Transcatheter Mitral Valve Intervention: Current and Future Role of Multimodality Imaging for Device Selection and Periprocedural Guidance.

Mitral regurgitation (MR) is a broadly diffuse valvular heart disease (VHD) with a significant impact on the healthcare system and patient prognosis. Transcatheter mitral valve interventions (TMVI) are now well-established techniques included in the therapeutic armamentarium for managing patients with mitral regurgitation, either primary or functional MR. Even if the guidelines give indications regarding the correct management of this VHD, the wide heterogeneity of patients' clinical backgrounds and valvular and heart anatomies make each patient a unique case, in which the appropriate device's selection requires a multimodal imaging evaluation and a multidisciplinary discussion. Proper pre-procedural evaluation plays a pivotal role in judging the feasibility of TMVI, while a cooperative work between imagers and interventionalist is also crucial for procedural success. This manuscript aims to provide an exhaustive overview of the main parameters that need to be evaluated for appropriate device selection, pre-procedural planning, intra-procedural guidance and post-operative assessment in the setting of TMVI. In addition, it tries to give some insights about future perspectives for structural cardiovascular imaging.

A fully automated artificial intelligence-driven software for planning of transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly performed for the treatment of aortic stenosis. Computed tomography (CT) analysis is essential for pre-procedural planning. Currently available software packages for TAVR planning require substantial human interaction. We describe development and validation of an artificial intelligence (AI) powered software to automatically rend anatomical measurements and other information required for TAVR planning and implantation. METHODS: Automated measurements from 100 CTs were compared to measurements from three expert clinicians and TAVR operators using commercially available software packages. Correlation coefficients and mean differences were calculated to assess precision and accuracy. RESULTS: AI-generated annular measurements had excellent agreements with manual measurements by expert operators yielding correlation coefficients of 0.97 for both perimeter and area. There was no relevant bias with a mean difference of -0.07 mm and - 1.4 mm2 for perimeter and area, respectively. For the ascending aorta measured 5 cm above the annular plane, correlation coefficient was 0.95 and mean difference was 1.4 mm. Instruction for use-based sizing yielded agreement with the effective implant size in 87-88 % of patients for self-expanding valves (perimeter-based sizing) and in 88 % for balloon-expandable valves (area-based sizing). CONCLUSIONS: A fully automated software enables accurate and precise anatomical segmentation and measurements required for TAVR planning without human interaction and with high reliability.

Valve-in-Valve Transcatheter Aortic Valve Replacement: From Pre-Procedural Planning to Procedural Scenarios and Possible Complications.

Over the last decades, bioprosthetic heart valves (BHV) have been increasingly implanted instead of mechanical valves in patients undergoing surgical aortic valve replacement (SAVR). Structural valve deterioration (SVD) is a common issue at follow-up and can justify the need for a reintervention. In the evolving landscape of interventional cardiology, valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has emerged as a remarkable innovation to address the complex challenges of patients previously treated with SAVR and has rapidly gained prominence as a feasible technique especially in patients at high surgical risk. On the other hand, the expanding indications for TAVR in progressively younger patients with severe aortic stenosis pose the crucial question on the long-term durability of transcatheter heart valves (THVs), as patients might outlive the bioprosthetic valve. In this review, we provide an overview on the role of ViV TAVR for failed surgical and transcatheter BHVs, with a specific focus on current clinical evidence, pre-procedural planning, procedural techniques, and possible complications. The combination of integrated Heart Team discussion with interventional growth curve makes it possible to achieve best ViV TAVR results and avoid complications or put oneself ahead of time from them.

Virtual reality training and modeling to aid in pre-procedural practice for thoracic nerve root block in the setting of a schwannoma.

