Aortic Outflow Tract Research Articles

Computational modeling of left ventricular flow using PC-CMR-derived four-dimensional wall motion.

Intracardiac hemodynamics plays a crucial role in the onset and development of cardiac and valvular diseases. Simulations of blood flow in the left ventricle (LV) have provided valuable insight into assessing LV hemodynamics. While fully coupled fluid-solid modelings of the LV remain challenging due to the complex passive-active behavior of the LV wall myocardium, the integration of imaging-driven quantification of structural motion with computational fluid dynamics (CFD) modeling in the LV holds the promise of feasible and clinically translatable characterization of patient-specific LV hemodynamics. In this study, we propose to integrate two magnetic resonance imaging (MRI) modalities with the moving-boundary CFD method to characterize intracardiac LV hemodynamics. Our method uses the standard cine cardiac magnetic resonance (CMR) images to estimate four-dimensional myocardial motion, eliminating the need for involved myocardial material modeling to capture LV wall behavior. In conjunction with CMR, phase contrast-MRI (PC-MRI) was used to measure temporal blood inflow rates at the mitral orifice, serving as an additional boundary condition. Flow patterns, including velocity streamlines, vortex rings, and kinetic energy, were characterized and compared to the available data. Moreover, relationships between LV wall kinematic markers and flow characteristics were determined without myocardial material modeling and using a non-rigid image registration (NRIR) method. The fidelity of the simulation was quantitatively evaluated by validating the flow rate at the aortic outflow tract against respective PC-MRI measures. The proposed methodology offers a novel and feasible toolset that works with standard PC-CMR protocols to improve the clinical assessment of LV characteristics in prognostic studies and surgical planning.

Effect and mechanism of EtOAc extract of Draconis Sanguis onimproving atherosclerosis in ApoE~(-/-) mice

This study aims to investigate the effect and mechanism of the EtO Ac extract of Draconis Sanguis(DSE) on improving athero sclerosis in ApoE gene knockout(ApoE~(-/-)) mice. The ApoE~(-/-) mice were randomly divided into five groups: control group, mo delgroup, positive group treated with ezetimibe of 5 mg·kg~(-1)(EG), and low(100 mg·kg~(-1)) and high dose(200 mg·kg~(-1)) groups ofDSE. xcept for the control group, all other groups were fed a high-fat diet and administered drugs for 16 successive weeks. After 16 weeks of Eadministration, the body weight, liver, and epididymal fat mass of the mice were measured; the level of blood lipid and the plaquearea of the aortic outflow tract were detected to evaluate the efficacy of DSE in vivo. In addition, in vitro cultures of human umbilical v ein endothelial cell(HUVEC) were conducted. Oxidative stress of endothelial cells was induced by oxidized low-density lipoprot ein(ox-LDL), and the effects of DSE on oxidative stress-related proteins in endothelial cells were examined. The results sho wedthat both doses of DSE significantly improved the epididymal fat mass and index of ApoE~(-/-) mice with atherosclerosis, lowered thelevels of plasma cholesterol, triglyceride, and non-high density lipoprotein cholesterol, and reduced the plaque area of the aortic ou tflow tract. totIn alvitro experiments confirmed that ox-LDL significantly increased the level of lipid peroxidation marker 4-HNE in HUVECcells, confirming that DSE improved the degree of atherosclerotic lesions in ApoE~(-/-) mice by inhibiting ox-LDL-induced oxidative stress in vascular endothelial cells.

Delayed Sternal Closure vs Emergency Sternal Reopening in Adults With Congenital Heart Disease

BackgroundLimited data exist regarding outcomes of delayed sternal closure (DSC) in adults with congenital heart disease (ACHD). MethodsWe reviewed 159 ACHD patients undergoing cardiac operation from 1993 to 2023 who required DSC (open sternum at the end of operation, n = 112) or sternum emergently reopened (n = 47). Regression models were performed to determine factors associated with outcomes. ResultsOf 112 patients undergoing DSC, 87 patients (77.6%) underwent DSC ≤4 days and 25 patients (22.3%) >4 days. The most common operations were valve (n = 35 [31.2%]), aortic (n = 33 [29.4%]), and right ventricular outflow tract procedures (n = 23 [20.5%]). Median time to chest closure was 2 days (interquartile range, 1-5 days). Apart from sex, baseline characteristics were similar between DSC groups. A stepwise increase in early mortality was observed from DSC ≤4 days to DSC >4 days (6.8% vs 32%), as well as the incidence of early complications, except sternal infection. Risk factors associated with early mortality were age (P = .02), DSC >4 days (P < .001), hemodynamic indication (P = .03), and single ventricle (P = .02). On multivariable analysis, lower ejection fraction (P = .04), hemodynamic indication (P = .02), single ventricle (P = .004), and diabetes mellitus (P = .03) were predictors of prolonged time to chest closure. Among hospital survivors, late survival was similar between patients undergoing DSC ≤4 days vs >4 days (P = .48). ConclusionsA brief duration of DSC in ACHD patients is associated with low morbidity and mortality. Higher early mortality and complications were observed among patients who did not achieve chest closure within 4 days.

