Guglielmo, Marco

Pavon, Anna Giulia

Utrecht University Repository

Received: 28 February 2024 Accepted: 1March 2024DOI: 10.1111/echo.15800COMMEN TAR YNeo-LVOTmeasurement in TMVR: time forMultimodality?Marco GuglielmoMD1,2 Anna Giulia PavonMD31Department of Cardiology, Division of Heart and Lungs, Utrecht University, Utrecht UniversityMedical Center, Utrecht, The Netherlands2Department of Cardiology, Haga Teaching Hospital, The Hague, Netherlands3Department of Cardiology, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, SwitzerlandCorrespondenceMarco Guglielmo, FEACVI, FSCCT, Department of Cardiology, Division of Heart and Lungs, Utrecht University, Utrecht UniversityMedical Center, 3584 Utrecht, TheNetherlands.Email: m.guglielmo@umcutrecht.nlKEYWORDScardiac CT, CT, neo-LVOT, TEE, TMVR, transcatheter mitral valve trplacement, transesophageal echocardiography.This issue of Echocardiography: a Journal of Multicardiac ImagingModality presents the interesting findings of Soha Hekal & Amr Y.Emam al.1In recent years, transcathetermitral valve replacement (TMVR) pro-cedures have emerged as an alternative solution for patients who havea prohibitive surgical risk for mitral valve surgery.A peculiar risk of TMVR procedures is the left ventricular outflowtract (LVOT) obstruction. The prosthesis, implanted in the mitral posi-tion, protrudes into the LVOT, narrowing it and creating a new spacesmaller than the original LVOT, called the neo-LVOT.2 To date, com-puted tomography (CT) assessment is the gold standard for measuringthe neo-LVOT area.With the aimof standardizing the phase of the cardiac cycle showingthe narrowest neo-LVOT at cardiac CT, SohaHekal &AmrY. Emamalsocompared a CTwith 3DTEEmeasurements of the neo-LVOT.In thismonocentric, retrospective study, first, a group of 20 patientsunderwent CT to identify the phase displaying the narrowest neo-LVOT area following a simulated TMVR. Following this, a cohort of49 patients was examined using the end-systolic phase, which wasfound to be the one with the narrowest neo-LVOT. A commerciallyavailable CT-based software and a newly developed three-dimensionaltransesophageal echocardiography (3DTEE)-based software (3men-sio Structural Heart, Pie Medical Imaging, The Netherlands) wereemployed for analysis. The parameters obtained from 3DTEE werethen compared with those derived from CT-based measurements.Remarkably, there was a strong correlation between measurementsobtained via 3DTEE and CT for various parameters, including mitralThis is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in anymedium, provided the original work is properly cited and is not used for commercial purposes.© 2024 The Authors. Echocardiography published byWiley Periodicals LLC.annulus dimensions and neo-LVOT area (all p < .0001). Virtualvalve sizing based on annulus measurement exhibited consistencybetweenCT and 3DTEE. Furthermore, both interobserver and intraob-server agreements were excellent, with ICCs exceeding .80 for allmeasurements.The authors suggest two possible clinical implications of theseresults:3DTEE could serve as a valid alternative for patients with con-traindications toCT, for example, compromised renal function.3DTEE could act as a gatekeeper for a CT scan if the patient isfound suitable based on the analysis.The authors should be commended for their work. Firstly, itmarks the first comparison between a specialized 3DTEE softwarefor TMVR planning and CT measurements. Unlike previous studies inliterature,3,4 this new software enables the simulation of valve implan-tationat themitral annulus andmeasures the remainingneo-LVOTareaafterwards. Secondly, the study provides remarkable insights into thebest phaseof the cardiac cycle displaying thenarrowest neo-LVOTareafollowing TMVR. Indeed, the dimensions of the LVOT change duringthe cardiac cycle, being smaller during diastole and bigger during sys-tole. However, no consensus exists on the best phase to measure theneo-LVOT. The result of the study suggests that the end-systolic phaseshould be used corresponding to the narrowest one.Nevertheless, we have to acknowledge two crucial limitations ofthe study. First, it is a retrospective study that included patients whoEchocardiography. 2024;41:e15800. wileyonlinelibrary.com/journal/echo 1 of 2https://doi.org/10.1111/echo.158002 of 2 GUGLIELMO and PAVONwerenot candidates for TMVRbut underwentCTandTEE for differentclinical indications.Second, since patients with prior cardiac surgery were included, weare unsure whether this 3DTEE software would perform well enoughfor planning TMVR in patients after a mitral valve repair or a mitralvalve replacement with a biological prosthesis.TMVR has emerged as an alternative solution for patients withmitral stenosis, mitral regurgitation, and a combination of the two con-ditions that have a prohibitive surgical risk for mitral valve surgery.TMVRcanbeperformedusing a transapical or percutaneous approach,with the latter via the venous system and necessitating an interatrialseptal puncture.Different TMVR treatments are possible for patients with