Log in to MyACC
3D Echo for Prediction of LVOT Area Prior to TMVR
Quick Takes
- In a cohort of 105 patients undergoing transcatheter mitral valve replacement (TMVR), predicted neo-LVOT dimensions were comparable between 3D TEE and CT.
Study Questions:
What is the accuracy of three-dimensional (3D) transesophageal echocardiography (TEE) in predicting neo–left ventricular outflow tract (neo-LVOT) dimensions in patients undergoing transcatheter mitral valve replacement (TMVR), as compared with baseline computed tomography (CT)?
Methods:
This retrospective study included consecutive patients who underwent TMVR at two centers between 2017 and 2023. Dedicated software was used to project a virtual valve on both baseline CT and 3D TEE. For both valve-in-ring (ViR) and valve-in-mitral annular calcification (ViMAC) procedures, the virtual valve was positioned in a 20% atrial and 80% ventricular position. The predicted neo-LVOT area was correlated with peak post-procedural LVOT gradients.
Results:
The study cohort included 105 patients (median age 75.8 years, 56.2% male) who had CT and 3D TEE images of sufficient quality. Failed bioprosthesis was the most common indication for TMVR (n = 51), followed by native mitral regurgitation (n = 30), native degenerative mitral stenosis (n = 12), and failed mitral annuloplasty (n = 12). Patients with lower left ventricular ejection fraction (EF) had significantly larger neo-LVOT areas. Following TMVR, peak LVOT gradient increased by a mean 4.8 mm Hg.
Bland-Altman analysis did not show any significant bias between TEE-derived and CT-derived neo-LVOT area or perimeter, but TEE significantly underestimated mitral annular parameters including area, perimeter, medial-to-lateral distance, and trigone-to-trigone distance. Based on a subgroup of patients who had post-TMVR imaging, both modalities significantly underestimated actual neo-LVOT area measured after implantation. This difference was primarily due to neo-LVOT underestimation in patients who underwent TMVR with dedicated mitral bioprostheses; prediction was more accurate in patients treated with aortic transcatheter valves.
Conclusions:
The authors report that in patients undergoing TMVR, neo-LVOT dimensions predicted by 3D TEE are similar to those predicted by CT.
Perspective:
LVOT obstruction is one of the most problematic complications of TMVR and the most significant barrier to the adoption of this therapy. CT is the current standard of care for predicting neo-LVOT dimensions, but especially in patients with kidney disease and iodinated contrast allergy, avoidance of CT may be desirable. All patients being evaluated for transcatheter mitral interventions also require TEE for preprocedural planning, and this study suggests that 3D TEE holds promise in predicting neo-LVOT dimensions. However, patients with suboptimal TEE image quality and those who required anterior mitral leaflet laceration were excluded from this study, limiting the generalizability of the findings. Prospective multicenter studies will be needed for validation.
Clinical Topics: Noninvasive Imaging, Valvular Heart Disease, Echocardiography/Ultrasound
Keywords: Echocardiography, Three-Dimensional, Mitral Valve Stenosis
