Critical role of multi-modality planning in Transcatheter Mitral Valve Replacement
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1 Critical role of multi-modality planning in Transcatheter Mitral Valve Replacement Dee Dee Wang, MD, FACC, FASE, FSCCT Director Structural Heart Imaging Medical Director 3D Printing Henry Ford Innovations Institute Henry Ford Health System
2 Disclosures Grant support: Director CT CoreLab: MITRAL trial, NIH LAMPOON clinical trial Director Echo CoreLab: NIH LAMPOON clinical trial Patent(s): co-inventor on a patent application, assigned to employer Henry Ford Health System, on software to predict LVOTO Consultant: Edwards LifeSciences Materialise
3 Poll: My institution plans on starting a TMVR program A. within the next 6months B. within the next 12months C. already doing TMVR D. not interested in doing TMVR
4 Poll: I have seen A. A valve embolize after Transcatheter Mitral Valve Replacement B. LVOT obstruction after TMVR C. All of the above D. None of the above
5 Goals Discuss risks of TMVR Identify key steps in planning safe TMVR Create awareness on new imaging technology
6 Risks of TMVR Undersized valve Valve embolization Oversized valve LVOT obstruction Death Difficult landing zone for the valve severe peri-valvular leak Death
7 2013 Case #1: we were lucky
8 Case #2
9 Echo and CT not enough, need depth perception
10 Risks: Trends in TMVR deployment Oversize to avoid embolization Flare the valve in the ventricle to anchor
11 Case #3: One shot
12 Deployed
13 Deployed Wang et al. Catheter Cardiovasc Interv 2017
14 Goals Discuss risks of TMVR Identify key steps in planning safe TMVR Create awareness on new imaging technology
15 Reassessing TMVR planning Sizing Predicting LVOT obstruction Landing Project
16 Sizing: area 369 sqmm
17 Sizing: area 503 sqmm
18 4D CT cine:
19 Subvalvular calcification: 28 mm flexible CarboMedics LA aorta Subvalvular calcification LAA LA aorta LV LVOT LV
20 TMVR planning Sizing Predicting LVOT obstruction Landing Project
21 Baseline LV AO gradient s 1. Rest:Pressure Calculations 10:04:56 AM-1 s AXIOM Sensis XP VC03G 0 1 s 5 10! II A! avl LV 200 mmhg B P2 200 mmhg AO 200 mmhg 25 mm/s CHRISTINE FRANTZ, Study: CATH49^CARDIOV... Date: 8/7/2014
22 Immediately post valve deployment s 2. Post Valvuloplasty:Pressure Calculations 1:12:46 PM AXIOM Sensis XP VC03G 0 1 s 5 10! II A! avl LV 200 mmhg B AO 200 mmhg mm/s CHRISTINE FRANTZ, Study: CATH49^CARDIOV... Date: 8/7/2014
23 LVOT TMVR kissing balloon inflations Video clip please click play
24 Lessons from Echo: size mitral annulus in diastole
25 Lessons from Echo: obstruct in mid to end-systole diastole systole
26 Mission: LVOT prediction modeling August 2013 to August 2017 Pre-TMVR Mitral CT Valve sized in diastolic phase Worse end-systolic phase identified
27 Science: LVOT prediction modeling Transcatheter heart valve modeled 60% ventricular / 40% atrial 80% ventricular / 20% atrial LVOT surface pre post valve recorded Post-TMVR Mitral CT
28 LVOT prediction modeling Intraprocedural cath gradients Intraprocedural TEE gradients Post-procedural TTE gradients MACE
29 Patient specific 3D Printed Anatomy CAD model of patient specific anatomy: pre-tmvr LVOT area CAD model of LVOT obstruction with proposed THV deployed Dark green: LVOT obstruction Light green: preserved LVOT flow Left atrium Mitral annular calcification LVOT Aorta Mitral annular calcification LVOT obstruction Mitral Ring Post TMVR preserved LVOT flow Surgical mitral bioprosthesis Mitral Bioprosthesis Transcatheter heart valve Surgical aortic bioprosthesis Wang et al. JACC: Cardiovascular Imaging Nov 2016, 9 (11)
30 Wang et al. JACC: Cardiovascular Imaging Nov 2016, 9 (11)
31 Predicting LVOTO after TMVR 27mm carpentier edwards Baseline LVOT surface area without TMVR Wang et al. JACC: Cardiovasc Imaging Nov 2016.
32 Predicting LVOTO after TMVR Predicted residual LVOT surface area post TMVR : Neo LVOT Wang et al. JACC: Cardiovascular Imaging Nov 2016, 9 (11)
33 Wang et al. JACC: Cardiovascular Imaging Nov 2016, 9 (11)
34 Wang et al. Catheter Cardiovasc Interv 2017
35 Critical role of 3D computer aided design in personalized TMVR planning LA aorta Bapat V. EuroIntervention Sep;10 Suppl U:U44-51.
36 Introducing PAM LAA aorta LV LV LV
37 Personalizing procedural planning LA aorta Wang et al. JACC: Cardiovasc Imaging Nov 2016
38 Wang et al. Catheter Cardiovasc Interv 2017
39 Wang et al. Catheter Cardiovasc Interv 2017
40 Pre versus post CT neo-lvot Wang et al. Catheter Cardiovasc Interv 2017
41 TMVR planning Sizing Predicting LVOT obstruction Landing & Project
42 Applying it clinically Fluoro overview
43 Baseline lvot surface area 26 S3 20%LA, 80%LV Neo-lvot surface area RAO 42 CAU 27
44 RAO 42 CAU 27 NO PASS ZONE
45 Never know what you will see
46 Max Diameter (mm) Min Diameter (mm) 36.3 mm 19.0 mm Annular Area (mm2) 714 mm 2
47
48 3D CAD Analysis: transseptal access??? LA AORTA LV MAC
49 SVC AORTA LA RA IVC
50 Take home points TMVR can be dangerous Risks can be decreased and avoided shown by MITRAL trial investigators Critical role of computer aided design in successful TMVR outcomes
51 Thank you
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