Aortic Annular Plane Research Articles

Transcatheter aortic valve replacement in patients with a pre-existing prosthetic mitral valve: a single center experience with two cases

BackgroundThe performance of transcatheter aortic valve replacement (TAVR) in patients with pre-existing prosthetic mitral valves is technically challenging due to the potential interference between both prosthetic devices. At present, there are no clear recommendations for this patient subset due to their exclusion from clinical trials. We report our experience of two cases with pre-existing prosthetic mechanical mitral valves who underwent TAVR.Case presentationThe first case was a 57 year old man with severe aortic stenosis and type 2 diabetes mellitus who had a mitral valve replacement 32 years ago. Operative mortality risk assessed by the Society for Thoracic Surgery (STS) Score was 1.7%, but he was considered high risk in view of previous cardiac surgery. Pre-procedure CT evaluation revealed favorable aortic root and femoral access anatomy with the mechanical mitral valve located 6.3 mm below the aortic annular plane. He underwent TAVR with a Medtronic Evolut R 29 mm self-expanding transcatheter heart valve via the femoral approach.The second case was a 66 year old lady who presented with severe aortic stenosis, atrial fibrillation and a history of mitral valve replacement 17 years ago for rheumatic mitral stenosis. Her STS score was 3.5%. Pre-procedure CT showed favorable aortic root and femoral access parameters with a mitral-aortic distance of 3.6 mm. TAVR was performed with a balloon expandable Myval 21.5 mm transcatheter heart valve via a transfemoral access. Both procedures were done successfully.ConclusionThis report highlights the feasibility of TAVR in post-mitral valve replacement patients provided careful pre-procedural evaluation, and planning is done.

Impact of implantation depth and calcium burden on infranodal conduction delay after transcatheter aortic valve replacement

Infranodal conduction disorders are common after transcatheter aortic valve replacement (TAVR). Risk factors are incompletely understood. The purpose of this study was to assess the impact of valve implantation depth and calcium burden of the device landing zone on infranodal conduction intraprocedure pre- and post-TAVR. In all patients undergoing TAVR between June 2020 and June 2021, the His-ventricle (HV) interval was measured pre- and post-valve deployment. The difference between the 2 measurements defined delta HV, whereas infranodal conduction delay was defined as HV interval >55 ms. Valve implantation depth was measured as the distance between the aortic annular plane and the ventricular prosthesis end. Calcium burden was quantified as the volume of calcium in 6 regions of interest: the non-, right, and left coronary cusps (NCC, RCC, and LCC, respectively) and the corresponding regions of the left ventricular outflow tract (LVOT) underlying each cusp (LVOTNCC, LVOTRCC, LVOTLCC, respectively). Of 101 patients (mean age 81 ± 5.7 years; 47% women), 37 demonstrated infranodal conduction delay intraprocedure post-TAVR. Overall, mean implantation depth was 5 ± 3.1 mm, median calcium volume was 2080 mm3 [interquartile range 632-2400]. Delta HV showed no correlation with implantation depth or calcium burden (r = -0.08 and r = 0.12, respectively). However, LVOTNCC calcification was a significant predictor for infranodal conduction delay post-valve deployment in a multivariable logistic regression model (odds ratio 1.62 per 100-mm3 increase (95% confidence interval 1.06-2.69; P = .04). Assessment of LVOTNCC calcification may identify patients at risk for infranodal conduction delay after TAVR, whereas implantation depth did not predict infranodal conduction delay.

Computed tomography to guide transcatheter aortic valve implantation.

Since its introduction in 2022, transcatheter aortic valve implantation (TAVI) has revolutionized the treatment and prognosis of patients with aortic stenosis. Robust clinical trial data and awealth of scientific evidence support its efficacy and safety. One of the key factors for success of the TAVI procedure is careful preprocedural planning using imaging. Computed tomography (CT) has developed into the standard imaging method for comprehensive patient assessment in this context. Suitability of the femoral and iliac arteries for transfemoral access, exact measurement of aortic annulus size and geometry as the basis for prosthesis selection, quantification of the spatial relationship of the coronary ostia to the aortic annular plane, and identification of optimal fluoroscopic projection angles for the implantation procedure are among the most important information that can be gained from preprocedural CT. Further research is aimed at improving risk stratification, for example, with respect to annular perforation, periprosthetic aortic regurgitation, and need for postprocedural implantation of apermanent pacemaker.

