Cardiac Computed Tomography Research Articles

Pulmonary Atresia with Intact Ventricular Septum: Correlation of Preoperative Computed Tomography-Derived Parameters with Echocardiographic Tricuspid Valve Z-Score and Surgical Outcomes.

The role of preoperative cardiac computed tomography (CT) in neonates with pulmonary atresia and intact ventricular septum (PA-IVS) remains unclear. This study was aimed to elaborate the role of preoperative CT-derived anatomical and functional findings in planning treatment strategies in neonates with PA-IVS. The presence of ventriculocoronary arterial connections was evaluated by CT. CT-derived ventricular volumetric parameters were compared and correlated with echocardiographic tricuspid valve (TV) z-score in 12 neonates with PA-IVS. Cardiac CT and echocardiographic findings were compared between definite surgical types (median follow-up, 4years). Ventriculocoronary arterial connections were identified with CT in 58.3% of cases (7/12) and associated with higher incidence of Fontan procedure (42.9%, 3/7) and high mortality (28.6%, 2/7). The CT-derived and echocardiographic TV z-scores exhibited a high correlation (R = 0.924, p < 0.001). The CT-derived right ventricle (RV) volume and RV-left ventricle volume ratio also displayed high correlations (R = 0.875 and 0.867, respectively; p < 0.001) with echocardiographic TV z-score. More positive echocardiographic TV z-score, high CT-derived RV end-diastolic volume and RV-left ventricle volume ratio, and low CT-derived left ventricular end-diastolic volume were observed in biventricular surgery group (N = 2), compared to Fontan operation (N = 3) and 1.5 ventricular surgery (N = 3) groups, and mortality cases (N = 3). Preoperative CT-derived coronary artery anatomy and ventricular volumetric parameters may supplement treatment planning in neonates with PA-IVS especially when multifactorial decision including echocardiographic TV z-score is in a gray zone.W.

Influence of cardiac cycle on myocardial extracellular volume fraction measurements with dual-layer computed tomography.

In cardiac computed tomography (CT), the best image quality is obtained at mid-diastole at low heart rates (HRs) and at end-systole at high HRs. On the other hand, extracellular volume (ECV) measurements may be influenced by the cardiac phase. Therefore, we aimed to clarify the influence of the cardiac phase on the image quality and ECV values obtained using dual-layer spectral computed tomography (DLCT). Fifty-five patients (68.0±14.5 years; 26 men) with cardiac diseases who underwent retrospective electrocardiogram-gated myocardial CT delayed enhancement (CTDE) between February 2019 to April 2022 were enrolled. The ECVs at the right ventricle (RV) and left ventricle (LV) walls in the end-systolic and mid-diastolic phases were calculated using iodine-density measurements from CTDE spectral data. Iodine-density image quality was classified on a 4-point scale. ECV and image quality across cardiac phases were compared using the t-test and Wilcoxon signed-rank test, respectively. Inter- and intraobserver variability were evaluated using intraclass correlation coefficient (ICC) values. The ECV of the septal regions during mid-diastole was significantly higher than that during end-systole. Other regions showed similar ECV measurements in both groups (P=0.13-0.97), except for the LV anterior wall and LV posterior wall at the base-ventricular level. The image-quality score in end-systole was significantly higher than that in mid-diastole (systole vs. diastole: 3.6±0.5 vs. 3.2±0.7; P=0.0195). Intra- and interobserver variabilities for RV ECV measurements at the end-systolic phase were superior to those at the mid-diastolic phase, whereas the corresponding values for LV ECV measurements were similar. Septal ECV showed small but significant differences while other region ECV showed no difference during the cardiac cycle. RV ECV measurements in the end-systolic phase were more reproducible than those in the mid-diastolic phase.

A large pericardial cyst causing persistent chest tightness and dyspnea: a case report

Pericardial cysts are a rare cause of mediastinal masses with an incidence of about 1 in 100,000 patients. Most of the cases are secondary to congenital incomplete fusion of the pericardial sac. More than two-thirds of pericardial cysts are located in the right cardiophrenic angle. Over 50% of pericardial cysts are asymptomatic and discovered incidentally during thoracic imaging such as chest X-ray, CT scans and transthoracic echocardiograms. Symptomatic cases commonly present with non-specific symptoms such as dyspnea, chest pain, and persistent cough. A 48-year-old female was referred for assessment of shortness of breath and atypical chest tightness for several years. The echocardiography revealed a large cystic- appearing mass presenting with slight compression of the right-atrium. A cardiac CT scan and MRI scan were performed, confirming the presence of a large pericardial cyst with no signs of complications like tamponade or pericarditis. As the patient had symptoms and cyst had compressive effects, surgical resection was done.

