Aortic Dimensions Research Articles

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.

Application of Machine Learning Technology to Automate Thoracic Aorta Dimensions by Echocardiography

Application of Machine Learning Technology to Automate Thoracic Aorta Dimensions by Echocardiography

Aortic dimensions in a large Australian adult cohort. New normal range?

Abstract Background There is little published data worldwide about the normal range of aortic dimensions in adults. Guidelines for dilated aortic dimensions and recommendations for surgery are based on small population cohorts and absolute values. Adjustment for BSA and height are becoming more accepted, however the normal range of aortic dimensions for a large population has not been previously published. We present the distribution of aortic dimensions in a large Australian population, with indexation for BSA and height as well as centiles of age. Methods All patients &amp;gt;18 years of age attending for routine echocardiography at our institution from 2007-2022 were included in the database. Measurements of aortic root, sinotubular junction and ascending aorta using ASE criteria were collated. Dimensions were adjusted for BSA and height. Data was analysed for centiles of weight and height and across decades of age. Results A total of 117,912 patients were included in the analysis, aged 62.8+17.6 years (range 18-107), 59% male, 83.7+21.1 kgs (range 32-337) and 169.8+10.3 cm (range 107-218). The aortic root and ascending aortic dimensions are presented in absolute values (average + SD), and height adjusted (cm/m) and BSA adjusted (cm/m2) values. Data was expressed per centile of height, age and weight. There was a progressive increase in aortic dimensions as expected for increasing height, however a robust relationship was identified when dimensions were indexed according to height at all centiles regardless of age and body weight. In contrast, when adjusted for BSA, the aortic dimensions were progressively and predictably under-reported in patients over 80kg for assessment for normal vs dilated. When analysed for centiles of age, there was a small progressive increase in dimensions observed with increasing age. The indexation for height was independently robust across patients of all centiles of height. Conclusion Aortic dimensions are consistently 2.0+0.5 cm/m when adjusted for patient height across all body weight and age centiles. Adjustment for BSA in patients over 80kg tends to under-represent aortic dimensions when assessing for dilatation. Dimensions tend to increase gently with increasing age. We propose a new nomogram for normal aortic dimensions in adults.

Systemic manifestations of connective tissue abnormalities in patients with Mitral Valve Prolapse assessed by Cardiac Magnetic Resonance

Abstract Background Mitral valve prolapse (MVP) reflects a connective tissue abnormality of the mitral leaflets leading to myxomatous degeneration. Early echocardiography and semeiotic assessment investigations suggested that connective tissue abnormalities might be extended to heart chambers, great vessels, and the skeletal system. Cardiac Magnetic Resonance (CMR) has unique potentials in evaluating MVP, cardiac chambers, aortic dimensions, and Haller Index, an expression of the deformity of the thoracic cage, at one time. Purpose We aimed to investigate the potential phenotypic systemic expressions of connective tissue disease in patients with MVP by CMR assessment. Methods This case-control study included consecutive patients with MVP and a control group of healthy volunteers undergoing CMR at our Institution from September 2020 to November 2023. Patients with more than mild mitral or aortic regurgitation, bicuspid aortic valve, or known systemic connective diseases were excluded. The MVP, cardiac chambers, aortic dimensions, and Haller Index were assessed according to standard practice. Results 103 patients with MVP and 57 healthy volunteers (51± 17 vs. 47±18 years, p=0.2, and 5% females vs. 54.4% females, p=0.8, respectively) were enrolled. Patients with MVP showed greater left ventricular end-diastolic (91±25 vs. 78±17 ml/m2; p=0.005) and end-systolic volumes (36±12 vs. 27±6; ml/m2; p&amp;lt;0.001), aortic annulus (13±2 vs. 12±2 mm/m2; p&amp;lt;0.001), sino-tubular junction (15±3 vs. 14±3 mm/m2; p=0.03), aortic root (19±3 vs. 17±3 mm/m2; p&amp;lt;0.001), and descending aorta (13±2 vs. 12±2 mm/m2; p=0.03), and higher Haller Index (2.8±0.6 vs. 2.6±0.4; p=0.02) than healthy controls. No differences were found in ascending aorta (18±3 vs. 17±3 mm/m2; p=0.3), pulmonary trunk (13±2 vs. 13±2 mm/m2; p=0.5), left atrial volume (38±18 vs. 30±15 ml/m2; p=0.20), right ventricular end-diastolic-volume (86±20 vs. 81±20 ml/m2; p=0.3) were found. At ANCOVA, sex and MVP affected the Haller Index values (p = 0.005 and 0.04). The association between MVP and Haller Index persisted after controlling for sex, age, and body surface area. In multivariate regression analysis, MVP and sex had an independent impact on ventricular and aortic dimensions, with MVP and male patients showing greater values. In particular, MVP was associated with an increase in the aortic annulus (Coefficient=1.2; p&amp;lt; 0.001), aortic root (Coefficient=1.5, p=0.001), descending aorta (Coefficient=0.7, p = 0.026), left ventricular end-diastolic-volume (Coefficient=11.1, p=0.01) and mass (Coefficient=5.7, p=0.02) after controlling for sex, age, and body surface area. Conclusions This pivotal study assessing systemic connective tissue disorders by CMR suggests abnormalities in the aorta and the skeletal system of patients with MVP, paving the way to larger investigations exploring the clinical impact of these findings.CMR findings in the study populationBox plots showing variables distribution

