Abstract 735 Characterisation of Dynamic Mitral Valve Geometry Changes throughout the Cardiac Cycle and Prediction of Transmitral Gradients after Transcatheter Mitral Valve Repair using Edwards PASCAL System

AIMS:
Transcatheter mitral valve repair (TMVR) is an effective and safe therapy of mitral valve regurgitation (MR). Quantification of the acute dynamic changes of mitral valve (MV) geometry throughout the cardiac cycle can reveal the effects of the unique grasping mechanism of the PASCAL system and allows for the more advanced detection of predictors of post-procedural transmitral gradients.

METHODS:
All patients underwent peri-procedural transoesophageal echocardiography including acquisition of pre- and post-interventional 3-dimensional MV imaging. Assessment of the acute dynamic MV geometry changes was performed using TOMTEC Arena 4D MV-Assessment application in a saddle-shape MV model. Analysis of predictors of transmitral gradients was performed in univariable linear regression. Following, significantly associated variables were included in a stepwise multivariable approach.

RESULTS:
A total of 50 patients suffering from relevant MR at suspected high operative risk with a suitable anatomy for PASCAL implantation were included in this analysis. MR aetiology was primary in 18% and secondary functional in 82% of patients. More than one PASCAL device was implanted in 42%. At discharge, 86% of patient had MR grade ≤1. Analysis of acute dynamic changes of MV geometry revealed a consistent significant reduction of the anterior-posterior (AP) diameter throughout the entire cardiac cycle (end-systolic ∆ -1.8mm; p<0.001) while lateral-medial (LM) diameter was left unchanged (end-systolic p=0.552) after PASCAL implantation. The annular sphericity index (ASI=AP/LM diameter) was significantly reduced (end-systolic ∆ -0.05; p<0.001). Assessment of changes of annular area (end-systolic ∆ -0.6cm²; p<0.001) and annular circumference (end-systolic ∆ -3.0mm; p<0.001) proofed a significant indirect annuloplasty of TMVR using PASCAL system.

Post-procedural elevations of transmitral gradients ≥5mmHg were observed in 12% of cases. Stepwise multivariable linear regression model proofed pre-procedural mid-diastolic/ end-systolic ASI ratio as a surrogate of MV annular compliance independently predictive for elevations of transmitral gradients at discharge (standardised beta -0.371; p=0.008).

CONCLUSION:
Leaflet approximation of MV using PASCAL device showed a significant reduction of AP diameter and concomitant indirect annuloplasty in the entire cardiac cycle. An estimate of MV annular compliance was independently predictive for post-procedural elevations of transmitral gradients in stepwise multivariable regression analysis.

Figure 1: Dynamic mitral valve geometry changes throughout the cardiac cycle after transcatheter mitral valve repair using PASCAL system

In the entire cardiac cycle PASCAL device implantation showed a significant reduction of the anterior-posterior Diameter (AP) and the annular sphericity index (ASI). Analysis of annular circumference and annular area proofed a significant indirect annuloplasty after TMVR.

Clin Res Cardiol (2022). https://doi.org/10.1007/s00392-022-02002-5
Characterisation of Dynamic Mitral Valve Geometry Changes throughout the Cardiac Cycle and Prediction of Transmitral Gradients after Transcatheter Mitral Valve Repair using Edwards PASCAL System
S. Rosch¹, L. Kösser², C. Besler¹, S. Leontyev², D. Holzhey³, M. A. Borger², H. Thiele¹, J. Ender⁴, P. Lurz¹, T. Noack²
¹Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig - Universität Leipzig, Leipzig; ²Universitätsklinik für Herzchirurgie, Herzzentrum Leipzig - Universität Leipzig, Leipzig; ³Klinik für Herz- und Thoraxchirurgie, Helios Klinikum Wuppertal - Herzzentrum, Wuppertal; ⁴Klinik für Anästhesiologie, Herzzentrum Leipzig - Universität Leipzig, Leipzig;
AIMS: Transcatheter mitral valve repair (TMVR) is an effective and safe therapy of mitral valve regurgitation (MR). Quantification of the acute dynamic changes of mitral valve (MV) geometry throughout the cardiac cycle can reveal the effects of the unique grasping mechanism of the PASCAL system and allows for the more advanced detection of predictors of post-procedural transmitral gradients. METHODS: All patients underwent peri-procedural transoesophageal echocardiography including acquisition of pre- and post-interventional 3-dimensional MV imaging. Assessment of the acute dynamic MV geometry changes was performed using TOMTEC Arena 4D MV-Assessment application in a saddle-shape MV model. Analysis of predictors of transmitral gradients was performed in univariable linear regression. Following, significantly associated variables were included in a stepwise multivariable approach. RESULTS: A total of 50 patients suffering from relevant MR at suspected high operative risk with a suitable anatomy for PASCAL implantation were included in this analysis. MR aetiology was primary in 18% and secondary functional in 82% of patients. More than one PASCAL device was implanted in 42%. At discharge, 86% of patient had MR grade ≤1. Analysis of acute dynamic changes of MV geometry revealed a consistent significant reduction of the anterior-posterior (AP) diameter throughout the entire cardiac cycle (end-systolic ∆ -1.8mm; p<0.001) while lateral-medial (LM) diameter was left unchanged (end-systolic p=0.552) after PASCAL implantation. The annular sphericity index (ASI=AP/LM diameter) was significantly reduced (end-systolic ∆ -0.05; p<0.001). Assessment of changes of annular area (end-systolic ∆ -0.6cm²; p<0.001) and annular circumference (end-systolic ∆ -3.0mm; p<0.001) proofed a significant indirect annuloplasty of TMVR using PASCAL system. Post-procedural elevations of transmitral gradients ≥5mmHg were observed in 12% of cases. Stepwise multivariable linear regression model proofed pre-procedural mid-diastolic/ end-systolic ASI ratio as a surrogate of MV annular compliance independently predictive for elevations of transmitral gradients at discharge (standardised beta -0.371; p=0.008). CONCLUSION: Leaflet approximation of MV using PASCAL device showed a significant reduction of AP diameter and concomitant indirect annuloplasty in the entire cardiac cycle. An estimate of MV annular compliance was independently predictive for post-procedural elevations of transmitral gradients in stepwise multivariable regression analysis. Figure 1: Dynamic mitral valve geometry changes throughout the cardiac cycle after transcatheter mitral valve repair using PASCAL system In the entire cardiac cycle PASCAL device implantation showed a significant reduction of the anterior-posterior Diameter (AP) and the annular sphericity index (ASI). Analysis of annular circumference and annular area proofed a significant indirect annuloplasty after TMVR.
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