Transcatheter Mitral Valve Planning and the Neo-LVOT: Utilization of Virtual Simulation Models and 3D Printing

  • Keshav Kohli
  • Zhenglun Alan Wei
  • Ajit P. Yoganathan
  • John N. Oshinski
  • Jonathon Leipsic
  • Philipp Blanke
Imaging (Q Truong, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Imaging


Purpose of review

Transcatheter mitral valve replacement (TMVR) is an emerging alternative for patients with severe mitral valve regurgitation who are considered at high risk for conventional surgical options. The early clinical experience with TMVR has shown that pre-procedural planning with computed tomography (CT) is needed to mitigate the risk of potentially lethal procedural complications such as left ventricular outflow tract (LVOT) obstruction. The goal of this review is to provide an overview of key concepts relating to TMVR pre-procedural planning, with particular emphasis on imaging-based methods for predicting TMVR-related LVOT obstruction.

Recent findings

Risk of LVOT obstruction can be assessed with CT-based pre-procedural planning by using virtual device simulations to estimate the residual ‘neo-LVOT’ cross-sectional area which remains after device implantation. A neo-LVOT area of less than 2 cm2 is currently thought to increase the risk of obstruction; however, additional studies are needed to further validate this cutoff value. Three-dimensional printing and personalized computational simulations are also emerging as valuable tools which may offer insights not readily confered by conventional two-dimensional image analysis. The simulated neo-LVOT should be routinely assessed on pre-procedural CT when evaluating anatomical suitability for TMVR.


Neo-LVOT Procedural planning Transcatheter mitral valve replacement Transcatheter mitral valve implantation TMVI TMVR 3D printing 


Compliance with Ethical Standards

Conflict of Interest

Zhenglun Alan Wei, Ajit P. Yoganathan, and John N. Oshinski each declare no potential conflicts of interest.

Keshav Kohli is a consultant to Abbott Laboratories.

Jonathon Leipsic is a consultant to Heartflow and Circle Cardiovascular Imaging.

