Aortic Valve Function Research Articles

Abstract 13873: Deep Learning-Based GWAS of Aortic Valve Function Links 81 Loci to Aortic Stenosis Risk

Background & Aims: The genetic influences on normal aortic valve (AV) function and their impact on aortic stenosis (AS) risk are of significant interest. We sought to identify common genetic determinants of normal variation in AV function, and to understand their relationship with clinical disease. Methods: We used deep learning to measure peak velocity, mean gradient, and aortic valve area from MRI in UK Biobank participants. We conducted genome-wide association studies (GWAS) in a subset of 44,780 participants without cardiovascular disease. We performed multi-trait analysis of GWAS (MTAG) to incorporate data from AV measurements and AS diagnoses in UK Biobank and FinnGen, and applied PRScs to construct polygenic scores (PGS). Results: In the unadjusted analysis, 26 loci were associated with at least one AV measurement. Incorporating the AS GWAS using MTAG, we identified 81 distinct loci (62 with AV traits, 54 with AS, 35 overlapping), including PCSK9 (β=0.032, P=5.8E-09) and LDLR (β=0.018, P=2.3E-10). Additional loci were associated with lipid metabolism (LPA, FADS2, SORT1), atherosclerosis (CDKN2B, ARHGEF26, OTUD7B, PRDM16), inflammation (IL6, KLF2, TRAF1), and cardiac development and aortic root function (SMAD3, GATA4, ELN, TBX20, TEX41). The PGS for the unadjusted mean gradient was predictive of AS in FinnGen (HR 1.36 for the top 5% of participants vs all others, P=1.8E-14). All of Us participants in the top 5% of the MTAG-adjusted peak velocity PGS had an HR of 2.5 for incident AS (P=4.4E-08). Mendelian randomization showed association between Lp(a) and LDL—but not ApoA—on greater peak velocity (P=2.7E-13, P=1.6E-16, and P=0.60, respectively). Conclusion: We identified 81 genetic loci linked to AV function or AS. AV measurement PGS were strong predictors of AS risk. ApoB and Lp(a) showed causal association with higher peak velocity. These findings have implications for the early pathogenesis of AS and suggest modifiable pathways as targets for prevention.

Abstract 14595: Leveraging Deep Learning to Elucidate Subclinical Aortic Stenosis Risk

Background and Aims: Aortic stenosis (AS) is associated with a high global burden of morbidity. Current guidelines do not fully define normal aortic valve (AV) function or mild AS. We aimed to study normal variation in AV function and address current gaps in knowledge. Methods: We developed a deep learning model to study velocity-encoded magnetic resonance imaging (MRI) in 47,223 UK Biobank participants. We calculated aortic valve area (AVA), peak velocity (PV), and mean gradient (MG). Results: In healthy individuals, we found an annual decrement of 0.03 cm2 in AVA. Normal variation in AV function was predictive of future AV surgery (HR 2.4 per SD increase in PV, P2.6E-110), heart failure (HR 1.23 per SD, P=2.4E-07), and coronary disease (HR 1.23 per SD, P=2.0E-14). Risk was still elevated when excluding participants with moderate-to-severe AS. We determined thresholds for abnormal AV function as being >95% for all age groups in 31,909 healthy people. This established the boundary between normal variation and mild AS as any of: PV >1.65m/s, MG >4.9mmHg, and AVA <2.1cm2 (men) or <1.7cms2 (women). A total of 3,288 participants (7.0%) met the definition of mild AS which was associated with high risk for AV surgery (HR 57.2, P=4.4E-29). Over a mean 3.1±2.0 years of follow-up, the incidence of AV surgery was 0.02% in those with normal AV function and nearly 20% among participants with MG ≥10mmHg. Greater levels of ApoB, triglycerides, Lp(a), and inflammatory markers were associated with higher AV gradients. Conclusion: In this study, we report the largest analysis of AV function and cardiovascular disease in the general population with MRI using deep learning. We propose thresholds to define the lower bounds of mild AS and demonstrate a step change in cardiovascular risk between normal AV function and mild AS. Atherogenic and inflammatory biomarkers were associated with increased AV gradients. These findings may inform earlier surveillance and efforts to prevent complications of AS.

