Annulus Diameter Research Articles

Computed tomography-based anatomic suitability of an Endo-Bentall prosthesis for ascending aortic aneurysms

IntroductionThis study aimed to evaluate the suitability of a coronary-branched ascending aortic endograft, paired with aortic valve (AV) prosthesis (Endo-Bentall), for the endovascular repair of ascending aortic aneurysms. MethodsPre-operative ≤1mm computed tomography angiographies of consecutive patients managed with Bentall procedure or ascending aortic replacement and AV reconstruction/replacement, in a single institution (01.01.2008-31.12.2023), were retrospectively analyzed. Dedicate software was used to assess: (1) vascular access, (2) proximal landing zone, (3) coronary artery anatomy and (4) distal landing. Eligibility criteria for Endo-Bentall were: ≥8mm iliac arteries, without severe calcification/tortuosity, proximal landing with 18-29mm aortic annulus diameter, ≥10mm annulus-coronary ostium distance, no mechanical AV, absence of coronary grafts in the ascending aorta, no left ventricle thrombus, coronary arteries ≥3mm wide and ≥10mm long, with no anatomic abnormalities, ostial stent or stenosis and ≥20mm long and ≤38mm wide distal landing zone within the ascending aorta or applicability of branched endovascular arch repair. ResultsTwenty-nine patients (55.2% females) were included. All patients had adequate proximal landing zone in terms of annulus diameter (median: 25mm, IQR: 5mm). Two (6.8%) had inadequate iliac access (external iliac artery <8mm). Two patients (6.8%) had a mechanical AV. Twenty-six patients (89.6%) had adequate landing zone for stenting of the left main coronary artery (LMCA; median diameter: 5.2mm, IQR: 1.8mm) and 28 (96.6%) had adequate right coronary artery (RCA) landing (median diameter: 4.1, IQR: 1mm). The LMCA and RCA were located at 5:00' and 10:50’ clock positions, respectively. Three patients (20.7%) had an adequate distal landing zone within the ascending aorta. The remaining were suitable for extension with a branched arch device. According to the predefined criteria, 75.9% of patients were anatomically suitable for Endo-Bentall. ConclusionThree out of four patients with ascending aortic aneurysms may be considered as anatomically eligible for endovascular treatment with an Endo-Bentall prosthesis.

Experimental study on radiative heat flux from annular pool fires under the cross airflow

This paper investigates the radiative heat flux of annular pool fires under cross airflow (0–5 m/s), a configuration that has been underexplored in fire safety research despite its relevance in industrial fire hazards. Results show that radiative heat flux decreases with increasing distance from the fire source but increases with higher cross airflow speeds and larger annular pool diameters (Din/Dout). Existing models overestimate radiative heat flux in annular pool fires due to the underrepresented hollow flame region. A new modified triangular prism radiation model was developed based on the similarity criterion of annular pool fires. An extensive comparative analysis was further conducted, encompassing a wide array of experimental configurations documented in the literature, characterized by varying diameters spanning from 0.1 m to 0.7 m and cross wind velocity ranges extending from 0 m/s up to 5 m/s. The results of this comprehensive examination reveal a good agreement between the newly established model and the empirical data, thereby substantiating the model’s universal applicability and robust reliability. The new model will effectively assist industrial facilities in enhancing fire safety design, strengthening thermal hazard prevention and control, and ensuring a higher level of fire safety design.

Abstract 4136604: Efficacy of angiotensin receptor blockers in thoracic aortic aneurysm: meta-analysis of randomized controlled trials

Background: Thoracic aortic aneurysm (TAA) poses a significant risk of aortic dissection and mortality. Angiotensin receptor blockers (ARBs) have been proposed as a potential therapeutic intervention to mitigate these risks but their effects are uncertain. Aim: To evaluate the efficacy of ARBs in patients with TAA. Methods: A comprehensive search of Cochrane CENTRAL, Ovid Medline R, Pubmed, and Web of Science yielded 2563 records, from which 8 unique randomized controlled trials (RCTs) (including 7 Marfan and 1 bicuspid aortic valve+TAA populations) comprising 1575 patients were included in the analysis. The primary outcome measures were aortic dissection and all-cause mortality. Pooled risk ratios (RR) or mean differences (MD) in an inverse variance random-effects model were generated and analyses were performed with “meta” package in R (version 4.3.2). Results: Our analysis reveals no significant beneficial effect of ARBs on aortic dissection (RR 0,62 [95%CI, 0,20; 1,92], I 2 :0%) and all-cause mortality (RR 0,61 [95%CI, 0,18; 2,05], I 2 :0%), irrespective of specific ARB agents (including losartan, irbesartan, and telmisartan), comparators (beta blocker, placebo, or no treatment), disease condition (Marfan syndrome or bicuspid aortic valve), and patient demographics (children or adults). Additionally, there were no significant differences observed between ARB and control groups in changes in ascending aorta and aortic annulus diameter, as well as aortic Z-score at the 3-year mark, including the annual change in ascending aorta (MD 0.04 mm/year [95% CI, -0.07 to 0.15], I 2 :0%) and aortic root diameter (MD -0.06 mm/year [95% CI, -0.22 to 0.10], I 2 :81%) by echocardiography. However, there was a significant reduction in aortic root diameter as assessed by MRI (MD -0.48 mm/year [95%CI, -0.89 to -0.08]) and echocardiography (MD -0.51 mm/3year [95%CI, -0.85 to -0.17]), with low heterogeneity when compared with control. Risk of aortic surgery and severe adverse events were also comparable. Conclusion: We found no significant beneficial effect of ARBs in reducing the risk of aortic dissection or all-cause mortality in patients with TAA. Despite observing a significant reduction in the aortic root diameter by MRI and echocardiography with ARB therapy, other imaging outcomes were comparable between ARB and control groups.