Native aortic leaflets and permanent pacemaker implantation risk following balloon-expandable transcatheter aortic valve implantation

ObjectivePermanent pacemaker implantation (PPI) risk is higher following transcatheter aortic valve implantation (TAVI) than surgical valve replacement. Native aortic leaflets are retained in patients undergoing TAVI, unlike in surgical valve replacement. Whether the retained leaflets influence PPI risk because of their proximity to the conduction system is unknown. The study sought to determine the association between infra-annular extension of native right coronary cusp/noncoronary cusp (RCC/NCC) post balloon-expandable TAVI and PPI risk. MethodsWe performed a retrospective analysis of 190 patients undergoing balloon-expandable TAVI at a single center. Manifestation of infra-annular extension of RCC/NCC was considered to be present when part of leaflet extended below aortic–annular plane on post-implantation aortic-root angiography. ResultsInfra-annular extension of RCC/NCC was observed in 33 patients (17.37%). PPI incidence post-TAVI was higher in patients with infra-annular extension of RCC/NCC than in those without (36.36% versus 8.92%, relative-risk: 4.08, p˂0.0001). On logistic-regression analysis, preexisting right bundle-branch block (RBBB) (odds-ratio: 12.73, 95% confidence-interval: 2.16–74.93, p = 0.005), and infra-annular extension of RCC/NCC (odds-ratio: 5.63, 95% confidence-interval: 2.17–14.58, p < 0.0001) were independently associated with PPI risk. Preexisting RBBB (φ = +0.25, p = 0.001) and infra-annular extension of RCC/NCC (φ = +0.30, p < 0.0001) showed a positive-correlation with PPI risk. Infra-annular extension of RCC/NCC was a significant predictor of PPI risk on receiver-operating-characteristic curve analysis (area under-the-curve 0.67; 95% confidence-interval: 0.54–0.79, p = 0.006). ConclusionThe retained native aortic leaflets play a significant role in PPI risk following balloon-expandable TAVI. Infra-annular extension of RCC/NCC is a novel predictor, and is associated with a four-fold higher risk of PPI.

Aortic Annulus Detection Based on Deep Learning for Transcatheter Aortic Valve Replacement Using Cardiac Computed Tomography.

To propose a deep learning architecture for automatically detecting the complex structure of the aortic annulus plane using cardiac computed tomography (CT) for transcatheter aortic valve replacement (TAVR). This study retrospectively reviewed consecutive patients who underwent TAVR between January 2017 and July 2020 at a tertiary medical center. Annulus Detection Permuted AdaIN network (ADPANet) based on a three-dimensional (3D) U-net architecture was developed to detect and localize the aortic annulus plane using cardiac CT. Patients (N = 72) who underwent TAVR between January 2017 and July 2020 at a tertiary medical center were enrolled. Ground truth using a limited dataset was delineated manually by three cardiac radiologists. Training, tuning, and testing sets (70:10:20) were used to build the deep learning model. The performance of ADPANet for detecting the aortic annulus plane was analyzed using the root mean square error (RMSE) and dice similarity coefficient (DSC). In this study, the total dataset consisted of 72 selected scans from patients who underwent TAVR. The RMSE and DSC values for the aortic annulus plane using ADPANet were 55.078 ± 35.794 and 0.496 ± 0.217, respectively. Our deep learning framework was feasible to detect the 3D complex structure of the aortic annulus plane using cardiac CT for TAVR. The performance of our algorithms was higher than other convolutional neural networks.

Impact of implantation technique on conduction disturbances for TAVR with the self-expanding portico/navitor valve.