Abstract 14148: Left Ventricular Outflow Tract Pseudoaneurysm in a Pediatric Patient: An Unusual Presentation of Endocarditis

Description of Case: A 12-year-old male with known bicuspid aortic valve presented with one month of progressive weight loss and subjective fevers. Transthoracic echocardiogram was concerning for a new left ventricular outflow tract (LVOT) aneurysm (figure 1). His aortic valve stenosis and regurgitation had notably progressed compared to a prior study one year ago. He was urgently referred for cardiac computed tomographic angiography (CCTA), which demonstrated a pseudoaneurysm of the LVOT inferior to the aortic valve and irregularly thickened aortic valve leaflets with a notable perforation (figure 2). Blood cultures were positive for Viridans streptococci, confirming the diagnosis of infective endocarditis. The patient was referred for a Bentall procedure with LVOT pseudoaneurysm repair. Pre-operative transesophageal echocardiogram demonstrated a communication of the non-coronary cusp of the aortic valve and LVOT. Ultimately, aortic root replacement was performed with a 23mm homograft. Our patient recovered well from surgery and now has excellent clinical status with normal aortic valve function. Discussion: Pseudoaneurysm of the LVOT as a result of infective endocarditis is a rare diagnosis, especially in the pediatric population. Of the case reports published, it is most seen in the setting of infection involving the native aortic valve but has also been reported after aortic valve replacement. As in our patient, the most commonly reported location involves the mitral-aortic intervalvular fossa. Symptoms have insidious onset and the diagnosis requires a high level of suspicion. A multimodal imaging approach is warranted for optimal diagnosis and treatment.

Multi-valve Libman-Sacks's endocarditis-related multiple, massive and fatal systemic embolization. A case report and a review of diagnostic work-up.

We reported a case of non-bacterial thrombotic endocarditis (NBTE) in a 37-year-old woman who presented with signs and symptoms of cardio-embolic cerebral stroke caused by a prothrombotic state due to underlying advanced uterine cancer. Multimodal imaging, including 3D-ecocardiography, as well as laboratory and cultural tests, were critical in making the diagnosis. After starting anticoagulation therapy with low molecular weight heparin (LMWH), the patient underwent surgical aortic valve replacement due to worsening aortic valve function, initial left ventricle enlargement, increasing dimensions, and mobility of vegetations. Unfortunately, vegetations relapsed on the aortic valve bio-prosthesis as well as the mitral leaflets, resulting in a final picture of multi-valve NBTE. The fatal outcome was due to a massive multiple limb embolism, which resulted in leg amputations and septical complications. Starting with the case, we present a brief overview of the pathology's presentation, treatment, management, and prognosis, as well as the diagnostic work-up.

Liraglutide Attenuates Aortic Valve Calcification in a High-Cholesterol-Diet-Induced Experimental Calcific Aortic Valve Disease Model in Apolipoprotein E-Deficient Mice.

Calcific aortic valve disease (CAVD) is a significant cause of morbidity and mortality among elderly people. However, no effective medications have been approved to slow or prevent the progression of CAVD. Here, we examined the effect of liraglutide on aortic valve stenosis. Male Apoe-/- mice were fed with a high-cholesterol diet for 24 weeks to generate an experimental CAVD model and randomly assigned to a liraglutide treatment group or control group. Echocardiography and immunohistological analyses were performed to examine the aortic valve function and morphology, fibrosis, and calcium deposition. Plasma Glucagon-like peptide-1 (GLP-1) levels and inflammatory contents were measured via ELISA, FACS, and immunofluorescence. RNA sequencing (RNA-seq) was used to identify liraglutide-affected pathways and processes. Plasma GLP-1 levels were reduced in the CAVD model, and liraglutide treatment significantly improved aortic valve calcification and functions and attenuated inflammation. RNA-seq showed that liraglutide affects multiple myofibroblastic and osteogenic differentiations or inflammation-associated biological states or processes in the aortic valve. Those liraglutide-mediated beneficial effects were associated with increased GLP-1 receptor (GLP-1R) expression. Liraglutide blocks aortic valve calcification and may serve as a potential therapeutic drug for CAVD treatment.