The aortic paradox: a nationwide analysis of 523,994 individual echocardiograms exploring aortic dissection

Abstract Background Increasing aortic dilation increases risk of aortic dissection. Nevertheless, dissection occurs below guideline-directed cut-offs for prophylactic surgery. There is no current large-scale population imaging data assessing aortic dimensions before dissection. Purpose To examine the proportion of aortic dissections occurring in people with aortic diameters below guidelines for prophylactic intervention. Methods Patients within the National Echo Database of Australia (NEDA) were stratified according to absolute, height-indexed and body surface area (BSA)-indexed aortic dimensions. Fatal thoracic aortic dissections (ICD-10-AM code I79) were identified via linkage with the National Death Index. Results 524,994 individuals were assessed, comprising patients with normal aortic dimensions (n=460,992), mild dilation (n=53,402), moderate dilation (n=10,029) and severe dilation (n=572). 274,992 (52.4%) were male, with median age 64 years and median follow-up time 6.9 years. 899 fatal aortic dissections occurred (normal diameter=610, mildly-dilated aorta=215, moderately-dilated =53 and severely-dilated=21). Using normal aortas as the reference population, odds of fatal dissection increased with aortic diameter (mild=OR 3.05, 95% confidence interval (CI) 2.61-3.56; moderate=OR 4.0, 95% CI 3.02-5.30; severe=OR 28.72, 95% CI 18.44-44.72). Due to the much larger number of patients without severe aortic dilation, 97.7% of fatal aortic dissections occurred in non-severely dilated aortas. Following sensitivity analysis, severe aortic dilation was responsible for at most 24.4% of fatal aortic dissections. Results were robust for absolute, height-indexed or BSA-indexed aortic measurements. Conclusion Although severe aortic dilatation is associated with a thirty-fold increase in fatal dissection, severely dilated aortas are implicated in only 2.3-24.4% of fatal dissections. This highlights the ‘aortic paradox’ and limitations of current guidelines. Future studies should seek to refine risk predictors in patients without severe aortic dilation.

