Dee Dee Wang

Transcatheter caval valve implantation using multimodality imaging: Roles of TEE, CT, and 3D printing

This iPIX illustrates 3-dimensional (3D) printing guided periprocedural, multimodality pictorial planning performed for a successful transcatheter caval valve implantation (CAVI). A 57-year-old patient with severe mitral valve regurgitation status post–mitral ring placement in 2001 (28-mm Cosgrove

Predicting LVOT Obstruction After TMVR

Evolution of catheter-based structural interventions has given patients less invasive alternatives to surgery; however, the current generation of transcatheter heart valves (THV) are not specifically designed for mitral position implantation and have intrinsic geometry that may make mitral

Short-term results of alcohol septal ablation as a bail-out strategy to treat severe left ventricular outflow tract obstruction after transcatheter mitral valve replacement in patients with severe mitral annular calcification

To evaluate the outcomes of the early experience of percutaneous alcohol septal ablation in patients with severe left ventricular outflow tract (LVOT) obstruction post transcatheter mitral valve replacement (TMVR).

Validating a prediction modeling tool for left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR)

Demonstrate proof‐of‐concept validation of a computed tomography (CT) computer‐aided design prediction modeling tool to identify patients at risk for left ventricular outflow tract (LVOT) obstruction in transcatheter mitral valve replacement (TMVR).

Long or redundant leaflet complicating transcatheter mitral valve replacement: Case vignettes that advocate for removal or reduction of the anterior mitral leaflet

Transcatheter mitral valve replacement (TMVR) procedures can be an alternative to surgical valve replacement for high surgical risk patients with bioprosthetic mitral valves, annuloplasty rings, or severe mitral annular calcification (MAC). TMVR can trigger acute left ventricular outflow tract (LVOT) obstruction from permanent displacement of the native anterior mitral leaflet toward the left ventricular septum, more often among patients undergoing valve‐in‐ring and valve‐in‐MAC procedures. Although acute LVOT obstruction is well described in the literature, there are important additional complications of TMVR related to the length and/or redundancy of the anterior mitral valve that have been recognized after mitral valve surgery and have not been previously reported in the setting of TMVR. These additional complications include acute mitral regurgitation secondary to prolapsing native leaflet through the TMVR, frozen TMVR leaflet secondary to overhanging native leaflet and late LVOT obstruction in the neo‐LVOT secondary to long native leaflet. Preprocedural planning with imaging (echocardiography and computed tomography) and measurement of anterior mitral leaflet length is critical important in understanding the risk for these complications. As transcatheter mitral valve technology proliferates, interactions with the anterior mitral leaflet after TMVR may be more frequent than initially anticipated. We believe that there is no advantage to an intact anterior leaflet and advocate removal or reduction of the leaflet prior to TMVR.

Thrombotic valvular dysfunction with transcatheter mitral interventions for postsurgical failures

Degenerated surgical mitral valve repairs or surgical prostheses are currently being treated with transcatheter mitral valve replacement (TMVR). We report the procedural and mid‐term assessment of thirteen cases.

Percutaneous alcohol septal ablation to acutely reduce left ventricular outflow tract obstruction induced by transcatheter mitral valve replacement

Transcatheter implantation of balloon expandable valves in native mitral valves (MV) has been performed in patients with severe MV annular calcification who are not good candidates for standard surgical MV replacement. Significant left ventricular outflow tract (LVOT) obstruction with hemodynamic compromise has been described as one of the potential complications of transcatheter MV replacement. Surgical rescue carries significant risk in this high‐risk patient population. We describe a percutaneous technique to acutely decrease transcatheter MV replacement‐induced LVOT obstruction.

Percutaneous Rescue of an Embolized Valve After Transcatheter Mitral Valve Replacement

Transcatheter mitral valve replacement (TMVR) with the compassionate use of aortic transcatheter valves (THV) has emerged as an alternative to surgery in patients with severe MV disease with severe mitral annular calcification (MAC) who are not eligible for standard MV surgery due to high surgical

TCT-626 Validating a prediction modeling tool for LVOT obstruction after transcatheter mitral valve replacement