Virtual reality (VR) is a tool to aid with pre-procedural modeling and practicing for complex procedures with anatomic variation. Here we demonstrate a case of a 64-year-old woman with neuroforaminal compression from a schwannoma that was modeled in VR in order to facilitate pre-procedural training prior to a transforaminal epidural steroid injection. The modeling session allowed for determination of the optimal fluoroscopic angulation to avoid any contact with the mass or nerve root during the procedure. This case study demonstrates a way to incorporate VR in pre-procedural planning and practicing for both learners and experienced interventionalists.

Is Increasing Age Associated with Higher Rates of Intercostal Arteries Vulnerable to Laceration? A Point of Care Ultrasound Study.

Ultrasound-guided pre-procedural planning decreases complications from bedside thoracentesis. Although rare, intercostal artery (ICA) laceration is a serious complication that occurs when vulnerable intercostal arteries (VICA) are no longer protected by the superior rib. We sought to determine if increasing patient age is associated with greater odds of encountering a VICA. Randomly selected in-patients underwent pre-procedural planning for a mock posterior bedside thoracentesis. ICAs were categorized as vulnerable if they were visible within the corresponding intercostal space (ICS). We recorded where the VICA entered and exited the ICS as well as its unshielded length. A total of 40 patients (20 male) were enrolled and 240 ICS (6 ICS per patient) were scanned. Within this cohort, 25% of patients were noted to have at least one VICA. We could not demonstrate any relationship between the patient's age or location of the ICS, with the odds of encountering a VICA (odds ratio (OR) = 1.0, p = 0.76; OR = 0.85, p = 0.27, respectively). Given the haphazard nature of VICA distribution and poor outcomes associated with inadvertent laceration, we recommend that ICA screening at the site of needle insertion be routinely performed prior to thoracentesis.

Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography.

Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

Percutaneous closure of a 'whale tail' left atrial appendage with a Watchman FLX device and pre-procedural FEops HEARTguide patient-specific computational simulation: a case report.

Background: Percutaneous left atrial appendage closure (LAAC) is an emerging alternative to oral anticoagulation for stroke prevention in atrial fibrillation (AF) in patients with AF, elevated stroke risk and contraindications to long-term anticoagulation treatment. Optimal pre-procedural planning is essential to ensure optimal procedural results. Case summary: We report the case of a 62-year-old man with a history of right cerebellar haematoma referred for LAA closure. We describe the first use of FEops HEARTguide patient-specific computational simulation in the planning of LAAC with the Watchman Flex device (Boston Scientific, Marlborough, MA, USA) in an unusual 'whale tail'-like LAA anatomy. Discussion: Percutaneous left atrial appendage (LAA) closure is feasible in the majority of patients. However, certain LAA anatomies may pose substantial technical challenges. This case shows the crucial role of a pre-procedural assessment based on patient-specific computational simulations for LAA closure in difficult scenarios resulting in a more efficient procedure with the optimal result and good clinical outcomes.

Transcatheter Repair and Replacement Technologies for Mitral Regurgitation: a European Perspective.

PURPOSE OF REVIEW: We aimed to picture the contemporary landscape of available catheter-based repair and replacement solutions for mitral regurgitation (MR) in Europe. RECENT FINDINGS: Edge-to-edge repair remains the dominant technique for transcatheter mitral valve repair especially in the context of secondary mitral regurgitation. Two recent randomized trials reported seemingly contradicting clinical results with transcatheter edge-to-edge repair for patients with heart failure and severe secondary MR. A proportionality framework related to secondary MR was proposed to help explain inconsistencies but requires further research. (In)Direct annuloplasty primarily aims to correct secondary MR; however, the scientific basis seems less robust. One dedicated transcatheter heart valve has the CE mark for mitral valve replacement but requires transapical access. Balloon-expandable transcatheter aortic valve platforms are emerging for transvenous transseptal mitral replacement in the context of mitral annular calcification, a failing surgical mitral bioprosthesis, or annuloplasty. Advanced computed tomography imaging techniques improved pre-procedural planning and introduced the option for modeling and simulation. Development of a toolbox of catheter-based technologies, complementary imaging modalities, and refined patient selection offer novel perspectives to high-risk patients with primary or secondary MR. Clinical trials are required to help formulate evidence-based guidelines for the management of mitral valve disease.

