Novel Multiphase Assessment for Predicting Left Ventricular Outflow Tract Obstruction Before Transcatheter Mitral Valve Replacement

Christopher U. Meduri; Michael J. Reardon; D. Scott Lim; Elliot Howard; Gan Dunnington; David P. Lee; David Liang; Robert Gooley; Daniel O'Hair; Martin K. Ng; Antony Walton; Konstantinos Spargias; Daniel Blackman; Augustin Coisne; David Hildick-Smith; Marine De Gouy; Sharla Chenoweth; Saibal Kar; Patrick M. McCarthy; Nicolo Piazza; Atif Qasam; Randolph P. Martin; Martin B. Leon; Michael J. Mack; David H. Adams; Vinayak Bapat

doi:10.1016/j.jcin.2019.06.015

Novel Multiphase Assessment for Predicting Left Ventricular Outflow Tract Obstruction Before Transcatheter Mitral Valve Replacement

Christopher U. Meduri, Michael J. Reardon, D. Scott Lim, Elliot Howard, Gan Dunnington, David P. Lee, David Liang, Robert Gooley, Daniel O'Hair, Martin K. Ng, Antony Walton, Konstantinos Spargias, Daniel Blackman, Augustin Coisne, David Hildick-Smith, Marine De Gouy, Sharla Chenoweth, Saibal Kar, Patrick M. McCarthy, Nicolo PiazzaAtif Qasam, Randolph P. Martin, Martin B. Leon, Michael J. Mack, David H. Adams, Vinayak Bapat^*

^*Corresponding author for this work

Surgery, Cardiac Surgery Division

Research output: Contribution to journal › Article › peer-review

54 Scopus citations

Abstract

Objectives: This study proposes a physiologic assessment of left ventricular outflow tract obstruction (LVOTO) that accommodates changes in systolic flow and accounts for the dynamic neo–left ventricular outflow tract (LVOT). Background: Patients considered for transcatheter mitral valve replacement trials often screen-fail because of the perceived risk of LVOTO. In the Intrepid Global Pilot Study, assumed risk of LVOTO was based on computed tomography estimates of the neo-LVOT area computed at end-systole. However, this may overestimate actual risk. Methods: Retrospective analyses were performed for screen-failed patients for potential LVOTO (n = 33) and treated patients (n = 29) with available dynamic computed tomography. A multiphase assessment of the neo-LVOT area was performed and represented as: 1) multiphase average; and 2) early systolic value. Prospective evaluation was performed in 9 patients approved for enrollment with multiphase and early systole methods that would have previously screen-failed with the end-systolic approach. Results: Of 166 patients screened for possible inclusion; 32 were screen-failed for nonanatomical reasons. Screen failure for assumed LVOTO risk occurred in 37 of 134 (27.6%) patients. Retrospective analysis indicated a potential enrollment increase of 11 of 33 (33.3%) and 18 of 33 (54.5%) patients using multiphase and early systolic assessment methods. In the prospective cohort, there were no clinical observations of LVOTO 30 days post-procedure, despite assumed risk based on end-systolic estimates. Conclusions: Multiphase, and specifically early systolic, assessment of the neo-LVOT may better determine risk of LVOTO with transcatheter mitral valve replacement compared with end-systolic estimates. This novel approach has the potential to significantly increase patient eligibility, with over one-half of patients previously screen-failed now eligible for treatment.

Original language	English (US)
Pages (from-to)	2402-2412
Number of pages	11
Journal	JACC: Cardiovascular Interventions
Volume	12
Issue number	23
DOIs	https://doi.org/10.1016/j.jcin.2019.06.015
State	Published - Dec 9 2019

Funding

Jessica Dries-Devlin, PhD, CMPP, an employee of Medtronic, provided medical writing support under the direction of the lead authors.

Keywords

LVOT
TMVR
left ventricular outflow tract obstruction
mitral valve
neo-LVOT

ASJC Scopus subject areas

Cardiology and Cardiovascular Medicine

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10.1016/j.jcin.2019.06.015

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Meduri, C. U., Reardon, M. J., Lim, D. S., Howard, E., Dunnington, G., Lee, D. P., Liang, D., Gooley, R., O'Hair, D., Ng, M. K., Walton, A., Spargias, K., Blackman, D., Coisne, A., Hildick-Smith, D., De Gouy, M., Chenoweth, S., Kar, S., McCarthy, P. M., ... Bapat, V. (2019). Novel Multiphase Assessment for Predicting Left Ventricular Outflow Tract Obstruction Before Transcatheter Mitral Valve Replacement. JACC: Cardiovascular Interventions, 12(23), 2402-2412. https://doi.org/10.1016/j.jcin.2019.06.015