nos: 626 646 TCT-626 Validating a prediction modeling tool for LVOT obstruction after transcatheter mitral valve replacement Dee Dee Wang, Marvin Eng, Adam Greenbaum, Mayra Guerrero, William O’Neill J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 8 , N O . 1 8 , S U P P L B , 2 0 1 6 B255 Henry Ford Hospital, Detroit, Michigan, United States; University Clinic of Munich; Henry Ford Hospital, Detroit, Michigan, United States; Evanston Hospital, Evanston, Illinois, United States; Henry Ford Hospital, Detroit, Michigan, United States BACKGROUND Left ventricular outflow tract (LVOT) obstruction is a fatal consequence of transcatheter mitral valve replacement (TMVR). Despite advancements in transcather aortic valve replacement therapies, there currently exists no LVOT prediction model to optimize patient procedural safety in TMVR. METHODS From 2013 to May 2016, 30 patients in 5 centers underwent TMVR with compassionate use of balloon-expandable valves for severe mitral valve dysfunction secondary to degenerative surgical mitral ring, bioprosthesis, or severe mitral stenosis secondary to severe mitral annular calcification. We performed a multi-center retrospective review of all thirty patients who underwent transcatheter mitral valve replacement. All patients had pre-procedural CT scans performed for LVOT prediction modeling, intraprocedural TEE and cardiac catheterization hemodynamics performed. Pre-procedural prediction modeling was performed utilizing computer-aided-design (CAD) modeling of the neo-LVOT post-TMVR. RESULTS All patients underwent successful transcatheter mitral valve replacement without device embolization. Five of the thirty patients experienced an increase of > 10mmHg in their LVOT peak gradient post-TMVR from their resting LVOT gradient. Utilizing an ROC curve comparing difference in LVOT peak gradient pre-and postTMVR compared to predicted neo-LVOT surface area post-TMVR, a predicted neo-LVOT surface area of 252.2 mm2 (93.1% classification rate) was identified as the cutoff neo-LVOT surface area necessary for successful TMVR without an associated significant increase in LVOT peak gradients. CONCLUSION The novel clinical application of CAD design, and CT post-processing in predicting LVOT obstruction may be invaluable for optimal mitral valve annulus sizing, and determination of the desired deployment angulation and landing height. The use of this technology may improve the technical success of TMVR and aid in the first steps towards personalized medicine in transcatheter heart valve therapies. CATEGORIES IMAGING: Imaging: Non-Invasive TCT-627 Cardiovascular Outcomes Assessment of MitraClip Therapy in Heart Failure Patients with Functional Mitral Regurgitation (The COAPT Trial): Baseline Characteristics and Preliminary 30-Day and 1-Year Outcomes of the Roll-In Cohort Gregg Stone, William Abraham, JoAnn Lindenfeld, Neil Weissman, Steven Marx, Jeff Ellis, Lori Anne Crosson, Michael Mack Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States; Ohio State University, Columbus, Ohio, United States; Vanderbilt University medical Center; MedStar Health Research Institute, Washington, District of Columbia, United States; Columbia University Medical Center; Abbott Vascular, Santa Clara, California, United States; Abbott Vascular, Menlo Park, California, United States; The Heart Hospital Baylor Plano, Plano, Texas, United States BACKGROUND Pts with functional mitral regurgitation (FMR) and heart failure (HF) have a poor prognosis. The COAPT Trial was designed to determine whether transcatheter mitral valve (MV) repair with the MitraClip is safe and effective for reducing recurrent HF hospitalizations in pts with FMR. Herein we describe demographics and 30-day outcomes from the COAPT roll-in cohort, performed at sites with little or no MitraClip experience. METHODS Pts enrolled in COAPT have 3+ FMR, are symptomatic despite maximally tolerated guideline-directed medical therapy, and have LVESD 70 mm and LVEF 20% 50%. A Central Eligibility Committee confirms that each pt has been optimally medically treated and will not undergo MV surgery. Endpoints include NYHA Class, Six Minute Walk Distance (6MWD) and echo measures analyzed by an independent core lab. RESULTS 49 roll-in pts (mean age 75 yrs, 61% male) at 34 US centers underwent the MitraClip procedure. Baseline co-morbidities included CAD (82%), renal disease (63%), prior CABG (53%) and COPD (43%). Mean STS score was 11 7%, and 69% were NYHA class III/IV. Baseline 3+/4+ FMR was present by core lab analysis in 55%/45% of patients (63% due to ischemic cardiomyopathy (CM), 37% idiopathic CM). LVEF was 37 11% and mean 6MWD was 234m. The Clip implant rate was 94% (mean 1.4 Clips), and MR was reduced to 2+ MR in 38/45 pts (84%) post procedure. Adverse events and functional measures were assessed at 30 days and 1 year (Table). Adjudicated Outcomes 30 Days 1 Year Death 0% (0/49) 15.2% (7/46) Stroke 0% (0/49) 2.2% (1/46) MI 2.0% (1/49) 2.2% (1/46) Heart failure re-hospitalization 12.1% (6/49) 28.3% (13/46) NYHA class III/IV 41.7% (20/48) 31.4% (11/35) NYHA improvement by 1 class 58.3% (28/48) 57.1% (20/35) MR 2+ 80.6% (29/36) 83.3% (20/24) Change in LV end-diastolic volume (ml) -7 25 (29/49 paired) -13 34 (15/39 paired) Change in 6MWD (m) 13 113 (45/49 paired) 13 96 (30/39 paired) CONCLUSION In the COAPT roll-in experience, among high-risk symptomatic HF pts with severe FMR, the MitraClip safely reduced MR and improved symptoms at 30 days and 1 year. Results from the ongoing randomized COAPT trial will determine whether reducing FMR in optimally treated patients with HF improves prognosis. CATEGORIES STRUCTURAL: Valvular Disease: Mitral TCT-628 Very Long-Term (Up To 23 Years) Follow-Up After Successful Mitral Balloon Valvuloplasty In A Large Series Of Patients With Rheumatic Mitral Stenosis Rafael Alexandre Meneguz-Moreno, Jose Costa, Jr., Nisia Lira Gomes, Auristela Ramos, Mercedes Maldonado, Alfredo Nunes Ferreira Neto, Zilda Meneghelo, Cesar Augusto Esteves, Sergio Braga, Alexandre Abizaid, Amanda Sousa Dante Pazzanese Institute of Cardiology, São Paulo, Brazil; Instituto Dante Pazzanese de Cardiologia, São Paulo, São Paulo, Brazil; Kobe University Hospital; Instituto Dante Pazzanese de c, São Paulo, São Paulo, Brazil; Aichi Medical University; Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil; Ospedale Santa Maria Goretti, Hemodynamic Department, Latina, Italy; Federal University of Sao Paulo; Rede D’OR Hosps.Morumbi/Brasil, São Paulo, São Paulo, Brazil; Dante Pazzanese, São Paulo, São Paulo, Brazil; Instituto Dante Pazzanese de Cardiologia, São Paulo, São Paulo, Brazil; Instituto Dante Pazzanese de Cardiologia, São Paulo, São Paulo, Brazil BACKGROUND Although there has been a steady decline in the incidence of rheumatic heart disease, rheumatic mitral stenosis still causes significant morbi-mortality worldwide. Percutaneous mitral balloon valvuloplasty (PMBV) remains as the preferred treatment option for patients with suitable anatomy and severe symptomatic rheumatic mitral stenosis. We sought to access the very long-term outcomes after successful PMBV. METHODS This is a single center analysis of all consecutive patients who underwent successful PBMV (post-procedural valve area 1.5 cm2 and moderate or less residual regurgitation, without in-hospital major adverse cardiac and cerebrovascular events) between 1988 and 2011. The primary endpoint was the incidence of major adverse cardiac events (MACE), including global death, need for mitral surgery or repeat PMBV up to 23 years after the procedure. RESULTS Among all 1577 patients, success was achieved in 91.3% (1140 patients). The predictors of success were NYHA functional class III-IV (hazard ratio [HR]: 1.73, 95% CI: 1.15-2.60, p1⁄40.008) and Wilkins-score <8 (HR: 1.8, 95% CI: 1.24-2.63, p1⁄40.002). Long-term followup (range 1-23) was obtained in 979 cases (68%). The incidence of the primary endpoint was 19.1% (95% CI: 17.0-21.1). The rate of global death, need for mitral surgery or repeat PMBV was 0.6% (95% CI: 0.3-1.2), 8.3% (95% CI: 7.0-9.9), and 10.0% (95% CI: 8.5-11.7), respectively. The mean MACE-free survival time was 18.9 years (95% CI: 18.4-19.35 years). Cumulative MACE-free survival rate at 23 years was 76.4%. At multivariate analysis, only NYHA functional class III-IV (HR: 2.07, 95% CI: 1.17-3.65, p1⁄40.01) and age (for each 1 year HR: 1.02, 95% CI: 1.00-1.05, p1⁄40.04) were identified as independent predictors of the primary endpoint.

