Annular Area Research Articles

Prediction of tricuspid regurgitation regression after mitral valve transcatheter edge-to-edge repair using three-dimensional transesophageal echocardiography

Abstract Aims We aimed to identify three-dimensional echocardiographic predictors of tricuspid regurgitation (TR) regression in patients with functional TR of moderate or greater severity undergoing mitral valve transcatheter edge-to-edge repair to optimize patient selection and improve clinical outcomes. Methods and Results This retrospective study analyzed 61 patients (mean age 81.3±7.6 years; 55.7% males) who underwent mitral valve transcatheter edge-to-edge repair. Two-dimensional transthoracic echocardiography was performed pre- and 1-month post-procedurally, while three-dimensional transesophageal echocardiography was performed pre-procedurally. We collected data on clinical variables, medications, and detailed echocardiographic measurements to evaluate procedural outcomes. TR severity was semi-quantitatively assessed and categorized. At the 1-month follow-up, TR severity had regressed in 43% of patients. A lower prevalence of atrial fibrillation, smaller left atrial volume index, and smaller right atrial area were significantly associated with TR regression. Multivariate analysis revealed the tricuspid valve annulus perimeter, area, and area change as significant predictors of post-procedure TR regression; tricuspid valve annulus perimeter was the strongest predictor among the three indicators (area under the receiver operating characteristic curve, 0.84 [95% confidence interval: 0.75–0.94], p<0.001). Receiver operating characteristic curve analysis indicated that tricuspid valve annulus perimeter cut-off of ≤13.75 cm was the best predictor of post-procedure TR regression. Additionally, tricuspid valve annulus area ≤13.55 cm² and annulus area change ≥17.5% were predictors of post-procedure TR regression. Conclusion In patients with relatively severe mitral regurgitation with a non-dilated tricuspid annulus and significant change in tricuspid valve annulus area, mitral valve transcatheter edge-to-edge repair may lead to TR regression.

Mitral annulus components in patients with metabolic syndrome and relapse after atrial fibrillation cardioversion

Abstract Background Metabolic syndrome (MetS) is associated with recurrent episodes of atrial fibrillation (AF) due to atrial remodeling. Four-dimensional transesophageal echocardiography (4DTEE) is an ideal imaging technique to evaluate these patients' complex morphology of the mitral valve apparatus (MVA). Purpose The study aimed to find some features of MVA components in patients with MetS and persistent AF and if some of them could be indicative of relapse after cardioversion. Methods The study enrolled 101 patients with persistent AF and mild/moderate functional mitral regurgitation (FMR) before cardioversion. According to the latest guidelines, 46(45,54%) of the patients were diagnosed with MetS. After performing two-dimensional transthoracic echocardiography (2DTTE), the study included only mild/moderate FMR patients. 4D TEE permitted a detailed examination of the MVA components, using an E95 machine for acquisition and an ECHOPAC 204 for image postprocessing with mitral valve quantification (MVQ) software. The studied measured: annulus area (AA)3D, annulus perimeter (AP), antero-posterior diameter (APD), posteromedial-anterolateral diameter (PM-ALD), commissural diameter (CD), inter-trigonal distance (ITd), annular height (AH), non-planar angle (NPa), mitral-aortic angle (MAa), anterior leaflet area (ALA), posterior leaflet area (PLA), anterior leaflet length (ALL), posterior leaflet length (PLL), anterior leaflet angle (ALa), posterior leaflet angle (PLa), tenting height (TH), tenting area (TA), and tenting volume (TV). Results 1. Relapse after cardioversion were 32,6% in MetS (+) patients and 17,85% in MetS (-) group. 2. Features of MA parameters in patients with or without MetS were: AA3D 13.09 vs. 12.18 (p= 0.02), AP 12.89 vs. 12.11 (P = 0.01), APD 3.75 vs. 3.6 (P = 0.07), PM-ALD 4.18 vs. 3.98 (P = 0.04), CD 4.2 vs. 4.04 (P = 0.08), and 2.91 vs. 2.88 (P = 0.7), AH 5.85 vs. 5.32 (P = 0.03), NPa 160.39 vs. 157.89 (P = 0.2), MAa 124 vs. 123.4 (P = 0.7), ALA 6.74 vs. 6.03 (P = 0.006), PLA 7.64 vs. 6.96 (P = 0.03), ALL 2.21 vs. 2.17 (P = 0.4), PLL 1.74 vs. 1.72 (P = 0.7), Ala 18.26 vs 17.56 (P = 0.6), Pla 23.41 vs 22.56 (P = 0.5), TH 1.43 vs 1.01 (P = 0.004), TA 1.85 vs 1.51 (P = 0.03), TV 2.76 vs 2.18 (P = 0.03). 3. Parameters that showed significant differences in patients with relapse with or without MetS were AA3D 15.25 vs. 13.45 (P = 0.03), AP 4.22 vs. 13.02 (p=0.04), PM-ALD 4.61 vs. 3.99 (P = 0.008), CD 4.75 vs. 4.02 (P < 0.0001), AH 6.37 vs. 4.91 (P = 0.004), and for the leaflets ALA 8.25 vs. 7.18 (P = 0.02), PLA 9.31 vs 7.97 (P = 0.04), TA 2.66 vs 1.79 (P = 0.02), TV 4.03 vs 2.27 (P = 0.006). Conclusions 1. Mitral annulus and mitral leaflet remodeling were more evident in patients with MetS with or without relapse. 2. The annular area, annular perimeter, posteromedial to anterolateral diameter, commissural diameter, leaflets area, and tenting parameters are most damaged in patients with MetS and relapse after the first cardioversion. 4DE reconstruction of the mitral valve Mitral valve apparatus evaluation by MVQ