Angle Dependence of Electrode Lead-Related Artifacts in Single- and Dual-Energy Cardiac ECG-Gated CT Scanning-A Phantom Study.

Background: The electrodes of implantable cardiac devices (ICDs) may cause significant problems in cardiac computed tomography (CT) because they are a source of artifacts that obscure surrounding structures and possible pathology. There are a few million patients currently with ICDs, and some of these patients will require cardiac imaging due to coronary artery disease or problems with ICDs. Modern CT scanners can reduce some of the metal artifacts because of MAR software, but in some vendors, it does not work with ECG gating. Introduced in 2008, dual-energy CT scanners can generate virtual monoenergetic images (VMIs), which are much less susceptible to metal artifacts than standard CT images. Objective: This study aimed to evaluate if dual-energy CT can reduce metal artifacts caused by ICD leads by using VMIs. The second objective was to determine how the angle between the electrode and the plane of imaging affects the severity of the artifacts in three planes of imaging. Methods: A 3D-printed model was constructed to obtain a 0-90-degree field at 5-degree intervals between the electrode and each of the planes: axial, coronal, and sagittal. This electrode was scanned in dual-energy and single-energy protocols. VMIs with an energy of 40-140 keV with 10 keV intervals were reconstructed. The length of the two most extended artifacts originating from the tip of the electrode and 2 cm above it-at the point where the thick metallic defibrillating portion of the electrode begins-was measured. Results: For the sagittal plane, these observations were similar for both points of the ICDs that were used as the reference location. VMIs with an energy over 80 keV produce images with fewer artifacts than similar images obtained in the single-energy scanning mode. Conclusions: Virtual monoenergetic imaging techniques may reduce streak artifacts arising from ICD electrodes and improve the quality of the image. Increasing the angle of the electrode as well as the imaging plane can reduce artifacts. The angle between the electrode and the beam of X-rays can be increased by tilting the gantry of the scanner or lifting the upper body of the patient.

Imaging in Infective Endocarditis-Current Opinions and Trends in Cardiac Computed Tomography.

Infective endocarditis is a rare disease with an increasing incidence and an unaltered high mortality rate, despite medical development. Imaging plays an integrative part in the diagnosis of infective endocarditis, with echocardiography as the initial diagnostic test. Research data in the utility of cardiac computed tomography (CCT) in the diagnostic algorithm of IE are rising, which indicates its importance in detection of IE-related lesion along with the exclusion of coronary artery disease. The latest 2023 European Society of Cardiology Guidelines in the management of IE classified CCT as class of recommendation I and level of evidence B in detection of both valvular and paravalvular lesions in native and prosthetic valve endocarditis. This review article provides a comprehensive and contemporary review of the role of CCT in the diagnosis of IE, the optimization of acquisition protocols, the morphology characteristics of IE-related lesions, the published data of the diagnostic performance of CCT in comparison to echocardiography as the state-of-art method, as well as the limitations and future possibilities.

Left ventricular unloading therapy using Impella 5.5 after emergency surgery for acute myocardial infarction mechanical complication: a case report

BackgroundFollowing an acute myocardial infarction (AMI), surgery for left ventricular free wall rupture (LVFWR) and ventricular septal rupture (VSR) has a high in-hospital mortality rate, which has not improved significantly over time. Unloading the LV is critical to preventing excessive stress on the repair site and avoiding problems such as bleeding, leaks, patch dehiscence, and recurrence of LVFWR and VSR because the tissue is so fragile. We present two cases of patients who used Impella 5.5 for LV unloading following emergency surgery for AMI mechanical complications.Case presentationA 76-year-old male STEMI patient underwent fibrinolysis of the distal right coronary artery. Three days later, he passed out and went into shock. Echocardiography revealed a cardiac tamponade. We found an oozing-type LVFWR on the posterolateral wall and treated it with a non-suture technique using TachoSil. Before the patient was taken off CPB, Impella 5.5 was inserted into the LV via a 10 mm synthetic graft connected to the right axillary artery. We kept the flow rate above 4.0 to 4.5 L/min until POD 3 to reduce LV wall tension while minimizing pulsatility. On POD 6, we weaned the patient from Impella 5.5. A postoperative cardiac CT scan showed no contrast leakage from the LV. However, a cerebral hemorrhage on POD 4 during heparin administration complicated his hospitalization. Case 2: A diagnosis of cardiogenic shock caused by STEMI occurred in an 84-year-old male patient, who underwent PCI of the LAD with IABP support. Three days after PCI, echocardiography revealed VSR, and the patient underwent emergency VSR repair with two separate patches and BioGlue applied to the suture line between them. Before weaning from CPB, we implanted Impella 5.5 in the LV and added venoarterial extracorporeal membrane oxygenation (VA-ECMO) support for right heart failure. The postoperative echocardiography revealed no residual shunt.ConclusionsPatients undergoing emergency surgery for mechanical complications of AMI may find Impella 5.5 to be an effective tool for LV unloading. The use of VA-ECMO in conjunction with Impella may be an effective strategy for managing VSR associated with concurrent right-sided heart failure.