Cardiovascular Events After Aortic Root Repair in Patients With Marfan Syndrome

BackgroundThe usefulness of aortic valve sparing operations to treat aortic root aneurysm in patients with Marfan syndrome (MS) remains controversial. ObjectivesThe purpose of this study was to evaluate the occurrence of cardiovascular events in patients with MS who have undergone valve-preserving aortic root replacement. MethodsPatients with MS who had aortic valve sparing operations (reimplantation of the aortic valve or remodeling of the aortic root) from 1988 through 2019 were followed prospectively for a median of 14 years. Pertinent data from clinical, echocardiographic, computed tomography, and magnetic resonance images of the aorta were collected and analyzed. ResultsThere were 189 patients whose mean age was 36 years, and 67% were men. Ten patients presented with acute type A dissection and 29 had mitral regurgitation. There were 52 patients at risk at 20 years. Mortality rate at 20 years was 21.5% (95% CI: 14.7%-30.8%); advancing age and preoperative aortic dissections were associated with increased risk of death by multivariable analysis. At 20 years, the cumulative incidence of moderate or severe aortic insufficiency was 14.5% (95% CI: 9.5%-22.0%), reoperation on the aortic valve was 7.5% (95% CI: 3.9%-14.7%), and new distal aortic dissections was 19.9% (95% CI: 13.9%-28.5%). Remodeling of aortic root was associated with greater risk of developing aortic insufficiency and aortic valve reoperation than reimplantation of the aortic valve. ConclusionsAortic valve sparing operations provide stable aortic valve function and low rates of valve-related complications during the first 2 decades of follow-up but aortic dissections remain problematic in patients with MS.

Abstract P3006: Inhibition Of Tnfα Signaling Delay CAVD Progression In Mice

Background: Inflammation is a prominent feature of calcific aortic valve disease (CAVD), a leading cause of aortic stenosis. Inflammation can activate surface valvular endothelial cells (VEC) to produce pathogenic signaling such as Tumor Necrosis Factor-alpha (TNFα), to valvular interstitial cells (VIC) in aortic valve leaflets, leading to pathological valve remodeling through increased extracellular matrix synthesis, calcium deposition, and cell death which underlies CAVD. Thus, TNFα inflammatory signaling maybe a major candidate therapeutic target for alleviating CAVD progression. Hypothesis: We hypothesized that inhibition of TNFα signaling may delay CAVD progression. Results: We compared CAVD progression in a mouse model of CAVD with deletion of Ldlr, low-density lipoprotein receptor, and fed with standard or high fat diet. We inhibited the TNFα inflammatory signaling in this CAVD model by crossing the Ldlr -/- mice with the Tnfr1 and Tnfr2 double null mice. The aortic valve functions were measured by echocardiogram and the results showed that aortic valve velocity was significantly decreased in the triple null ( Ldlr -/- ;Tnfr1 -/- ;Tnfr2 -/- ) group compared to the Ldlr -/- group, both fed with high fat diet. Contractile function (systole to diastole ratio) at the aortic root was significantly increased in the triple null group. Aortic valve histopathology was examined by various staining methods. In the triple null mice, Hematoxylin and Eosin (H&E) showed significantly reduced the thickness of aortic valve leaflets; Masson’s Trichrome, Picrosirius Red, and Rusell-Movat staining revealed significantly reduced fibrosis and collagen deposition, and Von Kossa and Alizarin Red staining showed significantly decreased calcium deposition. Furthermore, immunofluorescence staining demonstrated significantly decreased DNA damage and cell death, as well as cell proliferation in aortic valve leaflets of the triple null mice. Conclusion: Our findings demonstrate a promising role of inhibiting TNFα signaling in slowing CAVD progression in mice, suggesting pharmacological or immunological inhibition of TNFα signaling as a non-invasive therapeutic option to treat CAVD patients.

Effect of Aortic Valve Opening Pattern on Endothelial Function After Continuous-Flow Left Ventricular Assist Device Implantation.

