Aortic Annulus Research Articles

External Scaffold for Strengthening the Pulmonary Autograft in the Ross Procedure

Despite offering several potential benefits over standard prosthetic aortic valve replacement, the use of the pulmonary autograft has been limited to date due to concerns over the risk of pulmonary autograft expansion and the need for reintervention. Several techniques using materials with biomimetic potential have been developed to reduce this complication. The incidence, risk factors, and pathophysiology of pulmonary autograft dilatation are discussed in this article. This seminar will provide an overview of the techniques of external pulmonary autograft support and their advantages and limitations. It also considers future directions for further investigation and future clinical applications of external pulmonary autograft support. Dilatation of the autograft is more likely to occur in patients with aortic regurgitation and a dilated aortic annulus. External scaffolding may prevent autograft stretching and expansion in these specific cases. However, from a biomimetic point of view, any permanent scaffold potentially restricts the movement of the autograft root. This reduces some of the benefits associated with the use of autologous tissue, which is the priority of the Ross procedure. To address this issue, several bioresorbable matrices could be used to support the root during its initial adaptive phase. Control of blood pressure with aggressive therapy is the first line to avoid this problem in the first year after pulmonary autograft implantation, together with support of the annular and sinotubular junction in some selected cases. This is the best way to maintain stable autograft root dimensions while preserving root dynamics. However, to determine the efficacy of this combined external support and best medical management, it is important to perform regular imaging and clinical follow-up.

Lack of sex-specific differences in the associations between the dimensions of great vessels and exercise performance in amateur cyclists.

Endurance training enhances exercise capacity and triggers cardiovascular adaptations in both males and females. We investigated the relationship between the dimensions of great vessels and exercise capacity in amateur cyclists while considering sex differences. Using resting transthoracic echocardiography, we measured the dimensions of the main pulmonary artery (PA), aorta, and inferior vena cava (IVC) in 190 participants, who subsequently underwent a cardiopulmonary exercise test (CPET) until exhaustion. The mean age of study participants was 30 years. Males (71%) exhibited a larger aortic annulus (approximately 3.5 mm, p<0.0001) and PA diameter (2.4 mm, p<0.0001) than females. No significant sex differences were found in expiratory or inspiratory IVC diameters. Males achieved greater peak exercise capacity, including workload, O2 consumption (VO2), and O2 pulse. Aortic and PA dimensions showed strong correlations with energy expenditure, workload, VO2, and O2 pulse. However, these correlations weakened when analyzed separately by sex. Multivariate linear regression revealed associations between CPET results, vessels size, and sex, with sex differences observed only in the intercepts-not in interactions between sex and vessels size. Despite males having better CPET results and larger vessels, the relationships between peak exercise capacity parameters and vessel dimensions were similar in both sexes. Larger vessel dimensions (of the aorta, PA, and IVC) were associated with greater peak exercise capacity in amateur cyclists, with no significant sex differences in these associations.

Dealing With the Aortic Annulus: Surgical Aortic Annulus Enlargement With a Balloon Catheter.

Dealing With the Aortic Annulus: Surgical Aortic Annulus Enlargement With a Balloon Catheter.

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

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

Aortic valve tract dynamics in normal-flow low-gradient and normal-flow high-gradient severe aortic stenosis