Efficacy of Computed Tomography-Based Evaluation of Myocardial Extracellular Volume Combined With Red Flags for Early Screening of Concealed Cardiac Amyloidosis in Patients With Atrial Fibrillation.

The prevalence of transthyretin amyloid cardiomyopathy (ATTR-CM) in atrial fibrillation (AF) patients remains unclear. We explored the efficacy of computed tomography-based myocardial extracellular volume (CT-ECV) combined with red flags for the early screening of concealed ATTR-CM in AF patients undergoing catheter ablation.Methods and Results: Patients referred for AF ablation at Oita University Hospital were prescreened using the red-flag signs defined by echocardiographic or electrocardiographic findings, medical history, symptoms, and blood biochemical findings. Myocardial CT-ECV was quantified in red flag-positive patients using routine pre-AF ablation planning cardiac CT with the addition of delayed-phase cardiac CT scans. Patients with high (>35%) ECV were evaluated using technetium pyrophosphate (99 mTc-PYP) scintigraphy. A cardiac biopsy was performed during the planned AF ablation procedure if 99 mTc-PYP scintigraphy was positive. Between June 2022 and June 2023, 342 patients were referred for AF ablation. Sixty-seven (19.6%) patients had at least one of the red-flag signs. Myocardial CT-ECV was evaluated in 57 patients because of contraindications to contrast media, revealing that 16 patients had high CT-ECV. Of these, 6 patients showed a positive 99 mTc-PYP study, and 6 patients were subsequently diagnosed with wild-type ATTR-CM via cardiac biopsy and genetic testing. CT-ECV combined with red flags could contribute to the systematic early screening of concealed ATTR-CM in AF patients undergoing catheter ablation.

Diagnostic and Prognostic Value of Right Ventricular Fat Quantification from Computed Tomography in Arrhythmogenic Right Ventricular Cardiomyopathy.

Background: In arrhythmogenic right ventricular cardiomyopathy (ARVC) non-invasive scar evaluation is not included among the diagnostic criteria or the predictors of ventricular arrhythmias (VA) and sudden death (SD). Computed tomography (CT) has excellent spatial resolution and allows a clear distinction between myocardium and fat; thus, it has great potential for the evaluation of myocardial scar in ARVC. Objective: The objective of this study is to evaluate the feasibility, and the diagnostic and prognostic value of semi-automated quantification of right ventricular (RV) fat replacement from CT images. Methods: An observational case-control study was carried out including 23 patients with a definite (19) or borderline (4) ARVC diagnosis and 23 age- and sex-matched controls without structural heart disease. All patients underwent contrast-enhanced cardiac CT. RV images were semi-automatically reconstructed with the ADAS-3D software (ADAS3D Medical, Barcelona, Spain). A fibrofatty scar was defined as values of Hounsfield Units (HU) <-10. Within the scar, a border zone (between -10 HU and -50 HU) and dense scar (<-50 HU) were distinguished. Results: All ARVC patients had an RV scar and all scar-related measurements were significantly higher in ARVC cases than in controls (p < 0.001). The total scar area and dense scar area showed no overlapping values between cases and controls, achieving perfect diagnostic performance (sensitivity and specificity of 100%). Among ARVC patients, 16 (70%) had experienced sustained VA or aborted SD. Among all clinical, ECG and imaging parameters, the dense scar area was the only one with a statistically significant association with VA and SD (p = 0.003). Conclusions: In ARVC, RV myocardial fat quantification from CT is feasible and may have considerable diagnostic and prognostic value.