Tricuspid valve annulus remodeling and regurgitation analysis with 3-D transesophageal echocardiography after percutaneous transcatheter edge-to-edge repair

Abstract Introduction Tricuspid transcatheter edge-to-edge repair (Tr-TEER) is becoming an effective treatment for severe tricuspid regurgitation (TrR) in symptomatic patients who are high-risk candidates for surgery. Purpose Aims of the study were to assess immediate changes in tricuspid valve (TV) anatomy following Tr-TEER and to investigate the relationship between baseline geometry and residual intraoperative TrR. Methods Thirty-one consecutive patients (average age 77.3 years) with symptomatic severe TrR (≥ grade 4) underwent Tr-TEER. Intraoperative transesophageal echocardiographic 2D and 3D images were obtained before and immediately after the procedure. 3D datasets were analyzed offline using specialized software for 3D TV morphology analysis. Results All patients successfully underwent Tr-TEER: 24 patients (77%) achieved an optimal result with residual regurgitation ≤ 2, while 7 patients (23%) had a residual grade 3 or 4. The 3D datasets were suitable for analysis in 29 patients. Anatomic parameters of the TV, obtained via intraoperative transesophageal echocardiography before and after Tr-TEER, are presented in Table 1. The 2D and 3D annulus area, perimeter, diameter in the 2- and 4-chamber view, and minor and major diameter of the tricuspid annulus significantly decreased post-procedure. A significant reduction in TrR was noted regardless of annulus changes. Conclusions Tr-TEER is linked to a significant decrease in TrR and notable changes in TV geometry, particularly a substantial reduction in annulus area and perimeter. This may contribute to the effectiveness of Tr-TEER in promptly reducing TrR.

Acute tricuspid valve annulus remodeling after transcatheter edge-to-edge repair with Triclip

Abstract Background Right ventricular (RV) adverse remodeling together with RV dysfunction, and not only tricuspid regurgitation (TR) severity, are independently associated with survival in patients with medically treated significant TR. Nevertheless, changes in RV dimensions and function after transcatheter tricuspid valve intervention and their association with outcomes remain largely unexplored, as well as tricuspid valve annulus (TVA) reverse remodeling. Aim of our study is to assess acute remodeling of TVA after tricuspid transcatheter edge-to-edge repair (T-TEER) with the TriClip device (Abbott Vascular, Santa Clara, CA, USA) using intraprocedural trans-esophageal echocardiography (TEE). Materials and methods This prospective, single-center study, conducted at Fondazione Policlinico Universitario Campus Bio-Medico of Rome, enrolled 60 consecutive symptomatic patients referred with the diagnosis of at least severe TR who underwent T-TEER from March 2021 to June 2024 with the TriClip System. Intraprocedural TEE was performed using Siemens Acuson SC2000 (Siemens Medical Systems, Pleasanton, CA, USA) at the beginning, and then using Philips EpiQ CVx (Philips Medical System, Andover, MA). A full-volume 3D echocardiographic data set was acquired during the procedure for each patient before and after the grasping. The following parameters were assessed using a multiplanar reconstruction analysis performed off-line using a 3D dataset: septal-lateral (SL) and antero-posterior (AP) annulus diameters; annulus area; annulus perimeter and eccentricity index. Results The mean age of the study cohort was 77,77 ± 6,18 years, and 77% were female. Twenty-eight patients (46,7%) had severe (3+), twenty-four patients (40%) massive (4+) and eight patients (13,3%) torrential (5+) tricuspid regurgitation. The majority of them had atrial functional tricuspid regurgitation, mostly due to annular dilatation. The acute procedural success was achieved in 82.22%. We observed an acute reduction in SL (from a median of 45 to 38 mm, p<0.0001), AP (from a median of 47.5 to 45.8 mm, p<0.0001), area (from a median of 18.4 to 16.2 cm2, p<0.0001), perimeter (from a median of 149 to 141 mm, p<0.0001) and eccentricity index (from 0.92 to 0.87, p <0.0001). The TV annulus was larger in patients with residual TR >2+. Analysis of the subgroups according to procedural success showed an acute inverse remodeling of the TV annulus independent of residual TR grade. We observed a significative reduction of TVA three-dimensional measurements immediately after the procedure. Conclusions In our study we observed that the reduction of TVA begins immediately after TriClip implantation, proving that T-TEER is effective in reducing TR and in inducing reverse remodeling of the TV apparatus. Concurrently, the baseline TV geometry influences the procedural results. Our data are gathered during T-TEER procedure, follow up data are needed for monitoring right ventricular performance. tva measures using mpr tr grade at baseline and after t-teer

