One Anatomy, Multiple Valve Choices: Interobserver Agreement in Selecting Transcatheter Pulmonary Valve

Background: Transcatheter pulmonary valve replacement (TPVR) requires selecting the optimal device type, size, and position. Variability in anatomical shape may affect procedural planning. Aim: This study aimed to evaluate interobserver agreement (IOA) in TPVR device selection using 3D patient-specific anatomies and explore a framework for determining agreement. Methods: Six experienced observers from three regions of the Americas independently assessed valve type (self-expanding [S-E], balloon-expandable [B-E], surgical approach [SA]), size, and position for 60 3D reconstructed anatomies (pediatric and adult) derived from cardiac magnetic resonance images. Agreement was quantified using Cohen's and Fleiss' Kappa coefficients. Results and Discussion: Overall, IOA was fair to moderate in the adult group and slight to fair in the pediatric group. Perfect agreement occurred in only eight cases, seven involving S-E valves and one SA. S-E valves were generally selected for anatomies with regular geometry but variable curvature, while SA valves were mainly chosen for markedly large or small anatomies. B-E selections showed no consistent pattern. One consideration of this study is that not all transcatheter therapies were available across the regions, which may have influenced decision-making. Additionally, interventionists typically rely on 2D imaging for procedural planning, and the use of 3D reconstructions without clinical data may also have influenced the results. Coronary anatomy was not included in the assessment. Conclusion: Agreement in selecting TPVR devices is limited for the pediatric group but moderate for adults. Variation in preferences among observers highlights the need for equitable access to diverse valve solutions across different RVOT-PA anatomies and demographic contexts.