Preoperative Predictors of Recurrent Tricuspid Regurgitation After Annuloplasty: Insights into the Role of 3D Echocardiography.

While tricuspid annuloplasty (TAP) is an effective treatment option for tricuspid regurgitation (TR), understanding the echocardiographic factors contributing to recurrent TR can help in developing more effective preventive measures to reduce the rate of recurrent TR after TAP. This study was designed as a prospective observational cohort study to investigate factors contributing to recurrent TR following surgical tricuspid valve (TV) repair in patients with moderate or severe functional TR caused by left heart valvular disease, with severe mitral regurgitation as the dominant pathology. The study included 66 patients who underwent preoperative two-dimensional (2D) and three-dimensional (3D) echocardiographic assessments. Patients were divided into two groups based on TAP outcomes: the effective TAP group and the recurrent TR group. The analysis revealed that 3D-derived both septal-lateral diastolic and systolic tricuspid annulus (TA) diameter (odds ratio (OR) 1.77; 95% confidence interval (CI) 1.17-2.68 and OR 1.62; 95% CI 1.14-2.29, respectively), and major axis diastolic TA diameter (OR 1.59; 95% CI 1.15-2.2) had the highest OR among all echocardiographic parameters. The further univariate analysis of predefined echocardiographic values unveiled that the combined effect of heightened 3D-measured TA major axis diastolic diameter and increased right ventricle (RV) basal diameter exhibited the highest OR at 12.8 (95% CI 2.3-72.8) for a recurrent TR. Using ROC analysis, diastolic major axis (area under the curve (AUC) 0.848; cut-off 48.5 mm), septal-lateral systolic (AUC 0.840; cut-off 43.5 mm) and diastolic (AUC 0.840; cut-off 46.5 mm) TA diameter demonstrated the highest predictive value for recurrent TR from all TV parameters. Recurrent moderate or severe TR after TAP is associated with preoperative TA size, right atrium and RV geometry, but not with changes of RV function. The predictive capacity of 2D-assessed echocardiographic parameters was found to be lower when compared to their corresponding 3D parameters.

Lack of sex-specific differences in the associations between the dimensions of great vessels and exercise performance in amateur cyclists.

Endurance training enhances exercise capacity and triggers cardiovascular adaptations in both males and females. We investigated the relationship between the dimensions of great vessels and exercise capacity in amateur cyclists while considering sex differences. Using resting transthoracic echocardiography, we measured the dimensions of the main pulmonary artery (PA), aorta, and inferior vena cava (IVC) in 190 participants, who subsequently underwent a cardiopulmonary exercise test (CPET) until exhaustion. The mean age of study participants was 30 years. Males (71%) exhibited a larger aortic annulus (approximately 3.5 mm, p<0.0001) and PA diameter (2.4 mm, p<0.0001) than females. No significant sex differences were found in expiratory or inspiratory IVC diameters. Males achieved greater peak exercise capacity, including workload, O2 consumption (VO2), and O2 pulse. Aortic and PA dimensions showed strong correlations with energy expenditure, workload, VO2, and O2 pulse. However, these correlations weakened when analyzed separately by sex. Multivariate linear regression revealed associations between CPET results, vessels size, and sex, with sex differences observed only in the intercepts-not in interactions between sex and vessels size. Despite males having better CPET results and larger vessels, the relationships between peak exercise capacity parameters and vessel dimensions were similar in both sexes. Larger vessel dimensions (of the aorta, PA, and IVC) were associated with greater peak exercise capacity in amateur cyclists, with no significant sex differences in these associations.

Revisiting the Normal Ranges of Aortic Valve Area in 2D Echocardiography and Its Association With Age, Sex, and Anthropometric Characteristics.