Abstract Introduction Aortic stenosis (AS) is the most common valvular heart disease in developed countries. Severe AS is defined as a mean pressure gradient (MG) ≥ 40 mmHg, a maximum aortic jet velocity≥4 m/s and an aortic valve area (AVA)≤1 cm2. However, classification of AS severity may be challenging due to discordant results on echocardiography. The normal-flow low-gradient severe AS (NFLG-AS) is defined as AVA≤1 cm2, MG&amp;lt;40 mmHg, left ventricular ejection fraction ≥ 50%, and stroke volume index (SVi) ≥ 35 ml/m2, whereas in the presence of MG &amp;gt; 40mmHg the condition is described as normal-flow high-gradient AS (NFHG-AS). Purpose The purpose of this study was to seek differences in the dynamic changes of the aortic valve tract throughout the cardiac cycle between the two clinical entities: NFHG-AS (Group 1) and NFLG-AS (Group 2). Methods In total, 130 patients with normal flow severe AS who underwent TAVI and had 3D transoesophageal echocardiographic data sets were screened. 38 patients with NFHG-severe AS and 40 patients with NFLG-severe AS with matching clinical characteristics and aortic valve area were identified. A custom-made semi-automated application developed by SQ was used. The application allows tracking of the aortic valve tract surface throughout the cardiac cycle in 3D transoesophageal echocardiograms and provides measurements of the geometrical planes at 4 levels: left ventricular outflow tract (LVOT), aortic annulus (AoA), sinuses of Valsalva (SoV) and sinotubular junction (STJ). Results The echocardiographic characteristics and the dynamic changes of the aortic valve tract between the two groups are shown in Tables 1 and 2. Both groups had comparable echocardiographic characteristic apart from the mean aortic valve pressure gradient as expected. With regards to the aortic valve tract geometrical dynamic changes, the relative LVOT and AoA area changes were bigger in Group 1 (36.8±15.9% vs 29.1±11.9%; p=0.017 and 21.0±8.39% vs 17.1±6.6%; p=0.028). The SoV and STJ relative changes were similar between the two groups. The same applies to aortic stiffness parameters, namely compliance and distensibility of the ascending aorta, systemic arterial compliance, and valvulo-arterial impedance. Conclusion The LVOT and aortic annulus area demonstrate more prominent dynamic changes in patients with normal-flow high-gradient severe AS compared to individuals with normal-flow low-gradient severe AS. While the SoV and the STJ geometry does not change significantly through the cardiac cycle, a more elastic outflow tract allows larger expansion in systole and higher pressure gradients across the aortic valve, whereas a stiffer outflow tract and annulus result in lower pressure gradients, despite the presence of severe aortic stenosis (AVA&amp;lt;1.0cm2). These differences in dynamic LVOT and aortic annulus changes may explain the discrepancy between aortic valve area and pressure gradients in patients with normal-flow low-gradient AS.

Feasibility of ultra-low volume contrast pulmonary arterial injection protocol for CTA in TAVI candidates with severe renal failure

Abstract Introduction Computer tomography angiography (CTA) has an important role in patient screening before TAVI. The high volumes of iodinated contrast media (CM) injected during the examination represents the main limitation of CTA with a dose-dependent association with contrast-induced nephropathy. Purpose Show the feasibility of an ultra-low-dose CM pulmonary arterial injection protocol for CTA in TAVI candidates in high risk patients with severe renal failure. Methods In our retrospective study seventy-seven (77) patients with CKD on stage 3b or worse (eGFR ≤ 45/min/1.73 m2) underwent pre-procedural CTA for TAVI-planning with a pulmonary arterial administration of CM. All CTA examinations were performed using a Dual Source 256-slice CT system. All enhanced CT acquisitions were performed using our dedicated biphasic injection protocol composed of two connected phases of contrast medium injection using different amount of CM (8, 10, 15 and 20 ml) according to BMI (&amp;lt;22 kg/m2; 22-24 kg/m2; 24-28 kg/m2; &amp;gt;28 kg/m2). The CM was administered directly into the pulmonary artery in all patients. For each examination was measured Intraluminal attenuation at thoraco-abdominal aorta and along the ilio-femoral vessels using the ROI (mean SD in HU) as objective image parameters (Picture 1). Serum creatinine and the eGFR were recorded pre-TAVI CT scan and after the procedures as reference of CM to renal function. Results CTA was successfully performed in all patients. Mean creatinine was 2.25 ± 0,76 mg/dL and mean GFR was 26.5± 8.1 mL/min/m2. Mean vessel attenuation was 352±164 HU at the aortic annulus, 238.1 ± 141,3 HU in the aortic arch and 266±168 in the iliac arteries (Picture 2). The mean image noise was 28.2 ± 7 HU in the aortic annulus, 24.4 ± 10,9 in the right external iliac artery, and 25. ± 12,8 HU in the left external iliac artery. After CTA examination, a total of 74 patients (96%) underwent TAVI. Mean CM dose administered during TAVI procedure was 150,6 ± 85,8. Three patients (3.9%) were abolished for TAVI. Postprocedural settings complications were recorded. A total of 31 patients (41%) had grade 1 paravalvular regurgitation, 10 patients (14%) grade 2. No cases of valve embolization or anulus rupture occured. No major vascular complications occured. No significant differences between creatine and eGFR pre and post procedures (p&amp;lt;0,001). Conclusions The use of an ultra-low-dose CM pulmonary arterial injection protocol for CTA in TAVI candidates does not affect the renal function and procedural success rate is high and the clinical outcomes after TAVI is satisfactory according to the litterature.