Left ventricular posterior wall hypertrophy leads to poor prognosis of hypertrophic obstructive cardiomyopathy in children - a cohort study.

The modified Morrow operation for hypertrophic obstructive cardiomyopathy (HOCM) in children has a favorable outcome, but some children still have a poor prognosis after the procedure. In this study, we aimed to investigate the application of cardiac computed tomography (CCT) to construct a three-dimensional(3D) model of the left ventricle (LV) and analyze the association between hypertrophy in different parts of the LV and poor prognosis. We retrospectively analyzed 57 children with HOCM from April 2015 to October 2022, among whom 16 underwent preoperative CCT examination. All children underwent the modified Morrow surgery in our center. We defined heart failure (HF), malignant ventricular arrhythmia, and recurrent left ventricular outflow tract obstruction (LVOTO) as adverse events. We performed a retrospective Cox analysis and conducted genetic testing. A 3D model of the LV was built through the standard 17-segment method and analyzing the high-risk factors. 17 (29.8%) had adverse events during follow-up. Multivariate Cox analysis revealed that genetic mutation (HR:5.634, 95%CI:1.663-19.086, P=0.005), Noonan syndrome (HR:3.770, 95%CI:1.245-11.419, P=0.019), preoperational systolic anterior motion (SAM)(HR:4.596, 95%CI:1.532-13.792, P=0.007)and mid-ventricular obstruction (HR:4.763, 95%CI:1.538-14.754, P=0.007) were high-risk factors, suggesting that the degree of hypertrophy in the left ventricle is associated with poor prognosis. By analyzing the CCT with 3D model, children with poor prognosis have more hypertrophy in basal-inferior (P=0.014), mid-inferoseptal(P=0.044), mid-inferior(P=0.017). It suggests that a more hypertrophied posterior left ventricular wall portends a worse prognosis. Even after modified Morrow surgery, the prognostic impact of genetic mutation remains significant. Moreover, the degree of hypertrophy of the posterior wall in the LV was also related to the postoperative prognosis through CCT combined with 3D technology. It provides surgeons guiding to evaluate the overall prognosis and the treatment plan before surgery.

Impact of reconstruction parameters on the accuracy of myocardial extracellular volume quantification on a first-generation, photon-counting detector CT

BackgroundThe potential role of cardiac computed tomography (CT) has increasingly been demonstrated for the assessment of diffuse myocardial fibrosis through the quantification of extracellular volume (ECV). Photon-counting detector (PCD)-CT technology may deliver more accurate ECV quantification compared to energy-integrating detector CT. We evaluated the impact of reconstruction settings on the accuracy of ECV quantification using PCD-CT, with magnetic resonance imaging (MRI)-based ECV as reference.MethodsIn this post hoc analysis, 27 patients (aged 53.1 ± 17.2 years (mean ± standard deviation); 14 women) underwent same-day cardiac PCD-CT and MRI. Late iodine CT scans were reconstructed with different quantum iterative reconstruction levels (QIR 1−4), slice thicknesses (0.4−8 mm), and virtual monoenergetic imaging levels (VMI, 40−90 keV); ECV was quantified for each reconstruction setting. Repeated measures ANOVA and t-test for pairwise comparisons, Bland–Altman plots, and Lin’s concordance correlation coefficient (CCC) were used.ResultsECV values did not differ significantly among QIR levels (p = 1.000). A significant difference was observed throughout different slice thicknesses, with 0.4 mm yielding the highest agreement with MRI-based ECV (CCC = 0.944); 45-keV VMI reconstructions showed the lowest mean bias (0.6, 95% confidence interval 0.1–1.4) compared to MRI. Using the most optimal reconstruction settings (QIR4. slice thickness 0.4 mm, VMI 45 keV), a 63% reduction in mean bias and a 6% increase in concordance with MRI-based ECV were achieved compared to standard settings (QIR3, slice thickness 1.5 mm; VMI 65 keV).ConclusionsThe selection of appropriate reconstruction parameters improved the agreement between PCD-CT and MRI-based ECV.Relevance statementTailoring PCD-CT reconstruction parameters optimizes ECV quantification compared to MRI, potentially improving its clinical utility.Key points• CT is increasingly promising for myocardial tissue characterization, assessing focal and diffuse fibrosis via late iodine enhancement and ECV quantification, respectively.• PCD-CT offers superior performance over conventional CT, potentially improving ECV quantification and its agreement with MRI-based ECV.• Tailoring PCD-CT reconstruction parameters optimizes ECV quantification compared to MRI, potentially improving its clinical utility.Graphical

Feasibility of left atrial strain assessment using cardiac computed tomography in patients with paroxysmal atrial fibrillation.