Use of a right-left (R-L) cusp overlap view for transcatheter aortic valve replacement (TAVR) with self-expanding valves has recently been proposed aiming to reduce permanent pacemaker implantation (PPMI). An objective, data-driven explanation for this observation is missing. To assess the impact of different implantation techniques on the risk of PPMI following TAVR with the Portico/NavitorTM transcatheter heart valve (THV; Abbott). A TAVR-population treated with Portico/NavitorTM had the THV implanted in a right versus left anterior oblique (RAO/LAO) fluoroscopic view with no parallax in the delivery system. The impact of these different implantation views on the spatial relationship between THV and native aortic annulus and the risk of conduction disturbances and PPMI after TAVR was studied. A total of 366 matched TAVR patients were studied: 183 in the RAO group and 183 in the LAO group. The degree of aortic annulus plane tilt was significantly smaller in the RAO versus LAO group (median: 0°vs. 23°, p < 0.001), with no plane tilt in 105 out of 183 cases (57.3%) in the RAO group. At 30 days after TAVR, the overall PPMI and guideline-directed PPMI rates were 12.6% versus 18.0% (p = 0.15) and 8.2% versus 15.3% (p = 0.04) in the RAO versus LAO group, respectively. Use of a R-L cusp overlap (RAO-caudal) view for implantation of the Portico/NavitorTM valve results in less tilt of the native aortic annulus plane and a clear trend toward a lower 30-day PPMI rate as compared to TAVR using the conventional LAO implantation view.

Effect of Aortic Angulation on Outcomes in Transcatheter Aortic Valve Implantation with the Self-Expanding Portico Valve

Introduction: Aortic angulation (AA), defined as the angle between the aortic annulus plane and the horizontal plane, may result in failed prosthesis positioning. The effect of AA on the procedural and short-term outcomes with the portico valves for transcatheter aortic valve implantation (TAVI) has not been fully investigated. The present study aimed to evaluate the impact of AA on device success and early outcomes of TAVI using a selfexpanding portico valve. Patients and Methods: Preoperative computed tomography scans of 121 consecutive patients treated with the portico valve were analyzed. TAVI device success and outcomes were determined according to VARC-3 definitions. Patients were divided into two groups based on mean AA. Results: The mean AA was 48.7 ± 8.9°. There were no differences in technical success (92.2 vs 89.5%, p= 0.604), device success (81.2% vs 77.2%, p= 0.582), and early safety endpoints (68.8% vs 61.4%, p= 0.397) between the AA≤ 48° and AA&gt;48° groups. The frequency and severity of paravalvular aortic regurgitation (PAR) was statistically higher in patients with AA&gt; 48° (p= 0.028). Moreover, an increased AA was also associated with valve malposition (12.3% vs. 1.6%, p= 0.018), prolonged procedure time (85 ± 26 vs. 75 ± 20 minutes, p= 0.028), and greater Δimplantation depth (2.2 ± 0.5 vs. 0.8 ± 0.1 mm; p&lt;0.001). Conclusion: Despite comparable device success and early outcomes rates, increased AA is associated with higher rates of PAR and valve malposition, with the self-expanding portico valve.

Coronary arterial dominance in patients with congenital heart disease.

Coronary arterial dominance is concerned in the management of ischemic heart disease. In particular, right coronary arterial dominance is having a risk for three-vessel coronary artery disease. Thus, this study aimed to explore coronary arterial dominance in patients with congenital heart disease. The study involved 250 patients, of which 105 patients were with tetralogy of Fallot (TOF), 100 patients with ventricular septal defect (VSD), and 45 patients with Kawasaki disease (KD). We retrospectively reviewed their ascending aortography to determine their coronary arterial dominance, Z-scores of coronary artery diameter, and the ascending aortic curvature, which pertained to the angle between the aortic annulus plane and ascending aortic plane. We identified relevant factors that contribute to having right coronary arterial dominance. Age and weight of the 250 subjects were 2.9 (1.0-8.7) months and 7.7 (5.0-9.4) kg, respectively. The Z-scores of right coronary and anterior descending arteries significantly differed among patients with TOF, VSD, and KD (P < 0.001, P = 0.001). However, there were no significant differences in the Z-scores of left main trunk and circumflex arteries. Right coronary arterial dominance occurred in 89%, 49%, and 61% in patients with TOF, VSD, and KD, respectively (P < 0.001). The presence of TOF was the most powerful predictor for right coronary arterial dominance (odds ratio: 10.31, 95% confidence interval: 4.11-27.2, P < 0.001). We found the robust relationship between right coronary arterial dominance and TOF. Patients with TOF may have an increased risk for the development of coronary artery disease during adulthood.