Defining normative aortic echocardiographic values in each geographical district is crucial as aortic valve area (AVA) may vary across races, genders, and ages. Notably, variations in normal values can have implications for clinical decision-making, and available data on the Middle East population is also scarce. We sought to establish normal ranges for aortic valve echocardiographic parameters in the Iranian population and assess the effect of age, gender, weight, height, BMI, BSA, and blood pressure on them. Our data were provided from the web-based echocardiographic data registry of Imam Khomeini Hospital Complex (IKHC). A total of 3251 healthy subjects older than 18 years old without any valvular stenosis were included in our study. AVA's normal range was estimated at 1.92-4.52 and 1.67-3.80 cm2 in men and women, respectively. The annulus, AVA, AV VTI, and LVOT VTI were significantly larger in males, and this association remained significant after indexing AVA for weight, height, BMI, and BSA. Also, smaller AVA was associated with lower height, weight, BMI, and BSA in both men and women. Obese and hypertensive subjects had significantly larger AVA and annulus diameters. Our study provided region-specific normal reference values for AV echocardiographic parameters and compared them across genders, ages, BMI, and blood pressure groups in the Iranian population.

Is aortic elasticity associated with hydration status in stage of chronic renal disease in children?

Objective: We aimed to evaluate cardiovascular risks and influencing factors by measuring aortic elasticity parameters and carotid intima thickness in children with cronic kidney disease (CKD), and also evaluated the hydration status of patients with bioimpedance spectroscopy (BIS) measurements and investigated the effect of hydration status on vascular functions. Patients and Methods: The study group included an average of 13.3 ± 3.7 years (16 girls and 22 boys, 38 CKD patients), control group on average 12.1 ± 2.9 (16 girls and 15 boys, 31 healthy children). Systolic and diastolic diameters of the aortic annulus and aorta at each level were obtained; z-scores, aortic strain, distensibility, stiffness index were calculated. Carotid intima-media thickness and flow – mediated dilatation were studied. Bioimpedance spectroscopy was performed to all patients. Results: Interventricular septum and left atrial (p=0.002, p=0.013), sinus valsalva and sinotubular junction z scores (p=0.009, p=0.012) were found to be higher and distensibility and strain decreased, stiffness index increased in the abdominal aorta of patients with CKD (p=0.007, p=0.002, p=0.004). Patients with CKD had statistically significant over-hydration. Conclusion: Vascular wall changes that affect the elastic properties of the aortic wall begin to develop in childhood in patients with CKD.

Determination of Inoue Balloon Size by Analysis of Mitral Valve Geometry Using Three-Dimensional Transesophageal Echocardiography in Patients With Mitral Stenosis

In percutaneous mitral balloon commissurotomy (PMBC) for patients with mitral stenosis (MS), the size of the balloon has traditionally been determined using a crude method based on the patient's height or body surface area. We aimed to evaluate the clinical value of balloon size selection by quantitatively analyzing mitral valve geometry using 3-dimensional (3D) transesophageal echocardiography. In 184 consecutive patients who underwent PMBC, the geometry of the mitral valve annulus was analyzed during mid-diastole, including the measurement of lateral-medial diameters obtained from dedicated 3D software or from analysis using multiplanar reconstruction images. Patients were categorized into 3 groups: those with successful results after PMBC (SU group), those with residual mitral stenosis (MS group), and those with significant MR (MR group). The SU, MS, and MR groups included 110, 50, and 17 patients, respectively. We compared 3 conventional formulas (formulas 1, 2, and 3) based on the patient's height or body surface area, with 2 new formulas derived from data in the SU group: balloon size = 0.0684 × lateral-medial diameters obtained from dedicated 3D software + 24.309 (formula 4) and 0.061 × lateral-medial diameters obtained from analysis using multiplanar reconstruction images + 24.573 (formula 5). Compared with the calculated balloon sizes using formula 4, the inflated balloon sizes were significantly smaller (-0.78 ± 1.02, p <0.001) in the MS group, whereas they were significantly larger (0.56 ± 1.05, p = 0.04) in the MR group. This pattern was also consistent in formula 5. In conclusion, selecting the Inoue balloon inflation size based on the mitral annulus diameter determined by 3D transesophageal echocardiography might be a reasonable approach.

Comparison of the effects of pre-dilatation with conventional versus larger balloon sizes on clinical outcomes in transcatheter aortic valve implantation with self-expandable valves

