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 CARDIOLOGY GRAND ROUNDS Presentation: Use of CT to support appropriate selection of patients and devices / guide to non‐surgical mitral valve replacement Speaker: Jonathon A. Leipsic, MD, FRCPS, FSCCT
Chairman, Department of Radiology, Providence Health Care, Vancouver, BC Vice Chairman – Research, University of British Columbia, Department of Radiology Associate Professor of Radiology and Cardiology, University of British Columbia Canada Research Chair, Advanced Cardiopulmonary Imaging Date: Monday, October 26, 2015, 7:00 – 8:00 AM
Location: ANW Education Building, Watson Room
OBJECTIVES At the completion of this activity, the participants should be able to: 1. Review the role of MDCT for structural heart disease and transcatheter valvular assessment. 2. Review the current data for the use of MDCT for mitral valvular assessment and annular sizing for TMVI. 3. Discuss the unanswered questions that remain in transcatheter mitral valve implantation and how MDCT may provide some answers. ACCREDITATION Physicians: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Allina Health and Minneapolis Heart Institute Foundation. Allina Health is accredited by the ACCME to provide continuing medical education for physicians. Allina Health designates this live activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Nurses: This activity has been designed to meet the Minnesota Board of Nursing continuing education requirements for 1.2 hours of credit. However, the nurse is responsible for determining whether this activity meets the requirements for acceptable continuing education. Others: Individuals representing other professional disciplines may submit course materials to their respective professional associations for 1.0 hours of continuing education credit. DISCLOSURE STATEMENTS Speaker(s): Dr. Leipsic has declared following relationships. Consultant: Neovasc Inc. and Tendyne Holdings Inc. Planning Committee: Dr. Michael Miedema, and Eva Zewdie have declared that they do not have any conflicts of interest associated with the planning of this activity. Dr. Robert Schwartz declared the following relationships ‐ stockholder: Cardiomind, Interface Biologics, Aritech, DSI/Transoma, InstyMeds, Intervalve, Medtronic, Osprey Medical, Stout Medical, Tricardia LLC, CoAptus Inc, Augustine Biomedical; scientific advisory board: Abbott Laboratories, Boston Scientific, MEDRAD Inc, Thomas, McNerney & Partners, Cardiomind, Interface Biologics; options: BackBeat Medical, BioHeart, CHF Solutions; speakers bureau: Vital Images; consultant: Edwards LifeSciences. PLEASE SAVE A COPY OF THIS FLIER AS YOUR CERTIFICATE OF ATTENDANCE 11/2/2015
MDCT to Guide Mitral Valve Interventions
Jonathon Leipsic MD FRCPC FSCCT
Vice Chairman of Radiology
Associate Professor Radiology and Cardiology UBC
President Society of Cardiovascular CT
Canada Research Chair Advanced Cardiac Imaging
Disclosures
Speaker’s bureau: GE Healthcare and Edwards LifeSciences
Grant Support‐ CIHR, NIH, GE Healthcare, Heartflow
Consultant‐Heartflow, Edwards LifeSciences, Neovasc, Circle CVI
Corelab‐ NIH, Edwards Lifesciences, Neovasc, Tendyne
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Learning Lessons from TAVI The Virtual Basal Ring
Sinotubular junction
Aortic Annular Diameter
Aortic leaflets
Aortic Annulus
RC = Right coronary cusp; NC = Non-coronary cusp;
LC = Left coronary cusp
Source: Leipsic et al JACC Img April 2011
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Live Case Summary‐TCT
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89 year old female
Severe degenerative mitral regurgitation
NYHA III
Coronary artery bypass grafting ‐ 2008
Chronic kidney disease ‐ eGFR 40mL/min
Chronic bronchitis/COPD 6 minute walk test – 340m
STS – 16.1%
Neovasc Tiara Transcatheter Mitral Valve
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Anatomically shaped (D‐shaped)
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Nitinol based, self‐expanding frame
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Bovine pericardium leaflets
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Ventricular anchors to fix the valve onto fibrous trigone and posterior annulus
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Captures the anterior and posterior leaflets
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Annular Segmentation
Angle Prediction and coronary sinus localization 4
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Device Cloning and Neo LVOT
How did we get to this point together?