@article{66d9cf6bf704427297a3f33b814632cd,

title = "Novel Multiphase Assessment for Predicting Left Ventricular Outflow Tract Obstruction Before Transcatheter Mitral Valve Replacement",

abstract = "Objectives: This study proposes a physiologic assessment of left ventricular outflow tract obstruction (LVOTO) that accommodates changes in systolic flow and accounts for the dynamic neo–left ventricular outflow tract (LVOT). Background: Patients considered for transcatheter mitral valve replacement trials often screen-fail because of the perceived risk of LVOTO. In the Intrepid Global Pilot Study, assumed risk of LVOTO was based on computed tomography estimates of the neo-LVOT area computed at end-systole. However, this may overestimate actual risk. Methods: Retrospective analyses were performed for screen-failed patients for potential LVOTO (n = 33) and treated patients (n = 29) with available dynamic computed tomography. A multiphase assessment of the neo-LVOT area was performed and represented as: 1) multiphase average; and 2) early systolic value. Prospective evaluation was performed in 9 patients approved for enrollment with multiphase and early systole methods that would have previously screen-failed with the end-systolic approach. Results: Of 166 patients screened for possible inclusion; 32 were screen-failed for nonanatomical reasons. Screen failure for assumed LVOTO risk occurred in 37 of 134 (27.6%) patients. Retrospective analysis indicated a potential enrollment increase of 11 of 33 (33.3%) and 18 of 33 (54.5%) patients using multiphase and early systolic assessment methods. In the prospective cohort, there were no clinical observations of LVOTO 30 days post-procedure, despite assumed risk based on end-systolic estimates. Conclusions: Multiphase, and specifically early systolic, assessment of the neo-LVOT may better determine risk of LVOTO with transcatheter mitral valve replacement compared with end-systolic estimates. This novel approach has the potential to significantly increase patient eligibility, with over one-half of patients previously screen-failed now eligible for treatment.",

keywords = "LVOT, TMVR, left ventricular outflow tract obstruction, mitral valve, neo-LVOT",

author = "Meduri, {Christopher U.} and Reardon, {Michael J.} and Lim, {D. Scott} and Elliot Howard and Gan Dunnington and Lee, {David P.} and David Liang and Robert Gooley and Daniel O'Hair and Ng, {Martin K.} and Antony Walton and Konstantinos Spargias and Daniel Blackman and Augustin Coisne and David Hildick-Smith and {De Gouy}, Marine and Sharla Chenoweth and Saibal Kar and McCarthy, {Patrick M.} and Nicolo Piazza and Atif Qasam and Martin, {Randolph P.} and Leon, {Martin B.} and Mack, {Michael J.} and Adams, {David H.} and Vinayak Bapat",

note = "Publisher Copyright: {\textcopyright} 2019 American College of Cardiology Foundation",

year = "2019",

month = dec,

day = "9",

doi = "10.1016/j.jcin.2019.06.015",

language = "English (US)",

volume = "12",

pages = "2402--2412",

journal = "JACC: Cardiovascular Interventions",

issn = "1936-8798",

publisher = "Elsevier Inc.",

number = "23",

}

Meduri, CU, Reardon, MJ, Lim, DS, Howard, E, Dunnington, G, Lee, DP, Liang, D, Gooley, R, O'Hair, D, Ng, MK, Walton, A, Spargias, K, Blackman, D, Coisne, A, Hildick-Smith, D, De Gouy, M, Chenoweth, S, Kar, S, McCarthy, PM, Piazza, N, Qasam, A, Martin, RP, Leon, MB, Mack, MJ, Adams, DH & Bapat, V 2019, 'Novel Multiphase Assessment for Predicting Left Ventricular Outflow Tract Obstruction Before Transcatheter Mitral Valve Replacement', JACC: Cardiovascular Interventions, vol. 12, no. 23, pp. 2402-2412. https://doi.org/10.1016/j.jcin.2019.06.015

TY - JOUR

T1 - Novel Multiphase Assessment for Predicting Left Ventricular Outflow Tract Obstruction Before Transcatheter Mitral Valve Replacement

AU - Meduri, Christopher U.

AU - Reardon, Michael J.

AU - Lim, D. Scott

AU - Howard, Elliot

AU - Dunnington, Gan

AU - Lee, David P.

AU - Liang, David

AU - Gooley, Robert

AU - O'Hair, Daniel

AU - Ng, Martin K.

