To plan a transseptal Balloon-expandable ViVMitrale prosthesis implantation in a degenerated biological surgical prosthesis, follow these steps:

1. Pre-Procedural Assessment:

• Perform a computed tomography (MDCT) scan to obtain detailed images of the patient’s anatomy.
• Use TMVR planning software (such as Aycan, Osirix, or 3mensio Structural Heart software) to simulate the valve implantation and assess the risk of LVOT obstruction (Neo-LVOT).
• Analyze the aorto-mitral angle to predict any complications.
• Study the degenerated biological mitral prosthesis in depth: brand, model, size…
• Evaluate the Neo-LVOT area to identify patients at high risk of obstruction. A Neo-LVOT area of less than 1.7 cm² is a significant indicator of risk*.
• Assess atrial dimensions

2. Valve Selection:

• Choose the transcatheter valve size based on the manufacturer’s reported internal diameter of the degenerated biological prosthesis and CT scan measurements.
• Consult applications such as Valve in Valve Mitral app to ensure correct valve size selection.

3. Access and Techniques:

• Decide on the appropriate access (transseptal, transapical, or transatrial) based on the complexity of the patient’s anatomy and local guidelines.
• It is best to use a CE-certified balloon-expandable transcatheter valve for this type of procedure.

4. Implantation Procedure:

• Perform the valve implantation using standard techniques. Carefully monitor the patient’s hemodynamics during the procedure.
• Use intra-procedural angiography/echocardiography combo techniques to verify the correct valve position and to detect any complications such as LVOT obstruction.
  

5. Post-Procedural Monitoring:

• Perform an echocardiographic assessment to confirm the proper functioning of the implanted valve and to monitor the LVOT gradient.
• Plan regular check-ups to monitor any changes in the patient’s cardiac function and to manage complications.

6. Multidisciplinary Collaboration:

• Ensure that a multidisciplinary team of interventional cardiologists and cardiac surgeons are involved in the planning and execution of the procedure.
• Review the clinical, echocardiographic, and MDCT data for each patient in a pre-procedural meeting to discuss the case and plan the best strategy.

Image Preparation

1. Image Upload:Upload the patient’s CT images into the software. Ensure that the images are synchronized with the ECG for correct analysis of the systolic phase.

2. 3D Reconstruction:Use the software’s 3D reconstruction feature to get a detailed view of the cardiac anatomy, focusing on the left ventricular outflow tract (LVOT) area and the mitral annulus.

Segmentation and Planimetry

3. Mitral Ring Segmentation:Identify the annulus of the biological prosthesis on the CT images and take accurate measurements. The software should allow precise definition of the edges for accurate measurement.

4. Virtual Valve Implantation: Use the software’s simulation module to place a virtual valve in the mitral annulus. This will allow you to see how the valve will affect the anatomy of the Neo LVOT. Adjust the position of the virtual valve to most accurately reflect the intended position of the implanted valve.

Neo LVOT Measurement

5. Neo LVOT Plane Identification:Use the multiplanar reconstruction (MPR) feature to identify the transverse plane of the Neo LVOT. This plane is critical for accurate measurement. Align the center of the virtual mitral valve with the Neo LVOT plane, ensuring proper alignment for accurate measurement.

6. Neo LVOT Planimetry:Trace the outline of the Neo LVOT in the transverse plane using the software’s planimetry tools.Measure the traced Neo LVOT area and record the values. Ensure that the measurement is taken during the systolic phase when the Neo LVOT area is minimal.

Result Analysis

7. Size Assessment:Compare the measured Neo LVOT area to reference values ​​to identify the risk of obstruction. A Neo LVOT area less than 1.7 cm² is considered at high risk of obstruction.

8. Documentation and Reporting: Save annotated images and measurements in the patient’s image management system.Prepare a detailed report that includes Neo LVOT measurements and an obstruction risk assessment for clinical review. An ISO 9001-certified report is of added value.

Follow-Up

9. Multidisciplinary Discussion:: Present the measurement results in a multidisciplinary meeting with cardiologists and cardiac surgeons to plan the TAVR procedure.Evaluate the need for additional interventions (such as alcohol septal ablation or anterior mitral leaflet tear) to mitigate the risk of LVOT obstruction.

By following these steps, you will be able to effectively use the certified software to measure the Neo LVOT area and assess the risk of complications before a transcatheter mitral valve prosthesis implantation.

Take notes on the journey