Fetal Diagnosis of Supravalvular Aortic Stenosis and Pulmonary Stenosis in a Family with Non-Syndromic Elastin Mutation.

Supravalvular aortic stenosis (SVAS) has been well described in Williams-Beuren Syndrome and non-syndromic elastin (ELN) mutations. Non-syndromic ELN mutations are inherited in an autosomal dominant pattern with incomplete penetrance and variable expressivity. ELN haploinsufficiency leads to progressive arteriopathy, typically affecting the aortic sinotubular junction. Multi-level pulmonary stenosis has also been reported and biventricular obstruction may portend a worse prognosis. Fetal presentation of ELN mutation with SVAS has not been previously reported in the literature. We present a case of fetal diagnosis of SVAS and multi-level pulmonary stenosis in a family with a known pathogenic ELN mutation (Exon 6, c.278del [p.Pro93Leufs*29]). On the fetus' initial fetal echo, there was only mild flow acceleration through the aortic outflow tract, however, she went on to develop progressive bilateral obstruction. In the early post-natal period, the child was clinically asymptomatic and showed similar mild SVAS and mild valvar and supravalvular pulmonary stenosis. Our case highlights the need for serial monitoring of fetuses with suspected or confirmed ELN arteriopathy.

The prevalence of congenital cardiac tumours in unselected newborns

Abstract Background Primary cardiac tumours in children are rare. The most common cardiac tumour in newborns is rhabdomyomas, associated with tuberous sclerosis in &amp;gt;50% of cases. The estimated prevalence is 0.14‰ in fetuses, whereas in the paediatric population, a 20-fold difference in autopsy prevalence has been reported (0.017‰ to 0.27‰). Purpose To determine the pre- and postnatal prevalence of congenital cardiac tumours in a large, population-based cohort of prenatally enrolled newborns. Methods Systematic transthoracic echocardiography (TTE), including sub-xiphoid, apical, parasternal, and suprasternal views, was performed in unselected newborns included in a population study. Participants were included at time of the routine malformation scan (weeks 18-21), which included 4-chamber view, aortic and pulmonary outflow tracts, and three-vessel view. Cardiac tumours were defined as solid, echogenic masses, and the echocardiographic description included location, size, and number (one/multiple) of the tumour. Information on subsequent diagnosis of tuberous sclerosis was collected from review of medical charts. Results A total of 25,588 newborns (age 12±8 days, 51.6% male) were enrolled and underwent TTE. Prenatally, no cardiac tumours were reported in any of the participants. Postnatally, cardiac tumours were detected in 7 newborns (4 males), corresponding to a prevalence of 0.3 [0.1; 0.6] per 1,000 live-births. Through retrospective review of the prenatal scans, a possible tumour in the ventricle was suspected in 1 of the 7 cases; the remaining 6 cases showed no signs of tumours prenatally. Sex, gestational age at birth, birth length and weight, APGAR 5-score, age and weight at TTE, and maternal age and pre-pregnancy BMI, did not significantly differ between newborns with (n=7) and without (n=25,581) cardiac tumours (all p&amp;gt;0.05). Smoking during pregnancy was significantly more frequent among mothers to newborns with cardiac tumours compared to the remaining cohort (29% vs 4%, p=0.023). In all 7 newborns, the cardiac tumours were located in the ventricles (5 (71%) newborns with tumours in both ventricles, 2 (29%) with tumours in the right ventricle), with multiple tumours seen in 6 (86%), and with size ranging from 2.0x1.9 mm to 10.0x5.1 mm. All 7 newborns had otherwise structurally normal hearts and no flow obstruction. Three newborns with cardiac tumours in the ventricles (43%) were diagnosed with tuberous sclerosis within 4 months after birth. Conclusions Systematic TTE in unselected newborns revealed a prevalence of congenital cardiac tumours of 0.3‰. Prenatal screening in week 18-21 did not seem efficient for identification of cardiac tumours. Cardiac tumours were located in the ventricles and were most often multiple. Cardiac tumours in the ventricles were associated with tuberous sclerosis in almost half the cases. For newborns with cardiac tumours, maternal smoking during pregnancy was common (29%).Figure 1

Pitfalls and Tips in the Assessment of Aortic Stenosis by Transthoracic Echocardiography.