Pregnancy and inherited aortopathies: insights from specialized care

Abstract Background Genetic counselling, pregnancy follow-up and delivery planning in women with aortopathy should be conducted by a multidisciplinary team in an expert centre. Purpose Our objective was to analyze the impact of pregnancy on aortopathy outcomes in a centre specialized in inherited cardiovascular conditions in the United Kingdom. Methods All women with aortopathy referred to our centre due to pregnancy between 2016 and 2023 were retrospectively analyzed. Demographic, clinical, obstetric, genetic, electrocardiographic, and multimodal imaging variables were collected. Results Between 2016 and 2023, 22 women with aortopathy were referred to our centre for pregnancy follow-up and delivery planning. Among them, 14 (63.6%) had Marfan syndrome (FBN1+), 4 (18.2%) family history of aortic dissection without known genetic mutations, 2 (9.1%) bicuspid aortic valve with aortic dilation and 2 (9.1%) Loeys-Dietz syndrome (SMAD3+). The average number of births per patient was 1.55. Among those with an identified mutation, 4 (25%) underwent preimplantation diagnosis. In total, there were 40 pregnancies resulting in 34 live births. 15 women (68.2%) had an aortic root dimension &amp;lt;40mm and 7 (31.8%) ≥40mm. There were 4 (26.7%) and 5 (71.4%) patients in each group under beta-blockers. Out of the total 40 pregnancies, there were 6 (15%) miscarriages, all in the first trimester, 2 (5%) cases of preeclampsia and 1 (2.5%) case of gestational diabetes. There were no statistically significant differences between these complications and the aortic root dimension (8 (20%) &amp;lt;40mm vs 1 (2.5%) ≥40mm; p = 0.160) or the absence or presence of treatment (3 (7.5%) vs 6 (15%); p = 0.769). Regarding delivery, 16 patients (72.7%) underwent vaginal delivery and 6 (27.3%) has a caesarean section. After delivery, there were 6 cases of major bleeding, 4 (10%) after vaginal delivery and 2 (5%) after caesarean (p=0.376). One patient had a subacute type A aortic dissection in the context of Marfan syndrome with an aortic root of 40mm before pregnancy. No significant differences were observed in the occurrence of these complications based on the aortic root dimension (5 (12.5%) &amp;lt;40mm vs 2 (5%) ≥40mm; p = 0.928) or the absence or presence of treatment (2 (5%) vs 5 (12.5%) respectively; p = 0.591). 100% of the patients survived pregnancy and the postpartum period. Conclusions Our findings underscore the complexity of managing aortopathy during pregnancy. This highlights the importance of a comprehensive risk assessment for precise pregnancy and delivery planning.

2D Echocardiographic aortic root dimensions and longitudinal analysis with artificial intelligence using an open dataset from a UK-wide collaborative

Abstract Background Surveillance of aortic dimensions requires reproducible measurements, and knowledge of the rate of progression in those with dilatation. Purpose To develop an open machine-learning method for measuring the aortic root and proximal ascending aorta on echocardiograms, validate it through a multi-expert panel from the Unity UK Echocardiography AI Collaborative, and applying the AI to derive the rate of progression in historical databases. Methods The neural network was trained on 1478 parasternal long-axis images. Each image was labelled with key points for the aortic annulus, sinus and sinotubular junction, and proximal ascending aorta dimensions. Labels accommodated inner-to-inner and leading-to-leading conventions. For validation, the end-diastolic and mid-systolic images were identified (accommodating different guidelines recommendations) from 100 studies, and 10 expert echocardiographers made the aortic measurements. The consensus of experts defined the reference standard, and the variation between individual experts defined the acceptable variation for the AI. The AI was then applied to 724 echocardiograms of 102 patients under surveillance spanning 12 years (ranging from 4 to 17 scans per patient) without intervention. Training data labels and networks are made freely available on our project website. Results The median absolute deviations between the AI and the expert consensus ranged from 0.06cm to 0.17cm across the 16 measurements. For the individual expert opinions this was from 0.08cm to 0.19cm. For 7/16 measurements, there was no statistically significant difference between the AI deviation and the individual-expert deviation. The AI’s confidence level was a useful indicator of the reliability of the AI measure. For the top 9 deciles of AI confidence level, the AI measurements had significantly smaller deviations than the individual experts. The rates of progression averaged across the three aortic measurements was 2.0 mm/decade (95% CI 1.0 to 3.0; p =0.007). Conclusion Expert consensus can be used to both define the reference standard and also the range of acceptable deviation from consensus. Overall, the AI performs similarly to experts and more importantly, provides an automated estimate of confidence. The validated AI is consistent over time, and when applied retrospectively to patients with dilated aortic roots, found the rate of progression was more rapid than in previously reported healthy patients. This approach could be applied generally in developing medical AI to not only make reproducible measurements but to automate large scale longitudinal studies with little input, and ultimately serves as a useful research and clinical tool.Figure: AI(red) vs Expert (blue)Table: AIDeviations from Consensus

