Advanced Protocol for Three-Dimensional Transesophageal Echocardiography Guidance Implementing Real-Time Multiplanar Reconstruction for Transcatheter Mitral Valve Repair by Direct Annuloplasty

doi:10.1016/j.echo.2019.05.015

Journal of the American Society of Echocardiography

Volume 32, Issue 10, October 2019, Pages 1359-1365

https://doi.org/10.1016/j.echo.2019.05.015 Get rights and content

Highlights

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Multiplanar reconstruction (MPR) enables anatomically correct orientation in 3D-TEE.
•
TMVR by direct annuloplasty poses challenges for TEE guidance.
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Echo guidance using real-time MPR for TMVR is feasible and might increase safety.
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Our “how-to” article presents a detailed MPR-augmented protocol for echo guidance.

Transcatheter direct annuloplasty has been introduced as a novel interventional treatment option for severe mitral valve regurgitation. Until now, only one direct annuloplasty device (Edwards Cardioband) has been commercially available, being implanted in more than 250 patients worldwide. Yet this procedure poses greater challenges regarding optimal fluoroscopic and echocardiographic guidance compared with edge-to-edge repair: correct localization and orientation of the anchors upon penetration into the fibrous mitral annulus tissue and the basal left ventricular myocardium are preconditions for an optimal result and essential to avoid damage of the neighboring structures (atrioventricular node, circumflex artery, coronary sinus). Real-time single-beat multiplanar reconstruction has become available as an additional imaging tool for three-dimensional transesophageal echocardiography in most recent echo machines. In this review, we introduce a three-dimensional transesophageal echocardiography–based imaging protocol implementing real-time multiplanar reconstruction for transcatheter direct annuloplasty procedures, which optimizes and also simplifies echocardiographic guidance during the implantation. The advanced echocardiographic protocol might also help to expedite implantation times and potentially increase the safety of the procedure. In this “how-to” article, we describe in detail this novel approach for optimized guidance and compare its advantages and challenges to “conventional” echocardiographic imaging for transcatheter mitral valve repair.

Section snippets

Direct Transcatheter Annuloplasty

For this kind of TMVR, a flexible Dacron band, which has a series of anchoring clips along its length, is implanted by a steerable catheter system on the posterior annulus starting from the anterolateral left trigone to the posteromedial mitral valve right trigone. Depending on its size, up to 17 anchors are deployed, and the band is dynamically reduced (also referred to as “cinched”) to reduce mitral annular diameters (Figures 1 and 2). After initial experience by surgical implantation of a

Optimized Echocardiographic Protocol for TMVR by Direct Annulopasty

We elaborated an advanced echocardiographic protocol implementing single-beat MPR imaging in transcatheter direct annuloplasty (Figure 3, Figure 4, Figure 5), which incorporates several steps, beginning from the transseptal puncture and ending with evaluating the effects of dynamic reduction of the implanted device.

Summary

The 3D TEE guidance protocol implementing real-time and single-beat MPR presented in this review describes a novel imaging modality that might be beneficial compared with other, more “conventional” modes of 2D and 3D TEE visualization for some advanced forms of TMVR.

The crucial steps for guidance during interventional direct mitral valve annuloplasty include (1) 2D and 3D visualization of atrial structures for determination of the optimal transseptal puncture site, (2) real-time 3D device

Acknowledgments

Thomas Münzel is Principal Investigator of the German Center for Cardiovascular Research, Partner Site Rhine-Main, Mainz, Germany. We thank Margot Neuser for support in realization of the graphic illustration of the echo protocol (Figure 4).

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Cited by (11)