To evaluate the feasibility of left atrial strain (LAS) assessment using cardiac computed tomography (CT) in patients with paroxysmal atrial fibrillation (PAF). This retrospective single-center study included 98 patients with PAF who underwent cardiac CT and echocardiography before the first catheter ablation. LAS was analyzed using cardiac CT (CT-LAS) and speckle-tracking echocardiography (STE; STE-LAS). LA reservoir (LASr), conduit (LASc), and pump strain (LASp) were calculated by averaging LAS measured in 4- and 2-chamber views. The results were compared using Pearson's correlation coefficients, paired t-tests, and Bland-Altman analysis. Intraclass correlation coefficients (ICCs) were used to evaluate reproducibility. CT-LAS could be analyzed in all patients, while STE-LAS could be analyzed in 53 (54%) patients. LASr, LASc, and LASp showed significant correlations between CT- and STE-LAS: LASr, r = 0.68, p < 0.001; LASc, r = 0.47, p < 0.001; LASp, r = 0.67, p < 0.001. LASr, LASc, and LASp of CT- and STE-LAS were 23.7 ± 6.0% and 22.1 ± 6.7%, 11.1 ± 3.6% and 11.1 ± 4.1%, and 12.6 ± 4.6% and 11.0 ± 4.1%, respectively. LASr and LASp were significantly higher in CT-LAS than that in STE-LAS (p = 0.023 for LASr and p = 0.001 for LASp). CT-LAS showed excellent reproducibility. The intra- and interobserver ICCs were 0.96 to 0.99 and 0.89 to 0.90, respectively. CT-LAS was successfully analyzed in more patients than STE-LAS and was highly reproducible. The findings suggest that CT-LAS is feasible for patients with PAF.

Cardiac Computed Tomography Identification of the Septal Vein-A Small Retrospective Study.

The advancement of medical interventions towards minimally invasive procedures highlights the crucial role of precise pre-procedural evaluation, particularly in catheter-based treatments for heart and cardiovascular conditions. This study investigates innovative techniques such as mitral loop cerclage (MLC) and transcatheter intramyocardial radiofrequency ablation (TIRA), emphasizing the importance of preprocedural cardiac CT scans for accurate anatomical guidance in these emerging therapies. The objective of this study was to assess the cardiac cycle through examination of the proximal septal vein (ps) for mitral loop cerclage and the distal septal vein (ds) for transcatheter intramyocardial radiofrequency ablation. Forty patients (mean age 59.4 ± 14.7 years) undergoing third-generation dual-source computed tomography (DSCT) for chest pain evaluation were enrolled. CT scans, utilizing dual-energy CT (DECT) with iopamidol and saline, encompassed the carina to the heart base. A noise-optimized linear blended image was reconstructed at 10% intervals throughout the cardiac cycle, and the presence of ps and ds in each phase was noted by two radiologists. This study identified ps in 62.5% and ds in 72.5% of patients, with both present in 45% of cases. The observation of septal veins occurred more frequently in the sequence of 70, 60, 40, 80, 30, 20, and 10% for ps, and 60, 70, 40, 80, 30, 90, 20, and 10% for ds, respectively. DECT in cardiac imaging is instrumental in assessing septal vein frequency. The 70% phase is optimal for MLC, while the 60% phase is preferred for TIRA.

Artificial intelligence-analyzed computed tomography in patients undergoing transcatheter tricuspid valve repair

BackgroundBaseline right ventricular (RV) function derived from 3-dimensional analyses has been demonstrated to be predictive in patients undergoing transcatheter tricuspid valve repair (TTVR). The complex nature of these cumbersome analyses makes patient selection based on established imaging methods challenging. Artificial intelligence (AI)-driven computed tomography (CT) segmentation of the RV might serve as a fast and predictive tool for evaluating patients prior to TTVR. MethodsPatients suffering from severe tricuspid regurgitation underwent full cycle cardiac CT. AI-driven analyses were compared to conventional CT analyses. Outcome measures were correlated with survival free of rehospitalization for heart-failure or death after TTVR as the primary endpoint. ResultsAutomated AI-based image CT-analysis from 100 patients (mean age 77 ± 8 years, 63% female) showed excellent correlation for chamber quantification compared to conventional, core-lab evaluated CT analysis (R 0.963–0.966; p < 0.001). At 1 year (mean follow-up 229 ± 134 days) the primary endpoint occurred significantly more frequently in patients with reduced RV ejection fraction (EF) <50% (36.6% vs. 13.7%; HR 2.864, CI 1.212–6.763; p = 0.016). Furthermore, patients with dysfunctional RVs defined as end-diastolic RV volume > 210 ml and RV EF <50% demonstrated worse outcome than patients with functional RVs (43.7% vs. 12.2%; HR 3.753, CI 1.621–8.693; p = 0.002). ConclusionsDerived RVEF and dysfunctional RV were predictors for death and hospitalization after TTVR. AI-facilitated CT analysis serves as an inter- and intra-observer independent and time-effective tool which may thus aid in optimizing patient selection prior to TTVR in clinical routine and in trials.