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

The introduction of a dedicated cardiology clinic including a clinical scientist led pathway for women with turner's syndrome

Abstract Background There are more than 15,000 women living with Turner’s Syndrome (TS) in the UK, over 700 of whom are cared for within our linked Endocrinology services. Mortality is predominantly related to cardiovascular disease therefore close cardiology review with a focus on aortopathy is essential (1). However appropriate surveillance is challenging with growing pressures on all aortopathy services across the United Kingdom. Purpose To audit our current practise according to current international guidelines (2) and seek methods to improve the pathway for our growing population of TS patients including the feasibility of a Clinical Scientist led clinic, aiming to improve capacity and efficiency of our service. Methods A quality improvement project was conducted over a three-year period, piloting a dedicated clinical scientist-led clinic under close Cardiology Consultant supervision. Patients selected were deemed lower risk for cardiovascular complications according to American Heart Association (AHA) recommendations (2) (figure 1). Follow-up intervals of patients under both consultant-led and clinical scientist led pathways were analysed. Results Among a total of 226 patients analysed, 103 (46%) fell into the lowest risk category and therefore deemed suitable for prospective Clinical Scientist led pathway (figure 2). Analysis of all patients demonstrated that 60% had appropriate follow-up intervals according to guidelines, while 37% were too short and 3% were too long. A five-year projection indicated a consequential 96 unnecessary additional appointments for patients that were being seen too frequently. Further analysis showed that the time frame for follow up was too short in 25% of patients seen in the clinical scientist led clinic compared to 41% in the Consultant-led clinic. There were no aortic dissections in patients under surveillance during this period. In the last 10 years 1 patient on the waiting list for surgery (having presented with a type B dissection but requiring workup for liver cirrhosis) had a retrograde type A dissection (indexed aortic root dimension 2.4cm/m²). No other adverse events were recorded. Conclusion Auditing our service revealed safe management and improved adherence to guidelines in the clinical scientist-led clinic, identifying opportunities to optimize follow-up and enable physicians to focus upon high-risk patients. This pilot demonstrates the feasibility of a clinical scientist-led clinic in managing low risk TS patients, suggesting scalability to other conditions involving aortopathy to address capacity issues and improve pathways.

Gradual hypertensive response in aortic alterations and myocardial inflammatory activation in progressing HFpEF in mice

Abstract Introduction Hypertension is the most common comorbidity in patients affected by heart failure with preserved ejection fraction (HFpEF). Early effects of pressure overload and its contribution to the gradual development of cardiac and vascular pathology leading to HFpEF are not well recognized, as patients are diagnosed when the disease has already advanced and show symptoms. Several hypertensive HFpEF mouse models possessing the hallmarks of the clinical-like phenotype are available. Nonetheless, initial and gradual pathological manifestations of hypertensive HFpEF have not been comprehensively described. Purpose This study aimed to investigate the gradual progression of HFpEF phenotype development in mice from the early manifestation of cardiac and vascular pathology to global cardiac dysfunction to multiorgan syndrome in response to hypertension. Methods Hypertensive HFpEF was induced by angiotensin II infusion in C57BL/6JOlaHsd 18-20-week-old male mice that were given low, moderate and high doses (0.5mg/kg/day - 1.5 mg/kg/day) subcutaneously for 4 weeks. Cardiac physiology and alterations in haemodynamics were assessed with echocardiography of heart and aorta, weekly ECG monitoring, and blood pressure measurements from the mouse tail. Extensive histology and immunohistochemistry analyses of cardiac tissue, microvasculature, lungs and kidneys were performed. Results In the low dose group, loss of aortic wall flexibility and presence of aortic root dilatation were detected. This group also demonstrated initiation of concentric remodelling process with the upsurge in macrophage infiltration in myocardium, but the signs of diastolic dysfunction were not yet present. The high dose group exhibited characteristic HFpEF features with diastolic dysfunction, left ventricular hypertrophy and fibrosis. Pathology in cardiac conduction system was noticed in all groups, with prominent ECG waveform abnormalities already on week one. However, only the high dose group experienced non-recovery in impulse propagation, accompanied by significant prolongation of ventricular depolarization. Conclusion This study demonstrates that change in aortic root dimensions and aortic wall dynamics are the first hypertension-sensitive alterations together with myocardial inflammatory cell infiltration that may contribute to myocardial remodelling and subsequent development of HFpEF and systemic effects. Hypertensive angiotensin II-induced HFpEF is a relevant mouse model, recapitulating not only hallmarks of cardiac pathology but also an extensive range of vascular and multiorgan alterations, demonstrating similarities with the clinical phenotype.