Abstract Background Transcatheter aortic valve implantation (TAVI) is considered an established treatment option for patients with severe aortic stenosis. When implanting self-expandable valve, pre-dilatation is often necessary to facilitate optimal transcatheter heart valve (THV) deployment. Traditionally, balloon sizes chosen for pre-dilatation are smaller than the minimum annulus diameter. Insufficient pre-dilatation can result in under-expansion of the THV, necessitating post-dilatation, and can increase the risk of complications. However, this conventional approach may not always yield the best outcomes, prompting a reassessment of balloon sizing strategies to improve procedural success and patient outcomes. Purpose The aim of this study was to investigate the impact on procedural outcomes of using larger balloons, sized less than the mean annulus diameter, for pre-dilatation compared to the traditional practice of using balloons sized less than the minimum annulus diameter during the implantation of self-expandable valves. Methods We analyzed 785 patients who underwent TAVI with self-expandable valve with pre-dilatation out of a consecutive 3880 cases at 6 centers from 2010 to 2023 (Figure 1). Among them, we divided the patients into two groups: those who underwent pre-dilation with balloons smaller than the minimum annulus diameter defined as the Conventional-size group and those who underwent pre-dilatation with balloons smaller than the mean annulus diameter defined as the Large-size group. The primary endpoint of this study was procedural success, stroke and need for permanent pacemaker implantation as designated by the VARC-3criteria. Results Of patients (69% female; mean age 84.9), there were 563 (71.7%) patients in the Conventional-size group and 222 (28.2%) patients in the Large-size group. There was no annulus rupture in either group. The incidence of post-dilatation was significantly higher in the Conventional-size group than in the Large-size group (109 of 563 [19.4%] vs. 23 of 222 [10.3%], p=0.001) (Figure 2). There was no significant difference in the incidence of primary endpoints (all p &amp;gt; 0.05). In post-echocardiographic outcomes, there was no significant difference in effective orifice area, mean pressure gradient, patients-prosthesis mismatch, or paravalvular leakage between the groups (P &amp;gt; 0.05). Conclusions This study demonstrates that a large-size strategy using a balloon smaller than the mean annulus diameter in the deployment of self-expandable valves is safe and may avoid the need for post-dilatation compared to the traditional strategy using a balloon smaller than the smallest diameter.

The mechanical environment regulates the extent of aortic valve calcification and thickness: an ex vivo whole mouse heart study

Abstract Background Aortic stenosis (AS) is a narrowing of the aortic valve opening due to calcification and thickening of the leaflets. Calcifications are mostly located at regions with high mechanical stress and disturbed flow suggesting that mechanical environment is important in the regulation of calcification. However, direct evidence linking valve calcification and mechanical stress is still lacking. Recently, we established an ex vivo calcification model for whole mouse hearts (Miniature Tissue Culture System MTCS) which allows the study of the mechanical environment underlying aortic valve calcification. Purpose Aim of this study was to investigate the role of mechanical stress on aortic valve calcification and thickening using the MTCS. Methods Whole mouse hearts were cultured in the MTCS with 2 distinct configurations: 1) medium flowing from the aorta towards the aortic valve to create a continuous closed aortic valve (n=28) and 2) medium flowing from the left ventricle through the aortic valve towards the aorta to create a continuous open aortic valve (n=17) (Figure1). The hearts were subjected to low (300 ul/min) or high (3000 ul/min) flow speed in the presence of calcifying medium (3mM phosphate buffer). After culture for 1 week, the hearts were isolated and fixed overnight with 4% PFA/PBS. Alizarin red staining was performed to determine calcification presence. Quantifications were performed using Caseviewer software. Results Aortic valves in closed configuration exposed to a high flow speed, exhibited significant increase in calcification compared to aortic valves in the closed configuration exposed to low flow speed or aortic valve cultured in the open position (p&amp;lt;0.01, Figure2A). Of interest, the extent of calcification in the aortic valve in closed position exposed to high flow speed strongly correlated with the diameter of the aortic annulus (R²=0.86, p&amp;lt;0.0001, Figure2B). Conversely, leaflet thickness was significantly lower in the closed aortic valve configuration as compared with the open aortic valves configuration (p&amp;lt;0.05, p&amp;lt;0.001, Figure2C). Conclusion Our study demonstrates the influence of mechanical environment on aortic valve calcification and thickening. The presence of calcification in the closed but not the open aortic valve configuration exposed to high flow suggests that increased pressure promotes calcification. The correlation of the extent of aortic valve calcification with the diameter of the aortic annulus implies that configuration of the valve is an important determinator of calcification, with potential implications for the results of aortic valve repair. The presence of a minimal amount of mechanical stress as experienced by aortic valves in the open position, however, resulted in thicker aortic valves, indicating that the right balance of mechanical stresses is required to maintain normal valve morphology. These findings provide valuable insights into AS pathogenesis, guiding future therapeutic approaches.ex vivo cultured aortic valvesCalcification in ex vivo aortic valves

Fully automated CT analysis with a deep-learning based algorithm for pre-procedural planning in transcatheter aortic valve implantation

