Figure legends
Figure 1. Measurement of
aorto-mitral (AM) angle in patient with native MV disease.
Using the 2 orthogonal MV
long-axis planes, the MV short-axis cut plane was determined to include
the posterior saddle-shaped top and the lateral and medial commissures
(Panel A-C). The AV long-axis cut plane was then obtained to include the
aortic valve commissure between left- and non-coronary cusps (Panel D,
green line) and the center of the right-coronary cusp. In this process,
the MV short-axis cut plane was moved to obtain the aortic valve
commissure and rotated to search for the bottom of the right-coronary
cusp (= the center of the right-coronary cusp) in the AV long-axis cut
plane (Panel E). The MV anterior leaflet insertion point on the AV
long-axis cut plane was determined
by visual identification using
the cine loop. Finally, aortic annulus was obtained as the line that
connected the mitral anterior leaflet insertion point with the bottom of
the right-coronary cusp. 3D derived AM angle was measured as the obtuse
angle between the aortic annulus and the MV short-axis (Panel F).
AV indicates aortic valve; LA, left atrium; LV, left ventricle; and MV,
mitral valve.
Figure 2. Planimetry of the LVOT cross sectional area. Panel A
shows the left ventricular long-axis plane. Transcatheter heart valve
(green arrows) encroaches into LVOT. Panel B and C are the cross
sectional short-axis planes with orientation indicated by red dotted
lines [Panel A, (B) and (C)] at the valve stent distal edge and
middle portion of the valve stent. The short-axis cut plane is moved
manually up and down with rotation to search for the smallest area at
each level. Importantly, care was taken that this area should not be
moved from the plane perpendicular to the LV outflow long-axis. Panel D
shows the short-axis image of the aortic annulus identified at the level
of lowest aortic cusp hinge point. LVOT dimension and cross sectional
area are measured at 3 levels (d1-d3 and a1-a3). In a patient with
systolic anterior motion of mitral leaflet, who has the narrowest LVOT
area at the level of leaflet tip, LVOT dimension and area at the valve
stent distal edge are altered to these at the leaflet tip (Panel E-H).
The LVOT area at the level of the leaflet tip is 0.3
cm2, surrounded by the anterior mitral leaflet (white
arrowheads) and ventricular septum (yellow arrowheads).
Abbreviations as in Figure 1.
Calibration makers were shown on Figure A (for Figures A through D) and
E (for Figures E through H).
Figure 3. Change in pressure gradient across LVOT in study
patients.
LVOT indicates left ventricular outflow tract; and PG, pressure
gradient.
Figure 4. The LVOT
dimensions and cross sectional areas at 3 levels including the valve
stent distal edge, middle portion of the valve stent, and aortic
annulus. The LVOT dimension gradually became larger from the level at
the valve stent distal edge to the aortic annulus, while the LVOT cross
sectional area gradually became smaller from the level at the valve
stent distal edge to the aortic annulus. Of note, there were 9 patients
in whom LVOT area at the aortic annulus was not the minimum; 5 have the
minimum area at the valve stent distal edge (red lines) and the others
at the middle portion (green lines).
LVOT indicates left ventricular outflow tract.
*the most distal portion of the mitral valve stent that was closest to
the LV apex
Figure 5. Relationships
between LVOT cross sectional area at the valve stent distal edge versus
LVESV, LVEF, and aorto-mitral angle.
The correlations between the area
and LVESV, LVEF, and aorto-mitral angle were moderate.
LVEF indicates left ventricular ejection fraction; LVESV, and left
ventricular end-systolic volume.
Figure 6. Correlation
between LVOT cross sectional area at the valve stent distal edge and the
change in LVOT gradient.
∆PG indicates change in pressure gradient across LVOT.