Aortic stenosis (AS) is a valvular heart disease that significantly contributes to cardiovascular morbidity and mortality worldwide. The condition is characterized by calcification and thickening of the aortic valve leaflets, resulting in a narrowed orifice and increased pressure gradient across the valve. AS typically progresses from a subclinical phase known as aortic sclerosis, where valve calcification occurs without a transvalvular gradient, to a more advanced stage marked by a triad of symptoms: heart failure, syncope, and angina. Echocardiography plays a crucial role in the diagnosis and evaluation of AS, serving as the primary non-invasive imaging modality. However, to minimize misdiagnoses, it is crucial to adhere to a standardized protocol for acquiring echocardiographic images. This is because, despite continuous advances in echocardiographic technology, diagnostic errors still occur during the evaluation of AS, particularly in classifying its severity and hemodynamic characteristics. This review focuses on providing guidance for the imager during the echocardiographic assessment of AS. Firstly, the review will report on how the echo machine should be set to improve image quality and reduce noise and artifacts. Thereafter, the review will report specific emphasis on accurate measurements of left ventricular outflow tract diameter, aortic valve morphology and movement, as well as aortic and left ventricular outflow tract velocities. By considering these key factors, clinicians can ensure consistency and accuracy in the evaluation of AS using echocardiography.

What Is the Hypoplastic Left Heart Syndrome?

As yet, there is no agreed definition for the so-called "hypoplastic left heart syndrome". Even its origin remains contentious. Noonan and Nadas, who as far as we can establish first grouped together patients as belonging to a "syndrome" in 1958, suggested that Lev had named the entity. Lev, however, when writing in 1952, had described "hypoplasia of the aortic outflow tract complex". In his initial description, as with Noonan and Nadas, he included cases with ventricular septal defects. In a subsequent account, he suggested that only those with an intact ventricular septum be included within the syndrome. There is much to commend this later approach. When assessed on the basis of the integrity of the ventricular septum, the hearts to be included can be interpreted as showing an acquired disease of fetal life. Recognition of this fact is important to those seeking to establish the genetic background of left ventricular hypoplasia. Flow is also of importance, with septal integrity then influencing its effect on the structure of the hypoplastic ventricle. In our review, we summarise the evidence supporting the notion that an intact ventricular septum should now be part of the definition of the hypoplastic left heart syndrome.

Cough, with a sac of marbles in the chest.

A 48-year-old male patient presented with productive cough, dyspnea and abdominal pain of 2 months duration. He was diagnosed with diabetes mellitus 6 months ago and had not been regular with his medications. Clinical examination revealed a respiratory rate of 18 per min with room air saturation of 95%, and a paucity of movements with bronchial breath sounds identified on inspection and auscultation, respectively, over the right hemithorax. Chest skiagram and computed tomography images of his thorax are shown below [Figure 1].Figure 1: (a) shows chest skiagram and (b–d) shows high-resolution computed tomography images of the chest. A description of the images is in the accompanying textQuestion: What is the diagnosis? Answer: Pulmonary and hepatic hydatid disease. DISCUSSION The chest skiagram [Figure 1a] revealed a well-defined round radio-opacity in the right mid zone with a crescentic hyperlucent medial margin, called the crescent sign (white arrow). Figure 1b is a coronal view of high-resolution computed tomography (HRCT) scan of the chest lung window, which shows a large cyst in the right lung, with multiple small rounded opacities with fluid attenuation, some of which appear to be floating within it, appearing like a sac of marbles. This is consistent with a diagnosis of a hydatid cyst with multiple daughter cysts within it. There are pockets of air seen between the outer pericyst and inner endocyst, aptly named ‘air-crescent sign’ (blue arrow) and ‘signet ring sign’ (red arrow), which suggest a ruptured or complicated hydatid cyst. Figure 1c, the sagittal section of the HRCT scan of the chest lung window at the level of the aortic outflow tract, shows the ruptured hydatid cyst in the right lung. The daughter cysts have collected in the dependent area of the larger cyst, with some appearing to ‘rise’ over the rest, or the ‘rising-sun sign’ (blue arrow). Also seen is a small air pocket inferiorly (red arrow) between the pericyst and endocyst, called the ‘air-bubble sign’. The presence of air on either side of the endocyst (red arrowheads) gives the appearance of an ‘onion-peel sign’, or the ‘cumbo sign’. Figure 1d shows a large well-defined homogenous cyst in the right lobe of the liver.[1] Blood investigations revealed uncontrolled blood sugar levels. Armed with the characteristic radiology above, and supplemented by a positive serum latex agglutination test for Echinococcus antigen, he was diagnosed with pulmonary and hepatic hydatid disease. He was started on oral albendazole and subsequently underwent pericystectomy of lung cyst along with partial pericystectomy of cyst in the liver. Post-surgery, he is at present asymptomatic and is on regular follow-up. Hydatid disease is a zoonosis, commonly caused by the accidental ingestion of ova of the tapeworm Echinococcusgranulosus, which subsequently develop into larvae in the host intestine and migrate to other parts of the body where they develop into embryos, with the liver and lung being the most commonly involved organs.[1] Characteristic thoracic radiology should lead clinicians to suspect pulmonary hydatid disease, especially when dealing with patients with non-resolving pneumonia or lung mass. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Aorto-Left Ventricular Tunnel - Prenatal Diagnosis and Outcome.