Subaortic Membranes in Patients With Hereditary Hemorrhagic Telangiectasia and Liver Vascular Malformations.

BackgroundPatients with hereditary hemorrhagic telangiectasia have liver vascular malformations that can cause high‐output cardiac failure (HOCF). Known sequelae include pulmonary hypertension, tricuspid regurgitation, and atrial fibrillation.Methods and ResultsThe objectives of this study were to describe the clinical, echocardiographic, and hemodynamic characteristics and prognosis of hereditary hemorrhagic telangiectasia patients with HOCF who were found to have a subaortic membrane (SAoM). A retrospective observational analysis comparing patients with and without SAoM was performed. Among a cohort of patients with HOCF, 9 were found to have a SAoM in the left ventricular outflow tract by echocardiography (all female, mean age 64.8±4.0 years). The SAoM was discrete and located in the left ventricular outflow tract 1.1±0.1 cm below the aortic annular plane. It caused turbulent flow, mild obstruction (peak velocity 2.8±0.2 m/s, peak gradient 32±4 mm Hg), and no more than mild aortic insufficiency. Patients with SAoM (n=9) had higher cardiac output (12.1±1.3 versus 9.3±0.7 L/min, P=0.04) and mean pulmonary artery pressures (36±3 versus 28±2 mm Hg, P=0.03) compared with those without SAoM (n=19) during right heart catheterization. Genetic analysis revealed activin receptor‐like kinase 1 mutations in each of the 8 patients with SAoM who had available test results. The presence of a SAoM was associated with a trend towards higher 5‐year mortality during follow‐up.ConclusionsSAoM with mild obstruction occurs in patients with hereditary hemorrhagic telangiectasia and HOCF. SAoM was associated with features of more advanced HOCF and poor outcomes.

Hinge point-based annular plane with abnormal aortic cusps in transcatheter aortic valve replacement

A virtual aortic annular plane that is built using the three hinge points, known as the hinge point-based annular plane (HPAP), is routinely used during transcatheter aortic valve replacement (TAVR). Abnormal aortic cusps (AAC) with unequal length and size influence the relationship of the HPAP to the aortic root axis significantly and pose challenges to valve deployment, leading to paravalvular leak and valve embolisation. Obtaining a centreline-based aortic annular plane in addition may help to understand valve deployment behaviour in AAC better.

Automatic Detection of the Aortic Annular Plane and Coronary Ostia from Multidetector Computed Tomography.

Anatomic landmark detection is crucial during preoperative planning of transcatheter aortic valve implantation (TAVI) to select the proper device size and assess the risk of complications. The detection is currently a time-consuming manual process influenced by the image quality and subject to operator variability. In this work, we propose a novel automatic method to detect the relevant aortic landmarks from MDCT images using deep learning techniques. We trained three convolutional neural networks (CNNs) with 344 multidetector computed tomography (MDCT) acquisitions to detect five anatomical landmarks relevant for TAVI planning: the three basal attachment points of the aortic valve leaflets and the left and right coronary ostia. The detection strategy used these three CNN models to analyse a single MDCT image and yield three segmentation volumes as output. These segmentation volumes were averaged into one final segmentation volume, and the final predicted landmarks were obtained during a postprocessing step. Finally, we constructed the aortic annular plane, defined by the three predicted hinge points, and measured the distances from this plane to the predicted coronary ostia (i.e., coronary height). The methodology was validated on 100 patients. The automatic landmark detection was able to detect all the landmarks and showed high accuracy as the median distance between the ground truth and predictions is lower than the interobserver variations (1.5 mm [1.1–2.1], 2.0 mm [1.3–2.8] with a paired difference −0.5 ± 1.3 mm and p value <0.001). Furthermore, a high correlation is observed between predicted and manually measured coronary heights (for both R2 = 0.8). The image analysis time per patient was below one second. The proposed method is accurate, fast, and reproducible. Embedding this tool based on deep learning in the preoperative planning routine may have an impact in the TAVI environments by reducing the time and cost and improving accuracy.