This study aimed to evaluate the effects of aortic valve opening patterns on endothelial functions in patients undergoing continuous-flow left ventricular assist device (CF-LVAD) implantation. This study included 43 patients who underwent CF-LVAD implantation and 35 patients with heart failure reduced ejection fraction (HFrEF; control group). The CF-LVAD group was divided into three subgroups based on aortic valve opening patterns: open with each beat, intermittently opening, and not opening groups. Flow-mediated dilatation (FMD) and pulsatility index (PI) were compared before and 3 months after CF-LVAD implantation. Cardiopulmonary exercise test (CPET) and 6 minute walk test (6-MWT) scores were measured at baseline and follow-up in the CF-LVAD group. The mean FMD and PI of patients in the CF-LVAD group reduced 3 months after implantation. Patients with intermittently opening and not opening aortic valves had worse endothelial function at follow-up. Before and 3 months after implantation FMD% did not significantly differ in patients whose aortic valves were open with each beat (4.72 ± 1.06% vs. 4.67 ± 1.16%, p = 0.135). Pulsatility index changes paralleled FMD changes. Cardiopulmonary exercise test and 6-MWT scores improved after implantation but without significant differences between subgroups. Maintaining normal aortic valve function after CF-LVAD implantation may reduce endothelial dysfunction; however, larger studies are needed for long-term clinical effects.

Multimodality Imaging of Aortic Valve Calcification and Function in a Murine Model of Calcific Aortic Valve Disease and Bicuspid Aortic Valve.

Calcific aortic valve disease (CAVD) is a prevailing disease with increasing occurrence and no known medical therapy. Dcbld2-/- mice have a high prevalence of bicuspid aortic valve (BAV), spontaneous aortic valve calcification, and aortic stenosis (AS). 18F-NaF PET/CT can detect the aortic valve calcification process in humans. However, its feasibility in preclinical models of CAVD remains to be determined. Here, we sought to validate 18F-NaF PET/CT for tracking murine aortic valve calcification and leveraged it to examine the development of calcification with aging and its interdependence with BAV and AS in Dcbld2-/- mice. Methods: Dcbld2-/- mice at 3-4 mo, 10-16 mo, and 18-24 mo underwent echocardiography, 18F-NaF PET/CT (n = 34, or autoradiography (n = 45)), and tissue analysis. A subset of mice underwent both PET/CT and autoradiography (n = 12). The aortic valve signal was quantified as SUVmax on PET/CT and as percentage injected dose per square centimeter on autoradiography. The valve tissue sections were analyzed by microscopy to identify tricuspid and bicuspid aortic valves. Results: The aortic valve 18F-NaF signal on PET/CT was significantly higher at 18-24 mo (P < 0.0001) and 10-16 mo (P < 0.05) than at 3-4 mo. Additionally, at 18-24 mo BAV had a higher 18F-NaF signal than tricuspid aortic valves (P < 0.05). These findings were confirmed by autoradiography, with BAV having significantly higher 18F-NaF uptake in each age group. A significant correlation between PET and autoradiography data (Pearson r = 0.79, P < 0.01) established the accuracy of PET quantification. The rate of calcification with aging was significantly faster for BAV (P < 0.05). Transaortic valve flow velocity was significantly higher in animals with BAV at all ages. Finally, there was a significant correlation between transaortic valve flow velocity and aortic valve calcification by both PET/CT (r = 0.55, P < 0.001) and autoradiography (r = 0.45, P < 0.01). Conclusion: 18F-NaF PET/CT links valvular calcification to BAV and aging in Dcbld2-/- mice and suggests that AS may promote calcification. In addition to addressing the pathobiology of valvular calcification, 18F-NaF PET/CT may be a valuable tool for evaluation of emerging therapeutic interventions in CAVD.