Abstract Background Pre-procedural cardiac computed tomography analysis has emerged to an essential tool in transcatheter aortic valve implantation (TAVI). It facilitates the valve choice and allows for optimal vascular access planning. For this purpose, software programs have been specifically developed to assist a fast and precise analysis of the generated data set in high quality. However, these software programs only assist the evaluator and are not able to perform a complete analysis on their own. Purpose We report the performance of a fully-automated, deep-learning based algorithm for pre-procedural CT analysis as compared to the current clinical standard. Methods Ninety-eight patients with symptomatic severe aortic stenosis undergoing TAVI were retrospectively enrolled. The pre-procedural data set was analyzed in two ways: - conventionally with a commercially available TAVI CT-analysis software by experiences users . - by a fully-automated CT-analysis platform with a deep-learning based algorithm. The current beta-version of the platform allows the determination of the annulus diameter, -area, -perimeter and the distance measurements of the coronary arteries to the aortic annulus. Hence, analyzable parameters were limited to the aforementioned, to ensure comparability. Statistical analysis: Mean, standard deviation, mean of difference and the interclass-correlation coefficient (ICC) were calculated and Bland-Altman plots created. Results The mean annulus diameter was 24.5±2.5mm (conventional) vs. 24.1±2.4 mm (deep learning). The mean of difference was 0.42±0.82mm (Bland-Altmann diagram. Figure 1). The ICC was 0.964 (0.925; 0.980), showing an excellent correlation between the two values. The mean annulus perimeter was 77.7±7.4mm (conventional) vs. 75.6±9.3mm (deep learning), showing a very good correlation of the means [mean of difference: 2.11±5.75mm; ICC: 0.852 (0.759; 0.906)]. The distance from the annulus to the left coronary artery was 14.0±3.2mm (conventional) vs. 12.6±2.8mm (deep learning). We depicted a good correlation between the two values [mean of difference: 1.45±2.52mm; ICC 0.736 (IQR 0.483; 0.850)]. The distance from the annulus to the right coronary artery was 17.1±2.7mm (conventional) vs. 16.5±3.2mm (deep learning), respectively. A very good correlation between the two values could be shown [mean of difference 0.57±2.2mm; ICC 0.822 (0.730; 0.882)], as well. Additionally, both methods visualize the measurements and allow manual adjustments (Figure 2). Conclusion In this retrospective analysis, deep-learning based analysis of peri-procedural derived CT data sets showed an very good correlation with conventional assessment. If results can be sustained in a bigger patient cohort and extended to more complex measurements, this artificial intelligence based fully-automated CT-analysis could emerge to a valuable alternative to conventional CT assessment in the pre-procedural planning for TAVI.Figure 1 - Bland-Altman plotFigure 2- Measurements by both methods

Prevalence, mechanisms and prognostic impact of dynamic mitral regurgitation unmasked by handgrip exercise in patients with hypokinetic non-dilated and dilated cardiomyopathy

Abstract Background Recent studies suggest that mitral regurgitation (MR) is a dynamic condition influenced by global and regional left ventricular (LV) remodeling as well as mitral valvular deformation. Exercise testing plays a substantial role in assessing the hemodynamic relevance of MR and is recommended by current guidelines. Handgrip exercise may serve as alternative exercise intervention to bicycle exercise, as it is easy to perform even bedside. However, there are no data yet, on the prevalence, mechanisms and prognostic impact of dynamic MR in patients with dilated cardiomyopathy using isometric exercise testing. Aims We aimed to assess the prevalence, hemodynamic consequences, and prognostic impact of exercise-induced changes in MR in patients with hypokinetic non-dilated and dilated cardiomyopathy. Methods Patients with hypokinetic non-dilated and dilated cardiomyopathy and at least mild MR who underwent handgrip echocardiography at the University Hospital Duesseldorf between January 2018 and September 2021 were enrolled.Patients were followed-up for one year to assess clinical outcomes. We assessed all-cause mortality, HF-associated hospitalizations, MV surgery, transcatheter edge-to-edge repair (TEER), left ventricular assist device implantation and heart transplantation during follow-up. Results Fifty-eight patients were included (mean age 70±15 years; 41% female; mean LVEF 37±10%). At rest, 28 patients (48%) presented with mild MR, and 30 patients (52%) had moderate MR. Fifteen patients (26%) with non-severe MR at rest, developed dynamic severe MR during handgrip exercise. Patients with dynamic severe MR had advanced MR at rest, larger left atrial dimensions, and increased mitral annulus diameter (all p&amp;lt;0.01). During exercise, LVEDVi, LVESVi and parameters of local left ventricular remodeling (tenting height, tenting area) were increased in patients with dynamic severe MR compared to those with non-severe MR (all p&amp;lt;0.05). During one-year follow-up, there was no difference regarding all-cause mortality and HF hospitalizations in patients with dynamic severe MR and non-severe MR (Log-rank test Chi2 0.262; p=0.609)(Figure 1). However, patients with dynamic severe MR more often underwent mitral valve surgery/intervention than patients with non-severe MR (Log-rank test Chi2 29.41; p&amp;lt;0.001)(Figure 1). Conclusion Our results demonstrate that the evaluation of non-ischemic MR only at rest underestimates the full severity of the lesion. Handgrip exercise unmasks severe MR in every fourth patient with non-severe MR at rest. These data may have implications for therapeutic decision-making in symptomatic patients with hypokinetic non-dilated and dilated cardiomyopathy and non-severe MR at rest. TEER might present an effective treatment option to improve clinical outcomes in patients with non-ischemic cardiomyopathy and non-severe MR at rest but dynamic severe MR during exercise.Figure 1

Phenotype of patients with severe aortic stenosis and small aortic annulus: how does it impact on hemodynamics and on transcatheter aortic valve implantation outcomes