Gene-echocardiography: unmasking the covert role of fatty acid metabolism gene mutations in adult cardiomyopathy

Abstract Background Although the role of fatty acid metabolic deficiencies in cardiomyopathy is established, the precise identity of causative genes and their respective phenotypes in adult cardiomyopathy remains unclear. Methods We implemented a combination of echocardiography and whole exome sequencing in clinically diagnosed cardiomyopathy patients to uncover this relationship. This involved recording cardiac phenotypes, identifying genes associated with disrupted fatty acid metabolism, and subsequently followed up with these patients. Results Out of 802 cardiomyopathy patients, 27 exhibited mutations in genes tied to fatty acid metabolism. Specifically, 16 patients demonstrated a hypertrophic cardiomyopathy (HCM) phenotype, and 11 showed a dilated cardiomyopathy (DCM) phenotype. The implicated genes were SLC22A5 (n=7), ACADVL (n=6), ACADS (n=4), ACADM (n=3), SLC25A20 (n=3), ACADL (n=2), HADH (n=1), and AGK (n=1), with a higher prevalence in males. Among these, the SLC22A5 mutation was predominant and correlated with HCM phenotype. Notably, compound mutations were frequently observed (16/27), leading to earlier disease onset and diminished aortic sinus dimension. Further investigation showed that smaller aortic sinus dimensions resulted from abnormal left ventricular myocardial work. HCM phenotype mutation carriers showed more consistent left ventricular hypertrophy and a higher probability of right ventricular hypertrophy, while DCM phenotype mutation carriers exhibited impaired contractile function across all left ventricle segments. After a 24-month follow-up, the DCM phenotype group demonstrated higher cardiovascular risk, including two fatalities. Conclusion Our investigation highlights the significant prevalence of mutations related to abnormal fatty acid metabolism in adult cardiomyopathy patients, underscoring the utility of a gene-echocardiography approach for diagnosis.

Gene-echocardiography: refining genotype-phenotype correlations in cardiomyopathy patients with restrictive phenotype

Abstract Background The restrictive phenotype, the least frequent and genetically complex form of cardiomyopathy, is the focus of this investigation. The aim is to clarify the association between restrictive phenotype and genetic variants in cardiomyopathy patient. Methods We utilized whole-exome sequencing in a cohort of 568 cardiomyopathy patients and performed echocardiographic evaluations to identify restrictive phenotypes. Comprehensive analysis of cardiac characteristics and functionality was also undertaken. Results Among the cohort, 33 patients exhibited a restrictive phenotype. These patients were distributed as follows: 7 within the restrictive cardiomyopathy group (RCM), 20 in the hypertrophic cardiomyopathy group (HRCM), and 6 in the dilated cardiomyopathy group (HDRCM). A notable prevalence of gene mutations, mainly in the MYBPC3 gene, was found in these individuals. We observed that mutation carriers, characterized by smaller aortic sinus dimension, demonstrated an association with the mutation and diminished myocardial work. Furthermore, MYBPC3 mutation carriers showed a thicker ventricular wall and a higher predisposition for septal hypertrophy. Both HRCM and HDRCM groups displayed consistent hypertrophic manifestations, with the latter demonstrating a higher frequency of interventricular septal hypertrophy. The 5-year survival rate was calculated at 54.5%, with gene mutations not significantly affecting longevity. Conclusion Genetic factors profoundly influence the restrictive phenotype of cardiomyopathy. There is a strong link between restrictive phenotype and genetic variants in cardiomyopathy, providing a foundation for more accurate genetic testing and personalized management of patients. The emerging "gene-echocardiography" concept may refine the accuracy and productivity of genetic counseling and testing in cardiomyopathy.