MSMHSA-DeepLab V3+: An Effective Multi-Scale, Multi-Head Self-Attention Network for Dual-Modality Cardiac Medical Image Segmentation.

The automatic segmentation of cardiac computed tomography (CT) and magnetic resonance imaging (MRI) plays a pivotal role in the prevention and treatment of cardiovascular diseases. In this study, we propose an efficient network based on the multi-scale, multi-head self-attention (MSMHSA) mechanism. The incorporation of this mechanism enables us to achieve larger receptive fields, facilitating the accurate segmentation of whole heart structures in both CT and MRI images. Within this network, features extracted from the shallow feature extraction network undergo a MHSA mechanism that closely aligns with human vision, resulting in the extraction of contextual semantic information more comprehensively and accurately. To improve the precision of cardiac substructure segmentation across varying sizes, our proposed method introduces three MHSA networks at distinct scales. This approach allows for fine-tuning the accuracy of micro-object segmentation by adapting the size of the segmented images. The efficacy of our method is rigorously validated on the Multi-Modality Whole Heart Segmentation (MM-WHS) Challenge 2017 dataset, demonstrating competitive results and the accurate segmentation of seven cardiac substructures in both cardiac CT and MRI images. Through comparative experiments with advanced transformer-based models, our study provides compelling evidence that despite the remarkable achievements of transformer-based models, the fusion of CNN models and self-attention remains a simple yet highly effective approach for dual-modality whole heart segmentation.

Preprocedural imaging with cardiac computed tomography for endo-epicardial ventricular tachycardia ablation

BackgroundStudies evaluating the systematic use of cardiac computed tomography (CCT) for the preprocedural assessment of myocardial fibrosis are limited. Their implementation in the electrophysiology workflow has not been extensively described. ObjectiveThis study aimed to explore the degree of concordance between CCT and electroanatomic mapping (EAM) for the evaluation of cardiac fibrosis in patients undergoing endo-epicardial ventricular tachycardia (VT) ablation. MethodsFrom November 2017 to December 2021, patients undergoing endo-epicardial VT catheter ablation with CCT as the only source of preprocedural scar assessment were prospectively enrolled. After image integration, myocardial fibrosis detected with CCT was compared with low-voltage areas identified by endo-epicardial EAM. Postprocedural VT recurrences of this approach were evaluated after at least 1 year of follow-up. ResultsThe study enrolled 35 patients (mean age, 60.7 ± 13.2 years; 94.2% male). The most common underlying arrhythmic substrate was dilated cardiomyopathy (48.6%). CCT was employed for contraindications to cardiac magnetic resonance, such as unstable VTs (31.4%) or nonconditional implantable cardioverter-defibrillators (28.6%), but also for patients’ and operators’ preferences (14.3%–25.7%). Myocardial fibrosis was correctly identified by CCT and EAM, with strong agreement between these techniques both overall (Cohen κ for agreement, 0.933) and in per-segment analysis (κ ranging from 0.796 to 1.0). Ischemic patients showed the best correlation (κ = 1.000), whereas myocarditis showed the worst (κ = 0.750). After a median follow-up of 14 (12–24) months, 1-year freedom from recurrences was achieved in 74.3% patients; overall freedom from recurrences was 60.0%. ConclusionA CCT-based preprocedural assessment before VT ablation is feasible, showing high diagnostic concordance with EAM in detecting myocardial fibrosis.

Long-term cardiac computed tomography follow-up after left atrial appendage occlusion.

