Evaluation of Patients for Percutaneous Edge-to-edge Mitral Valve Repair: Comparison of Cardiac Computed Tomography Angiography With Transesophageal Echocardiography

PURPOSE

We sought to compare parameters derived from cardiac computed tomography angiography (CCTA) with those from transesophageal echocardiography (TEE) for the evaluation of patients with severe mitral regurgitation (MR) before percutaneous edge-to-edge mitral valve repair (PE2E). TEE is the mainstay for PE2E, although it has specific limitations. CCTA enables measurements in any arbitrary plane with high spatial resolution and offers good calcium visibility.

MATERIALS AND METHODS

Patients who underwent TEE and CCTA before scheduled PE2E at 2 medical centers were included in this retrospective analysis. Quantitative parameters relevant for PE2E were obtained from TEE and CCTA in a blinded manner and the intrareviewer variability was assessed.

RESULTS

All 30 patients (15 female, 76±10 y) had secondary MR attributable to ischemic (60%) or nonischemic cardiomyopathy (40%). On comparing parameters from TEE and CCTA, left ventricular end-diastolic diameter was 60±11 versus 64±11 mm (r=0.90), intercommissural mitral annulus was 35±5 versus 35±5 mm (r=0.88), long-axis annulus was 33±5 versus 33±5 mm (r=0.74), the distance between the fossa ovalis and the leaflet coaptation was 42±5 versus 41±5 mm (r=0.81), the anterior mitral leaflet was 21±6 versus 20±7 mm (r=0.81), the posterior mitral leaflet was 13±2 versus 13±2 mm (r=0.91), and the median mitral calcification was 1 (interquartile range: 0 to 2) versus 0 (interquartile range: 0 to 1; r=0.53), respectively. Intrareviewer agreement was good and excellent for continuous and categorical variables, respectively.

CONCLUSIONS

Our data suggest that evaluation of the mitral valve apparatus with CCTA in patients considered for PE2E is feasible, correlates well with TEE, and offers improved calcium visibility. In selected cases, additional information from CCTA may be helpful for achieving optimal interventional results.

Cardiac Computed Tomography: Application in Valvular Heart Disease

The incidence and prevalence of valvular heart disease (VHD) is increasing and has been described as the next cardiac epidemic. Advances in imaging and therapeutics have revolutionized how we assess and treat patients with VHD. Although echocardiography continues to be the first-line imaging modality to assess the severity and the effects of VHD, advances in cardiac computed tomography (CT) now provide novel insights into VHD. Transcatheter valvular interventions rely heavily on CT guidance for procedural planning, predicting and detecting complications, and monitoring prosthesis. This review focuses on the current role and future prospects of CT in the assessment of aortic and mitral valves for transcatheter interventions, prosthetic valve complications such as thrombosis and endocarditis, and assessment of the myocardium.

Multimodality imaging for the quantitative assessment of mitral regurgitation

The natural history of mitral regurgitation (MR) results in significant morbidity and mortality. Innovations in non-invasive imaging have provided new insights into the pathophysiology and quantification of MR, in addition to early detection of left ventricular (LV) dysfunction and prognostic assessment in asymptomatic patients. Transthoracic (TTE) and transesophageal (TOE) echocardiography are the mainstay for diagnosis, assessment and serial surveillance. However, the advance from 2D to 3D imaging leads to improved assessment and characterization of mitral valve (MV) disease. Cardiovascular magnetic resonance (CMR) is increasingly used for MR quantitation and can provide an alternative imaging method if echocardiography is suboptimal or inconclusive. Other techniques such as exercise echocardiography, tissue Doppler imaging and speckle-tracking echocardiography can further offer complementary information on prognosis. This review summarises the current evidence for state-of-the-art cardiovascular imaging for the investigation of MR. Whilst advanced echocardiographic techniques are superior in the evaluation of complex MV anatomy, CMR appears the most accurate technique for the quantification of MR severity. Integration of multimodality imaging for the assessment of MR utilises the advantages of each imaging technique and offers the most comprehensive assessment of MR.

Role of MDCT Imaging in Planning Mitral Valve Intervention

PURPOSE OF REVIEW

Recent advancements in transcatheter valvular interventions have resulted in a growing demand for advanced cardiac imaging to help guide these procedures.

RECENT FINDINGS

Both echocardiography and multi-detector computed tomography have played essential roles in the maturation of transcatheter aortic valve replacement and are now building on these experiences and helping inform the nascent field of transcatheter mitral interventions. Advanced imaging is essential to aid in the diagnosis and determination of the mechanism of mitral regurgitation. In addition, they are integral to annular sizing, determination of the suitability of patient anatomy for specific devices and increasingly important in the determination of the risk of left ventricular outflow tract obstruction and providing appropriate patient-specific fluoroscopic angulation in advance of the procedure.

A Review of the Use of Cardiac Computed Tomography for Evaluating the Mitral Valve before and after Mitral Valve Repair

The role of cardiac computed tomography (CT) for evaluating the mitral valve (MV) has been limited since echocardiography is the main method of evaluation. However, recent advances in cardiac CT have enable detailed evaluation of the anatomy and geometry of the MV. We describe assessments of the anatomy and coaptation geometric parameters of normal MVs, and also review repair of diseased/damaged MV. We also discuss pre- and post-surgical imaging of MV pathology using cardiac CT and various CT images. We found that cardiac CT could be used as an alternative imaging modality to echocardiography for pre-operative MV evaluation and to predict clinical outcomes following repair.