Enabling Automated Device Size Selection for Transcatheter Aortic Valve Implantation.

The number of transcatheter aortic valve implantation (TAVI) procedures is expected to increase significantly in the coming years. Improving efficiency will become essential for experienced operators performing large TAVI volumes, while new operators will require training and may benefit from accurate support. In this work, we present a fast deep learning method that can predict aortic annulus perimeter and area automatically from aortic annular plane images. We propose a method combining two deep convolutional neural networks followed by a postprocessing step. The models were trained with 355 patients using modern deep learning techniques, and the method was evaluated on another 118 patients. The method was validated against an interoperator variability study of the same 118 patients. The differences between the manually obtained aortic annulus measurements and the automatic predictions were similar to the differences between two independent observers (paired diff. of 3.3 ± 16.8 mm2 vs. 1.3 ± 21.1 mm2 for the area and a paired diff. of 0.6 ± 1.7 mm vs. 0.2 ± 2.5 mm for the perimeter). The area and perimeter were used to retrieve the suggested prosthesis sizes for the Edwards Sapien 3 and the Medtronic Evolut device retrospectively. The automatically obtained device size selections accorded well with the device sizes selected by operator 1. The total analysis time from aortic annular plane to prosthesis size was below one second. This study showed that automated TAVI device size selection using the proposed method is fast, accurate, and reproducible. Comparison with the interobserver variability has shown the reliability of the strategy, and embedding this tool based on deep learning in the preoperative planning routine has the potential to increase the efficiency while ensuring accuracy.

P3376Software-based automated CT analysis for planning TAVI-Procedures: Systematic validation against expert and novice human interpretation

Abstract Introduction Cardiac computed tomography (CT) is an established modality for planning TAVI procedures. We validated CT parameters measured by automated software analysis and by newly trained readers against expert readers. Methods Consecutive patients with symptomatic severe aortic valve stenosis referred for CT assessment of the aortic root prior to TAVI were included in this analysis. Measurements were performed manually by an expert reader, a newly trained reader as well as semi-automatically using a commercially available workstation. Manual measurements were performed as per clinical standard. For semi-automatic analysis, CT data sets were exported to a dedicated workstation with fully automated detection of the aortic annulus plane. Results Out of 159 consecutive patients, 146 patients were included in this analysis (83+10 years). The median annulus area for expert reader, newly trained reader and software measurement was 468 mm2, 511 mm2 and 513 mm2, respectively (p=0.28) whereas the mean annulus diameter showed a mean±SD of 25.6±2 mm, 25.5±2 mm and 25.6±2 mm, respectively, p=0.47. Agreement between expert and newly trained reader for annulus area was good with Bland-Altman analysis showing a systematic overestimation of the annulus area for the newly trained reader of 16 mm2 (95% limits of agreement 42 to −74 mm2) and for automatic software of 20 mm2 (95% limits of agreement 60 to −99 mm2). Assuming an annulus area-based recommendation for a balloon-expandable Sapien 3 prosthesis (23, 26 or 29 mm prosthesis), kappa statistics revealed moderate agreement between expert measurement, newly trained reader and software measurement (κ 0.60 for newly trained reader, κ 0.58 for software measurement, p&lt;0.0001 for all). The time needed for annulus adjustment measurement for the newly trained reader compared to software measurement was 2±0.6 minutes vs. 1±0.5 minutes, respectively, p&lt;0.0001). The software correctly identified the annulus plane without reader correction in 49% of cases and in 51% of cases manual correction of the cusp insertion point or annular tracing had to be performed. Agreement between expert predicted angulation and software predicted angulation was excellent in 55%, good in 29% vs. 31%, moderate in 11% vs. 6% and fair in 5% vs. 8% for LAO/RAO orientation, CAU/CRA orientation, respectively (assuming excellent agreement when difference: &lt;5°, good agreement: 5–10°, moderate agreement: 10–15° and fair agreement: &gt;15°). Conclusion Novice human interpretation manually and with semi-automatic assessment of the aortic root for planning TAVI procedures is feasible with good agreement with expert measurement for annulus dimensions and prediction of implantation angles, however with a trend for systematic overestimation of the annulus area. For semi-automatic assessment, reader correction of cusp insertion point and annular dimensions have to corrected for in 50% of cases