Abstract Background Discordant grading of severe aortic stenosis can result from a tight aortic valve area (&amp;lt;1cm2) with a low transvalvular mean gradient (&amp;lt;40 mmHg). Small aortic annulus dimensions and low flow status may contribute to discordant grading of severe aortic stenosis. However, the frequency of patients with small aortic annulus and discordant grading, along with their characteristics and outcomes after intervention, remains unknown. Purpose To investigate the frequency of discordant grading severe aortic stenosis in patients with a small aortic annulus and to evaluate their clinical characteristics, as well as outcomes after transcatheter aortic valve implantation (TAVI). Methods Patients with an aortic annulus diameter &amp;lt; 23 mm determined by cardiac computed tomography who underwent TAVI between 2018 to 2023 were retrospectively evaluated. Patients were followed for the occurrence of the composite endpoint of of all-cause mortality, rehospitalizations for heart failure, non-fatal myocardial infarction, and non-fatal stroke. Results Among 230 patients with severe aortic stenosis and a small aortic annulus, 52 (23%) had discordant gradient (24 with low flow low gradient (LFLG) and 28 with normal flow low gradient (NFLG)) while 120 (52%) exhibited normal flow high gradient (NFHG) and 58 (25%) had low flow high gradient (LFHG). The majority of the patients were female (Table 1). Differences were noted among the three groups regarding aortic transvalvular gradients, stroke volume index and ejection fraction. During a median follow-up of 2 years, the composite endpoint occurred in 20% of the total cohort. Patients with discordant grading severe aortic stenosis experienced the worse outcome (Figure1). Conclusions Most patients with severe aortic stenosis and small annulus have high gradient and only 23% of patients presented discordant grading. Patients with discordant grading severe aortic stenosis showed worse outcomes, suggesting potential delays in referral due to challenges in diagnosing severe aortic stenosis among patients with small aortic annulus.Basal clinical characteristicsKaplan-Meier survival curves

Mitral annular dynamics after transcatheter edge-to-edge repair for functional mitral regurgitation: comparison with surgical annuloplasty

Abstract Background Transcatheter edge-to-edge repair (TEER) is a recently emerged therapeutic option for functional mitral regurgitation (FMR). Although the mitral annular shape and function may play an important role in the pathophysiology of FMR, few reports have evaluated the impact of TEER. We sought to investigate the impact of TEER on the mitral annulus and its motion in FMR compared with that of mitral annuloplasty (MAP). Methods Using three-dimensional transesophageal echocardiography, we evaluated the mitral annular morphology and dynamic motion in patients who underwent TEER or MAP before and after the procedures. Mitral annulus analysis was performed by a semi-automatic program to create a dynamic model of the three-dimensional structure, where the end-systolic annular structure was semi-automatically annotated and manually corrected, followed by automatic tracking of the annulus throughout the cardiac cycle . The mitral annular parameters such as mitral annular diameters, area, circumference, and height at all frames were automatically calculated from the model. In order to align the cardiac phase in each patient (i.e. to set the start and the end of diastole and systole at the same time for all patient), data were spline-interpolated to 100 systolic and 200 diastolic frames and then statistically analyzed. The dynamic changes of the parameters during the cardiac cycle were calculated as (maximum – minimum value) / maximum value after the interpolation. Results Patients who underwent TEER (n=20, 69±15 years, 40% female) and those who underwent MAP (n=16, 64±11 years, 6% female) had similar echocardiographic characteristics before the procedures. The maximum anteroposterior diameter and annulus area decreased after both TEER and MAP, while the intercommissural diameter decreased only after MAP but not after TEER. After TEER, the dynamic change in anteroposterior diameter throughout the cardiac cycle tended to decrease (p=0.055), while intercommissural change rather increased (p=0.049), resulting in preserved change in annulus area (p=0.74). After MAP, changes in both diameters and area decreased significantly (all p&amp;lt;0.05). MAP was associated with postoperative mitral annulus area immobility after adjustment (p=0.030). Conclusions The dynamic motion of the mitral annulus in patients with FMR was better preserved after TEER than after MAP. There was a decreasing trend in anteroposterior motion, which was compensated for by intercommissural motion after TEER. Future studies are needed to determine the association of these results with cardiac function and prognosis.

Three-dimensional transthoracic vs transesophageal echocardiography vs computed tomography angiography aorta for aortic annular diameter measurement for TAVI in our hospital

