This study seeks to elucidate the pattern of annular size fluctuations across different cardiac phases in AR patients and to identify predictors for annular enlargement during either systole or diastole in aortic valve diseases.

Methods

A retrospective analysis was conducted on 55 patients with severe aortic valve diseases, including 26 patients with aortic stenosis (AS) and 29 with AR, to discern the two groups' contrasting and analogous patterns of annular changes. The patient sample was expanded to 107 to investigate the factors influencing the size of the annulus during different cardiac phases. Based on our findings, patients were then divided into two groups: those with an annulus that is larger during systole (83 patients) and those where the annulus is larger during diastole (24 patients).

Results

Typically, AR patients exhibit a dynamic annulus, with both perimeter and area being largest during mid-systole. These dimensions diminish progressively and then increase again in early diastole, a pattern consistent with observations in AS patients. Among 107 patients, 21% had diastolic enlargement. Systolic measurements would lead to prosthesis undersizing in 17% of these. Male gender and lower systolic annulus minimum relative to body surface area (AnMin index) were predictors of diastolic enlargement, with ROC curve areas of 0.70 and 0.87 for AR and AS, respectively.

Conclusions

Systolic measurements are recommended for AR patients. Gender and the AnMin index are significant predictors, particularly potent in AS patients.

Cardiac CT Beyond Coronaries: Focus on Structural Heart Disease

PURPOSE OF REVIEW

Cardiac computed tomography (CT) is an established non-invasive imaging tool for the assessment of coronary artery disease. Furthermore, it plays a key role in the preinterventional work-up of patients presenting with structural heart disease.

RECENT FINDINGS

CT is the gold standard for preprocedural annular assessment, device sizing, risk determination of annular injury, coronary occlusion or left ventricular outflow tract obstruction, calcification visualization and quantification of the target structure, and prediction of a co-planar fluoroscopic angulation for transcatheter interventions in patients with structural heart disease. It is further a key imaging modality in postprocedural assessment for prosthesis thrombosis, degeneration, or endocarditis. CT plays an integral part in the imaging work-up of novel transcatheter therapies for structural heart disease and postprocedural assessment for prosthesis thrombosis or endocarditis. This review provides a comprehensive overview of the key role of CT in the context of structural heart interventions.

Anatomical characteristics of aortic valve diseases: Implications for transcatheter aortic valve replacement

Background

The etiology of aortic stenosis (AS) significantly impacts transcatheter heart valve (THV) implantation, with rheumatic etiology posing challenges. The concept of valve anchoring during transcatheter aortic valve replacement (TAVR) for patients with aortic regurgitation (AR) remains unclear.

Objective

This study aims to investigate the clinical and CT anatomical characteristics of various aortic valve diseases.

Methods

A retrospective analysis was conducted on consecutive patients who underwent CT for severe aortic diseases between April 2019 and February 2023. CT analysis was performed in eight anatomical landmarks: left ventricular outflow tract (LVOT), aortic annulus, sinus of Valsalva (SOV), sinotubular junction (STJ), ascending aorta (AAO), coronary height, aortic angle, and aortic valve calcification volume.

Results

121 patients with severe aortic valve disease were included, divided into AS (71 cases, 59%) and AR (50 cases, 41%) groups. In patients with AR, the absolute diameters of the annulus, LVOT, SOV, STJ, and AAO, as well as the heights of SOV and STJ and the cardiac angle, are larger than those in patients with AS (all P < 0.05). In normalized aortic root dimensions, the AR group had a higher SOV and STJ diameter-to-annulus ratio than the AS group (STJ-SOV-annulus: 1.51-1.44-1.00 vs 1.33-1.28-1.00). The bicuspid and rheumatic AS groups had smaller sinuses (STJ-SOV-annulus:1.27-1.35-1.00, 1.17-1.30-1.00, respectively), necessitating the downsizing of the THV. For 74% of AR patients, the sinotubular junction could not be used as a second anchoring zone, and anchoring relied primarily on the annulus.