Two different geometric orientations for aortic neoroot creation in bicuspid aortic valve repair with root reimplantation

ObjectiveBicuspid aortic valve (BAV) represents 2 cusps oriented along a spectrum of equal (180°/180°) or unequal (150°/210°) leaflet surface area distribution along the aortic annular plane. We have taken the approach of respecting the native geometric orientation of the repaired BAV leaflets when creating the aortic neoroot during valve-sparing root reimplantation (VSRR) procedures. We investigated midterm outcomes with this 2-prong approach for VSRR in BAV syndrome. MethodsOf 72 patients in a prospectively maintained BAV repair database, 68 met inclusion criteria: 36 patients had 180°/180° neoroot geometry, and 32 patients had 150°/210° orientation. A multivariate ordinal logistic mixed effects model was performed to study parameters associated with recurrent AI greater than 2+. ResultsPreoperative parameters were similar between 180°/180° and 150°/210° groups, except for greater incidence of AI 4+ in the latter (50.0% [n = 16] vs 8.3% [n = 3]; P < .001). Postoperatively, stroke, renal failure, reoperation for bleeding, and pacemaker rates were 0 in the entire cohort. In-hospital/30-day mortality in the entire cohort was 1.5% (n = 1). Multivariate ordinal logistic mixed effects model showed that preoperative AI greater than 3+ (odds ratio, 0.4; P = .46) and geometric orientation of the aortic neoroot (odds ratio, 3.8; P = .25) were not significantly associated with recurrence of AI greater than 2+. ConclusionsRespecting BAV geometry for VSRR neoroot creation yields excellent midterm outcomes and may minimize conjoint cusp leaflet stress that may occur in “forcing” a 150°/210° type I BAV into a 180°/180° neoroot.

Sex differences in aortic root and vascular anatomy in patients undergoing transcatheter aortic valve implantation: A computed-tomographic study

BackgroundVery little data exist on the impact of sex on aortic and arterial anatomy as relevant for transcatheter aortic valve implantation (TAVI). ObjectiveTo investigate whether patients with severe aortic stenosis (AS) referred for TAVI display sex-specific differences in aortic root and ilio-femoral artery size. MethodsIn 506 patients referred for pre-procedural CT evaluation before TAVI we performed a detailed assessment of aortic root anatomy: size of the annulus and the sinus of Valsalva (SoV), diameter of the sino-tubular junction (STJ), and distance of the coronary artery ostia to the aortic annulus plane; we also determined the dimensions of aorta, subclavian, and ilio-femoral arteries. ResultsWomen had significantly smaller aortic root dimensions (annulus mean diameter: 22.9 ± 2.2 mm vs. 25.7 ± 2.7 mm, SoV mean diameter: 31.8 ± 4.2 mm vs. 36.3 ± 3.8 mm, STJ mean diameter: 26.3 ± 3.4 mm vs. 29.8 ± 4.2 mm) and lower left and right coronary artery ostia take-off (12.3 ± 2.4 vs. 14.1 ± 2.9 mm; 14.8 ± 2.6 vs. 17.1 ± 3.2 mm, respectively) than men (P < 0.001 for all), even after adjustment for their smaller body surface area (BSA) and height. Dimensions of the ascending aorta, subclavian and ilio-femoral arteries were also significantly smaller in women, but not when adjusted for BSA. ConclusionsWomen with severe AS had smaller aortic root dimensions even after correcting for their smaller body size and height, reflecting a sex-specific difference. In contrast, sex-related differences in aortic, subclavian, and ilio-femoral dimensions were fully explained by the smaller BSA of women.