Flow adjusted predicted prosthesis patient mismatch in patients undergoing transcatheter aortic valve implantation

Abstract Background Effective orifice area (EOA) is flow dependent. However, established methods for the assessment of prosthesis-patient mismatch (PPM) do not consider flow status, and therefore may underestimate the rate and impact of PPM in patients with abnormal flow status. Objectives To investigate the clinical impact of flow-adjusted predicted PPM in patients undergoing transcatheter aortic valve implantation (TAVI). Methods Patients undergoing TAVI in a prospective TAVI registry were stratified by the presence of moderate or severe PPM (EOA index to body surface area [EOAi]: 0.65-0.85 or ≤0.65 and 0.55-0.70 or ≤0.55 cm2/m2 if obese). PPM was defined according to echocardiographically measured EOAi (measured PPM) or unadjusted or flow-adjusted predicted EOAi. Predicted EOAs were based on reference values of EOA for each valve generation and size (predicted PPMTHV) or native aortic annulus dimension (predicted PPMCT). Results Among 1,510 patients included (August 2007-June 2022), rates of moderate or severe PPM differed according to method of assessment; 27.0% and 8.7% according to measured PPM, 11.3% and 1.2% according to predicted PPMTHV, 12.0% and 0.1% according to PPMCT, 21.6% and 0.2% according to flow-adjusted predicted PPMTHV, and 25.1% and 0.4% according to flow-adjusted predicted PPMCT. Five-year mortality was comparable in patients with and without flow-adjusted predicted PPM defined by either method. These results were consistent when patients were stratified by flow status. Conclusions Rates of PPM differ considerably when flow status is considered. There was no consistent signal of increased risk of adverse events up to 5 years in patients with flow-adjusted predicted PPM.Frequency of PPM afteer TAVICumulative event curves for death

Cusp-overlap technique to reduce permanent pacemaker implantation rate after transcatheter aortic valve implantation

Abstract Background Persistent conduction disturbances requiring permanent pacemaker (PPM) implantation are one of the most common complications after Transcatheter Aortic Valve Implantation (TAVI). Cusp-Overlap Technique (COT) is a novel approach for self-expandable valve implantation to minimize the rate of procedural complications, mainly PPM implantation. Purpose To determine if the COT during TAVI with self-expandable valves leads to a reduction of PPM implantation rate in the real-world setting. Methods A retrospective analysis of consecutive patients undergoing TAVI between January 2020 and November 2023 in one high-volume tertiary care center in Portugal was conducted. Two groups were defined, the COT group and the control group based on the fluoroscopic approach. A baseline comparison between the 2 groups was made using independent-samples t-test and chi-square analysis to determine if there was a difference between the prevalence of known risk factors for PPM implantation after TAVI. Afterwards, chi-square analysis was used to determine if COT led to a reduction in the PPM implantation rate. Results Of the 539 completed procedures in this timeframe, 289 were excluded due to previous pacemaker implantation, use of a valve not amenable to COT or valve-in-valve implantation. COT was used in 57.6% of eligible cases. Baseline comparison did not show a significant difference in the prevalence of several known risk factors for PPM implantation, including complete right bundle branch block, atrio-ventricular block, calcium score, aortic ring dimensions and pre/post-dilation. PPM implantation after TAVI was required in 31.6% of cases. In the COT group the PPM implantation rate was 22.9% and in the control group 43.4%. Chi-square analysis showed a very statistically significant difference between the 2 analyzed groups (p-value = 0.001). Conclusion PPM implantation remains a frequent complication of TAVI. However, this study showed that the utilization of COT leads to a reduction of the PPM implantation rate.

