FunctionalmitralregurgitationrevisitedCMRandCT:addedvalue?

AnaG.Almeida

Functionalmitralregurgitation

Ischemic- InferiorMI- Papillarymusclerupture–

LCX/RCA- AnteriorMIandLVremodeling

Non-ischemic- DilatedCMP- HCM

Ischemicmitralregurgitation

AsymmetricversusSymmetricTethering

LocalizedremodellingPMdisplacementMildannulusdilatationAsymmetrictetheringModeratetenting

GlobalremodellingAnnulus dilatationSymmetrictetheringSeveretenting

PosteriorMI Ischemiccardiomyopathy

Ø CMRandCT

Ø Addedvaluetoechoassessment?

• Mitralregurgitationseverity

CMR:Qualitative assessment

Quantitative assessment

• Accurateandreproducibleassessment,independentofjetnumberandeccentricity

• Reliablewhenthereare2associatedlesions

• LVstroke volume-RVstroke volume=Rvol and RF

• LVstroke volume-aortic forward flow=Rvol/RF

• Anatomiccharacterization,etiologyandpredictionoffMR

CMR:Mitralvalveanatomy

Speaker

5mmstackcoveringallMVscallops

CMRandCT

Ø Tentingarea,coaptation depth,annulusdimension,leafletlength……..

Fernandez-Golfin etal.Int JCvim 2011

EDinterPMdistance ESinterPMdistance

CMRbetterthanCT(temporalresolution)

Fernandez-Golfin etal.Int JCvim 2011

Mitralregurgitation– ischemicversusnon-ischemic

380pts withMI,20%withpartialPMinfarctionBouam etal.Clin ResCardiol 2016

PredictorsofFunctionalMitralRegurgitation

Bouam etal.Clin ResCardiol 2016

Chinitz etal.JACCCardiov Im 2013

- 153firstMI,PMI30%- PMIwasnotindependentlyassociatedtofMR- Inmultivariableanalysis,lateralwallinfarctsizewasindependentlyassociatedwith≥moderatefMR

Totalmitralleafletarea Beaudoin etal.Circ Cardiovasc Imaging.2013

Mitralclosurearea

Beaudoin etal.Circ Cardiovasc Imaging.2013

Nl versusDCM(withoutMRversuswithfMR)

Beaudoin etal.Circ Cardiovasc Imaging.2013

MitralvalveenlargementforadaptingtopreventMRinpatientswithabnormalLVfunction

Mitralleafletssize- CTreproducibility

• Prognosis

Pts withIMRandannuloplasty

ExtentoffibrosiswasrelatedtopostopLVEF

Takedaetal.Circ j2011

• Basalsegmentswithfibrosis- lackofimprovementafterannuloplasty(lackofreverseremodelingandgeometricrecovery)

• ThebasalportionoftheLVisconnectedwithlongitudinalsubendocardialmusclefibers sensitivetopathologicalconditionsincludingischemiaandinfarctionascomparedwiththeapicalportion

Takedaetal.Circ j2011

Fig2

The Annals of Thoracic Surgery 2014 98, 1557-1563DOI: (10.1016/j.athoracsur.2014.06.049)

FibrosisbyLGECMRwasanindependentpredictorofMACEaftersurgicalrepairamongclinicalvariables,riskfactorsandpre-operativecharacteristicsofMV

FibrosisandpredictionofMACEafterMitraclip

33pts Mitraclip forfunctionalmitralregurgitation;fibrosisofinferolateral segmentswerethemostprevalent

Velu etal.CatheterCardiovasc Interv.2018;1–4.

• Assessmentbeforeintervention

Blanke etal.JACCCVIm 2015

TranscatheterMitralValveReplacement

Mak Getal.Circ CVImag 2016

Transcatheter mitralvalveinterventions/CT

• Cross-sectionalarea,perimeter,anddiametersoftheannulus

• Annuluscalcification• Papillarymuscleanatomy• Landingzoneand

myocardialshelf• Distance

annulus/coronarysinus• Distance

annulus/circunflex• Aorto-mitralangle

Mak Getal.Circ CVImag 2016

- Characterizationofapost-procedural"neo-LVOT.”- Factorsthatpredictneo-LVOTobstruction- acuteaortomitral angle,smallLVcavitysize,andbasalseptalhypertrophy

Transcatheter mitralvalveinterventions/CTPredictingLVobstruction– Virtualplacement

Blanke etal,JACCCVImag 2016

Conclusions

• CMRandCTareusefulandpromisingtoolsforpreciseandaccurateassessmentoffunctionalmitralregurgitation

• Thesemodalitiesprovideinformationonanatomy,etiology,functionalseverity,tissuecharacterization,prognosisandprocedure’splanning,yetawaitingfuturedevelopments