SPREAD multicentre study: sports practice and its effect on bicuspid aortic valve disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Bicuspid aortic valve (BAV) is the most common congenital cardiac condition among the general population and competitive athletes. BAV could be associated with progressive aortic dilatation, stenosis and/or regurgitation. There are concerns about the possible detrimental effects of exercise training on aortic size and valve function due to the hemodynamic stress on the aorta during exercise. However, data in the literature are scarce and sometimes discordant. Objectives This multicenter study aimed to analyze the influence of sport on aortic size and valve function in BAV patients. Methods Three groups were analyzed: competitive athletes with BAV, athletes with tricuspid aortic valve (TAV) and sedentary controls with BAV, age- and sex-matched. We assessed the morphology and degree of aortic valve stenosis, regurgitation, aortic dimension, and left ventricular (LV) characteristics by 2D echocardiography. Individuals with moderate-severe stenosis and regurgitation or relevant aortic dilation (&amp;gt; 45 mm (men) or &amp;gt;41 mm (women) were excluded from the study. Results The study population was composed of 500 subjects:184 BAV athletes (84% males; mean age 30±11 years), 191 TAV athletes (82% males; mean age 30±11 years), 125 BAV sedentary controls (82% males; mean age 34±10 years). The aortic annulus was greater in BAV athletes (25.0±3.6 mm) than in TAV athletes (21.7±2.9 mm) and BAV controls (23.9±3.6 mm), p&amp;lt;0.005. Sinuses of Valsalva, sinotubular junction and ascending aorta diameters were smaller in TAV athletes than in BAV subjects (&amp;lt;0.005), but there were no significant differences between BAV athletes and BAV controls. LV index volumes and mass were greater in BAV athletes than in the other two groups (p&amp;lt;0.005). Moreover, BAV athletes showed higher gradients than sedentary controls (p&amp;lt;0.005). Conclusions This multicenter study demonstrated that athletes with BAV have larger aortic diameters than athletes with TAV. However, no differences between BAV athletes and sedentary controls were observed, suggesting that exercise training does not significantly affect aortic dilation, with the exception of aortic annulus. Conversely, sports practice negatively influenced valve function in BAV athletes. Valvular dysfunction seems to affect the LV geometry, with a trend for being more dilated and hypertrophic in BAV athletes than in the other groups.

Reimplantation of the aortic valve in patients with tricuspid aortic valve: the Toronto General Hospital experience.

Aortic valve sparing operations were introduced three decades ago but controversy remains regarding its appropriateness, reproducibility and durability. This article describes the long-term outcomes of patients who had reimplantation of the aortic valve. All patients who had reimplantation of a tricuspid aortic valve at Toronto General Hospital from 1989 through 2019 were selected for this study. Patients were followed prospectively with periodical clinical assessments and imaging of the heart and aorta. Four hundred and four patients were identified. The median age was 48.0 [interquartile range (IQR), 35.0-59.0] years and 310 (76.7%) were men. There were 150 patients with Marfan syndrome, 20 with Loeys-Dietz syndrome and 33 with acute or chronic aortic dissections. The median follow-up was 11.7 (IQR, 6.8-17.1) years. There were 55 patients alive and without reoperation at 20 years. The cumulative mortality at 20 years was 26.7% [95% confidence interval (CI): 20.6-34.2%], the cumulative incidence of reoperation on the aortic valve was 7.0% (95% CI: 4.0-12.2%) and the development of moderate or severe aortic insufficiency was 11.8% (95% CI: 8.5-16.5%). We could not identify variables associated with reoperation on the aortic valve or with the development of aortic insufficiency. New distal aortic dissections were common in patients with associated genetic syndromes. Reimplantation of the aortic valve in patients with tricuspid aortic valve provides excellent aortic valve function during the first two decades of follow-up. Distal aortic dissections are relatively common in patients with associated genetic syndromes.

Echocardiography of the aortic root: a practical approach for aortic valve-sparing surgery.

Owing to its excellent long-term results, aortic valve-sparing surgery is increasingly used in patients with aortic regurgitation and/or ascending aortic aneurysm. Moreover, in patients with a bicuspid valve who meet the criteria for replacement of the aortic sinuses or aortic regurgitation surgery, valve-sparing surgery may be considered if performed at a comprehensive valve center (Class 2b indication in both the American and European guidelines). Reconstructive valve surgery aims at restoring a normal aortic valve function and a normal aortic root shape as well. Echocardiography plays a central role in defining abnormal valve morphologies, in quantifying aortic regurgitation and mechanisms, and in appreciating tissue valve quality and surgical results. Therefore, despite the emergence of other tomographic techniques, 2D and 3D echocardiography represents the cornerstone for patient selection and prediction of the probability of a reliable repair. The present review focuses on echocardiographic evaluation to detect aortic valve and aortic root abnormalities, to quantify aortic valve regurgitation, to predict aortic valve reparability, and to assess immediate postoperative results in the operating room. Echocardiographic predictors of successful valve and root repair are presented in a practical way.