Aorto-left ventricular tunnel (ALVT) is an extremely rare, albeit prenatally detectable, extracardiac channel that connects the ascending aorta to the cavity of the left ventricle. All ALVTs diagnosed prenatally (2006-2020) in five tertiary referral centers were retrospectively assessed for prenatal ultrasound findings, intrauterine course, postnatal outcome, and surgical treatment. We focused on the size of the tunnel and alterations of perfusion of the left ventricular outflow tract and aortic arch. 11 fetuses were diagnosed with ALVT at a mean gestational age of 24.8 weeks. All cases were associated with severe dilatation of the left ventricle and a to-and-fro flow in the left outflow tract. Signs of congestive heart failure were present in five fetuses, four of which were terminated and one of which died in the neonatal period. One fetus died in utero at 34 weeks without prior signs of cardiac failure. Of the five survivors, two underwent the Ross procedure. In both cases the prenatal left ventricular outflow was exclusively via a large tunnel. The remaining three neonates underwent patch closure of the tunnel. In these cases, the prenatal outflow of the left ventricle was via the aortic valve and simultaneously over the tunnel. Prenatal diagnosis of ALVT should be considered in the presence of left ventricular hypertrophy, dilatation of the aortic root, and to-and-fro flow in the aortic outflow tract. Signs of heart failure are associated with an unfavorable outcome. Large tunnels, particularly in combination with the absence of flow over the aortic valve, may be an unfavorable predictor of surgical repair.

Evaluation of cardiovascular morphology and associated anomalies in patients with crossed pulmonary arteries on multidetector computed tomography angiography.

The present study sought to study morphology and associated cardiovascular anomalies in patients with crossed pulmonary arteries on multidetector computed tomography (CT) angiography. We retrospectively evaluated all CT angiography studies performed at a tertiary medical center from January2014 to December2021 to identify patients with crossed pulmonary arteries. The associated cardiovascular anomalies as identified on CT angiography were evaluated. Out of 4773 patients who had undergone CT angiography for evaluation of congenital heart diseases, we identified 24 (0.5%) patients (18 males; mean age: 7.7 years) with crossed pulmonary arteries. Tetralogy of Fallot was associated in seven (29.17%) patients, double outlet right ventricle in one (4.17%) patient, and common arterial trunk in four (16.67%) patients. An aortopulmonary window was seen in three (12.5%) patients while atrial septal defect and ventricular septal defect were seen in two (8.33%) and 16 (66.67%) patients, respectively. Aortic arch anomalies were present in 16 (66.67%) patients including interrupted aortic arch and coarctation of aorta with hypoplastic aortic arch seen in two (8.33%) patients each. A double aortic arch with an atretic left arch was seen in one (4.17%) patient. Coronary artery anomalies were seen in three (12.5%) patients. Crossed pulmonary arteries are a rare anomaly and their presence suggests the coexistence of a variety of cardiovascular anomalies, including aortic arch anomalies and outflow tract malformations. Comprehensive CT angiography-based evaluation of cardiovascular morphology is imperative in the presence of crossed pulmonary arteries to facilitate presurgical planning.