Transcatheter Mitral Valve Interventions for Mitral Regurgitation: A Review of Mitral Annuloplasty, Valve Replacement, and Chordal Repair Devices
2022, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
En echocardiography then is used to guide the implantation catheter into the LA. Multiplanar reconstruction views can be used then to provide real-time 2-dimensional (2D) and 3-dimensional (3D) images to determine the appropriate positioning and anchoring sites from the lateral commissure posteriorly to the medial commissure.14 Prior to releasing each anchor, TEE is used to confirm adequate tissue anchoring during a pull test.
Significant mitral regurgitation (MR) is the most common valvular disease in the United States in patients older than 75. However, many patients with severe MR are at a high risk for surgical repair due to other significant comorbidities. Over the past decade, many transcatheter mitral valve devices have been studied that address the different mechanisms of MR, but only a few have received a Conformité Européene (CE) mark or United States Food and Drug Administration (FDA) approval. The Carillon, Cardioband, and Mitralign all received CE marking for percutaneous mitral annuloplasty, while the Tendyne and SAPIEN 3 received a CE mark and FDA approval, respectively, for transcatheter mitral valve replacement. Finally, the NeoChord DS 1000 received a CE mark for transcatheter chordal repair. Each of these devices is reviewed in detail, including device indications, performance in clinical trials, anesthetic management, intraprocedural imaging guidance, and postprocedural complications. Although percutaneous devices will appear and disappear from use, understanding the procedural considerations remains highly relevant, as these key principles will apply to the next generation of transcatheter valve interventions.
Anatomical and Technical Predictors of Three-Dimensional Mitral Valve Area Reduction After Transcatheter Edge-To-Edge Repair
2022, Journal of the American Society of Echocardiography
Citation Excerpt :
According to our data, a cutoff >3.6 mm Hg best predicts an MVA < 1.5 cm2 after one implant, which demonstrates that these thresholds are imprecise and arbitrary. For all these reasons, intraprocedural decisions should rather rely on direct 3D planimetry that can be performed within a few minutes by appropriately trained interventional echocardiographers; as for other complex interventional MR treatments,17 a dedicated echocardiography team and an advanced guidance protocol are needed to achieve optimal results. Furthermore, preprocedural planning should be based on anatomical and technical predictors.
Among current transcatheter therapies for the treatment of mitral regurgitation, the MitraClip (MC; Abbott Vascular, Abbott Park, IL) system is the most commonly used. MitraClip implantation is usually contraindicated in patients with a mitral valve area (MVA) < 4.0 cm². However, little is known about the real impact of MC implantation on MVA. Our goal was to investigate the factors influencing MVA reduction and derive the minimal MVA required to prevent the development of a clinically significant mitral stenosis (MVA < 1.5 cm²) in different clinical scenarios.
Using three-dimensional data sets, the annulus and leaflet anatomy and MVA before clip implantation (MVA_BC) were assessed. After each MC implant (NTR or XTR), the relative MVA reduction and the absolute residual MVA were measured and their predictors evaluated.
The present analysis included 116 patients. An MC XTR was the first device implanted in 50% of the subjects, and 53% were treated with a single implant. The MVA reduction following one XTR was 57% ± 7% versus 52% ± 8% after one NTR (P = .001). A lower MVA reduction was observed when the MC was placed commissural/central versus paracentral (50% ± 8% vs 57% ± 7%, P < .0001). After a second device, the additional MVA reduction was higher when creating a triple-compared with a double-orifice morphology (34% ± 11% vs 25% ± 9%, P = .001). The MVA after one MC correlated with MVA_BC as well as with the clip type and position (r = 0.91, P < .0001). The MVA_BC, orifice morphology, and first device position predicted MVA after two implants (r = 0.82, P < .0001). Based on the mathematical relationship between these parameters, the minimal MVA_BC needed in eight different clinical scenarios was summarized in a decision algorithm: the values ranged from 3.5 to 4.7 cm² for one and 4.5 to 6.3 cm² for two MC strategies.
The minimal native MVA preventing clinically relevant MS after transcatheter edge-to-edge repair is predicted by the number and location of clip(s), orifice morphology, and device type. Based on these parameters, an algorithm has been derived to optimize patient selection and preprocedural planning.
The Revolution in Heart Valve Therapy: Focus on Novel Imaging Techniques in Intra-Procedural Guidance
2021, Structural Heart
Transcatheter valvular interventions have undergone significant progress over the last years with novel treatment options in even complex valvular conditions. In conjunction with this development, innovative technologies have emerged to facilitate a comprehensive and precise imaging for optimal procedural guidance. These imaging novelties include fusion imaging, three-dimensional (3D) intracardiac echocardiography, and advanced and refined 3D echocardiography rendering tools. The present review provides an overview of these novel imaging tools in transcatheter valvular interventions with a focus on intraprocedural imaging.