Outlet Ventricular Septal Defect: Impact of Surgery on the Late Aortic and Pulmonary Valve Functions

This study retrospectively evaluated long-term post-operative aortic and pulmonary valve functions in outlet ventricular septal defects. We evaluated aortic regurgitation and pulmonary regurgitation using pre- and post-operative echocardiograms. Overall, 158 patients who underwent intracardiac repair due to outlet ventricular septal defects with aortic valve deformity or congestive heart failure were included. The median follow-up period was 7years (interquartile range: 0-17years), without deaths or pacemaker implantations. The age, weight, ventricular septal defect size, and mild aortic regurgitation at surgery were factors associated with post-operative residual aortic regurgitation. Mild pulmonary regurgitation was observed in 12%, 30%, and 40% of patients 5, 10, and 15years after surgery, respectively. There were no significant differences in age and weight at which surgery was performed between patients with mild pulmonary regurgitation and those with less than mild pulmonary regurgitation. However, the number of sutures across the pulmonary valve was associated with post-operative pulmonary regurgitation (P < 0.01). As some patients with mild pre-operative aortic regurgitation may not improve even after surgery, early surgical intervention is necessary when aortic regurgitation appears. Some patients may develop post-operative pulmonary regurgitation in the long term, suggesting the need for careful follow-up.

Application value of image fusion technology in transcatheter aortic valve implantation

Objective: To analysis the application value of image fusion technology in transcatheter aortic valve implantation (TAVI). Methods: A total of 35 patients underwent trans-femoral TAVI using the first-generation VENUS-A valve in Heart Center of Henan Provincial People's Hospital from January 2020 to May 2021 were analyzed retrospectively. Among them, there were 21 males and 14 females, aged from 64 to 81 years, with a mean (SD) of (71.37±5.66) years. They were divided into conventional group (n=22) and fusion group (n=13), according to whether image fusion technology was used during operation. The preoperative general data, intraoperative data, differences of postoperative renal function and residence time in intensive care unit (ICU) were analyzed and compared between the two groups. The postoperative echocardiography and 12 lead ECG were observed. Results: All 35 patients in this study were with severe aortic stenosis, of which, 10 patients were complicated with moderate to severe regurgitation. Compared with the conventional group, the intraoperative fusion group had fewer angiography times [3.0 (3.0, 4.0) vs 5.0 (5.0, 6.0)], X-ray absorbed dose [342.0 (44.5) mGy vs 388.4 (71.0) mGy], and contrast dosage [(73.5±10.5) ml vs (90.3±10.3) ml], and shorter rapid pacing time [(14.0±1.6) seconds vs (16.5±2.0) seconds] (all P<0.05). There was no significant differences in X-ray irradiation time, operation time, sizing of the pre-dilated balloon, valve implantation depth and other indicators (all P>0.05). There was no significant differences in ICU retention time and postoperative renal function (all P>0.05). Postoperative echocardiography showed that the function of aortic valve was good, with mild perivalvular leakage in 2 cases in the conventional group and 1 case in the fusion group; and one patient was implanted with permanent pacemaker after TAVI in the conventional group. Conclusion: Image fusion technology simplifies the TAVI process, shortens the ventricular pacing time and reduces the dosage of X-ray and contrast, and has certain clinical application value.