Predictors of cardiovascular complications in patients with arterial hypertension and comorbid pathology

Aim. To study the relationship between central arterial pressure (BP) and cystatin C in patients with arterial hypertension and comorbid pathology, depending on gender differences.&#x0D; Materials and methods. The study involved 162 patients aged 39 to 82 years, suffering from hypertension and comorbid pathology. The average age of the surveyed was 58.610.3 years. The following nosological forms were revealed: coronary heart disease 40.7% of the examined, overweight 33.9%, 1st degree obesity 30.8%, type 2 diabetes mellitus 29.0%, chronic obstructive disease lungs 16.6%, cerebrovascular diseases 13.5%. All participants underwent general clinical examinations. The concentration of the lipid spectrum was investigated: the levels of total cholesterol, triglycerides, cholesterol high density lipoproteins (HDL cholesterol) and low density lipoprotein cholesterol (LDL cholesterol) and plasma cystatin C. Glomerular filtration rate (GFR) was calculated according to F. Hoek's formula (80.35/cystatin C 4.32=GFR). Study of central aortic pressure (CAP), mm Hg Art., was carried out using the device "AngioScan". Echocardiography was performed on a "Vivid q" apparatus (USA, 2014) according to the generally accepted technique. All examined patients were divided into 2 subgroups. The 1st subgroup includes women, the 2nd men.&#x0D; Results. In patients with hypertension and comorbid pathology, the most common abnormalities were an increased level of LDL cholesterol (58%), a decreased level of HDL cholesterol (51.8%), hypercholesterolemia (54.3%), hypertriglyceridemia (43.8%) and tachycardia (40.7%). In 51.8% of the surveyed, and more among males, the achievement of the target blood pressure level was detected. In women, the indicators of average age, body mass index, the content of total cholesterol, LDL cholesterol and HDL cholesterol were significantly higher. In male patients, the indicators of the diameter of the aortic outflow tract, end systolic and diastolic dimensions of the left ventricle (LV) significantly exceeded those of women, and the ejection fraction of the LV was significantly lower. The prevalence of LV hypertrophy (LVH) was 37% in the total sample, and it was higher in women than in men (45.9 and 26.6%, respectively, p=0.012). At the same time, the frequencies of concentric and eccentric types of LVH in both subgroups were similar. The incidence of LV concentric remodeling in women and men was 5.7 and 13.3%, respectively (p=0.001). In both subgroups, a negative correlation was found between the LV myocardial mass index and the calculated GFR. A positive correlation was noted between the levels of systolic blood pressure and CAP, the concentrations of cystatin C and plasma triglycerides.&#x0D; Conclusion. In hypertension, the structure of comorbid pathology is dominated by coronary heart disease, obesity and type 2 diabetes mellitus, when hyper- and dyslipidemia were often detected. The incidence of LVH in the general group of subjects was 37.0%, and in women this indicator was higher. In the subgroup of men, cases of LV concentric remodeling were significantly more frequent. An increase in the level of CAP and systolic blood pressure, as well as the concentration of cystatin C, was associated with an increase in the LV myocardial mass index, especially in the subgroup of women.

Left atrial geometry in an ovine ischemic mitral regurgitation model: implications for transcatheter mitral valve replacement devices with a left atrial anchoring mechanism

BackgroundTranscatheter mitral valve replacement (TMVR) is a challenging, but promising minimally invasive treatment option for patients with mitral valve disease. Depending on the anchoring mechanism, complications such as mitral leaflet or chordal disruption, aortic valve disruption or left ventricular outflow tract obstruction may occur. Supra-annular devices only anchor at the left atrial (LA) level with a low risk of these complications. For development of transcatheter valves based on LA anchoring, animal feasibility studies are required. In this study we sought to describe LA systolic and diastolic geometry in an ovine ischemic mitral regurgitation (IMR) model using magnetic resonance imaging (MRI) and echocardiography in order to facilitate future research focusing on TMVR device development for (I)MR with LA anchoring mechanisms.MethodsA group of 10 adult male Dorsett sheep underwent a left lateral thoracotomy. Posterolateral myocardial infarction was created by ligation of the left circumflex coronary artery, the obtuse marginal and diagonal branches. MRI and echocardiography were performed at baseline and 8 weeks after myocardial infarction (MI).ResultsSix animals survived to 8 weeks follow-up. All animals had grade 2 + or higher IMR 8 weeks post-MI. All LA geometric parameters did not change significantly 8 weeks post-MI compared to baseline. Diastolic and systolic interpapillary muscle distance increased significantly 8 weeks post-MI.ConclusionsSystolic and diastolic LA geometry do not change significantly in the presence of grade 2 + or higher IMR 8 weeks post-MI. These findings help facilitate future tailored TMVR device development with LA anchoring mechanisms.