Abstract Background Tans femoral transcatheter aortic valve implantation (TF-TAVI) was recently the standard treatment option in patient with severe aortic stenosis. All patients undergoing TF-TAVI needed computed tomography angiography (CTA) aorta not only to evaluate entry site but to measure the annulus size to determine the prosthesis valve size. In Siriraj hospital we have protocol to perform Three-dimensional transthoracic echocardiography (3D-TTE) and three-dimensional esophageal echocardiography (3D-TEE) prior to TF-TAVI. We aimed to evaluate the correlation between conventional CTA aorta vs 3D-TEE vs 3D-TTE aortic annulus size. Method and result We performed a cross sectional study in all patients undergone TF-TAVI in our hospital who had all 3 aortic annulus sizes measured by 3 methods: CTA aorta, 3D-TEE vs 3D-TTE during 2015-2023. For 244 patients underwent TAVI, 52 patients were excluded (22 Transapical approach, 10 valve in valve TAVI, 6 not complete annulus measurement, 6 transcarotid, 3 severe AR, etc.) One hundred sixteen patients were female (60.4%) with average age of 83.2 years old. 98% of patients had comorbid disease; hypertension 84%, dyslipidemia 79%, diabetes 47%, coronary artery disease 55% (9% CABG), 2.6% of patients were bicuspid aortic valve. 27% of patients had LVEF less than 55%, average AVA was 0.71 centimeter-square, average mean pressure gradient was 52.5 mmHg. We analyzed the co-relation between these 3 methods by Bland–Altman plot which revealed the Pearson's correlation coefficient (r) between CTA Aorta and 3D-TEE was 0.814 with average difference of 0.68 mm (95% limit of agreement –1.68 - 3.04) and r between CTA Aorta and 3D-TTE was 0.442 with average difference of 0.41 mm (95% limit of agreement –3.82 - 4.63) Conclusion 3D-TTE annulus sizing had a reasonable correlation with CTA annulus sizing (Pearson’s correlation of 0.442) while 3D-TEE annulus sizing had a very high correlation with CTA annulus sizing (Pearson’s correlation of 0.814). In patient which CTA was not available to measure annulus size 3D-TEE annulus sizing might be reasonable method to measure the annulus size for TF-TAVI. Keyword trans femoral transcatheter aortic valve implantation (TF-TAVI), annulus size, three-dimensional transthoracic echocardiography (3D-TTE), three-dimensional esophageal echocardiography (3D-TEE), computed tomography angiography (CTA) aorta

3D transesophageal echocardiographic assessment of acute reverse remodeling of the tricuspid annulus after transcatheter edge-to-edge repair.

Our study aims to evaluate the acute remodeling of the tricuspid valve annulus immediately after the T-TEER by using intraprocedural transesophageal three-dimensional (3D) echocardiography. We prospectively enrolled 62 consecutive symptomatic patients with at least severe TR, who underwent T-TEER with the TriClip System between March 2021 and June 2024. 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.The acute procedural success was achieved in 85,5%. We observed an acute reduction in SL (from a median of 43 to 38 mm, p<0,0001), AP (from a median of 46 to 45 mm, p<0,0001), area (from a median of 17,9 to 15,95 cm2, p<0,0001), perimeter (from a median of 145,5 to 137 mm, p<0,0001) and eccentricity index (from 0,92 to 0,87, p<0,0001). The TV annulus was progressively larger in patients with higher residual TR. Analysis of the subgroups according to procedural success showed an acute inverse remodeling of the TV annulus independent of the acute procedural success. The TV geometry necessitates the use of 3D echocardiography for accurate assessment of annular remodeling post T-TEER. The reduction in TR grade and TV annulus dimensions begins immediately after TriClip implantation. Concurrently, the baseline TV geometry influences the procedural results.

Efficacy and Safety of Cardioband in Patients with Tricuspid Regurgitation: Systematic Review and Meta-Analysis of Single-Arm Trials and Observational Studies.

Background/Objectives: The incidence and prevalence of tricuspid regurgitation (TR) are increasing worldwide. "Traditional" drug therapy with diuretics is often ineffective and the identification of new strategies, including non-pharmacological ones, is an urgent need. The aim of this study was to summarize the results on the efficacy and safety of Cardioband, one of the few approved transcatheter tricuspid valve repair systems, in patients with TR. Methods: Three databases (Medline, Scopus, and CENTRAL) were searched to identify clinical trials and observational studies on the efficacy (primary outcome) and safety (secondary outcome) of Cardioband. A random-effects meta-analysis was performed with R software (version 4.3.3). Survival and freedom from heart failure (HF) hospitalization were estimated with the method of reconstructing individual patient data from Kaplan-Meier curves (IPDfromKM). Results: Eleven studies were included in this systematic review and meta-analysis. Cardioband significantly reduced annulus diameter (-9.31 mm [95% Confidence Interval, CI: -11.47; -7.15]), vena contracta (-6.41 mm [95% CI: -8.34; -4.49]), and effective regurgitant orifice area (EROA) (-0.50 cm2 [95% CI: -0.72; -0.28]) in patients with TR. Cardioband reduced the severity of TR and the extent of heart failure in 91% [95% CI: 85; 97] and 63% [95% CI: 52-75] of patients, respectively. Finally, Cardioband implantation was associated with prolonged survival and freedom from HF hospitalization (80.1% and 57.8% at 24 months, respectively). Conclusions: This study demonstrates that Cardioband implantation leads to cardiac remodeling and mechanical improvements, reduces the severity of TR, and improves quality of life. Therefore, Cardioband is an effective option for the non-pharmacological treatment of TR.

