Predicting LVOT Obstruction in Transcatheter Mitral Valve Replacement for Failed Surgical Annuloplasty

Echocardiography to estimate high filling pressure in patients with heart failure and reduced ejection fraction

Aims: Echocardiographic assessment of left ventricular filling pressures is performed using a multi-parametric algorithm. Unselected sample of patients with heart failure with reduced ejection fraction (HFrEF) patients may demonstrate an indeterminate status of diastolic indices making interpretation challenging. We sought to test improvement in the diagnostic accuracy of standard and strain echocardiography of the left ventricle and left atrium (LA) to estimate a pulmonary capillary wedge pressure (PCWP) > 15 mmHg in patients with HFrEF. Methods and results: Out of 82 consecutive patients, 78 patients were included in the final analysis and right heat catheterization, and echocardiogram…

Simulation of left ventricular outflow tract (LVOT) obstruction in transcatheter mitral valve-in-ring replacement.

Left ventricular outflow tract (LVOT) obstruction is a feared complication of transcatheter mitral valve replacement (TMVR). This procedure leads to an elongation of LVOT in the left ventricle (namely, the neoLVOT), ultimately portending hemodynamic impairment and death. This study sought to understand the biomechanical implications of LVOT obstruction in two patients who underwent TMVR as an "off-label" application of the Edwards SAPIEN 3 (S3) Ultra transcatheter heart valve (THV). A computational framework of TMVR was developed to assess the neoLVOT area and quantify the sub-aortic flow structure. We observed that the annuloplasty ring serves as the key anchor zone of S3 Ultra THV. A good…

Numerical simulation of transcatheter mitral valve replacement: The dynamic implication of LVOT obstruction in the valve-in-ring case.

Transcatheter mitral valve replacement (TMVR) has been used for “off-label” treatment when annuloplasty band ring for mitral repair fails. However, the complex anatomy and function of the mitral valve may lead to fatal complications as a result of the left ventricular outflow tract (LVOT) obstruction in TMVR. We report the structural and hemodynamic response of LVOT obstruction resulting from TMVR with the Edwards SAPIEN 3 Ultra (S3) device. We modified the original Living Heart Human Model (LHHM) to account for a failed mitral valve with an annuloplasty band ring and simulated the cardiac beating condition in the setting of S3 device implantation. Findings demonstrated a high dynamic behav…

Simulation study of transcatheter heart valve implantation in patients with stenotic bicuspid aortic valve

Bicuspid aortic valve (BAV) anatomy has routinely been considered an exclusion in the setting of transcatheter aortic valve implantation (TAVI) because of the large dimension of the aortic annulus having a more calcified, bulky, and irregular shape. The study aims to develop a patient-specific computational framework to virtually simulate TAVI in stenotic BAV patients using the Edwards SAPIEN 3 valve (S3) and its improved version SAPIEN 3 Ultra and quantify stent frame deformity as well as the severity of paravalvular leakage (PVL). Specifically, the aortic root anatomy of n.9 BAV patients who underwent TAVI was reconstructed from pre-operative CT imaging. Crimping and deployment of S3 fram…

Pre-Operative Modeling of Transcatheter Mitral Valve Replacement in a Surgical Heart Valve Bioprosthesis

Obstruction of the left ventricular outflow tract (LVOT) is a common complication of transcatheter mitral valve replacement (TMVR). This procedure can determine an elongation of an LVOT (namely, the neo-LVOT), ultimately portending hemodynamic impairment and patient death. This study aimed to understand the biomechanical implications of LVOT obstruction in a patient who underwent TMVR using a transcatheter heart valve (THV) to repair a failed bioprosthetic heart valve. We first reconstructed the heart anatomy and the bioprosthetic heart valve to virtually implant a computer-aided-design (CAD) model of THV and evaluate the neo-LVOT area. A numerical simulation of THV deployment was then deve…

Transcatheter Heart Valve Implantation in Bicuspid Patients with Self-Expanding Device

Bicuspid aortic valve (BAV) patients are conventionally not treated by transcathether aortic valve implantation (TAVI) because of anatomic constraint with unfavorable outcome. Patient-specific numerical simulation of TAVI in BAV may predict important clinical insights to assess the conformability of the transcathether heart valves (THV) implanted on the aortic root of members of this challenging patient population. We aimed to develop a computational approach and virtually simulate TAVI in a group of n.6 stenotic BAV patients using the self-expanding Evolut Pro THV. Specifically, the structural mechanics were evaluated by a finite-element model to estimate the deformed THV configuration in …

CAD Modeling for Evaluating LVOT Obstruction in Transcatheter Mitral Valve Replacement

The current generation of transcatheter heart valves (THV), as the Edwards SAPIEN 3 Ultra (S3), is not specifically designed for mitral position implantation and has intrinsic design geometry that may make mitral implantation suboptimal. This study aimed to develop a computed-tomography (CT) based CAD workflow for the preoperative planning of transcatheter mitral valve replacement (TMVR) by evaluating the resulting obstruction in the left ventricular outflow tract (LVOT). Specifically, the computational framework to reconstruct heart anatomy and virtually deploy the THV into mitral valve annulus was developed and successively applied to the cases of two patients who experienced annuloplasty…