Role of Echocardiography in Transcatheter Mitral Valve Replacement in Native Mitral Valves and Mitral Rings

Adaptation and evolution of transcatheter aortic valve replacement (TAVR) technologies has led to approval of TAVR for consideration in patients at intermediate risk for surgical aortic valve intervention. As TAVR becomes more mainstream, attention is shifting toward percutaneous mitral valve (MV) repair and transcatheter MV replacement (TMVR) techniques. Transcatheter heart valves (both purpose-built and off-label-use TAVR valves) are being implanted during TMVR procedures to treat clinically significant MV disease (native disease, degenerated bioprosthetic valves, and dysfunctional surgical MV annuloplasty repairs) when the risk of open heart MV surgery is prohibitive. The success of these high-risk procedures is directly related to accurate periprocedural imaging with echocardiography and other modalities. Although a multidisciplinary heart valve team approach is necessary for optimal patient selection, a multimodality team-based imaging approach and comprehensive understanding of the MV are required for safe procedural planning. Collaboration between noninvasive cardiac imagers and the intraprocedural interventional imaging team and translation of the periprocedural imaging to the implanting team are crucial to the success of TMVR technology. Currently, the TMVR procedures discussed here are conducted either as part of clinical research or off label. The US Food and Drug Administration-approved mitral valve-in-valve procedures for the treatment of degenerated mitral bioprosthetic valves are not discussed here.