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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 1 11/2/2015 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 2 11/2/2015 Live Case Summary‐TCT • • • • • • • • 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 • Anatomically shaped (D‐shaped) • Nitinol based, self‐expanding frame • Bovine pericardium leaflets • Ventricular anchors to fix the valve onto fibrous trigone and posterior annulus • Captures the anterior and posterior leaflets 3 11/2/2015 Annular Segmentation Angle Prediction and coronary sinus localization 4 11/2/2015 Device Cloning and Neo LVOT How did we get to this point together? 5 11/2/2015 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) 6 11/2/2015 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 7 11/2/2015 Normal Mitral Valve Anatomy on MDCT Mitral Valvular Disease • Patient with rheumatic mitral valve and mild mitral stenosis (valve area 1.6 cm2) 8 11/2/2015 Mitral valve stenosis‐ Limited Data Planimetry by CT vs. Echocardiography Messika-Zeitoun et al. JACC 2006 Moderate Mitral Stenosis 9 11/2/2015 Mitral Regurgitation MR can be isolated in location (involved scallops) or timing (part of systole) Minimum Intensity Projection Any MR? Moderate MR by TEE 10 11/2/2015 Mitral regurgitation Facts • 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 11/2/2015 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 12 11/2/2015 Mitral valve apparatus Papillary muscles Mitral Valve Prolapse 13 11/2/2015 Mitral Valve Prolapse Mitral Valve Prolapse (MVP) Importance of the employed view MVP should never be diagnosed on 4 chamber reconstruction 14 11/2/2015 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 15 11/2/2015 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 11/2/2015 2‐ MDCT allows for a granular and clear definition of the mitral annulus MDCT to Guide Transcatheter Mitral Valve Replacement 17 11/2/2015 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 18 11/2/2015 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 19 11/2/2015 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 20 11/2/2015 Mitral annulus CT segmentation ‐ Saddle‐shaped annulus Saddled Annulus Projected area Traditional Method for Mitral Annular Assessment 21 11/2/2015 Mitral Annulus in the context of TMVI Projected area Source: Blanke et al JCCT 2014 and iJACC Imaging 2015 Re‐thinking the Mitral Annulus 22 11/2/2015 “unsaddled” annulus TT “unsaddled” annulus TT 23 11/2/2015 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 24 11/2/2015 Dynamic Changes of the Aortic Annulus CT for Valvular Heart Disease CT…….. Early S End S Atrial kick LV largest 25 11/2/2015 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 11/2/2015 Different devices with different designs Source: In press Blanke et al JACC Imaging Confirmation of Mitral Valve Prolapse 27 11/2/2015 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 28 11/2/2015 Landing Zone Characterization Mitral annular calcium 3‐Co‐planar angle prediction with MDCT 29 11/2/2015 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 30 11/2/2015 Not all preferred projections are feasible Prediction of fluoroscopy angulation • Corresponding LAO/RAO and CRA/CAU Variable projections for different devices 31 11/2/2015 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 32 11/2/2015 Clinical Implications for TMVI Source: in press JCCT 4‐ Prediction of LVOT Obstruction 33 11/2/2015 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 34 11/2/2015 Concept of the Neo‐LVOT Mechanisms of LVOT Obstruction 35 11/2/2015 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 36 11/2/2015 Determination of LVOT Clearance Important lessons from post implant CT to understand device positioning and capture Learning from post‐implant geometry 37 11/2/2015 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 38 11/2/2015 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 39 11/2/2015 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 40 11/2/2015 Whole thorax allows localization of the appropriate rib space for puncture 41 11/2/2015 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 42 11/2/2015 Edwards FORMA Repair System FORMA System consists of: 1. Spacer – – Positioned into the regurgitant orifice Creates a platform for native leaflet coaptation 2. Rail – – Tracks Spacer into position Distally and proximally anchored Echo Confirmation of Severe TR • Dilated annulus (>>40 mm) • Dilated right atrium • Leaflet mal‐coaptation 43 11/2/2015 Echo Confirmation of Severe TR Echo Confirmation of Severe TR Vena contracta 44 11/2/2015 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 45 11/2/2015 Co‐planar angle prediction with MDCT RAO42 CAU2 Localization of the cardiac apex APEX projects anterior to Trans‐section point with myocardium 46 11/2/2015 Orthogonal view LA048 CAU2 APEX 4 chamber view 47 11/2/2015 Surgical Cut‐Down Subclavian Vein 24 F Sheath in Left Subclavian Vein Anchoring of the Delivery Rail 48 11/2/2015 Anchoring of the Delivery Rail Spacer Positioning in the Tricuspid Valve Initial position Final position 49 11/2/2015 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 50 11/2/2015 Final location of FORMA spacer in the Tricuspid Valve Anchor Spacer Systole Valve leaflet Rail Diastole Using CT to understand device positioning A B 51 11/2/2015 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 52