A false left ventricular non-compaction; Late discovery of a corrected transposition of the great vessels in a 63-year-old patient

We report the case of a 63-year-old patient, admitted for NSTEMI, where the first examinations in ICU are in favor of a DCM with LV non-compaction associated with AAOCA, multimodal imaging will correct the final diagnosis by objectifying the CCTGA. 63-year-old patient, history of murmur and cardiomegaly without real follow-up or diagnosis, dyspnea on exertion for a few months, NYHA II, who presents a typical angina associated with a significant rise in cardiac biomarkers and is admitted in ICU for NSTEMI. Mitral regurgitation murmur 2/6 th, under crackles at the bases. ECG in wide LBBB, with bradycardia, axis in VR. NT pro BNP high. Pulmonary x-ray shows cardiomegaly with a rebounded left edge of the heart. The echocardiography shows a dilated LV, very trabeculated, globular appearance, with a very wide range of non-compaction, a moderate mitral insufficiency (left valve), the operator noted in his report the impossibility to image well the aortic and pulmonary outflow tract (Fig. 1). The patient has an angiogram which finds a weakly atheromatous network, however with AAOCA; birth of the LAD from the RCA and a very large and dominant CX giving 5 marginal branches of important caliber. Subsequently, a CT scan and cardiac MRI were done. First, the MRI, which finds a ventricle in a very trabecular systemic position and which clearly shows the mitro aortic rupture (major sign of TGA); as well as a wide range of late enhancement with some cryptic thrombis, the RV in the systemic position has an altered EF, LV in the upright position, with better systolic function (Fig. 2, Fig. 3). And the CCTA that signs the NCVG with an anterior aortic birth and to the left of the PA (Fig. 4, Fig. 5). The patient was treated with altered EF treatment (recommendations differ, however, on their effectiveness in CCTGA) with establishment of an ICD-CRT in a specialized center.

Causal Relationship of the Transverse Left Ventricular Band and Bicuspid Aortic Valve.

ObjectivesBicuspid aortic valve (BAV) is the most common congenital lesion found in adults. It can be seen in combination with a transverse left ventricular (LV) band. This study aimed to find an essential relationship between the presence of transverse ventricular band and BAV.MethodsA total of 13 patients from a tertiary care centre in India with transverse LV band were investigated during a six-month period from January 2019 to July 2019. LV band thickness and gradients at the site of the LV band were evaluated as part of its effect on LV haemodynamics. The morphology of the aortic valve and LV outflow tract gradients was assessed.ResultsThe mean age of the participants was 41 years. A majority had a BAV (n = 11). Average thickness of the LV band was 6.2 mm and the average mean aortic gradient was 4 mmHg. Sequestration of blood was noted at the level of the transverse band in all the patients with two separate jets at the left ventricular outflow tract. The anterolateral jet was deflected from the transverse band and showed higher velocity compared to the other jet, causing turbulence at the BAV. No correlation was found between the thickness of the transverse band and aortic valve gradient.ConclusionPresence of a robust transverse LV band can serve as a surrogate marker for BAV.

Mid-term Outcome of the Edge-To-Edge Mitral Valve Repair Via Aortic Outflow Tract in High-Risk Patients

The edge-to-edge mitral valve repair technique, invented by Alfieri and colleagues, introduced valve repair as a treatment option for patients with complex diseases where standard annuloplasty and related repair techniques are insufficient, due to annular calcification and patient frailty. We retrospectively evaluated the results of a transaortic edge-to-edge mitral valve repair (Alfieri stitch) in high-risk patients who were undergoing aortic valve replacement. From February, 2012 to December, 2017, 43 patients underwent transaortic edge-to-edge mitral valve repair with concomitant aortic valve replacement at a single institution. Preoperative and postoperative echocardiograms were compared. Home telephone follow up was conducted and postoperative morbidity was examined, including the need for reoperation, stroke and cardiac arrhythmia. 30-day and long-term survival rates were also determined. Mitral regurgitation (MR) was graded semi-quantitatively as 0 (trace and/or none), mild (1), moderate (2) or moderate to severe (3-4). The patients were 74 ± 7.8 years old. 65% of the patients were male. Mean cardiopulmonary bypass time was 115 ± 37 minutes and mean cross-clamp time was 71 ± 23 minutes. There was a significant improvement in preoperative vs postoperative median MR grade (2 (IQR 2-3) vs 0 (IQR 0-1); P = 0.05). Follow-up transthoracic echocardiograms in 29 patients obtained at a median of 9 months' (range 3 - 19 months') and in 16 patients at a median of 34 months' postoperatively (range 21 - 53 months') showed mild (1 (IQR 1-2)) grade of mitral regurgitation. 30-day survival was 98%. Long term survival at 12 and 24 months' were 88% and 81% respectively. Mitral valve reoperation was conducted in 1 patient (2%), who was suffering of endocarditis. Stroke occurred in 2 patients (7%). Cardiac arrhythmia was observed in 15 patients (35%). 8 patients (19%) suffered from atrial fibrillation and 7 patients (16%) displayed atrioventricular blockage. 10 patients (23%) could be treated conservatively and 5 patients (12%) needed implantation of a pacemaker. Transaortic edge-to-edge mitral valve repair can be safely performed during aortic valve replacement in high-risk patients and improves even long-term MR grade. Postoperative cardiac arrhythmia occurs frequently. 66% of them could be treated successfully by conservative procedures.