Philipp Blanke is a consultant to Edwards Lifesciences, Tendyne, Neovasc, and Circle Cardiovascular Imaging.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Blanke P, Naoum C, Webb J, Dvir D, Hahn RT, Grayburn P, et al. Multimodality imaging in the context of transcatheter mitral valve replacement establishing consensus among modalities and disciplines. JACC Cardiovasc Imaging. 2015;8(10):1192–208. Scholar
  2. 2.
    Sorajja P, Gössl M, Bae R, Tindell L, Lesser JR, Askew J, et al. Severe mitral annular calcification: first experience with transcatheter therapy using a dedicated mitral prosthesis. JACC Cardiovasc Interv. 2017;10(11):1178–9. Scholar
  3. 3.
    Cheung A, Denti P, Kiaii B, Bagur R, Webb J, Latib A, et al. Mitral valve-in-ring implantation with a dedicated transcatheter mitral valve replacement system. JACC Cardiovasc Interv. 2017;10(19):2012–4. Scholar
  4. 4.
    Regueiro A, Granada JF, Dagenais F, Rodés-Cabau J. Transcatheter mitral valve replacement: insights from early clinical experience and future challenges. J Am Coll Cardiol. 2017;69(17):2175–92. Scholar
  5. 5.
    Alkhouli M, Alqahtani F, Aljohani S. Transcatheter mitral valve replacement: an evolution of a revolution. J Thorac Dis. 2017;9(Suppl 7):S668–72. Scholar
  6. 6.
    Muller DWM, Farivar RS, Jansz P, Bae R, Walters D, Clarke A, et al. Transcatheter mitral valve replacement for patients with symptomatic mitral regurgitation: a global feasibility trial. J Am Coll Cardiol. 2017;69(4):381–91. Scholar
  7. 7.
    Bapat V, Rajagopal V, Meduri C, Farivar RS, Walton A, Duffy SJ, et al. Early experience with new Transcatheter mitral valve replacement. J Am Coll Cardiol. 2018;71(1):12–21. Scholar
  8. 8.
    Descoutures F, Himbert D, Maisano F, Casselman F, de Weger A, Bodea O, et al. Transcatheter valve-in-ring implantation after failure of surgical mitral repair. Eur J Cardio-thoracic Surg. 2013;44(1):e8–e15. Scholar
  9. 9.
    Ye J, Cheung A, Yamashita M, Wood D, Peng D, Gao M, et al. Transcatheter aortic and mitral valve-in-valve implantation for failed surgical bioprosthetic valves an 8-year single-center experience. JACC Cardiovasc Interv. 2015;8(13):1735–44. Scholar
  10. 10.
    • Guerrero M, Urena M, Himbert D, Wang DD, Eleid M, Kodali S, et al. 1-year outcomes of Transcatheter mitral valve replacement in patients with severe mitral annular calcification. J Am Coll Cardiol. 2018;71(17):1841–53. Guererro and colleagues report the 1-year outcomes of their early clinical experience with transcatheter valve implantation in patients with severe mitral annular calcification. The primary predictor of mortality at 30 days and 1-year was the occurrence of left ventricular outflow tract obstruction, highlighting the need to avoid this complication intra-procedurally.CrossRefPubMedGoogle Scholar
  11. 11.
    Alsidawi S, Eleid MF, Rihal CS, Nkomo VT, Pislaru S. Significant LVOT obstruction after mitral valve in ring procedure. Eur Heart J Cardiovasc Imaging. 2015;16(12):1389. Scholar
  12. 12.
    Paradis JM, Del Trigo M, Puri R, Rodés-Cabau J. Transcatheter valve-in-valve and valve-in-ring for treating aortic and mitral surgical prosthetic dysfunction. J Am Coll Cardiol. 2015;66(18):2019–37. Scholar
  13. 13.
    •• Blanke P, Naoum C, Dvir D, Bapat V, Ong K, Muller D, et al. Predicting LVOT obstruction in transcatheter mitral valve implantation: concept of the neo-LVOT. JACC Cardiovasc Imaging. 2017;10(4):482–5. Blanke and colleagues introduce the concept of simulating the neo-left ventricular outflow tract (neo-LVOT) using baseline computed tomography in combination with post-processing techniques. The neo-LVOT cross-sectional area can be measured to identify patients who may be at increased risk of outflow tract obstruction after transcatheter mitral valve replacement.CrossRefPubMedGoogle Scholar
  14. 14.
    Levine RA, Cape EG, Yoganathan AP. Pressure recovery distal to stenoses: expanding clinical applications of engineering principles. J Am Coll Cardiol. 1993;21(4):1026–8. Scholar
  15. 15.
    Guerrero M, Wang DD, Himbert D, Urena M, Pursnani A, Kaddissi G, et al. Short-term results of alcohol septal ablation as a bail-out strategy to treat severe left ventricular outflow tract obstruction after transcatheter mitral valve replacement in patients with severe mitral annular calcification. Catheter Cardiovasc Interv. 2017;90(7):1220–6. Scholar
  16. 16.
    Blanke P, Dvir D, Cheung A, Levine RA, Thompson C, Webb JG, et al. Mitral annular evaluation with CT in the context of transcatheter mitral valve replacement. JACC Cardiovasc Imaging. 2015;8(5):612–5. Scholar
  17. 17.
    Blanke P, Park JK, Grayburn P, Naoum C, Ong K, Kohli K, et al. Left ventricular access point determination for a coaxial approach to the mitral annular landing zone in transcatheter mitral valve replacement. J Cardiovasc Comput Tomogr. 2017;11(4):281–7. Scholar