New generation software for evaluation of annular dynamics and reverse remodeling after transcatheter repair in patients with severe atrial functional tricuspid regurgitation

Abstract Introduction Functional tricuspid regurgitation (fTR) is the most common cause of TR. The routine imaging method of the right ventricle is 2D echocardiography. CMR is gold standard. 3D echocardiography imaging made RV and tricuspid valve assessment more detailed and comprehensive. Aims to assess if a successful TEER is able to induce some degree of reverse remodelling, defined as a significant reduction of 3D end diastolic and systolic volumes and tricuspid anulus remodeling, defined as a significant reduction in tricuspid area and diameters, with the respect to basal assessment. The primary efficacy endpoint was a TR reduction of at least one grade as assessed by transthoracic echocardiography (TTE) at discharge (procedural success). Methods From April 2022 to June 2023 twenty-five patients underwent tricuspid valve edge-to-edge repair, of which nine patients were excluded. Fifteen patients with secondary atrial TR were performed echocardiographic analysis pre-procedure and within 7 days after procedure and after 6 month followup. 3D tricuspid annulus measurements were gathered using a 4D Auto Tricuspid Valve Quantification software package. Results At baseline all patients had a grade 4 TR or worse according to the new classification system. After TTVR TR was reduced to grade 3 or less in 80% of the patients. Two patients had a reduction of only one grade (both from massive to severe) and one patient had no significant reduction (Fig. 1) The reduction of TR was accompanied by an improvement of symptoms (NYHA class) during follow-up. At baseline 74 % of patients had NYHA class 3, which was reduced to NYHA II in 60 % during follow-up. Right ventricular end diastolic diameter (RVEDD) and end diastolic area decreased respectively from 49 ± 6 mm at baseline to 46 ± 6 mm (p <0.001) at 6 months follow-up (Figure 2A) and 27± 7 cm2/m2 to 23 ±7 cm/m2 (p <0.001). Similarly, right ventricle end-diastolic volume and end-systolic volume decreased from 153 ± 57 ml to 108 ± 43 ml (p = 0.001) (Figure 2B) and from 79+34 ml to 57+ 30 ml (p <0.0001) at baseline and 6-months respectively. Significant changes were observed in the morfphology of tricuspid anulus after triclip repair. Tricuspid annulus area, antero-posterior diameter and sfericity index were respectively decreased at 6 months follow up from 17,2±4.1 % to 13,4±3,1 % , from 43±6 mm to 37.5 mm and from 88 ±6 mm to 81±6 mm. All above had p <0.001. Conclusions The main findings are: (1) TEER is effective and durable in reducing TR; (2) positive structural right chamber reverse remodelling occurs soon after the procedure; and (3) sustained improvements in clinical status, quality of life and no evidence of re-hospitalisation up to six months were seen in our patients. The resulting echocardiographic improvements indicate tricuspid valve leaflet approximation does not just significantly reduce the grade of TR, but also affects adjacent structures and improves right ventricular afterload adaptation.