Quantification and Clinical Relevance of the Aortic Annulus Plane Orientation in Transcatheter Aortic Valve Implantation

Quantification and Clinical Relevance of the Aortic Annulus Plane Orientation in Transcatheter Aortic Valve Implantation

Assessment of Post-Procedural Aortic Regurgitation After TAVR: An Intraprocedural TEE Study

ObjectivesThe purpose of this study was to determine which echocardiographic parameters, including holodiastolic flow reversal (HDFR) in the descending aorta, were useful for grading of post-procedural aortic regurgitation (PAR) after transcatheter aortic valve replacement (TAVR) using intraprocedural transesophageal echocardiography. BackgroundReliable assessment of PAR in a catheterization laboratory is essential for an optimal outcome after TAVR; however, such an assessment has not been determined. MethodsThree hundred eighty patients who underwent TAVR with the Edwards (Irvine, California) balloon-expandable transcatheter heart valve were retrospectively assessed by intraprocedural transesophageal echocardiography. PAR was evaluated by 2-dimensional color Doppler and pulse-wave Doppler in the descending aorta. Using 2-dimensional color Doppler, we measured the cross-sectional area of the vena contracta, the circumferential extent at the aortic annular plane, the longitudinal jet length, and the jet extent (with a mosaic pattern in the left ventricular outflow tract) compared with the location of the tip of the anterior mitral leaflet (AML). Grading of PAR was determined using the following vena contracta cutoffs: mild ≤9 mm2; moderate 10 to 29 mm2; and severe ≥30 mm2. Significant PAR was defined as at least moderate grade. ResultsAll patients with consistent HDFR had significant PAR. By multivariable analysis, consistent HDFR and the jet extent beyond the tip of AML were independent predictors of significant PAR. Consistent HDFR and jet extent beyond the tip of AML predicted significant PAR with specificities of 100% and 97%, respectively. In contrast, patients with both negative HDFR and a jet extent of less than halfway to the tip of AML had no significant PAR, with 97% specificity. ConclusionsThe presence of consistent HDFR and jet extent beyond the tip of AML are indicative of significant PAR after TAVR.

The impact of calcium volume and distribution in aortic root injury related to balloon-expandable transcatheter aortic valve replacement

BackgroundA detailed assessment of calcium within the aortic root may provide important additional information regarding the risk of aortic root injury during transcatheter heart valve replacement (TAVR). ObjectiveWe sought to delineate the effect of calcium volume and distribution on aortic root injury during TAVR. MethodsThirty-three patients experiencing aortic root injury during TAVR with a balloon-expandable valve were compared with a control group of 153 consecutive TAVR patients without aortic root injury (as assessed by post-TAVR multidetector CT). Using commercial software to analyze contrast-enhanced pre-TAVR CT scans, calcium volume was determined in 3 regions: (1) the overall left ventricular outflow tract (LVOT), extending 10 mm down from the aortic annulus plane; (2) the upper LVOT, extending 2 mm down from the annulus plane; and (3) the aortic valve region. ResultsCalcium volumes in the upper LVOT (median, 29 vs 0 mm3; P < .0001) and overall LVOT (median, 74 vs 3 mm3; P = .0001) were higher in patients who experienced aortic root injury compared with the control group. Calcium in the aortic valve region did not differ between groups. Upper LVOT calcium volume was more predictive of aortic root injury than overall LVOT calcium volume (area under receiver operating curve [AUC], 0.78; 95% confidence interval, 0.69–0.86 vs AUC, 0.71; 95% confidence interval, 0.62–0.82; P = .010). Upper LVOT calcium below the noncoronary cusp was significantly more predictive of aortic root injury compared to calcium underneath the right coronary cusp or the left coronary cusp (AUC, 0.81 vs 0.68 vs 0.64). Prosthesis oversizing >20% (likelihood ratio test, P = .028) and redilatation (likelihood ratio test, P = .015) improved prediction of aortic root injury by upper LVOT calcium volume. ConclusionCalcification of the LVOT, especially in the upper LVOT, located below the noncoronary cusp and extending from the annular region, is predictive of aortic root injury during TAVR with a balloon-expandable valve.