Left atrial appendage occlusion (LAAO) is performed increasingly, but long-term follow-up imaging data are lacking. The aim of this study was to evaluate the safety and durability of the Amplatzer Amulet device >4 years after LAAO. This was a prospective observational cohort study including 52 patients implanted with the Amplatzer Amulet device at Aarhus University Hospital, Denmark. A >4-year follow-up cardiac computed tomography (CT) scan after LAAO was performed and compared with the results from the 2-month and 12-month scans. The primary outcome was left atrial appendage (LAA) sealing based on distal LAA contrast patency and peridevice leakage (PDL), stratified into complete occlusion (grade 0 [G0]) and grade 1-3 leakage (G1-3), respectively. Secondary outcomes were low- and high-grade hypoattenuated thickening (HAT), device-related thrombosis (DRT) and device durability. The median (interquartile range [IQR]) follow-up time from LAAO to the latest CT scan was 5.8 years (4.5; 6.3). At 2-month (n=52), 12-month (n=27) and >4-year CT follow-ups (n=52), rates of both complete occlusion (33%, 37%, 35%) and G2 leaks (52%, 52%, 48%) remained stable. Rates of G1 leaks varied (14%, 4%, 6%) and G3 leaks rose (2%, 7%, 12%) from earliest to latest follow-up. The median left atrial (LA) volume increased from 127 mL (96; 176) to 144 mL (108; 182) and 147 mL (107; 193). No DRT was found. The structural device integrity was preserved. This study indicates a stable LAA sealing status throughout the follow-up period, emphasising the importance of the procedural result in avoiding PDL. Few patients displayed PDL progression, which might partly be related to LA remodelling with increasing volume. The long-term device durability appears excellent. Larger studies are warranted to confirm these findings.

The Role of Echocardiography in the Diagnosis of Infective Endocarditis and its Complications

Infective endocarditis (IE) remains associated with high morbidity and mortality rates despite advances in medical technology, diagnostics, and treatment. Hospital mortality for IE reaches up to 22%, with a five-year mortality rate of 40%. Globally, the incidence of IE has increased, with recent figures indicating 13.8 cases per 100,000 annually, up from 1.5–11.6 per 100,000 reported between 1990 and 2010. A retrospective cohort study in a tertiary care center in Korea demonstrated a significant rise in the monthly incidence of IE from 2.0 in 2005 to 3.8 in 2017. This increase is attributed to the enhanced utilization of diagnostic tools such as echocardiography, computed tomography (CT), and positron emission tomography (PET). The 2015 European Society of Cardiology (ESC) guidelines incorporated complementary imaging modalities like Single Photon Emission Computed Tomography-CT (SPECT/CT), 18F-FDG PET/CT, and Cardiac CT, alongside traditional transthoracic and transesophageal echocardiography. The 2023 ESC guidelines further expanded these algorithms to include Cardiac CTA, MRI, PET/CT, and WBC SPECT. However, transthoracic, and transesophageal echocardiography remain the primary and essential diagnostic tools for suspected IE. This review examines the role of echocardiography in diagnosing IE, highlighting typical ultrasound findings, valve damage, and associated complications. Ultrasound is pivotal for early detection and prognosis of IE, identifying vegetations, abscesses, pseudoaneurysms, and fistulas. New vegetations typically appear irregular and oscillate, with transthoracic echocardiography detecting vegetations larger than 5mm with 90% sensitivity. Detailed echocardiographic assessment provides critical insights for the surgical management of IE and enhances the understanding of IE’s complex pathology.

TAVR with self- expandable valves: what challenges in bicuspid aortic valve disease?

Background: The bicuspid aortic valve (BAV) represents a complex anatomic entity for transcatheter aortic valve replacement (TAVR) because of its unique technical challenges. All the randomized clinical trials comparing outcomes of TAVI with surgery till date, have excluded patients with bicuspid aortic valve. The only data in literature come from empirical observations, with large variability in implantation techniques across different centers and operators. Objective: These case reports describe the results of transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve stenosis (BAV) using self-expandable valves with their clinical, imaging, procedural, and follow-up settings. Case reports: We report 3 cases of TAVR with BAV. The patients were at high risk of surgery. Baseline cardiac computed tomography (CT) was analyzed by interventional cardiologists. We used self-expandable valves in all the procedures. There were no cases of valve embolization or need for a second valve, no post-dilatation, no cases of moderate or severe aortic regurgitation, and none of the cases required a permanent pacemaker implantation. Conclusion: With the available observational data, it seems that TAVI is indeed technically feasible in selected BAV patients with acceptable results. Self-expandable valves can be safe and effective devices for these procedures. Most of the current data studies highlight the importance of preprocedural imaging determining the outcome of TAVI in BAV patients. Advancements device iterations and procedural refinements will continue to improve the outcomes of these patients treated by TAVR.