Evaluation of Prospective ECG-Triggered CT Scan as a Practical Alternative to Standard Retrospective ECG-Gated Scan for Pre-TAVI Patients

Purpose: CT-TAVI is a critical component of pre-TAVI assessment. The conventional method, retrospective ECG-gated scan, covering a complete cardiac cycle, measures the annulus during optimal systolic phases. Recently, prospective ECG-triggered scans acquiring images at a specific interval of the cardiac cycle were evaluated, allowing faster acquisition and lower contrast doses. Moreover, these scans might be beneficial for elderly patients, reducing the need for breath-holding and easing cooperation requirements. Still, their impact on annular measurement and procedural success has yet to be fully evaluated. Methods: This retrospective, single-center study included 419 patients who underwent CT-TAVI scans, by either prospective or retrospective scanning methods. Baseline data and calculated surgical risk scores were collected, with propensity score matching performed, followed by univariate analysis, Cox regression, and multivariable regression analysis. Results: A total of 171 patient pairs were generated via propensity score matching, ensuring that both groups had similar distributions of age (81 ± 8 years), sex (55% males), and baseline comorbidities. The patients in the prospective ECG-triggered group were exposed to a smaller amount of contrast material (40.0 ± 12 mL vs. 70.0 ± 48 mL, p < 0.001) and radiation (4.4 ± 3.6 mSv vs. 8.0 ± 10.3 mSv, p < 0.001). The prospective ECG-triggered group had a smaller aortic annulus area and diameter (426.6 ± 121.0 mm2 vs. 469.1 ± 130.8 mm2, p = 0.006 and 23.3 ± 3.2 mm vs. 24.5 ± 3.6 mm, p = 0.004) but no excess paravalvular leak was observed. Multivariable analysis showed no significant differences in mortality and composite endpoints between the two groups after 23 months of follow-up. Conclusion: Prospective ECG-triggered, ultra-fast, low-dose, high-pitch scan protocol, used in selected patients offers comparable safety and clinical procedural outcomes along with time and contrast savings.

Exclusive propagation characteristics of topological optical fibers

Abstract As per bulk-edge correspondence, the junction between two topologically distinct lattices in a topological optical fiber supports topological interface states, which enable highly stable, scattering-free, robust propagation of light. We investigate the propagation characteristics of a multi-channel topological optical fiber having co-existing multiple topological interface states in the presence of potential structural defects and deformation in shape. The tolerance analysis has been carried out by deliberately introducing structural imperfections upto ≤ 4% with reference to the annular area at the topological junction of trivial and non-trivial lattices. These studies demonstrate robust properties of multiple topological interface states despite the presence of such structural deformations. Furthermore, a deliberately introduced lateral misalignment upto a maximum of 800 nm of the topological junction exhibits a low splice loss of 0.3 dB and high confinement properties of the multiple topological interface states. These results clearly indicate that the propagation characteristics and properties of the co-existing multiple topological interface states exhibit exceptional tolerance to structural defects, junction deformations, and lateral misalignments, surpassing the performance of state-of-the-art conventional optical fibers. Hence, topological optical fibers could outperform conventional optical fibers in terms of undistorted signal transmission irrespective of fabrication-related potential structural defects.

Long-Term Bioprosthetic Valve Durability After Transcatheter Aortic Valve Replacement With Supra-Annular Self-Expanding Versus Intra-Annular Balloon-Expandable Valves in Patients With a Small Aortic Annulus.

The long-term valve durability of supra-annular self-expanding valves (SEV) and intra-annular balloon-expandable valves (BEV) in patients with small aortic annuli remains unexplored. This study aimed to determine the long-term bioprosthetic valve durability with SEV versus BEV in patients with small aortic annuli. This retrospective study included patients with severe aortic stenosis (AS) and an aortic annulus area of 430 mm2 or less who underwent transcatheter aortic valve replacement using SEV and BEV between October 2009 and December 2022. Based on the Valve Academic Research Consortium's three definitions, the endpoints were hemodynamic structural valve deterioration (SVD) and bioprosthetic valve failure (BVF). Inverse probability of treatment weighting (IPTW) was used to compare between the two groups and adjust for baseline characteristics. The Fine-Gray subdistribution hazard model accounted for the competing risk of death. In total, 565 patients (204 treated with SEV and 361 treated with BEV) were included. The median follow-up duration was 3.6 years [2.0 years, 5.7 years], and the maximum was 12.3 years. Hemodynamic SVD and BVF were less frequently identified in the SEV group than in the BEV group (1.1% vs. 9.1% within 5 years, 0.7% vs. 8.1% within 5 years, respectively). On the IPTW adjusted Fine-Gray subdistribution hazard model analysis, hemodynamic SVD was less frequent in SEV compared with BEV (Hazard Ratio [HR]: 0.16; 95% Confidence Interval [CI]: 0.04-0.56, p = 0.004). SEV was also associated with a lower BVF risk than BEV (HR: 0.25; 95% CI: 0.08-0.76, p = 0.015). SEV appears to be more suitable for long-term valve durability in patients with a small aortic annulus.

The Role OF 3D echocardiography in prediction of pulmonary vascular resistance and its reversibility in simple congenital heart disease with secondary pulmonary hypertension.