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1‐ MDCT aids in the diagnosis of valvular disease
CT Limitations Assessing Valves
Temporal Resolution
• Echo > 30 fps (<33 msec)
• 64‐slice CT 165 msec
• Dual‐source CT 83 msec (2nd Gen. 75msec)
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CT Limitations Assessing Valves
• Irregular rhythms (variability, gating)
• Difficult images and artifacts
– Obesity
– Calcium and leads
– Motion artifacts
Strength of CT is Anatomical Detail
Unicuspid Valve
Quadricuspid
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Normal Mitral Valve Anatomy on MDCT
Mitral Valvular Disease
• Patient with rheumatic mitral valve and mild mitral stenosis (valve area 1.6 cm2)
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Mitral valve stenosis‐ Limited Data
Planimetry by CT vs. Echocardiography Messika-Zeitoun et al. JACC 2006
Moderate Mitral Stenosis
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Mitral Regurgitation
MR can be isolated in location (involved
scallops) or timing (part of systole)
Minimum Intensity Projection
Any MR? Moderate MR by TEE
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Mitral regurgitation
Facts
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Most common valvular heart disease
Classification
• due to a primary abnormality of the valve apparatus – Mitral valve prolapse (aka "degenerative" or myxomatous
mitral valve disease)
– Rheumatic heart disease
– Infective endocarditis
•
secondary to another cardiac disease (functional)
– Ischemic cardiomyopathy
– Dilated cardiomyopathies Mitral Valve Prolapse (MVP)
Definition
• abnormal systolic displacement of one or both leaflets into the left atrium (systolic billowing) due to a disruption or elongation of leaflets, chordae, or papillary muscles
• Echocardiography: Billowing of any portion of the mitral leaflets ≥2 mm above the annular plane in a long axis view (parasternal or apical three‐chamber) Classification
• abnormal movement of the valve: • Billowing: when the tips of leaflets remain in the left ventricle
• Flail: when the tip(s) of one (or both) leaflets prolapses into the left atrium 11
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Mitral Valve Prolapse (MVP)
Ethiology of MVP and mechanism of MR
Disease
Mechanism of regurgitation
Primary MVP
Fibroelastic deficiency
Isolated prolapse of the mitral leaflet (commonly P2 scallop)
Frequent chordal rupture
Mild annular enlargement
Forme fruste Barlow disease
Intermediate
Barlow disease
Diffusely thickened, redundant mitral leaflets
Chordal elongation/rupture
Severe annular enlargement
Secondary MVP
Diffusely thickened, redundant mitral leaflets
Associated with connective tissue Chordal elongation/rupture
disease*
Severe annular enlargement
Associated with congenital heart Thickened, redundant mitral leaflets
¶
disease
Chordal elongation/rupture possible
Acute myocardial ischemia
annular
Papillary muscle dysfunction with secondary prolapse/papillary muscle rupture
Acute rheumatic fever
Chordal and leaflet destruction by acute inflammatory process
Endocarditis
Chordal and leaflet destruction by infectious process; vegetations
Other (trauma, severe mitral
calcification, hypertrophic
cardiomyopathy)
Ruptured chordae, no myxomatous changes of mitral valve leaflets
Image: Adams et al. EHJ 2010
Table: Uptodate.com
Mitral valve apparatus
Leaflet anatomy
MPR
minIP
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Mitral valve apparatus
Papillary muscles
Mitral Valve Prolapse
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Mitral Valve Prolapse
Mitral Valve Prolapse (MVP)
Importance of the employed view
MVP should never be diagnosed on 4 chamber reconstruction
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Mitral Valve Prolapse (MVP)
Importance of the employed view
Levine et al. Circulation 1989
https://depts.washington.edu/cvrtc/iafnew.gif
Mitral Valve Prolapse (MVP)
Pseudoprolapse
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Diagnostic Accuracy of MDCT for MVP
Source: Feuchtner et al Radiology 2010
4 ways CT can help with TMVI in 2015
• Anatomic assessment of valvular apparatus
• Help with annular sizing and device selection • Understanding mechanisms and risk of LVOT obstruction
• Prediction of appropriate fluoroscopy angles for coaxial deployment 16
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2‐ MDCT allows for a granular and clear definition of the mitral annulus
MDCT to Guide Transcatheter
Mitral Valve Replacement
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Advantages to MDCT methods Greater reproducibility (less operator dependent)
Less sensitive to minor changes in obliquity
“3‐D”
“2D”
Source: Gurvitch et al JACC Interventions Nov 2011
Mitral Annulus is non‐planar
Saddle shape with a valley and 2 peaks extending to the aortic root
Source: Levine et al Circulation 1989
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Mitral Annular Segmentation with MDCT
The mitral annulus is segmented posteriorly along the insertion of the posterior
mitral valve leaflet and anteriorly along the insertion of the intervalvular fibrosa.