Phenotype of patients with severe aortic stenosis and small aortic annulus: how does it impact on hemodynamics and on transcatheter aortic valve implantation outcomes

Abstract Background Discordant grading of severe aortic stenosis can result from a tight aortic valve area (&amp;lt;1cm2) with a low transvalvular mean gradient (&amp;lt;40 mmHg). Small aortic annulus dimensions and low flow status may contribute to discordant grading of severe aortic stenosis. However, the frequency of patients with small aortic annulus and discordant grading, along with their characteristics and outcomes after intervention, remains unknown. Purpose To investigate the frequency of discordant grading severe aortic stenosis in patients with a small aortic annulus and to evaluate their clinical characteristics, as well as outcomes after transcatheter aortic valve implantation (TAVI). Methods Patients with an aortic annulus diameter &amp;lt; 23 mm determined by cardiac computed tomography who underwent TAVI between 2018 to 2023 were retrospectively evaluated. Patients were followed for the occurrence of the composite endpoint of of all-cause mortality, rehospitalizations for heart failure, non-fatal myocardial infarction, and non-fatal stroke. Results Among 230 patients with severe aortic stenosis and a small aortic annulus, 52 (23%) had discordant gradient (24 with low flow low gradient (LFLG) and 28 with normal flow low gradient (NFLG)) while 120 (52%) exhibited normal flow high gradient (NFHG) and 58 (25%) had low flow high gradient (LFHG). The majority of the patients were female (Table 1). Differences were noted among the three groups regarding aortic transvalvular gradients, stroke volume index and ejection fraction. During a median follow-up of 2 years, the composite endpoint occurred in 20% of the total cohort. Patients with discordant grading severe aortic stenosis experienced the worse outcome (Figure1). Conclusions Most patients with severe aortic stenosis and small annulus have high gradient and only 23% of patients presented discordant grading. Patients with discordant grading severe aortic stenosis showed worse outcomes, suggesting potential delays in referral due to challenges in diagnosing severe aortic stenosis among patients with small aortic annulus.Basal clinical characteristicsKaplan-Meier survival curves

Aortic valve tissue quantification in bicuspid aortic valve stenosis

Abstract Background The relative contribution of calcific versus noncalcific aortic valve tissue volume to aortic stenosis (AS) in bicuspid aortic valve (BAV) is unclear. Purpose We aimed to assess the association of aortic valve tissue volume quantified by contrast-enhanced CT with echocardiographic AS severity, and diagnostic implication of noncalcific tissue volume for severe AS. Methods We retrospectively identified 234 patients with BAV who had echocardiographic AS severity and contrast-enhanced CT evaluation within six months and left ventricular ejection ≥50%, including 150 severe AS (aortic valve area≤1 cm2 or indexed valve area≤0.6cm2/m2 plus mean grdient≥40mmHg or peak velocity≥4 m/s), 84 nonsevere AS (61 with at least mild AS: peak veloicty≥2.0 m/s plus mean gradient ≥10mmHg, and 23 with normal aortic valve function). Contrast-enhanced CT aortic valve calcific volume and noncalcific (fibrosis) volume were quantified using patient-specific Hounsfield unit thresholds (Figure). Noncontrast CT aortic valve calcium score (AVCscore) was quantified by the Agaston method. CT measurements were indexed to echocardiographic aortic valve annulus area and square-root transformed for the analysis. Results Of 234 patients, the mean age was 64±11 years, and 64% were men. There were positive correlations of indexed calcific volume, noncalcific volume, and inverse correlations of percentages of noncalcific volume (noncalcific volume divided by the sum of calcific and noncalcific volume) with peak velocity and mean gradient (|r|=0.30 to 0.68). Among 150 patients with severe AS, 28 had an AVCscore below the severe AVC threshold (1200 AU in women and 2000 AU in men) while exhibited a higher percentage of noncalcific volume compared to 122 patients with severe AVCscore (67±15% vs. 39±15%, p&amp;lt;0.001). After excluding 122 patients with severe AS and severe AVCscore, the indexed noncalcific volume was associated with severe AS (β±S.E: 0.18±0.07, p=0.005) with an area under the curve of 0.71; in contrast, AVCscore was not (p=0.55). Conclusion Both calcific and noncalcific aortic valve tissue volume contribute to AS severity in patients with BAV. Notably, noncalcific tissue volume is a key factor in determining severe AS in patients without severe AVCscore, suggesting its potential diagnostic value.Figure