Pulmonary hypertension is a progressive and often fatal disease that frequently presents with the non-specific symptom of dyspnea on exertion. To determine non-Invasive Predictors of Pulmonary vascular resistance severity and reversibility in simple Congenital Heart Disease Patients Using 3D Echocardiography. This was a Prospective cohort study conducted on 40 patients selected from attendees of Cardiology clinics of Ain Shams University Hospitals over a period of 2 years. There was a statistically significant positive correlation between PVR and its reversibility and right ventricular parameters (EDV/ESV/SVI), tricuspid valvular parameters (Coaptation height/Tenting volume/Annulus perimeter/Major axis/Minor axis) measured by 3D echocardiography (P < 0.05). On the other hand, no statistically significant correlation was found between PVR or its reversibility and ejection fraction, and annulus area (P < 0.05). All echocardiographic parameters are either excellent or good predictors for reversibility of PVR except for EF, FAC, and S'. We conclude that EDV, ESV, SVI, CoH, tenting volume, and annulus perimeter were the most important variables to predict the PVR and found that all echocardiographic parameters were either excellent or good predictors for reversibility of PVR except for EF, FAC, and S'.

Interobserver and intraobserver variability among different vendors for mitral valve assessment: implications for transcatheter mitral valve repair.

Pre-procedural imaging is critical for transcatheter mitral valve repair planning in patients with mitral valve disease. As differences among various measurement techniques for valve evaluation are still poorly understood, we sought to assess the intra- and interobserver agreement of complex measurements derived from a prototype mitral evaluation tool (Siemens) and a commercially available tool (CVI42) using both saddle- and D-shaped mitral annulus techniques. Multiphasic cardiac computed tomography angiography data were loaded into each software. Three expert readers independently measured the annuli on systolic- and diastolic-phase images using both tools. Measurement agreement between the tools was assessed with t tests, with p ≤ 0.05 considered statistically significant. Intraclass correlation coefficient (ICC) was used for interobserver agreement. Bland-Altman plots were used to assess for systematic differences. Ten patients (mean age: 61.9 ± 9.9years, 70%males) were included, with either normal mitral valve (n = 5) or with primary mitral regurgitation (n = 5). The intraobserver comparison showed statistically significantly different circumference and planar surface areas only for one reader in each group. However, there was significant difference (p ≤ 0.05) between measurements for intercommissural distance, septolateral distance, and intertrigone distance. The interobserver agreement was good (ICC, 0.60-0.74) to excellent (ICC, 0.75-1.00). There were systematic differences in mitral annulus area parameters for both saddle- and D-shaped annulus. Both tools effectively assess mitral annulus with good-to-excellent interobserver agreement. As there were systematic differences in the annular area and distance, use of the same software should be considered in clinical and research workflows.

Association of aortic valve size with the degree of aortic valve calcification in severe high-gradient aortic stenosis.

Less pronounced calcification of the aortic valve (AVC) was observed in women with aortic stenosis (AS) as compared to men. Since women have smaller aortic valves (AV), this could explain a lower calcium load. We aimed to analyze the association of AV size with AVC independent from sex. Consecutive patients with high-gradient AS, who underwent cardiac computed tomography (CT), were assessed. AV annulus area and AVC with the Agatston score were measured on CT. In total, 601 patients (mean age 80±7 years, 45% female) were included. Women had smaller AV annulus areas (4.12±0.67cm2 vs 5.15 ±0.78cm2, p<0.001) and lower Agatston scores (2018 [1456-3017] vs. 3394 [2562-4530]; p<0.001) than men. We found a significant correlation (r=0.594, p<0.001) and independent association (β=926.20, p<0.001) of AV annulus area with AVC. On separate regression analyses for men and women, AVC was independently associated with AV annulus area in both sexes (βmen=887.77; βwomen=863.48, both p<0.001). When patients were stratified into AV size quartiles, patients in the lower quartiles were more likely to have AVC values below recommended sex-specific AVC thresholds. In the lowest quartile 28% of female and 27% of male patients had Agatston scores below 1200AU (women) and 2000AU (men) while this proportion decreased to 6% and 2%, respectively, in the quartiles with the largest annulus areas. In high-gradient AS, AVC strongly depends on AV annulus area. This association is not dependent on sex. Thus, AVC should be indexed to AV size in addition to sex.

Investigation of 3D iris morphology early alteration after implantable collamer lens implantation by using SS-OCT.