Source: Blanke et al. JACC Imaging 2015
Segmentation of the Saddle and D Shaped Annulus
Source: Blanke and Naoum et al JACC Imaging 2015
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Saddle Shaped Annulus
Mitral annulus
• Posterior peak: Insertion of the posterior mitral
leaflet at atrioventricular
junction
• Anterior/aortic peak:
insertion of intervalvular
fibrosa at the left atrium, in part continuous with the aortic annulus • Nadirs: are located at the level of fibrous trigones. Lee et al. Circulation 2013
Flachskampf et al. Circulation 2000
Mitral Annular Segmentation with MDCT
The mitral annulus is segmented posteriorly along the insertion of the posterior
mitral valve leaflet and anteriorly along the insertion of the intervalvular fibrosa.
Source: Blanke et al. JACC Imaging 2015
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Mitral annulus
CT segmentation ‐ Saddle‐shaped annulus
Saddled Annulus
Projected area
Traditional Method for Mitral Annular Assessment 21
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Mitral Annulus in the context of TMVI
Projected area
Source: Blanke et al JCCT 2014 and iJACC Imaging 2015
Re‐thinking the Mitral Annulus
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“unsaddled” annulus
TT
“unsaddled” annulus
TT
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Conformational similarities with an implanted device in vivo
Source: Cheung et al. JACC 2014
Aortic Annulus is Dynamic Source: Blanke et al JACC Int ; Leipsic et al Circ Imaging Jun 2013
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Dynamic Changes of the Aortic Annulus
CT for Valvular Heart Disease
CT……..
Early
S
End
S
Atrial kick
LV largest
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Mitral Annulus is also Dynamic
Source: Unpublished data
3‐Different devices with different designs have different anatomical requirements
Tiara
Fortis
Tendyne
Source: Cheung et al JACC 2014; Bapat Euroint 2014; Moat et al JACC 2015 26
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Different devices with different designs
Source: In press Blanke et al JACC Imaging
Confirmation of Mitral Valve Prolapse
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Anatomical assessment of device anchoring by MDCT
Device anchoring
Sufficient posterior shelf
in the setting of dilated
LV, persisting in diastole
and systole
Sufficient posterior shelf in the setting of a focal basal scar and dilated LV, persisting in diastole and systole
Landing Zone Characterization
Landing zone differs among mitral pathologies and patients LA
LA
LA
myocardial
shelf
MA disjuction
MAd
LV
A
LV
B
LA
LV
C
LA
LA
MA disjuction
myocardial
shelf
D
LV
E
LV
F
LV
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Landing Zone Characterization
Mitral annular calcium
3‐Co‐planar angle prediction with MDCT
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Fluoroscopy angulation prediction
Line of perpendicularity
Identification
of annulus
plane Adjusting to
LAO 0˚ Adjusting to
CAU 0˚
Adjusting to
LAO 30˚
1 2 3 1 2 3 Blanke, Leipsic Radiology 2013
MDCT vs 3‐D Angio CT for Angle Prediction
Source: Binder et al. TCT 2011 , Circ Interventions April 2012
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Not all preferred projections are feasible
Prediction of fluoroscopy angulation
• Corresponding LAO/RAO and CRA/CAU
Variable projections for different devices
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Coronary sinus segmentation to aid with deployment
Simulation of the coronary sinus wire (yellow line) and mitral annular plane in “compromise views” in two different patients.