Multislice computed tomography-based prediction of the implantation plane in transcatheter aortic valve implantation: determination of the line of perpendicularity and the implanter's views.

We demonstrate a multislice computed tomography (MSCT)-based method to calculate the prediction of the so-called 'line of perpendicularity' (LOP) and the 'implanter's views' (IVs) for transcatheter aortic valve implantation (TAVI) procedures. The LOP represents all possible angiographic angulations that result in an orthogonal view to the aortic annulus plane. The IVs allow visual confirmation of correct implantation planes, and are crucial for the commissural aligned implantation of second-generation TAVI prostheses. The LOP and IVs of 335 concomitant patients were prospectively analysed using multiple plane reconstruction (MPR) of the patient's MSCT scans. Exclusion criteria were bicuspid valves (n = 18) and valve-in-valve TAVI (n = 15). In the MPRs, the aortic cusps' lowest points were marked. With the marker's three-dimensional coordinates, the graph of the LOP with the IVs was calculated and plotted using vector mathematics. In the last 244 cases, the IV with the right coronary cusp in front was chosen for the first aortic root angiogram of the TAVI procedure. The finally used angulation was confirmed by aortic angiogram prior to the valve implantation. Solid angle differences that show the combined left anterior oblique/right anterior oblique and cranio/caudal movement of the C-arm allow quantification of corrections as well as demonstrate interindividual variations. There is a broad interindividual variation of the aortic valve's topology with solid angle variations of up to 74°. The shape of the LOPs is extremely varying, especially regarding the slope of the curve that indicates differences in valve orientations. Among the 244 patients for whom we used the prediction for the procedure, the first angiogram was considered perfect for implantation without further corrections in 97% (n = 237) of them. In case of the 7 patients with subsequent corrections, the mean solid angle between the prediction and the final angiogram prior to implantation was 6.2° (±5°); the largest correction was 14°. Prediction of the implantation plane by analysing the patient's MSCT is highly reliable in achieving an adequate view of the aortic annulus in TAVI. The analysis of LOPs showed the large interindividual differences that permit using a standard implantation plane. Therefore, we strongly recommend determining the LOP and IVs during the patient's screening process in each single TAVI case.

Abstract 12320: Assessment of Post-Procedural Aortic Regurgitation After Transcatheter Aortic Valve Replacement During the Procedure: An Intraprocedural Transesophageal Echocardiography Study

Introduction: The assessment of post-procedual aortic regurgitation (PAR) after transcatheter aortic valve replacement (TAVR) has not been validated. The purpose of this study was (1) to investigate the value of holodiastolic flow reversal (HDFR) in the descending aorta in patients with PAR after TAVR and (2) to determine which color Doppler parameters are useful for PAR grading using the intraprocedural transesophageal echocardiography (iTEE). Hypothesis: We hypothesized that HDFR in the descending aorta and any color Doppler parameters can delineate significant PAR after TAVR. Methods: Three hundred-eighty patients with severe aortic stenosis underwent TAVR with the Edwards SAPIEN valve with 131 pulsed-wave Doppler tracings from the descending aorta had assessed by iTEE. PAR was evaluated using 2D color Doppler by the cross-sectional area of the vena contracta (VCA) at the aortic annular plane, and by the longitudinal jet extent (mosaic signals, Figure A) compared to the location of the tip of the anterior mitral leaflet (AML). Significant PAR was defined as VCA of ≥10 mm2, corresponding to greater than a moderate grade. Results: In patients with any grade of PAR, pulsed-wave Doppler tracing from the descending aorta, jet extent and VCA were obtained in 100%, 80%, and 74%, respectively. All patients with consistent HDFR had significant PAR. By multivariate analysis, a consistent HDFR and jet extent beyond the tip of AML were independent predictors of significant PAR. A consistent HDFR and jet extent beyond the tip of AML predicted significant PAR with specificity of 100% and 97%, respectively. In the other hand, patients with both negative HDFR and jet extent of less than halfway to the tip of AML had no significant PAR with a 97% specificity. Conclusions: The presence of HDFR with each cardiac cycle and jet extent beyond the tip of AML are indicative of significant PAR.