3D: Three-dimensional; ICE: Intracardiac echocardiography; TEE: Transesophageal echocardiography; CT: Computed tomography; CMR: Cardiac magnetic resonance tomography; TAVR: Transcatheter aortic valve replacement; MPR: Multiplanar reconstruction; TMVR: Transcatheter mitral valve replacement; PVL: Paravalvular leak
Imaging for Native Mitral Valve Surgical and Transcatheter Interventions
2021, JACC: Cardiovascular Imaging
Citation Excerpt :
The implantation of the Cardioband (Edwards Lifesciences) is a step-by-step procedure. Each step is repeated for the number of total anchors to be implanted and consists of the following phases: 1) trans-septal puncture; 2) positioning the delivery system at the optimal location for anchors moves to a possible implant position; 3) deployment of anchors when the position and the angulation of the delivery system is optimal; and 4) pull test to assess the resistance of the anchors, and release of the anchor if the pull test is successful (62). These steps are repeated for deployment of each anchor, and 2D or 3D TEE and fluoroscopy guides each of these steps (Table 6, Video 11).
There has been rapid progress in transcatheter therapies for mitral regurgitation. These developments have elevated the need for the imager to have a core understanding of the functional mitral valve anatomy. Pre- and intraoperative echocardiography for surgical mitral valve repair for mitral regurgitation has defined contemporary interventional imaging in many ways. The central tenets of these principles apply to interventional imaging of transcatheter mitral valve interventions. However, the heightened emphasis on procedural planning and procedural imaging is one of the new challenges posed by transcatheter interventions. This need for accurate and reliable information has required the imager to be agnostic to the imaging modality. Cardiac computed tomography has become critical in procedural planning in this new paradigm. The expanded use of pre-procedural cardiac magnetic resonance to quantify mitral regurgitation and characterize the left ventricle is another illustration of this newer approach. Other illustrations of the new world of interventional imaging include the expanded use of 3-dimensional (3D) transesophageal echocardiography and real-time fusion of echocardiography and fluoroscopy images. Imaging data are also the basis for computational modeling, 3D printing, and artificial intelligence. These technologies are being increasingly explored to improve therapy selection and prediction of procedural outcomes. This review provides an update of the essentials in present interventional imaging for surgical and transcatheter interventions for mitral regurgitation.
Contemporary advances in medical imaging
2020, Machine Learning in Cardiovascular Medicine
Contemporary advances in imaging technology have revolutionized the field of cardiovascular disease with improved detection of disease states coupled with innovative therapeutic interventions. As a result, clinicians have a plethora of diagnostic tools including echocardiography, cardiac computed tomography (CT), cardiac magnetic resonance (CMR), and nuclear imaging. Echocardiography is widely available and provides a comprehensive assessment of cardiac anatomy, function, and hemodynamics. Complementary to echocardiography, CMR provides accurate cardiac volumes, function, and noninvasive hemodynamic assessment of valvular disease and flows. Innovations in cardiac CT have provided the ability to noninvasively image the coronary arteries, as well as cardiac structures that are useful in preprocedural planning for cardiac surgery or transcatheter heart interventions. Nuclear imaging has previously been the mainstay of ischemia assessment in coronary artery disease using exercise or vasodilator testing. Advances in CT-fractional flow reserve, CMR with scar imaging, and positron emission tomography (PET) with coronary flow reserve provide an ability to detect ischemia while extracting vital prognostic data for each patient. Recent advances in technetium-99m pyrophosphate, PET, and CMR have improved the ability to noninvasively detect cardiomyopathies such as cardiac amyloidosis, sarcoidosis, and inflammatory or infiltrative diseases. Nevertheless, each imaging modality is complementary to each other and often a multimodality patient-specific approach is needed. Furthermore, the integration of artificial intelligence within a clinical workflow allows for a safer, time and cost-effective approach to clinical practice and management.
Clinical Utility of Three-Dimensional Echocardiography in the Evaluation of Mitral Valve Disease: Tips and Tricks
2023, Journal of Clinical Medicine

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: Ralph Stephan von Bardeleben is a member of the advisory board to GE Healthcare, Philips Health Systems, Edwards Lifesciences. The other authors have no conflict of interest to declare.

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2019 by the American Society of Echocardiography.

State-of-the-Art ReviewAdvanced Protocol for Three-Dimensional Transesophageal Echocardiography Guidance Implementing Real-Time Multiplanar Reconstruction for Transcatheter Mitral Valve Repair by Direct Annuloplasty

Highlights

Section snippets

Direct Transcatheter Annuloplasty

Optimized Echocardiographic Protocol for TMVR by Direct Annulopasty

Summary

Acknowledgments

JACC Cardiovasc Imaging

J Am Soc Echocardiogr

Prog Cardiovasc Dis

JACC Cardiovasc Intervent

Am J Cardiol

JACC Cardiovasc Intervent

J Am Soc Echocardiogr

State-of-the-Art Review
Advanced Protocol for Three-Dimensional Transesophageal Echocardiography Guidance Implementing Real-Time Multiplanar Reconstruction for Transcatheter Mitral Valve Repair by Direct Annuloplasty