nativevalvulopathies or after mitral valve surgery, including valve-in-MAC(ViMAC), valve-in-valve (ViV) procedures, and valve-in-ring (ViR).While TMVR has been primarily performed using transcatheter aor-tic valves,5 various prostheses with different characteristics andanchoring systems have been proposed.6 Significant discrepanciesexist among ViV, ViMAC, and ViR concerning procedural efficacy andoutcomes.7 TMVR inViV for degenerated bioprostheses demonstratesa remarkable feasibility rate of 94.4%, accompanied by 30-day and1-year all-cause mortality rates of 6.2% and 14%, respectively.7 Incontrast, ViMAC exhibits a procedural success rate of only 62.8%,with corresponding 30-day and 1-year all-cause mortality rates of34.5% and 62.8%.7 ViR has intermediate feasibility andmortality ratesbetween ViMAC and ViV extremes.7Indeed, with the exception of ViV interventions, TMVR remains ahigh-risk procedure, and multimodality imaging is paramount to detailthe anatomy of the patient before the procedure.Thanks to its high spatial resolution, CT assessment is consideredthe gold standard for neo-LVOTmeasurement. This assessment is doneusing dedicated software, which allows the insertion of a virtual valveinside themitral valve annulus or the degenerated bioprosthesis.New software based on 3DTEE datasets is the focus of the analysisof the study of SohaHekal &Amr Y. Emamet al.1 and holds promises toprovide a further method for neo-LVOTmeasurements.A comprehensive non-invasive imaging study of the patient’sanatomy with echocardiography and CT is paramount before TMVRto reduce the risk of complications. Echocardiography remains thefirst-line test for the evaluation of the mechanism and severity ofmitral valve dysfunction. Moreover, it is valuable for assessing differ-ent parameters that represent a risk of LVOT obstruction after TMVR,including left ventricle dimension, interventricular septum thickening,andanglebetween the septumand themitral annulus. Beyond themea-surement of the area of the neo-LVOT, CT can help identify the bestangulation for fluoroscopy during the procedure, rule out coronaryartery disease, and assess the patency of the venous system in a one-stop-shop approach.6 In the transapical approach, preprocedural CT isalso used to identify the best access route to the LV apex to ensure acoaxial deployment of the prosthesis.8New prospective studies, including patients with and without ahistory of previous surgery on themitral valve, arewarranted to under-stand if 3D TEE could represent a valid alternative, a gatekeeper, or avaluable companion to CT for measuring the neo-LVOT.CONFLICT OF INTEREST STATEMENTThe authors declare no conflicts of interest.ORCIDMarcoGuglielmoMD https://orcid.org/0000-0003-1718-9949AnnaGiulia PavonMD https://orcid.org/0000-0002-8001-1476REFERENCES1. Hekal S, Emam AY, Thabet N, et al. Standardization and validationof neo-LVOT assessment using three-dimensional trans-esophagealechocardiography before trans-catheter mitral valve replacement.Echocardiography.2. Reid A, Ben Zekry S, TuragaM, et al. Neo-LVOT and transcathetermitralvalve replacement: expert recommendations. JACC Cardiovasc Imaging.2021;14(4):854-866.3. Coisne A, Pontana F, Aghezzaf S, et al. Utility of three-dimensionaltransesophageal echocardiography for mitral annular sizing intranscatheter mitral valve replacement procedures: a cardiaccomputed tomographic comparative study. J Am Soc Echocardiogr.2020;33(10):1245-1252. e1242.4. Mak GJ, Blanke P, Ong K, et al. Three-dimensional echocardiographycompared with computed tomography to determinemitral annulus sizebefore transcatheter mitral valve implantation. Circ Cardiovasc Imaging.2016;9(6):e004176. doi:10.1161/CIRCIMAGING.115.0041765. UrenaM,VahanianA, Brochet E, DucrocqG, IungB,HimbertD. Currentindications for transcatheter mitral valve replacement using tran-scatheter aortic valves: valve-in-valve, valve-in-ring, and valve-in-mitralannulus calcification. Circulation. 2021;143(2):178-196.6. Hensey M, Brown RA, Lal S, et al. Transcatheter mitral valve replace-ment: an update on current techniques, technologies, and futuredirections. JACC Cardiovasc Interv. 2021;14(5):489-500.7. Yoon SH, Whisenant BK, Bleiziffer S, et al. Transcatheter mitral valvereplacement for degenerated bioprosthetic valves and failed annulo-plasty rings. J Am Coll Cardiol. 2017;70(9):1121-1131.8. Ranganath P, Moore A, GuerreroM, et al. CT for pre- and postprocedu-ral evaluation of transcatheter mitral valve replacement. Radiographics.2020;40(6):1528-1553.How to cite this article: GuglielmoM, Pavon AG. Neo-LVOTmeasurement in TMVR: time forMultimodality?.Echocardiography. 2024;41:e15800.https://doi.org/10.1111/echo.15800 15408175, 2024, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/echo.15800 by Cochrane Netherlands, Wiley Online Library on [19/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Neo-LVOT measurement in TMVR: time for Multimodality?

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Neo-LVOT measurement in TMVR: time for Multimodality?

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