VIDEO: CT imaging for TAVR and TMVR structural heart interventions

 

Joao Cavalcante, MD, FSCCT, FACC, director, cardiac MRI and structural CT labs, Minneapolis Heart Institute, and director, Cardiovascular Imaging Research Center and Core Lab, Minneapolis Heart Institute Foundation, discusses the use of cardiac CT imaging to plan and guide structural heart procedures. He presented on this in sessions at the at the 2022 Society of Cardiovascular Computed Tomography (SCCT) conference on the use of CT for high-risk transcatheter mitral valve replacement (TMVR) and preplanning procedures to enable the valve to fit in the anatomy.

He was among the experts that led a packed day-long workshop at SCCT on pre-procedural imaging workups on transcatheter aortic valve replacement (TAVR) and TMVR. 

"While TAVR has become commonplace, TAVR has also become a lot more complicated," Cavalcante said. "Yes, TAVR is straightforward, but now we have expanded indications with bicuspid valves, we have valve-in-valves, and we have post TAVR followup."

He said the workshop organizers, which included a few of the top imagers in the field, realized by 2 p.m. they had not even gotten to the mitral valve. That told them the field is now completely on its own and has outgrown a single-day course to cover both valves. "The learning lesson for us was that we can now separate the valves into their own day-long sessions," he said.

Mitral valve LVOT issues can be assessed with CT

In the mitral valve space, Cavalcante said there is now an indication for the Sapien TAVR valve to be used in the mitral position as a replacement valve in high-risk surgical patients. However, there are issues that come with using that valve in the mitral position for which it was not designed for. The biggest issue for imagers in pre-procedural CT screenings is to assess patients to see if they can receive the valve, as the long overhang of the valve skirt into the ventricle can cause LVOT obstruction. This is critical because LVOT obstruction can cause serious blockage of flow and cause adverse hemodynamics leading to poor outcomes or death.

In addition to LVOT obstruction, imagers now also calculated the area of the Neo-LVOT, because this number can predict poor outcomes in patients and help decide it the valve or ventricle need to be modified to make more room for the valve implant and ensure good hemodynamics. 

"Imaging plays a critical role for the procedure's success," Cavalcante said. "The Neo-LVOT is one of the key pieces that we do in the analysis. The other piece too that were are starting to learn is at what part of the cycle do you evaluate the Neo-LVOT? Do you do it at very end systoly when there is no more blood and the ventricle is the smallest? Yes, we like to be a bit conservative and that would be the worse case scenario, but that measure could be rejecting a lot of potential patients that you could still treat. So we are still learning and finding that maybe changing that neo-LVOT area, rather than a single cutoff, might be better."

New transcatheter procedures have been developed to modify the valve area and increase the real-estate to place these valves, Cavalcante said. This includes cutting the native leaflet using a LAMPOON (Intentional Laceration of the Anterior Mitral leaflet to Prevent left ventricular Outflow ObstructioN during transcatheter mitral valve implantation) procedure prior to the prosthetic transcatheter valve implant to enable better blood flow. Another method is the SESAME (septal scoring along the midline endocardium), which uses an electrified wire to trim tissue on the septum to create more room for the valve. Radiofrequency ablation and alcohol septal ablation also can reduce the size of the septum. All these procedures require pre-planning and enable more patients to be treated, he said. 

Cavalcante also discusses the need for automation of measurements in structural heart and the deeper involvement of radiology at hospitals without dedicated cardiac imaging programs.
 

Dave Fornell is a digital editor with Cardiovascular Business and Radiology Business magazines. He has been covering healthcare for more than 16 years.

Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com

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