CT and MRI in periprocedural transcatheter mitral valve replacement: expert recommendations by the European Society of Cardiovascular Radiology (ESCR) and the North American Society for Cardiovascular Imaging (NASCI)

Transcatheter mitral valve replacement (TMVR) is a minimally invasive treatment option for symptomatic patients with severe mitral valve disease who are at high surgical risk or ineligible for open-heart surgery. The procedure has been associated with improved quality of life and functional status in selected patients and is increasingly recognized as a valuable therapeutic option in the management of complex mitral valve disorders. A multidisciplinary Heart Team is essential to ensure the clinical success of TMVR, and imaging specialists play a central role in the preprocedural assessment for patient and device selection, during the procedure, to guide and monitor the implantation, and after the procedure, for follow-up and for the correct diagnosis of short- or long-term complications. Echocardiography is required for initial diagnosis, for assessment of valve hemodynamics, intraprocedural guidance and monitoring. However, a multimodality approach including CT and/or MRI is frequently needed to correctly manage the phase of preprocedural planning and the diagnosis of complications. This consensus document, developed by a working group of experts from the European Society of Cardiovascular Radiology (ESCR) and the North American Society for Cardiovascular Imaging (NASCI), provides evidence-based recommendations for CT and cardiac MRI acquisition and post-processing in procedural planning and postprocedural evaluation in patients undergoing TMVR. Emphasis is placed on the technical requirements and standardization of imaging protocols, which must account for the heterogeneity of imaging equipment used in clinical settings. The document also outlines recommendations for all necessary preprocedural measures to ensure consistency, accuracy, and effective communication among specialists. KEY POINTS: Question How can CT and MRI acquisition, measurement, and reporting for TMVR be standardized to support accurate procedural planning, device selection, and follow-up? Findings This expert consensus provides recommendations for standardized CT and MRI protocols, key measurements, and structured reporting throughout TMVR planning and follow-up. Clinical relevance CT and MRI assessment may improve patient selection, procedural planning, multidisciplinary communication, and detection of postprocedural complications, supporting safer and more consistent TMVR practice across centers.