Akirin is critical for early tinman induction and subsequent formation of the heart in Drosophila melanogaster

The regulation of formation of the Drosophila heart by the Nkx 2.5 homologue Tinman is a key event during embryonic development. In this study, we identify the highly conserved transcription cofactor Akirin as a key factor in the earliest induction of tinman by the Twist transcription cofactor. akirin mutant embryos display a variety of morphological defects in the heart, including abnormal spacing between rows of aortic cells and abnormal patterning of the aortic outflow tract. akirin mutant embryos have a greatly reduced level of tinman transcripts, together with a reduction of Tinman protein in the earliest stages of cardiac patterning. Further, akirin mutants have reduced numbers of Tinman-positive cardiomyoblasts, concomitant with disrupted patterning and organization of the heart. Finally, despite the apparent formation of the heart in akirin mutants, these mutant hearts exhibit fewer coordinated contractions in akirin mutants compared with wild-type hearts. These results indicate that Akirin is crucial for the first induction of tinman by the Twist transcription factor, and that the success of the cardiac patterning program is highly dependent upon establishing the proper level of tinman at the earliest steps of the cardiac developmental pathway.

Aortic valve calcification is subject to aortic stenosis severity and the underlying flow pattern

Sex- and flow-related aortic valve calcification (AVC) studies are still limited in number, and data on the exact calcium quantity and distribution are scarce. Therefore, we aimed to (1) re-define the best threshold of AVC load to distinguish severe from moderate aortic stenosis (AS) in common AS entities and to (2) evaluate differences in the aortic annulus and left ventricular outflow tract (LVOT) calcium load. Nine hundred and thirty-eight patients with contrast-enhanced cardiac MSCT and moderate-to-severe aortic stenosis (AS) were retrospectively enrolled. Patients with severe AS ≤ 1.0 cm2 (n = 841) were further separated into three AS entities: high gradient (HGAS, n = 370, 44.0%), paradoxical low gradient (pLGAS, n = 333, 39.6%), and classical low gradient (LGAS, n = 138, 16.4%). AVC, leaflet, and LVOT calcification were quantified. Aortic valve calcification scores were highest in severe HGAS, and lower in severe pLGAS and classical LGAS. In all severity and AS entities, the non-coronary cusp (NCC) was the most calcified one. LVOT calcification was consistently comparable between gender and AS entities. Accuracy of logistic regression was the highest in HGAS (male vs. female: AVC > 2156 Agatston units (AU), c-index 0.76; vs. AVC > 1292 AU, c-index 0.85; or AVC density > 406 AU/cm2, c-index 0.82; vs. > 259 AU/cm2, c-index 0.86; each p < 0.0001*) to diagnose severe AS. AVC could only be used in men to differentiate between severe LGAS and moderate AS. Data from this retrospective analysis indicate that the NCC is subject to pre-dominant degeneration throughout gender, AS severity, and several AS entities. AVC was consistently comparable in severe pLGAS and classical LGAS, but only AVC in severe LGAS could sufficiently distinguish from moderate AS in men. LVOT calcification failed to be a reliable indicator of accelerating AS.

Contribution of systemic blood flow to untreated or inadequately controlled systolic--diastolic or isolated systolic hypertension in a community sample of African ancestry.

Age-related increases in systemic blood flow [stroke volume (SV), cardiac output (CO), and aortic flow (Q)] contribute substantially to untreated or inadequately controlled (uncontrolled) blood pressure (BP) in Africa. We aimed to identify the haemodynamic determinants of uncontrolled systolic--diastolic (Syst--diast HT) versus uncontrolled isolated systolic (ISH) or diastolic (IDH) hypertension. Using central arterial pressure and aortic outflow tract velocity and diameter measurements (echocardiography), the haemodynamic correlates of BP were determined in 725 community participants of African ancestry (19.6% uncontrolled Syst--diast HT, 9.2% uncontrolled ISH, 11.3% uncontrolled IDH). Independent of confounders, compared with those with a normotensive BP, those with uncontrolled Syst--diast HT had increases in SV, CO, Q, systemic vascular resistance (SVR) and aortic characteristic impedance (Zc) and decreases in total arterial compliance (TAC) (P < 0.05--P < 0.0001). In multivariate regression models, uncontrolled Syst--diast HT was as strongly associated with Q, SV or CO as with SVR (P = 0.04--P = 0.20), Zc (P = 0.74--P < 0.0005) and TAC (P = 0.43--P < 0.005). Independent of confounders, compared with normotensive individuals those with uncontrolled ISH had increases in SV, CO, Q and Zc but not SVR, and decreases in TAC (P < 0.05-P < 0.0001), and those with IDH only had increases in SVR (P < 0.0001). Uncontrolled ISH was more strongly associated with Q, SV and CO than with SVR (P < 0.0005), but less than with TAC (P < 0.05--P < 0.0005). In groups of African ancestry living in Africa, hypertension because of increases in either SBP or DBP is as strongly associated with increases in systemic flow (SV, Q) as with arterial and arteriolar effects (Zc, TAC, SVR).