Pre-procedural planning of transcatheter mitral valve replacement in mitral stenosis with multi-detector tomography-derived 3D modeling and printing: a case report.

BACKGROUND: Transcatheter mitral valve replacement (TMVR) may be a valuable treatment option for mitral annular calcification and severe mitral stenosis (MS) in patients at high operative risk. Pre-procedural virtual and printed simulations may aid in procedure planning, device sizing, and mitigate complications such as valve embolization or left ventricular outflow tract (LVOT) obstruction. CASE SUMMARY: We describe a case of TMVR in which multi-detector computed tomography (MDCT) derived, three-dimensional virtual planning and a 3D-printed model of the patients' left heart provided enhanced understanding of an individual patient's unique anatomy to determine feasibility, device sizing, and risk stratification. This resulted in deployment of an adequately sized valve. Post-TMVR LVOT obstruction was treated with LVOT balloon dilatation and percutaneous transluminal septal myocardial ablation. DISCUSSION: Advanced MDCT-derived planning techniques introduce consistent 3D modeling and printing to enhance understanding of intracardiac anatomical relationships and test device implantation. Still, static measurements do not feature haemodynamic factors, tissue, or device characteristics and do not predict device host interaction. Transcatheter mitral valve replacement is feasible in MS when adequately pre-procedurally planned. Multi-detector computed tomography-derived, 3D, virtual and printed models contribute to adequate planning in terms of determining patient eligibility, procedure feasibility, and device sizing. However, static 3D modeling cannot completely eliminate the risk of peri-procedural complications.

Simulation to Success: Treatment of a 3D Printed Heart Before Complex Systemic Venous Baffle Intervention.

Three-dimensional imaging and printed heart models have become increasingly valuable in the management of patients with complex congenital heart disease. We successfully simulated a stenting procedure on a 3-dimensional printed model of a patient with d-transposition of the great arteries status post-Mustard operation with caval baffle atresia and stenosis. (Level of Difficulty: Advanced.).

Blood Pool Contrast-enhanced Magnetic Resonance Angiography with Correlation to Digital Subtraction Angiography: A Pictorial Review.

Magnetic resonance angiography (MRA) provides noninvasive visualization of the vascular supply of soft tissue masses and vascular pathology, without harmful radiation. This is important for planning an endovascular intervention, and helps to evaluate the efficiency and effectiveness of the treatment. MRA with conventional extracellular contrast agents relies on accurate contrast bolus timing, limiting the imaging window to first-pass arterial phase. The recently introduced blood pool contrast agent (BPCA), gadofosveset trisodium, reversibly binds to human serum albumin, resulting in increased T1 relaxivity and prolonged intravascular retention time, permitting both first-pass and steady-state phase high-resolution imaging. In our practice, high-quality MRA serves as a detailed "roadmap" for the needed endovascular intervention. Cases of aortoiliac occlusive disease, inferior vena cava thrombus, pelvic congestion syndrome, and lower extremity arteriovenous malformation are discussed in this article. MRA was acquired at 1.5 T with an 8-channel phased array coil after intravenous administration of gadofosveset (0.03 mmol/kg body weight), at the first-pass phase. In the steady-state, serial T1-weighted 3D spoiled gradient echo images were obtained with high resolution. All patients underwent digital subtraction angiography (DSA) and endovascular treatment. MRA and DSA findings of vascular anatomy and pathology are discussed and correlated. BPCA-enhanced MRA provides high-quality first-pass and steady-state vascular imaging. This could increase the diagnostic accuracy and create a detailed map for pre-intervention planning. Understanding the pharmacokinetics of BPCA and being familiar with the indications and technique of MRA are important for diagnosis and endovascular intervention.