The mechanical environment regulates the extent of aortic valve calcification and thickness: an ex vivo whole mouse heart study

Abstract Background Aortic stenosis (AS) is a narrowing of the aortic valve opening due to calcification and thickening of the leaflets. Calcifications are mostly located at regions with high mechanical stress and disturbed flow suggesting that mechanical environment is important in the regulation of calcification. However, direct evidence linking valve calcification and mechanical stress is still lacking. Recently, we established an ex vivo calcification model for whole mouse hearts (Miniature Tissue Culture System MTCS) which allows the study of the mechanical environment underlying aortic valve calcification. Purpose Aim of this study was to investigate the role of mechanical stress on aortic valve calcification and thickening using the MTCS. Methods Whole mouse hearts were cultured in the MTCS with 2 distinct configurations: 1) medium flowing from the aorta towards the aortic valve to create a continuous closed aortic valve (n=28) and 2) medium flowing from the left ventricle through the aortic valve towards the aorta to create a continuous open aortic valve (n=17) (Figure1). The hearts were subjected to low (300 ul/min) or high (3000 ul/min) flow speed in the presence of calcifying medium (3mM phosphate buffer). After culture for 1 week, the hearts were isolated and fixed overnight with 4% PFA/PBS. Alizarin red staining was performed to determine calcification presence. Quantifications were performed using Caseviewer software. Results Aortic valves in closed configuration exposed to a high flow speed, exhibited significant increase in calcification compared to aortic valves in the closed configuration exposed to low flow speed or aortic valve cultured in the open position (p&amp;lt;0.01, Figure2A). Of interest, the extent of calcification in the aortic valve in closed position exposed to high flow speed strongly correlated with the diameter of the aortic annulus (R²=0.86, p&amp;lt;0.0001, Figure2B). Conversely, leaflet thickness was significantly lower in the closed aortic valve configuration as compared with the open aortic valves configuration (p&amp;lt;0.05, p&amp;lt;0.001, Figure2C). Conclusion Our study demonstrates the influence of mechanical environment on aortic valve calcification and thickening. The presence of calcification in the closed but not the open aortic valve configuration exposed to high flow suggests that increased pressure promotes calcification. The correlation of the extent of aortic valve calcification with the diameter of the aortic annulus implies that configuration of the valve is an important determinator of calcification, with potential implications for the results of aortic valve repair. The presence of a minimal amount of mechanical stress as experienced by aortic valves in the open position, however, resulted in thicker aortic valves, indicating that the right balance of mechanical stresses is required to maintain normal valve morphology. These findings provide valuable insights into AS pathogenesis, guiding future therapeutic approaches.ex vivo cultured aortic valvesCalcification in ex vivo aortic valves

Fully automated CT analysis with a deep-learning based algorithm for pre-procedural planning in transcatheter aortic valve implantation

Abstract Background Pre-procedural cardiac computed tomography analysis has emerged to an essential tool in transcatheter aortic valve implantation (TAVI). It facilitates the valve choice and allows for optimal vascular access planning. For this purpose, software programs have been specifically developed to assist a fast and precise analysis of the generated data set in high quality. However, these software programs only assist the evaluator and are not able to perform a complete analysis on their own. Purpose We report the performance of a fully-automated, deep-learning based algorithm for pre-procedural CT analysis as compared to the current clinical standard. Methods Ninety-eight patients with symptomatic severe aortic stenosis undergoing TAVI were retrospectively enrolled. The pre-procedural data set was analyzed in two ways: - conventionally with a commercially available TAVI CT-analysis software by experiences users . - by a fully-automated CT-analysis platform with a deep-learning based algorithm. The current beta-version of the platform allows the determination of the annulus diameter, -area, -perimeter and the distance measurements of the coronary arteries to the aortic annulus. Hence, analyzable parameters were limited to the aforementioned, to ensure comparability. Statistical analysis: Mean, standard deviation, mean of difference and the interclass-correlation coefficient (ICC) were calculated and Bland-Altman plots created. Results The mean annulus diameter was 24.5±2.5mm (conventional) vs. 24.1±2.4 mm (deep learning). The mean of difference was 0.42±0.82mm (Bland-Altmann diagram. Figure 1). The ICC was 0.964 (0.925; 0.980), showing an excellent correlation between the two values. The mean annulus perimeter was 77.7±7.4mm (conventional) vs. 75.6±9.3mm (deep learning), showing a very good correlation of the means [mean of difference: 2.11±5.75mm; ICC: 0.852 (0.759; 0.906)]. The distance from the annulus to the left coronary artery was 14.0±3.2mm (conventional) vs. 12.6±2.8mm (deep learning). We depicted a good correlation between the two values [mean of difference: 1.45±2.52mm; ICC 0.736 (IQR 0.483; 0.850)]. The distance from the annulus to the right coronary artery was 17.1±2.7mm (conventional) vs. 16.5±3.2mm (deep learning), respectively. A very good correlation between the two values could be shown [mean of difference 0.57±2.2mm; ICC 0.822 (0.730; 0.882)], as well. Additionally, both methods visualize the measurements and allow manual adjustments (Figure 2). Conclusion In this retrospective analysis, deep-learning based analysis of peri-procedural derived CT data sets showed an very good correlation with conventional assessment. If results can be sustained in a bigger patient cohort and extended to more complex measurements, this artificial intelligence based fully-automated CT-analysis could emerge to a valuable alternative to conventional CT assessment in the pre-procedural planning for TAVI.Figure 1 - Bland-Altman plotFigure 2- Measurements by both methods