Using a fully automated multitask deep learning method, which enabled simultaneous segmentation and quantification of all major anterior segment structures with swept-source optical coherence tomography (SS-OCT), we aimed to investigate the three-dimensional (3D) alterations in iris morphology before and after implantable collamer lens (ICL) surgery. All enrolled patients underwent anterior segment SS-OCT (ANTERION) within one week before and after ICL surgery. A multitask network automatically performed iris SS-OCT image segmentation and quantitative measurements of 3D iris morphology (iris thickness and volume of the inner 1-mm annular area and the outer 1-2-mm annular area, iris curvature [I-Curve], and iris smooth index [SI]). Forty-six eyes of 27 patients (average age, 26.0±5.3 years) were included in the final data analysis. The spherical equivalent ranged from -15.75 to -4.00 diopters (D). The mean ICL vault values were 537.92±161.69μm, which positively and significantly correlated with the pre- (r=0.333, P=0.024) and postoperative (r=0.351, P=0.017) anterior chamber depth (ACD). The mean pupil diameter significantly decreased, whereas both ACD and lens thickness significantly increased postoperatively. The iris thickness, iris volume of the inner 1-mm annular area and the outer 1-2-mm annular area, and SI decreased significantly within one week after ICL implantation. All mean values of the I-Curve increased dramatically postoperatively. Iris morphology, ACD, and lens thickness were significantly altered after ICL implantation.

Right ventricular longitudinal strain in valvular heart disease: A comprehensive review.

Right ventricular (RV) longitudinal strain has emerged as a crucial tool for evaluating RV systolic function in patients with heart disease. The complex anatomy of the RV presents challenges for functional assessment, traditionally conducted using conventional parameters, such as tricuspid annular plane systolic excursion and RV fractional area change. While these conventional methods are simple and practical, they have limitations in reflecting the majority of global RV systolic function. In contrast, RV longitudinal strain, measured using speckle tracking echocardiography, offers a more accurate evaluation of RV systolic function with high reproducibility. It is less dependent on angle and load and utilizes automated techniques. The utility of RV longitudinal strain in patients with valvular heart disease has been reported, showing its effectiveness in detecting early RV systolic dysfunction and providing valuable prognostic information compared to conventional methods. Treatment options for valvular heart disease include not only traditional open-heart surgery but also catheter-based interventions, which have become increasingly available in recent years. In addition to conventional risk assessment, considering treatment choices based on RV systolic function may be beneficial. This approach could provide a new method for determining the optimal treatment plan for individual patients. Despite challenges such as imaging quality and vendor-specific variability, RV longitudinal strain remains a valuable tool for early detection of RV systolic dysfunction, optimizing patient management, and improving outcomes. This review examines the clinical utility of RV longitudinal strain in patients with valvular heart disease, focusing on its prognostic value and role in patient management.

Sex-specific anatomic differences in patients undergoing transcatheter aortic valve implantation: insights from the ST-TAVI registry.

The anatomic considerations of transcatheter aortic valve implantation (TAVI) have an important role for the procedure planning; however, sex-specific data are lacking. All eligible cases undergoing evaluation for TAVI procedure in the period from November 2019 to July 2023at the University Hospital of Split were included. Cardiac computed tomography was analyzed to derive the measures of left ventricular outflow tract (LVOT), aortic root, ascending aorta, and ilio-femoral arteries. A sex-based comparison was conducted using the descriptive statistics. There were 140 female (43.8%) and 180 male patients (56.2%). Female patients had smaller dimensions of aortic annulus (area 391.9 vs. 491.5mm2, p<0.001), LVOT (area 373.3 vs. 481.8mm2, p<0.001), and ascending aorta (maximal diameter 32.7 vs. 34.5mm, p<0.001), as well as ilio-femoral arteries bilaterally (p<0.001). There was no significant difference in the proportion of ilio-femoral unfeasibility for transfemoral TAVI procedure, as measured by diameter of ilio-femoral arteries<5.0mm (9.0% in males vs. 6.1% in females, p=0.441) and<5.5mm (24.7% in males vs. 16.7% in females, p=0.156). Female patients were more likely to receive the smallest valve across different valve platforms (p<0.001). There were sex-specific differences in the availability of conventional valve sizes across different platforms (p<0.001). Female patients had significantly higher periprocedural mortality (7.9% vs. 1.7%, p=0.030), whereas there were no differences in other clinical outcomes and no association of periprocedural mortality with anatomic measures. Female patients showed smaller absolute dimensions of LVOT, aortic root, and ilio-femoral arteries than male patients. There were no differences in the prevalence of ilio-femoral unfeasibility for the transfemoral TAVI procedure; however, there were sex-specific differences in the availability of conventional valve sizes across different platforms. Female patients exhibited a higher periprocedural mortality, with no difference in other clinical outcomes.

Automatic Aortic Valve Extraction Using Deep Learning with Contrast-Enhanced Cardiac CT Images.