AU - Walton, Antony

AU - Spargias, Konstantinos

AU - Blackman, Daniel

AU - Coisne, Augustin

AU - Hildick-Smith, David

AU - De Gouy, Marine

AU - Chenoweth, Sharla

AU - Kar, Saibal

AU - McCarthy, Patrick M.

AU - Piazza, Nicolo

AU - Qasam, Atif

AU - Martin, Randolph P.

AU - Leon, Martin B.

AU - Mack, Michael J.

AU - Adams, David H.

AU - Bapat, Vinayak

PY - 2019/12/9

Y1 - 2019/12/9

N2 - Objectives: This study proposes a physiologic assessment of left ventricular outflow tract obstruction (LVOTO) that accommodates changes in systolic flow and accounts for the dynamic neo–left ventricular outflow tract (LVOT). Background: Patients considered for transcatheter mitral valve replacement trials often screen-fail because of the perceived risk of LVOTO. In the Intrepid Global Pilot Study, assumed risk of LVOTO was based on computed tomography estimates of the neo-LVOT area computed at end-systole. However, this may overestimate actual risk. Methods: Retrospective analyses were performed for screen-failed patients for potential LVOTO (n = 33) and treated patients (n = 29) with available dynamic computed tomography. A multiphase assessment of the neo-LVOT area was performed and represented as: 1) multiphase average; and 2) early systolic value. Prospective evaluation was performed in 9 patients approved for enrollment with multiphase and early systole methods that would have previously screen-failed with the end-systolic approach. Results: Of 166 patients screened for possible inclusion; 32 were screen-failed for nonanatomical reasons. Screen failure for assumed LVOTO risk occurred in 37 of 134 (27.6%) patients. Retrospective analysis indicated a potential enrollment increase of 11 of 33 (33.3%) and 18 of 33 (54.5%) patients using multiphase and early systolic assessment methods. In the prospective cohort, there were no clinical observations of LVOTO 30 days post-procedure, despite assumed risk based on end-systolic estimates. Conclusions: Multiphase, and specifically early systolic, assessment of the neo-LVOT may better determine risk of LVOTO with transcatheter mitral valve replacement compared with end-systolic estimates. This novel approach has the potential to significantly increase patient eligibility, with over one-half of patients previously screen-failed now eligible for treatment.

AB - Objectives: This study proposes a physiologic assessment of left ventricular outflow tract obstruction (LVOTO) that accommodates changes in systolic flow and accounts for the dynamic neo–left ventricular outflow tract (LVOT). Background: Patients considered for transcatheter mitral valve replacement trials often screen-fail because of the perceived risk of LVOTO. In the Intrepid Global Pilot Study, assumed risk of LVOTO was based on computed tomography estimates of the neo-LVOT area computed at end-systole. However, this may overestimate actual risk. Methods: Retrospective analyses were performed for screen-failed patients for potential LVOTO (n = 33) and treated patients (n = 29) with available dynamic computed tomography. A multiphase assessment of the neo-LVOT area was performed and represented as: 1) multiphase average; and 2) early systolic value. Prospective evaluation was performed in 9 patients approved for enrollment with multiphase and early systole methods that would have previously screen-failed with the end-systolic approach. Results: Of 166 patients screened for possible inclusion; 32 were screen-failed for nonanatomical reasons. Screen failure for assumed LVOTO risk occurred in 37 of 134 (27.6%) patients. Retrospective analysis indicated a potential enrollment increase of 11 of 33 (33.3%) and 18 of 33 (54.5%) patients using multiphase and early systolic assessment methods. In the prospective cohort, there were no clinical observations of LVOTO 30 days post-procedure, despite assumed risk based on end-systolic estimates. Conclusions: Multiphase, and specifically early systolic, assessment of the neo-LVOT may better determine risk of LVOTO with transcatheter mitral valve replacement compared with end-systolic estimates. This novel approach has the potential to significantly increase patient eligibility, with over one-half of patients previously screen-failed now eligible for treatment.

KW - LVOT

KW - TMVR

KW - left ventricular outflow tract obstruction

KW - mitral valve

KW - neo-LVOT

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UR - http://www.scopus.com/inward/citedby.url?scp=85075314211&partnerID=8YFLogxK

U2 - 10.1016/j.jcin.2019.06.015

DO - 10.1016/j.jcin.2019.06.015

M3 - Article

C2 - 31629753

AN - SCOPUS:85075314211

SN - 1936-8798

VL - 12

SP - 2402

EP - 2412

JO - JACC: Cardiovascular Interventions

JF - JACC: Cardiovascular Interventions

IS - 23

ER -

Novel Multiphase Assessment for Predicting Left Ventricular Outflow Tract Obstruction Before Transcatheter Mitral Valve Replacement

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