Distal ascending aortic dilatation portends a near 2-fold greater risk of cardiovascular mortality than proximal enlargement: results from 120,000 patients in a nationwide echocardiographic database

Abstract Background The management of thoracic aortic dilatation is clinically challenging and acute aortic dissection (AD) is under-recognised as a primary cause of death. Despite the majority of AD occurring in non-severely dilated aortas, absolute aortic diameter remains the most utilised criterion for adjudging preventative surgical correction. In order to improve outcomes and guide management, greater prognostic understanding is needed. Purpose We examined a nationwide echocardiographic dataset linked to mortality outcomes to determine how ascending thoracic aortic dilatation and its site affects cardiovascular disease (CVD) mortality over time. Methods The National Echocardiography Database Australia (NEDA) was examined for aortic dimensions at the sinuses of Valsalva (SoV), sinotubular junction (STJ) and ascending aorta (AscAo) in patients who had undertaken &amp;gt;1 echocardiographic study. Following separation of those who had undergone corrective aortic surgery, patients were stratified according to absolute aortic diameters and grouped as normal (&amp;lt;4cm), mild (4.0-4.5cm), moderate (4.5-5cm) and severely (&amp;gt;5cm) dilated at the prescribed thoracic aortic sites. Mortality data was then linked from the National Death Index (NDI). Results 398,905 echocardiographs from 121,115 patients with a mean age of 62.6±16.2 years were included. At the time of mortality data linkage, 38,681 (32%) had died, of whom 13,292 (34%) died from CVD causes and only 276 (0.007%) had aortic dissection recorded as their primary cause of death. Severe aortic dilatation at any site increased the likelihood of 10-year CVD mortality (29% vs. 15% in those with normal diameters; HR 3.00; CI 1.60-5.63; p&amp;lt;0.0001), with an incremental increase in the probability of CVD death when moving from the proximal to distal ascending aorta; 10-year CVD mortality at the SoV 26% (HR 1.93; CI 1.29-2.87; p&amp;lt;0.001), STJ 39% (HR 2.82; CI 1.64-4.86; p&amp;lt;0.001) and AscAo 44% (HR 4.74; CI 2.46-9.13; p&amp;lt;0.001) respectively (Figure 1). When examining those patients who had undergone corrective aortic surgery, the likelihood of 10-year CVD mortality was comparable to the population with normal aortic diameters (17 vs. 15%, HR 1.1; CI 0.9-1.36; p=0.3) (Figure 2). Conclusion Severe aortic dilatation increases the probability of 10-year cardiovascular mortality. Interestingly, there is an incremental increase in the likelihood of CVD mortality when moving from the proximal to distal ascending aorta, with severe AscAo dilatation conferring a near 2-fold greater risk of CVD mortality compared with severe SoV aneurysms. Additionally, surgical aortic intervention nearly normalises survival probability to the population with healthy aortic diameters. These results identify new considerations for prognostication, risk stratification and surgical guidance of aortic repair.CVD mortality by aortic dilatationCVD mortality after aortic intervention

Aortic integral distensibility based on the auto-segmented dynamic motion of the aortic wall

Abstract Background Aortic stiffness is important in cardiovascular diseases and predicting outcomes. Echocardiography is a widely used noninvasive imaging modality for assessing aortic stiffness, but its accuracy can be limited by the low spatial resolution of ultrasound-based images and the subjectivity of manual measurements of aortic dimensions. Automated segmentation analysis can provide a more accurate and objective measure. Objective An automated algorithm and software have been developed for segmenting the aortic wall. A new measurement technique called "Aortic Integral Distensibility (AID)" has been formulated using this framework. This method overcomes limitations of traditional method focusing solely on the two positions of Aortic Distensibility (AD). Method In this particular investigation, 112 participants were subjected to echocardiography in order to quantify the dynamics of the aortic wall. An automated algorithm was devised to delineate the aortic wall by utilizing an M-mode echocardiography scan. The statistical analysis encompassed the measurement of AD and AID before and after the age of 65 group. This analysis was conducted considering various risk factors, including age, gender, weight, BMI, smoking, and blood pressure. Additionally, clinical parameters, specifically AIx @75 (Augmentation Index) and Framingham Risk Score (FRS), were evaluated as well. Inter-rater reliability was conducted between the traditional AD and the newly implemented AID. Results The results indicate that the group under 65 had more distensibility than the group over 65, and AID measurements were slightly higher than AD measurements. SBP showed a strong correlation with AID, rather than AD. AIx @75 and FRS had a negative relationship with distensibility. In the 65 years or older group, there was a significant negative correlation observed between AIx @75 and AID (r = -0.4, p = 0.012). Furthermore, a strong correlation was also observed between FRS and AID (r = -0.53, p = 0.002). Bland-Altman analysis demonstrated that the automated methodology had better reproducibility and less variability in distensibility measurements than the manual methodology. Conclusion The study suggests that AID could be valuable for assessing aortic stiffness. AID could help clinicians diagnose and manage cardiovascular diseases more accurately. The automatic approach provides reliable measurements for aortic distensibility and strain, which has clinical implications.Schematic Chart of the Study Process

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.