Intraventricular Flow Patterns in Patients Treated with Left Ventricular Assist Devices.

The success of left ventricular assist device (LVAD) therapy is hampered by complications such as thrombosis and bleeding. Understanding blood flow interactions between the heart and the LVAD might help optimize treatment and decrease complication rates. We hypothesized that LVADs modify shear stresses and blood transit in the left ventricle (LV) by changing flow patterns and that these changes can be characterized using 2D echo color Doppler velocimetry (echo-CDV). We used echo-CDV and custom postprocessing methods to map blood flow inside the LV in patients with ongoing LVAD support (Heartmate II, N = 7). We compared it to healthy controls (N = 20) and patients with dilated cardiomyopathy (DCM, N = 20). We also analyzed intraventricular flow changes during LVAD ramp tests (baseline ± 400 rpm). LVAD support reversed the increase in blood stasis associated with DCM, but it did not reduce intraventricular shear exposure. Within the narrow range studied, the ventricular flow was mostly insensitive to changes in pump speed. Patients with significant aortic insufficiency showed abnormalities in blood stasis and shear indices. Overall, this study suggests that noninvasive flow imaging could potentially be used in combination with standard clinical methods for adjusting LVAD settings to optimize flow transport and minimize stasis on an individual basis.

Redo aortic root operations in late prosthetic endocarditis: clinical case series

Prosthetic aortic valve endocarditis is a severe disease that quickly leads to heart failure. Owing to microorganisms and their toxins constantly entering the bloodstream, bypassing biological barriers, and hemodynamic disturbances, systemic embolism develops quite quickly, leading to sepsis and multi-organ failure. Conservative antibiotic therapy is often not effective because the infectious focus is located in the avascular zone. The presence of an implanted foreign body promotes adhesion of bacteria on the surface of the prosthetic tissue with simultaneous isolation from the action of phagocytes. Conservative treatment of prosthetic infectious endocarditis has an extremely unfavourable prognosis. Hospital mortality without operation is approximately 80%. Operations for prosthetic infectious endocarditis of the aortic valve are technically complex and require a highly qualified operating surgeon. The most difficult operations involve extension of the abscess to the aortic root, area of mitralaortic continuity and left ventricular outflow tract. In such situations, it is necessary to perform complex reconstructive operations on the aortic root, mitral-aortic continuity and left ventricular outflow tract. This study presents an overview of a series of complex redo operations on the aortic root and the ascending aorta in late prosthetic infectious endocarditis, with an analysis of the main tactical and technical aspects of the operations. Moreover, similar operations can be performed with good results by an experienced cardiac surgeon. In this case, it is necessary that prior to operation, the surgeon develops an algorithm of actions and determines 1) optimal access to the heart, 2) perfusion scheme, 3) type of implantable conduit, 4) cardiolysis performance features, 5) myocardial protection scheme and 6) features of the treatment of the infectious focus.Received 29 October 2019. Revised 19 December 2019. Accepted 23 December 2019.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Author contributionsDrafting the article: I.I. Skopin, P.V. Kakhktsyan, M.S. Latyshev, D.V. Murysova, T.A. Kupriy, I.A. ZhangerievCritical revision of the article: I.I. Skopin, P.V. Kakhktsyan, M.S. Latyshev, D.V. Murysova, T.A. Kupriy, I.A. Zhangeriev, E.V. Khasigova, L.Zh. EnokyanSurgical treatment I.I. Skopin, P.V. KakhktsyanDiagnostics: L.Zh. EnokyanTreatment: D.V. Murysova, T.A. KupriyAssistance in surgery: M.S. Latyshev, E.V. KhasigovaFinal approval of the version to be published: I.I. Skopin, P.V. Kakhktsyan, M.S. Latyshev, D.V. Murysova, T.A. Kupriy, I.A. Zhangeriev, E.V. Khasigova, L.Zh. Enokyan