This study evaluates the use of deep learning techniques to automatically extract and delineate the aortic valve annulus region from contrast-enhanced cardiac CT images. Two approaches, namely, segmentation and object detection, were compared to determine their accuracy. A dataset of 32 contrast-enhanced cardiac CT scans was analyzed. The segmentation approach utilized the DeepLabv3+ model, while the object detection approach employed YOLOv2. The dataset was augmented through rotation and scaling, and five-fold cross-validation was applied. The accuracy of both methods was evaluated using the Dice similarity coefficient (DSC), and their performance in estimating the aortic valve annulus area was compared. The object detection approach achieved a mean DSC of 0.809, significantly outperforming the segmentation approach, which had a mean DSC of 0.711. Object detection also demonstrated higher precision and recall, with fewer false positives and negatives. The aortic valve annulus area estimation had a mean error of 2.55 mm. Object detection showed superior performance in identifying the aortic valve annulus region, suggesting its potential for clinical application in cardiac imaging. The results highlight the promise of deep learning in improving the accuracy and efficiency of preoperative planning for cardiovascular interventions.

Investigation of heat transfer and fluid flow in annular curved tubes in laminar flow using Al2O3–water nanofluid

In the present study, the combination of both the secondary flow and the nanofluids as a passive approach as a method to maximize the effectiveness of heat exchangers, and reducing the size was examined. The thermo-fluid behavior of annular curved tubes was investigated numerically ANSYS-FLUENT 14.5 CFD package. The effects of key design parameters, such as different annular tube designs (helical, spiral, and conical), different annular cross-sectional shapes (circular, elliptical, square, rectangular, and triangular), and different annular cross-sectional areas, were studied to evaluate the best design for annular curved heat exchanger. Furthermore, the effects of Al2O3–water nanofluids were presented to evaluate their superiority over the water. To achieve thermal and fluid characteristics, the coils are the same length and cross-sectional area. The numerical simulations were performed at Reynolds numbers, Re, of 850–6400 for various nanofluid concentrations, φ, of 1%, 3%, and 5%. The numerical findings showed that the annular helical tube design exhibited better performance than both the spiral and conical tube designs by 5.1% and 10.4%, respectively, while the pressure drop, ΔP, growth was almost negligible. A circular cross section achieved better heat transfer enhancement among the elliptical, square, rectangular, and triangular shapes by 13%, 30%, 40.5%, and 52.9%, respectively, for the same cross section area. At an Al2O3/water nanofluid concentration of 5%, the heat transfer augmentation was 31.7% greater than that of water, while the pressure drop was 2.37 times greater than that of water. The maximum thermo-hydraulic performance index, η, reaches 1.1% for Al2O3–water at a nanofluid concentration of 5%.Graphical abstract

Very severe aortic valve stenosis: Diagnostic value of computed tomography aortic valve calcium scoring

Background(A) Very severe aortic valve stenosis (VSAS; Vmax ≥ 5 ​m/s, MPG ≥60 ​mmHg) is a critical condition with unfavorable clinical outcomes. Guidelines regard VSAS as one criterion for considering valve replacement in asymptomatic patients. (B) Guidelines recommend the use of aortic valve calcium (AVC) scoring as a parameter to differentiate between moderate and severe aortic valve stenosis (SAS). The aim of our study is to propose AVC thresholds for the discrimination between SAS and VSAS. MethodsData of patients from a single center who underwent transcatheter aortic valve implantation (n ​= ​523) were retrospectively analyzed. Patients with concordant AS (n ​= ​430) were divided into SAS (n ​= ​344) and VSAS (n ​= ​86) groups and compared in terms of absolute AVC and indexed AVC (body surface area; aortic valve annulus area). ResultsMean AVC was significantly higher in men (m) than in women (w), and significantly higher in VSAS than in SAS (m: SAS 3572.0 AU; VSAS 5465.0 AU; w: SAS 2252.5 AU; VSAS 3064.5 AU; all p ​< ​0,001). ROC curve analyses showed AVC to be a predictor of VSAS in both sexes (m: AUC 0.794; p ​< ​0.001; w: AUC 0.725; p ​< ​0.001), with optimal cut-off values of 3706.5 AU (m) and 2374.5 (w). Some indexed AVC had a slightly, but not relevantly, better predictive value. ConclusionThe proposed AVC thresholds – approximately 3700 AU (m) and 2400 AU (w) - showed significant predictive power to differentiate SAS from VSAS in the study cohort.

Preoperative mitral valve annulus area size is an important factor in avoiding functional mitral stenosis after mitral valve repair.