Atrial anatomical variations on computed tomography angiography associated with atrial fibrillation and those predicting recurrence following pulmonary vein isolation

Abstract Background We aim to investigate the atrial anatomical variations in patients with and without atrial fibrillation (AF) using cardiac-computed tomography angiography (CCTA) and identify features associated with AF recurrence following pulmonary vein isolation. Materials and Methods We retrospectively reviewed 502 CCTAs of patients with AF performed prior to a pulmonary vein isolation procedure with 1058 CCTAs of patients without AF performed to rule out coronary artery disease between 2014 and 2017. Anatomical variations of both atria including left atrial diverticula (LAD), right atrial diverticula (RAD), Bachmann bundle shunt (BBS), and pulmonary vein anatomy were assessed. Results We found that patients with AF were older (67 ± 14 vs 63 ± 13 years, P = .039), had a higher prevalence of diabetes (24.4%) versus (14.7%), P = .006, and cerebrovascular accidents (3.8%) versus (0.9%), P = .044 when compared with patients without AF. Furthermore, on CCTAs patients with AF demonstrated a significantly higher prevalence of BBS (11% vs 4.1%, P &amp;lt; .001), LAD (19% vs 7.7%, P &amp;lt; .001), and RAD (9.8% vs 2.1%, P &amp;lt; .001) when compared to patients without AF. Logistic multivariable regression analyses of CCTA findings demonstrated increased odd ratios (OR) in those with AF of BBS (OR = 3.51, 95% CI, 2.32-5.35, P &amp;lt; .001), LAD (OR = 2.94, 95% CI, 2.12-4.07, P &amp;lt; .001), RAD (OR = 1.54, 95% CI, 1.19-2.11, P = .03), LA diameter (OR = 2.42, 95% CI, 1.65-3.39, P &amp;lt; .001). Importantly, multivariate Cox regression showed that the LA dimension is a predictor of AF recurrence (HR = 1.019, 95% CI, 1.001-1.051, P = .02). Conclusion AF patients have a higher prevalence of BBS, LAD, and RAD in comparison to patients without AF. Mean LA diameter predicts AF recurrence after the pulmonary vein isolation procedure.

Impact of commissural versus coronary alignment on risk of coronary obstruction following transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) with commissural alignment aims to limit the risk of coronary occlusion and maintain good coronary access. However, due to coronary origin eccentricity within the coronary cusp, coronary-commissural overlap (CCO) may still occur. TAVI using coronary alignment, rather than commissural alignment, may further improve coronary access. To compare rates of CCO after TAVI using commissural versus coronary alignment methodology. Cardiac CT scans from 102 patients with severe (tricuspid) aortic stenosis referred for TAVI were analysed. Native cusp asymmetry and coronary eccentricity were defined and used to simulate TAVI using commissural versus coronary alignment. Rates of optimal coronary alignment (< 10° from cusp centre) and severe misalignment (< 15° from coronary-commissural overlap) were compared. Additionally, the impact of valve misalignment during implantation was assessed. The native right coronary artery (RCA) origin was 15.8° (9.5 to 24°) closer to the right coronary cusp/non-coronary cusp (RCC-NCC) commissure than the centre of the right coronary cusp. The native left coronary artery (LCA) origin was 4.5° (0 to 11.5°) closer to the left coronary cusp/non-coronary cusp (LCC-NCC) commissure than the centre of the left coronary cusp (p < 0.01). Compared to commissural alignment, coronary alignment doubled the proportion of optimally-aligned RCAs (62/102 [60.8%] vs. 31/102 [30.4%]; p < 0.001), without a significant change in optimal LCA alignment (62/102 [60.8% vs. 74/102 [72.6%]; p = 0.07). There were no cases of severe misalignment with either strategy. Simulating 15° of valve misalignment resulted in severe RCA compromise risk in 7/102 (6.9%) of commissural alignment cases, compared to none using coronary alignment. Fluoroscopic projection was similar with both approaches. Coronary alignment resulted in a 2-fold increase of optimal TAVI positioning relative to the RCA ostium when compared to commissural alignment without impacting the LCA. Use of coronary alignment rather than commissural alignment may improve coronary access after TAVI and is less sensitive to valve rotational error, particularly for the right coronary artery.