PLEASE SAVE A COPY OF THIS FLIER AS YOUR CERTIFICATE OF ATTENDANCE CARDIOLOGY GRAND ROUNDS Presentation: Use of CT to support appropriate selection of patients and devices / guide to non‐surgical mitral valve replacement Speaker: Jonathon A. Leipsic, MD, FRCPS, FSCCT Chairman, Department of Radiology, Providence Health Care, Vancouver, BC Vice Chairman – Research, University of British Columbia, Department of Radiology Associate Professor of Radiology and Cardiology, University of British Columbia Canada Research Chair, Advanced Cardiopulmonary Imaging Date: Monday, October 26, 2015, 7:00 – 8:00 AM Location: ANW Education Building, Watson Room OBJECTIVES At the completion of this activity, the participants should be able to: 1. Review the role of MDCT for structural heart disease and transcatheter valvular assessment. 2. Review the current data for the use of MDCT for mitral valvular assessment and annular sizing for TMVI. 3. Discuss the unanswered questions that remain in transcatheter mitral valve implantation and how MDCT may provide some answers. ACCREDITATION Physicians: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Allina Health and Minneapolis Heart Institute Foundation. Allina Health is accredited by the ACCME to provide continuing medical education for physicians. Allina Health designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit TM . Physicians should only claim credit commensurate with the extent of their participation in the activity. Nurses: This activity has been designed to meet the Minnesota Board of Nursing continuing education requirements for 1.2 hours of credit. However, the nurse is responsible for determining whether this activity meets the requirements for acceptable continuing education. Others: Individuals representing other professional disciplines may submit course materials to their respective professional associations for 1.0 hours of continuing education credit. DISCLOSURE STATEMENTS Speaker(s): Dr. Leipsic has declared following relationships. Consultant: Neovasc Inc. and Tendyne Holdings Inc. Planning Committee: Dr. Michael Miedema, and Eva Zewdie have declared that they do not have any conflicts of interest associated with the planning of this activity. Dr. Robert Schwartz declared the following relationships ‐ stockholder: Cardiomind, Interface Biologics, Aritech, DSI/Transoma, InstyMeds, Intervalve, Medtronic, Osprey Medical, Stout Medical, Tricardia LLC, CoAptus Inc, Augustine Biomedical; scientific advisory board: Abbott Laboratories, Boston Scientific, MEDRAD Inc, Thomas, McNerney & Partners, Cardiomind, Interface Biologics; options: BackBeat Medical, BioHeart, CHF Solutions; speakers bureau: Vital Images; consultant: Edwards LifeSciences.
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PLEASE SAVE A COPY OF THIS FLIER AS YOUR CERTIFICATE OF ATTENDANCE
C A R D I O L O G Y G R A N D R O U N D S Presentation: Use of CT to support appropriate selection of patients and devices
/ guide to non‐surgical mitral valve replacement
Speaker: Jonathon A. Leipsic, MD, FRCPS, FSCCTChairman, Department of Radiology, Providence Health Care, Vancouver, BC Vice Chairman – Research, University of British Columbia, Department of Radiology Associate Professor of Radiology and Cardiology, University of British Columbia Canada Research Chair, Advanced Cardiopulmonary Imaging
Date: Monday, October 26, 2015, 7:00 – 8:00 AM
Location: ANW Education Building, Watson Room
OBJECTIVES At the completion of this activity, the participants should be able to: 1. Review the role of MDCT for structural heart disease and transcatheter valvular assessment. 2. Review the current data for the use of MDCT for mitral valvular assessment and annular sizing for TMVI. 3. Discuss the unanswered questions that remain in transcatheter mitral valve implantation and how MDCT may
provide some answers.
ACCREDITATION Physicians: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Allina Health and Minneapolis Heart Institute Foundation. Allina Health is accredited by the ACCME to provide continuing medical education for physicians.
Allina Health designates this live activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Nurses: This activity has been designed to meet the Minnesota Board of Nursing continuing education requirements for 1.2 hours of credit. However, the nurse is responsible for determining whether this activity meets the requirements for acceptable continuing education.
Others: Individuals representing other professional disciplines may submit course materials to their respective professional associations for 1.0 hours of continuing education credit.
DISCLOSURE STATEMENTS Speaker(s): Dr. Leipsic has declared following relationships. Consultant: Neovasc Inc. and Tendyne Holdings Inc.
Planning Committee: Dr. Michael Miedema, and Eva Zewdie have declared that they do not have any conflicts of interest associated with the planning of this activity. Dr. Robert Schwartz declared the following relationships ‐ stockholder: Cardiomind, Interface Biologics, Aritech, DSI/Transoma, InstyMeds, Intervalve, Medtronic, Osprey Medical, Stout Medical, Tricardia LLC, CoAptus Inc, Augustine Biomedical; scientific advisory board: Abbott Laboratories, Boston Scientific, MEDRAD Inc, Thomas, McNerney & Partners, Cardiomind, Interface Biologics; options: BackBeat Medical, BioHeart, CHF Solutions; speakers bureau: Vital Images; consultant: Edwards LifeSciences.