Activation of the Hedgehog signaling pathway leads to fibrosis in aortic valves

BackgroundFibrosis is a pathological wound healing process characterized by excessive extracellular matrix deposition, which interferes with normal organ function and contributes to ~ 45% of human mortality. Fibrosis develops in response to chronic injury in nearly all organs, but the a cascade of events leading to fibrosis remains unclear. While hedgehog (Hh) signaling activation has been associated with fibrosis in the lung, kidney, and skin, it is unknown whether hedgehog signaling activation is the cause or the consequence of fibrosis. We hypothesize that activation of hedgehog signaling is sufficient to drive fibrosis in mouse models.ResultsIn this study, we provide direct evidence to show that activation of Hh signaling via expression of activated smoothened, SmoM2, is sufficient to induce fibrosis in the vasculature and aortic valves. We showed that activated SmoM2 -induced fibrosis is associated with abnormal function of aortic valves and heart. The relevance of this mouse model to human health is reflected in our findings that elevated GLI expression is detected in 6 out of 11 aortic valves from patients with fibrotic aortic valves.ConclusionsOur data show that activating hedgehog signaling is sufficient to drive fibrosis in mice, and this mouse model is relevant to human aortic valve stenosis.

Hydrodynamic ex vivo analysis of valve-sparing techniques: assessment and comparison.

Valve-sparing procedures are surgical techniques allowing to restore adequate function of the native aortic valve by replacing the dysfunctional ascending aorta with a prosthetic conduit. A number of techniques are currently used, such as Yacoub's remodelling and David's reimplantation, based on a regular straight conduit. More recently, the De Paulis proposed the use of bulging conduits to reconstruct the shape of the Valsalva sinuses. This work investigates the impact of the valve-sparing technique on the aortic valve function. The performance of 3 porcine aortic roots (Medtronic Freestyle™) was assessed in a cardiovascular pulse duplicator before and after performing 3 alternative valve-sparing procedures: David's reimplantation, Yacoub's remodelling and De Paulis' reimplantation. The porcine aortic roots, representative of the healthy native configuration, were characterized by the highest efficiency, with a mean energetic dissipation under normal operating conditions of 26 mJ. David's and Yacoub's techniques resulted in significantly lower performance (with mean energetic loss of about 70 mJ for both cases). The De Paulis' procedure exhibited intermediate behaviour, with superior systolic performance and valve dynamics similar to the native case, and a mean energetic loss of 38 mJ. The dynamics and performance after valve-sparing strongly depend on the adopted technique, with the use of conduits replicating the presence of Valsalva sinuses restoring more physiological conditions.

Fate of aortic regurgitation after isolated repair of ventricular septal defect with concomitant aortic regurgitation in children

ObjectivesThe aim of the study was to evaluate the course of aortic valve regurgitation in patients with preoperative aortic valve regurgitation and ventricular septal defect who underwent repair of the ventricular septal defect without aortic valve repair. MethodsA total of 37 consecutive patients with a ventricular septal defect and aortic regurgitation who underwent surgery between April 2007 and March 2016 were included in the study. Demographic, echocardiographic, operative, and clinical data were reviewed. Early and late mortality and morbidity were analyzed. Aortic regurgitation grade, left ventricular function, and dimensions were compared between the preoperative transesophageal echocardiography and postoperative transthoracic echocardiogram at last follow-up. Multivariate logistic regression analysis was performed to determine factors associated with improvement of aortic valve function. ResultsThere was no early or late mortality. No reoperations or reinterventions were required. A total of 17 patients had mild or greater aortic regurgitation preoperatively. Only 5 patients had mild or greater aortic regurgitation at follow-up of 4.3 years (0.5-10.1). Twenty-eight (76%) of the 37 patients showed an improvement in their aortic regurgitation grade. Left ventricular end-systolic and end-diastolic diameter z-scores were significantly lower at follow-up (P = .007 and P = .001, respectively). Multivariable logistic regression identified low preoperative left ventricular ejection fraction as the only predictor of nonimprovement of aortic regurgitation (95% confidence interval, 0.732-0.999, P = .002). ConclusionsRepair of a ventricular septal defect with accompanying aortic regurgitation can be performed with excellent results without surgical intervention on the aortic valve. Accompanying aortic regurgitation, especially trivial to mild, at the time of ventricular septal defect repair improves in the majority of cases. Low preoperative left ventricular ejection fraction is predictive of nonimprovement of aortic regurgitation grade.