Multimodality imaging assessment of mitral valve anatomy in planning for mitral valve repair in secondary mitral regurgitation

Secondary mitral regurgitation (MR) is frequent valvular heart disease and conveys worse prognostic. Therapeutic surgical or percutaneous options are available in the context of severe symptomatic secondary MR, but the best approach to treat these patients remains unclear, given the lack of clear clinical evidence of benefit. A comprehensive evaluation of the mitral valve apparatus and the left ventricle (LV) has the ability to clearly define and characterize the disease, and thus determine the best option for the patient to improve its clinical outcomes, as well as quality of life and symptoms. The current report reviews the mitral valve (MV) anatomy, the underlying mechanisms associated with secondary MR, the related therapeutic options available, and finally the usefulness of a multimodality imaging approach for the planning of surgical or percutaneous mitral valve intervention.

Current challenges in interventional mitral valve treatment

Transcatheter mitral valve therapies have emerged as an alternative option in high surgical risk or inoperable patients with severe and symptomatic mitral regurgitation (MR). As multiple technologies and different approaches will become available in the field of mitral valve interventions, different challenges are emerging, both patient- (clinical challenges) and procedure-related (technical challenges). This review will briefly explore the current open challenges in the evolving fields of interventional mitral valve treatment.

Assessment of mitral valve adaptation with gated cardiac computed tomography: validation with three-dimensional echocardiography and mechanistic insight to functional mitral regurgitation

BACKGROUND

Mitral valve (MV) enlargement is a compensatory mechanism capable of preventing functional mitral regurgitation (FMR) in dilated ventricles. Total leaflet area and its relation with closure area measured by 3-dimensional (3D) echocardiography have been related to FMR. Whether these parameters can be assessed with other imaging modalities is not known. Our objectives are to compare cardiac computed tomography (CT)-based measurements of MV leaflets with 3D echocardiography and determine the relationship of these metrics to the presence of FMR.

METHODS AND RESULTS

We used 2 cohorts of patients who had cardiac CT to measure MV total leaflet, closure, and annulus areas. In cohort 1 (26 patients), we validated these CT metrics to 3D echocardiography. In cohort 2 (66 patients), we assessed the relation of MV size with the presence of FMR in 3 populations: heart failure with FMR, heart failure without FMR, and normal controls. Cardiac CT and 3D echocardiography produced similar results for total leaflet (R(2)=0.97), closure (R(2)=0.89), and annulus areas (R(2)=0.84). MV size was the largest in heart failure without FMR compared with controls and patients with FMR (9.1 ± 1.7 versus 7.5 ± 1.0 versus 8.1 ± 0.9 cm(2)/m(2); P<0.01). Patients with FMR had reduced ratios of total leaflet to closure areas and total leaflet to annulus areas when compared with patients without FMR (P<0.01).

CONCLUSIONS

MV size measured by CT is comparable with 3D echocardiography. MV enlargement in cardiomyopathy suggests leaflet adaptation. Patients with FMR have inadequate adaptation as reflected by decreased ratios of leaflet area and areas determined by ventricle size (annulus and closure areas). These measurements provide additional insight into the mechanism of FMR.

Evaluation of the aortic and mitral valves with cardiac computed tomography and cardiac magnetic resonance imaging

Cardiac computed tomography (CT) produces high-quality anatomical images of the cardiac valves and associated structures. Cardiac magnetic resonance imaging (MRI) provides images of valve morphology, and allows quantitative evaluation of valvular dysfunction and determination of the impact of valvular lesions on cardiovascular structures. Recent studies have demonstrated that cardiac CT and MRI are important adjuncts to echocardiography for the evaluation of aortic and mitral valvular heart diseases (VHDs). Radiologists should be aware of the technical aspects of cardiac CT and MRI that allow comprehensive assessment of aortic and mitral VHDs, as well as the typical imaging features of common and important aortic and mitral VHDs on cardiac CT and MRI.

Cardiac imaging in valvular heart disease

The aim of this article is to provide a perspective on the relative importance and contribution of different imaging modalities in patients with valvular heart disease. Valvular heart disease is increasing in prevalence across Europe, at a time when the clinical ability of physicians to diagnose and assess severity is declining. Increasing reliance is placed on echocardiography, which is the mainstay of cardiac imaging in valvular heart disease. This article outlines the techniques used in this context and their limitations, identifying areas in which dynamic imaging with cardiovascular magnetic resonance and multislice CT are expanding.

CT and MR imaging of the mitral valve: radiologic-pathologic correlation

Computed tomography (CT) and magnetic resonance (MR) imaging are increasingly important adjuncts to echocardiography for the evaluation of mitral valve disease. The mitral valve may be involved in various acquired or congenital conditions with resultant regurgitation or stenosis, and many of these conditions can be identified with CT or MR imaging. In addition, CT is useful for detecting and monitoring postoperative complications after mitral valve repair or replacement. As the use of CT and MR imaging increases, awareness of the CT and MR imaging appearances of the normal mitral valve and the various disease processes that affect it may foster recognition of unsuspected mitral disease in patients undergoing imaging for other purposes. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.306105518/-/DC1.