Aortic root parameter analysis for transcatheter aortic valve implantation in the Pakistani population: a retrospective study

BackgroundTranscatheter aortic valve implantation (TAVI) is a growing treatment for aortic stenosis, but anatomical variations exist across populations. Asians tend to have smaller aortic annuli and higher bicuspid valve morphology compared to Westerners, potentially impacting TAVI valve selection and outcomes. This study analyzes aortic root parameters in Pakistani patients undergoing TAVI.ResultsWe conducted a retrospective analysis of 78 patients who underwent TAVI at the Peshawar Institute of Cardiology from January 2021 to March 2024. Pre-procedural CT scans were analyzed for aortic annulus diameters, area, and other relevant parameters. The mean age was 72.41 years (SD ± 11.99), and 61.5% were male. Aortic annulus diameters (minimum, mean, maximum) were 21.18 mm (SD ± 3.99), 24.21 mm (SD ± 3.93), and 27.49 mm (SD ± 4.43), respectively. Bicuspid aortic valves were present in 34.61% of patients.ConclusionsOur findings suggest that Pakistani patients undergoing TAVI may have aortic root dimensions comparable to Western populations, with a substantial prevalence of bicuspid valves. However, coronary heights were similar to those reported in Asian populations with smaller annuli. Further studies are needed to assess TAVI outcomes in Pakistani patients and determine if tailored valve sizing strategies are required.

Experimental investigation into thermal characteristics of subcooled flow boiling in horizontal concentric annuli for cooling ultra-fast electric vehicle charging cables

In an effort to reduce the charging time of electric vehicles (EVs), the thermal management of the charging system has emerged as one of the most urgent issues. The charging rate has been restricted to avoid thermal failure especially in charging cable. Recently, a direct contact cooling technique that utilizes subcooled flow boiling for charging cables has been proposed and has shown promising thermal management performance. However, there has been a lack of clear explanation regarding its thermal characteristics due to its intrinsically complicated flow features. This study investigates the thermal characteristics of subcooled flow boiling in a horizontally aligned concentric annular tube intended to simulate the direct contact cooling technique employed for charging cables. For the experimental investigation, the wall temperature measurements and high-speed flow visualization images acquired from the transparent test module annulus, with inner and outer diameters of 6.35 mm and 22.0 mm, were utilized. Three key axial thermal characteristics of subcooled flow boiling in annulus have been analyzed, and they are flow regime transition, variation of heat transfer mechanisms, and occurrence of critical heat flux (CHF). The transition of flow regimes and the variation of dominant heat transfer mechanisms in the axial direction are mutually influencing due to the coupled effects between the hydrodynamic and thermal characteristics of simultaneously developing flows. The flow regime changes from partially developed boiling (PDB) to fully developed boiling (FDB) as the intensities of nucleate boiling and bubble recondensation vary in the axial direction, while the dominant heat transfer mechanism shifts from single-phase convection to nucleate boiling, corresponding to the flow regime transition from PDB to FDB. The departure from nucleate boiling (DNB) type CHF is observed, manifested by the wavy interface propagating from the far downstream to the upstream region, and the intensities of nucleate boiling and bubble recondensation are also identified as the dominant parameters in determining the occurrence of CHF. Charging time estimation reveals that the proposed method can achieve an 80 % charge for 100-kWh EV batteries in 98 s, while maintaining the cable wire temperature below the safety limit of 80 °C. This strongly supports its potential as a promising thermal management technique for future ultra-fast charging systems.

Transapical Transcatheter Aortic Valve Replacement Under 3-Dimensional Guidance to Treat Pure Aortic Regurgitation in Patients with a Large Aortic Annulus.

Transcatheter aortic valve replacement (TAVR) is a challenge for patients with aortic regurgitation (AR) and a large annulus. Our goal was to evaluate the clinical outcomes and predictors of transapical TAVR in AR patients with a large annulus and noncalcification and the feasibility and safety of 3-dimensional printing (3DP) in the preprocedural simulation. Patients with a large annulus (diameter >29 mm) were enrolled and divided into the simulation (n = 43) and the nonsimulation group (n = 82). Surgeons used the specific 3DP model of the simulation group to simulate the main steps before the procedure and to refit the transcatheter heart valve (THV) according to the simulated results. The average annular diameter of the overall cohort was 29.8 ± 0.7 mm. Compared with the nonsimulation group, the simulation group used a higher proportion of extra oversizing for THVs (97.6% vs. 85.4%, p = 0.013), and the coaxiality performance was better (9.7 ± 3.9° vs. 12.7 ± 3.8°, p < 0.001). Both THV displacement and ≥ mild paravalvular leakage (PVL) occurred only in the nonsimulation group (9.8% vs. 0, p < 0.001; 9.8% vs. 0, p < 0.001). Multivariate regression analysis showed that extra oversizing, coaxial angle and annulus diameter were independent predictors of THV displacement and ≥ mild PVL, respectively. Based on 3DP guidance, transapical TAVR using extra oversizing was safe and feasible for patients with noncalcified AR with a large annulus. Extra oversizing and coaxial angle were predictors of postprocedural THV displacement and ≥ mild PVL in such patients.