van den Dorpel Mark M P, de Sá Marchi Mauricio Felippi, Rahhab Zouhair, Ooms Joris F, Adrichem Rik, Verhemel Sarah, Ren Claire Ben, Nuis Rutger-Jan, Daemen Joost, Hirsch Alexander, Van den Branden Ben J L, Van Mieghem Nicolas M
Department of Cardiology, Cardiovascular Institute, Erasmus University Medical Centre, Rotterdam, The Netherlands.
Department of Cardiovascular Medicine, Heart Institute, Clinical Hospital, Faculty of Medicine, University of São Paulo, São Paulo, Brazil.
Neth Heart J. 2024 Dec;32(12):442-454. doi: 10.1007/s12471-024-01893-5. Epub 2024 Sep 16.
Transcatheter mitral valve replacement (TMVR) has emerged as a minimally invasive alternative to mitral valve surgery for patients at high or prohibitive operative risk. Prospective studies reported favourable outcomes in patients with annulus calcification (valve-in-mitral annulus calcification; ViMAC), failed annuloplasty ring (mitral valve-in-ring; MViR), and bioprosthetic mitral valve dysfunction (mitral valve-in-valve; MViV). Multi-slice computed tomography (MSCT)-derived 3D-modelling and simulations may provide complementary anatomical perspectives for TMVR planning.
We aimed to illustrate the implementation of MSCT-derived modelling and simulations in the workup of TMVR for ViMAC, MViR, and MViV.
For this retrospective study, we included all consecutive patients screened for TMVR and compared MSCT data, echocardiographic outcomes and clinical outcomes.
Sixteen out of 41 patients were treated with TMVR (ViMAC n = 9, MViR n = 3, MViV n = 4). Eleven patients were excluded for inappropriate sizing, 4 for anchoring issues and 10 for an unacceptable risk of left ventricular outflow tract obstruction (LVOTO) based on 3D modelling. There were 3 procedure-related deaths and 1 non-procedure-related cardiovascular death during 30 days of follow-up. LVOTO occurred in 3 ViMAC patients and 1 MViR patient, due to deeper valve implantation than planned in 3 patients, and anterior mitral leaflet displacement with recurrent basal septum thickening in 1 patient. TMVR significantly reduced mitral mean gradients as compared with baseline measurements (median mean gradient 9.5 (9.0-11.5) mm Hg before TMVR versus 5.0 (4.5-6.0) mm Hg after TMVR, p = 0.03). There was no residual mitral regurgitation at 30 days.
MSCT-derived 3D modelling and simulation provide valuable anatomical insights for TMVR with transcatheter balloon expandable valves in ViMAC, MViR and MViV. Further planning iterations should target the persistent risk for neo-LVOTO.
经导管二尖瓣置换术（TMVR）已成为一种微创替代方案，适用于手术风险高或手术禁忌的二尖瓣手术患者。前瞻性研究报告了瓣环钙化（二尖瓣瓣环内瓣膜置换术；ViMAC）、瓣环成形环失败（二尖瓣环内瓣膜置换术；MViR）和生物人工二尖瓣功能障碍（瓣膜内二尖瓣置换术；MViV）患者的良好预后。多层螺旋计算机断层扫描（MSCT）衍生的三维建模和模拟可为TMVR规划提供补充性的解剖学视角。
我们旨在阐述MSCT衍生的建模和模拟在ViMAC、MViR和MViV的TMVR检查中的应用。
在这项回顾性研究中，我们纳入了所有接受TMVR筛查的连续患者，并比较了MSCT数据、超声心动图结果和临床结果。
41例患者中有16例接受了TMVR治疗（ViMAC组9例，MViR组3例，MViV组4例）。基于三维建模，11例患者因尺寸不合适被排除，4例因锚定问题被排除，10例因左心室流出道梗阻（LVOTO）风险不可接受被排除。在30天的随访期间，有3例与手术相关的死亡和1例与手术无关的心血管死亡。3例ViMAC患者和1例MViR患者发生LVOTO，3例患者是由于瓣膜植入比计划更深，1例患者是由于二尖瓣前叶移位伴基底间隔反复增厚。与基线测量相比，TMVR显著降低了二尖瓣平均梯度（TMVR前中位数平均梯度为9.5（9.0 - 11.5）mmHg，TMVR后为5.0（4.5 - 6.0）mmHg，p = 0.03）。30天时无残余二尖瓣反流。
MSCT衍生的三维建模和模拟为ViMAC、MViR和MViV中使用经导管球囊扩张瓣膜的TMVR提供了有价值的解剖学见解。进一步的规划迭代应针对新的LVOTO持续风险。