Endovascular Technique for Ascending Aorta Repair Based on TEVAR and TAVI Procedures

Purpose: Ascending aorta (AAo) acute pathology still has an open-surgery indication with a high mortality rate associated to cardiopulmonary bypass and circulatory arrest. In these cases, the endovascular aortic approach could be an excellent option. The aim of the present study is to detail an optimized technique for the endovascular treatment of AAo diseases, based on thoracic endovascular aortic repair (TEVAR) and transcatheter aortic valve implantation (TAVI) procedures. Technique: The procedure implies the usual preparation for TEVAR and TAVI implants. A transient pacemaker lead is necessary to deliver the prosthesis under “rapid pacing.” As in the TAVI technique, a final high-support guidewire is placed at the left ventricle. The proximal landing zone is the sinotubular junction (zone 0B). Transesophageal echocardiography is essential to ensure aortic valve function and patency in coronary arteries during the delivery. To assess a potential occlusion of the brachiocephalic artery, a guidewire is positioned in the descending aorta from the axillary artery. Finally, a noncovered stent is implanted to stabilize the AAo prosthesis. Conclusion: The technique presented here can standardize a safe and reproducible procedure to endovascular repair of AAo diseases. However, new devices specifically designed for the AAo could facilitate the transcatheter approach. Clinical Impact Ascending aorta acute pathology still has an open-surgery indication with high mortality rate associated to cardiopulmonary bypass and circulatory arrest. Moreover, near 30% of patients are not considered suitable for surgery because of age, critical situation or the presence of severe comorbidities. The present study provides a detailed and optimized technique for the endovascular treatment of ascending aorta disease, based on TEVAR and TAVI procedures.

Planning of graft size and 3D reconstruction using virtual reality technique in aortic valve reimplantation.

To evaluate applicability and feasibility of the virtual imaging technology for diagnosis and planning of the aortic valve sparing procedure. Pre-operative electrocardiography-gated computed tomography images of 12 adult patients with aortic root pathology were used for 3D reconstruction of the aortic root geometry. The structural analysis was conducted with focusing on spatial architecture of key aortic root structures such as the three commissures, intervalvular triangles (IVT), as well as on morphology of the aortic root base (AoB) and of the sinotubular junction (STJ). In all included patients, the 3D mapping of aortic root (AoR) morphology was successfully performed. The pre-operative diameter of the AoB was 30.6 ± 2.6 mm and of the STJ 46.5 ± 7.5 mm (p < 0.001). Based on measured AoB diameter, the mean size of prosthesis used was 28.3 ± 1.37 mm. The planar arrangement of the three commissures was similar to an equilateral triangle where the three commissures were at similar distance for each individual sinus with 39.8 ± 6.64 mm for right, 37.5 ± 7.10 mm for left, and 39.2 ± 7.52 mm for non-coronary sinus (p = 0.72) subsequently. The similar height of the three IVT's with 32.6 ± 5.87 mm for right, 33.6 ± 6.14 mm for anterior, and 31.7 ± 5.83 mm for left IVT (p = 0.73) was suggestive for all three commissures being positioned in the same plane. Consequently at reimplantation, the orientation of the three commissures followed the pattern of an equilateral triangle. The reconstructed images revealed a detailed 3D anatomy of the aortic root, with the spatial arrangement of the intervalvular triangles, planimetric orientation of the commissures, as well as determination of the AoB and STJ diameters. Obtained information was successfully applied to pre-operative surgical planning. The reimplantation technique, the height of the reimplanted intervalvular triangles, as well as their orientation are crucial for achieving adequate aortic valve function.

Echocardiography protocol: A tool for infrequently used parameters in mice.

Echocardiography is frequently used to evaluate cardiac function in rodent models of cardiovascular disease. Whereas methods to acquire the commonly used echocardiography parameters are well-described in published protocols or manuals, many important parameters are ill-defined and often open to subjective interpretation. Such lack of uniformity has engendered conflicting interpretations of the same parameters in published literature. In particular, parameters such as mitral regurgitation, mitral stenosis, pulmonary regurgitation, and aortic regurgitation that are required to define more esoteric etiologies in rarer mouse models often remain equivocal. The aim of this methods paper is to provide a practical guide to the acquisition and interpretation of infrequently used echocardiography parameters and set a framework for comprehensive analyses of right ventricle (RV), pulmonary artery (PA) pulmonary valve (PV), left atrium (LA), mitral valve (MV), and aortic valve (AoV) structure and function.