Only some angles are feasible in the hybrid OR
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Clinical Implications for TMVI
Source: in press JCCT
4‐ Prediction of LVOT Obstruction
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Predisposing factors for LVOT obstruction Small LVOT‐diameter
Septal bulge
Larger Aorto‐mitral angle
Device protrusion into LV Device flaring Remaining systolic function
Mechanisms of LVOT Obstruction‐ Concept of the Neo‐LVOT
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Concept of the Neo‐LVOT
Mechanisms of LVOT Obstruction
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Implications for Sizing and LVOT Clearance
Source: Blanke et al JACC Imaging
Modeling the risk of LVOT Obstruction‐
Need dynamic data to more deeply understand individual risk
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Determination of LVOT Clearance Important lessons from post implant CT to understand device positioning and capture
Learning from post‐implant geometry
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Modeling the risk of LVOT Obstruction‐
Need dynamic data to more deeply understand individual risk
Mechanism of LVOT Obstruction in native Transcatheter Mitral Valve Implantation
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5‐ Aids in access localization to guide co‐planar device deployment
Source: Blanke et al JACC Imaging 2015
Historical approach for TA procedures may not be adequate in TMVI
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Echo views: Purple line rotational axis through apex, blue line ideal access trajectory
3CH‐View
Dependent x‐plane
90degrees
Plane through ideal access point
14mm Antero‐lateral
Blue line indicates view above
Varied offset of Optimal access point and traditional apex
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Whole thorax allows localization of the appropriate rib space for puncture
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Expanding to the Tricuspid Space
Clinical Experience to date
• 13 patients (Canada and Switzerland)
• Prohibitive risk for cardiac surgery per heart team (compassionate use)
• Left sided disease with secondary RV dilation
• Severe functional TR
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Edwards FORMA Repair System
FORMA System consists of:
1. Spacer
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Positioned into the regurgitant orifice
Creates a platform for native leaflet coaptation
2. Rail
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Tracks Spacer into position
Distally and proximally anchored
Echo Confirmation of Severe TR
• Dilated annulus (>>40 mm)
• Dilated right atrium
• Leaflet mal‐coaptation
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Echo Confirmation of Severe TR
Echo Confirmation of Severe TR
Vena contracta
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Pre‐procedural Evaluation I
• Short axis view
• Large central
gap
Pre‐procedural Evaluation I
• Annular area = 20 cm2
• 15 mm Spacer area = 1.76 cm2
• Very low risk of Stenosis
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Co‐planar angle prediction with MDCT
RAO42 CAU2 Localization of the cardiac apex
APEX projects anterior
to Trans‐section point with myocardium
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Orthogonal view LA048 CAU2
APEX
4 chamber view 47
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Surgical Cut‐Down
Subclavian Vein
24 F Sheath in Left Subclavian Vein
Anchoring of the Delivery Rail
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Anchoring of the Delivery Rail
Spacer Positioning in the Tricuspid Valve Initial position
Final position
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Intra‐procedural reduction of TR severity
Before spacer
After spacer
Proximal locking and Closure
Proximal part of the delivery rail is coiled and secured in a subcutaneous pocket
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Final location of FORMA spacer
in the Tricuspid Valve
Anchor
Spacer
Systole
Valve leaflet
Rail
Diastole
Using CT to understand device positioning
A
B
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Conclusions
• Rapid evolution of transcatheter solutions for functional mitral regurgitation
• Role of MDCT is evolving particularly with regards to Transcatheter Mitral Valve Replacement
• Outcomes data is needed to better optimize the integration of MDCT to guide minimally invasive mitral valve interventions
• Continued learning to integrate MDCT into right sided valvular disease
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