Effect of aortic valve phenotype and sex on aorta dilation in patients with aortic stenosis

BackgroundBicuspid aortic valve (BAV) is often associated with a concomitant aortopathy. However, few studies have evaluated the effect of the aortic valve (AV) phenotype on the rate of dilation of...

Aortic arch anatomical differences in male type B aortic dissection patients vs. healthy male individuals

BackgroundUnderstanding the distinct anatomical differences between patients with type B aortic dissection (TBAD) and control patients (CPs) can enhance our knowledge of normal and pathological aortic dimensions. This study aimed to deepen our knowledge of these dimensions by measuring and comparing the anatomical indices of the aortic arch in male patients with TBAD and non-TBAD male patients.MethodsIn this cross-sectional observational study, 62 TBAD patients (TBADPs) and 43 CPs were assessed. Using a fit centerline approach, we identified three pivotal anatomical landmarks: Point A, Point B, and Point C. These landmarks represented intersections of the aortic arch with the brachiocephalic trunk, left common carotid artery, and left subclavian artery, respectively. These points defined Zones 1, 2, and 3, which collectively span the entire proximal aorta from the proximal end of the aortic valve to Point C. Our analyses compared key anatomical indices such as diameter of the circumscribed circle (Dcirc), ellipticity, curvature, tortuosity between TBADP and CP at critical points and regions.ResultsTBADPs showed a more circular cross-sectional shape at Points A, B and C, as indicated by reduced values of Dcirc_A (P = 0.031), ellipticity_A (P = 0.034) and ellipticity_B (P = 0.048), together with a significant decrease in Dcirc_C (P = 0.015) and ellipticity_C (P = 0.007). The aortic arch in TBADPs showed enhanced tortuosity in Zone 1 (p = 0.002) and extended elongation in Zone 3 (p = 0.001).ConclusionsThe study found that the aortic arch in male TBAD patients is more circular near its primary branches, has greater tortuosity in Zone 1, and is longer in Zone 3 compared to male control patients.

Aortic valve function and aortic dimensions in obese and overweight patients with bicuspid aortic valve.

Bicuspid aortic valve is the most common CHD and commonly associated with activity restrictions that may lead to a sedentary lifestyle known to increase obesity risk. It is unknown whether obesity is associated with changes in aortic dimensions or aortic valve function in young people with bicuspid aortic valve. This study investigates whether overweight and obese children with bicuspid aortic valve have worse aortic valve function or increased aortic dimensions compared to healthy weight children with bicuspid aortic valve. This was a single centre retrospective cohort study comprised of patients 5 to 25 years old with a diagnosis of bicuspid aortic valve between 1 January, 2019 and 31 December, 2020. Patients were classified as healthy weight or overweight/obese. Values for aortic dimensions as well as peak and mean aortic valve gradients were obtained from echocardiogram reports. About 251 patients were analysed. Demographics were similar between groups. When indexed to height, the aortic valve annulus (1.28 ± 0.14 vs. 1.34 ± 0.15, p = 0.001) and sinotubular junctions (1.44 ± 0.21 vs. 1.49 ± 0.24, p = 0.038) were larger in the overweight/obese group, with no differences in aortic root or ascending aorta sizes. The obese/overweight group had a higher peak aortic valve gradient (23.03 ± 1.64 mmHg vs. 16.17 ± 1.55 mmHg, p = 0.003) compared to the healthy weight group. Healthy weight patients did not have larger aortic dimensions compared to the overweight/obese patients. There was evidence of worsening aortic valve stenosis in overweight/obese patients compared to those at a healthy weight.