  18. 18.
    Blanke P, Dvir D, Naoum C, Cheung A, Ye J, Thériault-Lauzier P, et al. Prediction of fluoroscopic angulation and coronary sinus location by CT in the context of transcatheter mitral valve implantation. J Cardiovasc Comput Tomogr. 2015;9(3):183–92. Scholar
  19. 19.
    Walmsley R. Anatomy of left ventricular outflow tract. Heart. 1979;41(3):263–7. Scholar
  20. 20.
    Blanke P, Russe M, Leipsic J, Reinöhl J, Ebersberger U, Suranyi P, et al. Conformational pulsatile changes of the aortic annulus: impact on prosthesis sizing by computed tomography for transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2012;5(9):984–94. Scholar
  21. 21.
    Wang DD, Eng MH, Greenbaum AB, Myers E, Forbes M, Karabon P, et al. Validating a prediction modeling tool for left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR). Catheter Cardiovasc Interv. 2017;92:379–87. Scholar
  22. 22.
    Blanke P, Dvir D, Cheung A, Ye J, Levine RA, Precious B, et al. A simplified D-shaped model of the mitral annulus to facilitate CT-based sizing before transcatheter mitral valve implantation. J Cardiovasc Comput Tomogr. 2014;8(6):459–67. Scholar
  23. 23.
    Levine RA, Triulzi MO, Harrigan P, Weyman AE. The relationship of mitral annular shape to the diagnosis of mitral valve prolapse. Circulation. 1987;75(4):756–67. Scholar
  24. 24.
    Lefebvre XP, Yoganathan AP, Levine RA. Insights from in-vitro flow visualization into the mechanism of systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy under steady flow conditions. J Biomech Eng. 1992;114(3):406–13. Scholar
  25. 25.
    Levine RA, Jimoh A, Cape EG, McMillan S, Yoganathan AP, Weyman AE. Pressure recovery distal to a stenosis: potential cause of gradient “verestimation” by Doppler echocardiography. J Am Coll Cardiol. 1989;13(3):706–15. Scholar
  26. 26.
    Cape EG, Simons D, Jimoh A, Weyman AE, Yoganathan AP, Levine RA. Chordal geometry determines the shape and extent of systolic anterior mitral motion: in vitro studies. J Am Coll Cardiol. 1989;13(6):1438–48. Scholar
  27. 27.
    Levine RA, Vlahakes GJ, Lefebvre X, Guerrero JL, Cape EG, Yoganathan AP, et al. Papillary muscle displacement causes systolic anterior motion of the mitral valve: experimental validation and insights into the mechanism of subaortic obstruction. Circulation. 1995;91(4):1189–95.CrossRefGoogle Scholar
  28. 28.
    Bapat V, Pirone F, Kapetanakis S, Rajani R, Niederer S. Factors influencing left ventricular outflow tract obstruction following a mitral valve-in-valve or valve-in-ring procedure, part 1. Catheter Cardiovasc Interv. 2015;86(4):747–60. Scholar
  29. 29.
    Wang DD, Eng M, Greenbaum A, Myers E, Forbes M, Pantelic M, et al. Predicting LVOT obstruction after TMVR. JACC Cardiovasc Imaging. 2016;9(11):1349–52. Scholar
  30. 30.
    de Vecchi A, Niederer S, Karády J, Ntalas I, Maurovich-Horvat P, Rajani R. Computational fluid dynamic modelling to determine the hemodynamic effects of implanting a transcatheter mitral valve within the left ventricle. Int J Cardiovasc Imaging. 2017;34(5):803–5. Scholar
  31. 31.
    Alharbi Y, Lovell NH, Otton J, Muller D, Al Abed A, Dokos S. Image-based fluid dynamics analysis of left ventricle outflow tract pressure gradient after deployment transcatheter mitral valve. Conf Proc Annu Int Conf IEEE Eng Med Biol Soc IEEE Eng Med Biol Soc Annu Conf. 2017;2017:4223–6. Scholar
  32. 32.
    Karády J, Ntalas I, Prendergast B, Blauth C, Niederer S, Maurovich-Horvat P, et al. Transcatheter mitral valve replacement in mitral annulus calcification – “the art of computer simulation”. J Cardiovasc Comput Tomogr. 2018;12(2):153–7. Scholar
  33. 33.
    El Sabbagh A, Eleid MF, Matsumoto JM, et al. Three-dimensional prototyping for procedural simulation of transcatheter mitral valve replacement in patients with mitral annular calcification. Catheter Cardiovasc Interv. 2018;(December 2017):1–13.
  34. 34.
    Vaquerizo B, Theriault-lauzier P, Piazza N. Percutaneous transcatheter mitral valve replacement: heart model and prototyping. Rev Española Cardiol (English Ed). 2015;68:1165–73. Scholar
  35. 35.
    Kohli K, Wei ZA, Sadri V, Easley T, Pierce E, Oshinski J, et al. TCT-19 Predicting TMVR-related LVOT obstruction: concept of fluid mechanics modeling. J Am Coll Cardiol. 2018;72:B8–9. CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Keshav Kohli
    • 1
  • Zhenglun Alan Wei
    • 1
  • Ajit P. Yoganathan
    • 1
  • John N. Oshinski
    • 1
  • Jonathon Leipsic
    • 2
  • Philipp Blanke
    • 2
    • 3
  1. 1.Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of Technology and Emory UniversityAtlantaUSA
  2. 2.St. Paul’s Hospital & University of British ColumbiaVancouverCanada
  3. 3.Department of Radiology, St. Paul’s Hospital/ Providence Health CareVancouverUSA

Personalised recommendations