Conclusions

Patients with rheumatic etiology require smaller valves, and anchoring in AR patients depends on the valve annulus. These structural characteristics will influence TAVR selection.

Aortic regurgitation: A multimodality approach

Aortic regurgitation (AR) is a common valvular pathology. Multimodality noninvasive cardiovascular imaging is routinely used to assess the mechanism of AR, degree, and its hemodynamic impact on the cardiovascular system. Collecting this information is crucial in establishing the prognosis and in guiding patient management and follow-up. While echocardiography remains the primary test to assess AR, a comprehensive assessment of this valvulopathy can be obtained by combining the information from different techniques. This state-of-the-art review is intended to provide an update ed overview of the applications, strengths, and limits of transthoracic echocardiography, cardiac magnetic resonance, and cardiac computed tomography in patients with AR.

Multidimensional Approach of Heart Failure Diagnosis and Prognostication Utilizing Cardiac Imaging with Biomarkers

Heart failure (HF) is a clinical syndrome caused by various etiologies that results in systolic and diastolic cardiac dysfunction with congestion. While evaluating HF and planning for treatment, physicians utilize various laboratory tests, including electrocardiography, diverse imaging tests, exercise testing, invasive hemodynamic evaluation, or endomyocardial biopsy. Among these, cardiac imaging modalities and biomarkers are the mainstays during HF diagnosis and treatment. Recent developments in non-invasive imaging modalities, such as echocardiography, computed tomography, magnetic resonance imaging, and nuclear imaging, have helped us understand the etiology, pathophysiology, and hemodynamics of HF, and determine treatment options and predict the outcomes. Due to the convenience of their use and potential impact on HF management, biomarkers are increasingly adopted in our clinical practice as well as research purpose. Natriuretic peptide is the most widely used biomarker for the diagnosis of HF, evaluation of treatment response, and prediction of future outcomes. Other cardiac biomarkers to evaluate the pathophysiological mechanisms of HF include myocardial injury, oxidative stress, inflammation, fibrosis, hypertrophy, and neurohormonal activation. Because HF results from complex cardiac disorders, it is essential to assess the disease status multidimensionally. The proper utilization of multimodality imaging and cardiac biomarkers can improve the quality of patient management and predict clinical outcomes in HF in the era of personalized medicine.

Multimodality Evaluation of Aortic Insufficiency and Aortitis in Rheumatologic Diseases

Aortic insufficiency is commonly observed in rheumatologic diseases such as ankylosing spondylitis, systemic lupus erythematosus, antiphospholipid syndrome, Behçet's disease, granulomatosis with polyangiitis, and Takayasu arteritis. Aortic insufficiency with an underlying rheumatologic disease may be caused by a primary valve pathology (leaflet destruction, prolapse or restriction), annular dilatation due to associated aortitis or a combination of both. Early recognition of characteristic valve and aorta morphology on cardiac imaging has both diagnostic and prognostic importance. Currently, echocardiography remains the primary diagnostic tool for aortic insufficiency. Complementary use of computed tomography, cardiac magnetic resonance imaging and positron emission tomography in these systemic conditions may augment the assessment of underlying mechanism, disease severity and identification of relevant non-valvular/extracardiac pathology. We aim to review common rheumatologic diseases associated with aortic insufficiency and describe their imaging findings that have been reported in the literature.

Diagnosis and Management of Aortic Valve Stenosis: The Role of Non-Invasive Imaging

Aortic stenosis is the most common heart valve disease necessitating surgical or percutaneous intervention. Imaging has a central role for the initial diagnostic work-up, the follow-up and the selection of the optimal timing and type of intervention. Referral for aortic valve replacement is currently driven by the severity and by the presence of aortic stenosis-related symptoms or signs of left ventricular systolic dysfunction. This review aims to provide an update of the imaging techniques and seeks to highlight a practical approach to help clinical decision making.