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MDCT to Guide Mitral Valve Interventions
Jonathon Leipsic MD FRCPC FSCCTVice Chairman of Radiology
Associate Professor Radiology and Cardiology UBC
President Society of Cardiovascular CTCanada Research Chair Advanced Cardiac
Imaging
Disclosures
Speaker’s bureau: GE Healthcare and Edwards LifeSciences
Grant Support‐ CIHR, NIH, GE Healthcare, Heartflow
• Ventricular anchors to fix the valve onto fibrous trigone and posterior annulus
• Captures the anterior and posterior leaflets
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Annular Segmentation
Angle Prediction and coronary sinus localization
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Device Cloning and Neo LVOT
How did we get to this point together?
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1‐MDCT aids in the diagnosis of valvular disease
Temporal Resolution
• Echo > 30 fps (<33 msec)
• 64‐slice CT 165 msec
• Dual‐source CT 83 msec (2nd Gen. 75msec)
CT Limitations Assessing Valves
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CT Limitations Assessing Valves
• Irregular rhythms (variability, gating)
• Difficult images and artifacts
–Obesity
–Calcium and leads
–Motion artifacts
Strength of CT is Anatomical DetailUnicuspid Valve Quadricuspid
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Normal Mitral Valve Anatomy on MDCT
Mitral Valvular Disease
• Patient with rheumatic mitral valve and mild mitral stenosis (valve area 1.6 cm2)
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Mitral valve stenosis‐ Limited Data
Planimetry by CT vs. Echocardiography
Messika-Zeitoun et al. JACC 2006
Moderate Mitral Stenosis
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Mitral Regurgitation
MR can be isolated in location (involved
scallops) or timing (part of systole)
Minimum Intensity Projection
Any MR? Moderate MR by TEE
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• Most common valvular heart disease
Classification
• due to a primary abnormality of the valve apparatus
– Mitral valve prolapse (aka "degenerative" or myxomatousmitral valve disease)
– Rheumatic heart disease
– Infective endocarditis
• secondary to another cardiac disease (functional)
– Ischemic cardiomyopathy
– Dilated cardiomyopathies
Mitral regurgitationFacts
• abnormal systolic displacement of one or both leaflets into the left atrium (systolic billowing) due to a disruption or elongation of leaflets, chordae, or papillary muscles
• Echocardiography: Billowing of any portion of the mitral leaflets ≥2 mm above the annular plane in a long axis view (parasternal or apical three‐chamber)
Mitral Valve Prolapse (MVP)
Definition
Classification
•abnormal movement of the valve: • Billowing: when the tips of leaflets remain in the left ventricle• Flail: when the tip(s) of one (or both) leaflets prolapses into the left atrium
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Mitral Valve Prolapse (MVP)
Ethiology of MVP and mechanism of MR
Disease Mechanism of regurgitation
Primary MVP
Fibroelastic deficiencyIsolated prolapse of the mitral leaflet (commonly P2 scallop)Frequent chordal ruptureMild annular enlargement
Acute rheumatic fever Chordal and leaflet destruction by acute inflammatory process
Endocarditis Chordal and leaflet destruction by infectious process; vegetations
Other (trauma, severe mitralannular calcification, hypertrophic
cardiomyopathy)Ruptured chordae, no myxomatous changes of mitral valve leaflets
Image: Adams et al. EHJ 2010 Table: Uptodate.com
Mitral valve apparatusLeaflet anatomy
MPR minIP
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Mitral valve apparatusPapillary muscles
Mitral Valve Prolapse
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Mitral Valve Prolapse
Mitral Valve Prolapse (MVP)
Importance of the employed view
MVP should never be diagnosed on 4 chamber reconstruction
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Mitral Valve Prolapse (MVP)
Importance of the employed view
https://depts.washington.edu/cvrtc/iafnew.gifLevine et al. Circulation 1989
Mitral Valve Prolapse (MVP)
Pseudoprolapse
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Diagnostic Accuracy of MDCT for MVP
Source: Feuchtner et al Radiology 2010
4 ways CT can help with TMVI in 2015
• Anatomic assessment of valvular apparatus
• Help with annular sizing and device selection
• Understanding mechanisms and risk of LVOT obstruction
• Prediction of appropriate fluoroscopy angles for coaxial deployment
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2‐MDCT allows for a granular and clear definition of the mitral
annulus
MDCT to Guide TranscatheterMitral Valve Replacement
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Advantages to MDCT methods
Greater reproducibility (less operator dependent)
Less sensitive to minor changes in obliquity
“3‐D”“3‐D”
“2D”Source: Gurvitch et al JACC Interventions Nov 2011
Mitral Annulus is non‐planar
Source: Levine et al Circulation 1989
Saddle shape with a valley and 2 peaks extending to the aortic root
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The mitral annulus is segmented posteriorly along the insertion of the posteriormitral valve leaflet and anteriorly along the insertion of the intervalvular fibrosa.
Mitral Annular Segmentation with MDCT
Source: Blanke et al. JACC Imaging 2015
Segmentation of the Saddle and D Shaped Annulus
Source: Blanke and Naoum et al JACC Imaging 2015
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Saddle Shaped Annulus
Mitral annulus
• Posterior peak: Insertion of the posterior mitralleaflet at atrioventricularjunction
• Anterior/aortic peak:insertion of intervalvularfibrosa at the left atrium, in part continuous with the aortic annulus
• Nadirs: are located at the level of fibrous trigones.
Lee et al. Circulation 2013
Flachskampf et al. Circulation 2000
The mitral annulus is segmented posteriorly along the insertion of the posteriormitral valve leaflet and anteriorly along the insertion of the intervalvular fibrosa.