Figure 6.

A through D, ECG gated, contrast‐enhanced cardiac computerized tomography (CT) images at end systole showing (A) commissural and (B) 3‐chamber views with a simulated cylindrical device (29 mm) oriented perpendicularly to the annular plane. One third of the cylinder volume is projected to remain above the plane in the commissural view. The neo–left ventricular outflow tract (LVOT) formed by the septal myocardium and the device is shown in (C) with cross‐sectional area of 2.0 cm², indicating risk for LVOT obstruction. D, Three‐dimensional segmented rendering of the cylinder within the left ventricle. E through H, Contrast‐enhanced cardiac CT at end systole showing a deployed 26‐mm Edwards SAPIEN 3 transcatheter heart valve in the mitral position, which was placed more apically than on the 3‐dimensional (3D) simulation. Commissural (E), 3‐chamber (F), and neo‐LVOT (G) views demonstrate end‐systolic area of 0.99 cm². A transthoracic echocardiogram (H) showed flow acceleration across the LVOT with evidence of dynamic obstruction (peak gradient measured at 58 mm Hg and mean gradient at 26 mm Hg). Despite this, the procedure was clinically successful, as the patient experienced significant improvement in her functional status. Mean gradients across the mitral valve decreased from 11 mm Hg (at a heart rate of 70 beats/min) to 6 mm Hg (at a heart rate of 80 beats/min).