Functional mitral stenosis (FMS) following mitral valve (MV) repair for degenerative mitral regurgitation (DMR) is known as a poor prognostic factor. The parameters for avoiding postoperative FMS in MV repair for DMR have not been established. Two-hundred-and-twenty patients (mean age 61.1 ± 13.3years, 144 males) who underwent MV repair for DMR were analyzed. MV annulus area was measured pre- and postoperatively using three-dimensional transesophageal echocardiography (TEE). Trans-mitral pressure gradient (TMPG) was evaluated by postoperative transthoracic echocardiography and FMS was defined as a mean TMPG ≥ 5mmHg. FMS was present in 14 patients (6.4%). Pre- versus postoperative MV annulus area change ratio was greater in the FMS group than in the non-FMS group (62.5 ± 7.2% vs. 48 ± 11.2%, p < 0.0001). On multivariate logistic regression analysis, MV annulus area change ratio was an independent predictor of FMS (odds ratio 1.19, 95% confidence interval 1.09-1.33, p < 0.0001), while receiver operating characteristics analysis showed that the optimal threshold for MV annulus area change ratio to predict FMS was 56.2% (area under the curve, 0.87; p < 0.0001). The preoperative MV annulus area on TEE can be used to determine the postoperative MV annulus area to avoid FMS after MV repair.

Abstract 4140136: Aortic Valve Calcification Density Performs Better Compared to Absolute Aortic Valve Calcification in Aortic Stenosis Risk Stratification

Aortic valve calcification (AVC) scores can be used to stratify aortic stenosis (AS) severity. Current practice guidelines recommend use of absolute AVC scores without considering body surface area or aortic annulus size. We investigated whether size variation in aortic annular area should be considered in identifying optimal AVC cutoffs for patients with severe AS. This was a retrospective analysis of AS patients that underwent AVC assessment during 2018-2023. Outcomes were composite of valve intervention or all-cause mortality. AVC density was defined by dividing AVC by echo-derived left ventricular tract area. Receiver operator curve analysis determined optimal AVC density scores. Absolute AVC cutoffs of &gt;1200AU for females and &gt;2000AU for males were used to identify severe AS. The study included 749 patients (mean age 78 years, 46% female). Median CT-annulus area was larger for males compared with females (532mm 2 [Q1, Q3: 479, 582] vs. 413mm 2 [370, 458], p&lt;0.001). There was a strong association of absolute AVC with CT-annulus area for both males and females (Spearman coefficient: 0.87 and 0.83, p&lt;0.01 each) respectively (Figure 1). The optimal AVC density cutoffs for males and females were 427 and 326, respectively (accuracy 76%, sensitivity 83%, specificity 51%). Composite outcomes were better differentiated with AVC density (males: HR 2.48, 95% CI: 1.82-3.37, p&lt;0.001; females: HR 2.37 (1.71-3.28), p&lt;0.001) compared with absolute AVC scores (males: HR 1.81 (1.43-2.30), p&lt;0.001; females: HR 2.11 (1.62-2.74), p&lt;0.001) (Figure 2). AVC is strongly associated with CT-annulus area and risk stratification is improved with the use of AVC density compared with absolute AVC. This may be especially helpful in patients with extremes of annulus area sizes.

Long-Term Mortality and Impact of Implantation-Associated Factors on the Incidence of Patient-Prosthesis Mismatch After Transcatheter Aortic Valve Implantation in Patients With Small Annuli

BackgroundProsthesis-patient mismatch (PPM) is a common phenomenon after transcatheter aortic valve implantation (TAVI), especially in patients with small aortic annuli (SAA). Whether factors during implantation, such as the implantation depth, have an impact on the occurrence of PPM is currently unclear. Objectives of our study were (i) to investigate the influence of procedure planning and implantation-related factors on the occurrence of PPM and (ii) to evaluate the impact of PPM on long-term mortality after TAVI. Methods and ResultsData from 315 patients with SAA, defined as multidetector computed tomography-derived annulus area < 400 mm2, treated with transfemoral TAVI between 2014 and 2021 were retrospectively analyzed. TAVI was performed with ballon-expandable valves (BEV) in 113 and self-expanding valves (SEV) in 202 cases. PPM was defined according to VARC 3 and follow-up was obtained within 5 years after TAVI.Overall, PPM occurred in 121 patients (38.4%) and was significantly more frequent in patients treated with BEV (54.9%) than with SEV (29.2%, p<0.001). Evaluation of planning- and implantation-related factors found that deeper implantation of BEV significantly increased the risk of PPM (p=0.014), while no association was observed in SEV. Overall mortality at 3 and 5 years was 25.5% and 43.1%, respectively, without significant differences between patients with and without PPM. ConclusionPPM occurred frequently, especially after BEV implantation. In these patients, implantation depth was identified as a predictor of PPM while no association was found for SEV implantation. In addition, there was no difference in longer-term mortality between patients with and without PPM.