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

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

Three-dimensional transthoracic vs transesophageal echocardiography vs computed tomography angiography aorta for aortic annular diameter measurement for TAVI in our hospital

Abstract Background Tans femoral transcatheter aortic valve implantation (TF-TAVI) was recently the standard treatment option in patient with severe aortic stenosis. All patients undergoing TF-TAVI needed computed tomography angiography (CTA) aorta not only to evaluate entry site but to measure the annulus size to determine the prosthesis valve size. In Siriraj hospital we have protocol to perform Three-dimensional transthoracic echocardiography (3D-TTE) and three-dimensional esophageal echocardiography (3D-TEE) prior to TF-TAVI. We aimed to evaluate the correlation between conventional CTA aorta vs 3D-TEE vs 3D-TTE aortic annulus size. Method and result We performed a cross sectional study in all patients undergone TF-TAVI in our hospital who had all 3 aortic annulus sizes measured by 3 methods: CTA aorta, 3D-TEE vs 3D-TTE during 2015-2023. For 244 patients underwent TAVI, 52 patients were excluded (22 Transapical approach, 10 valve in valve TAVI, 6 not complete annulus measurement, 6 transcarotid, 3 severe AR, etc.) One hundred sixteen patients were female (60.4%) with average age of 83.2 years old. 98% of patients had comorbid disease; hypertension 84%, dyslipidemia 79%, diabetes 47%, coronary artery disease 55% (9% CABG), 2.6% of patients were bicuspid aortic valve. 27% of patients had LVEF less than 55%, average AVA was 0.71 centimeter-square, average mean pressure gradient was 52.5 mmHg. We analyzed the co-relation between these 3 methods by Bland–Altman plot which revealed the Pearson's correlation coefficient (r) between CTA Aorta and 3D-TEE was 0.814 with average difference of 0.68 mm (95% limit of agreement –1.68 - 3.04) and r between CTA Aorta and 3D-TTE was 0.442 with average difference of 0.41 mm (95% limit of agreement –3.82 - 4.63) Conclusion 3D-TTE annulus sizing had a reasonable correlation with CTA annulus sizing (Pearson’s correlation of 0.442) while 3D-TEE annulus sizing had a very high correlation with CTA annulus sizing (Pearson’s correlation of 0.814). In patient which CTA was not available to measure annulus size 3D-TEE annulus sizing might be reasonable method to measure the annulus size for TF-TAVI. Keyword trans femoral transcatheter aortic valve implantation (TF-TAVI), annulus size, three-dimensional transthoracic echocardiography (3D-TTE), three-dimensional esophageal echocardiography (3D-TEE), computed tomography angiography (CTA) aorta

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

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

Morphological phenotype of right ventricular outflow tract is associated with cardiovascular outcomes and premature death

Morphology of right ventricular outflow tract (RVOT) is potentially related to cardiovascular outcomes. However, this relationship still remains to be verified with direct evidence. We retrospectively reviewed cases from the autopsy specimen library in the Center of Forensic Medicine in Sun Yat-sen University from 2017 to 2023. Six RVOT morphological characteristics were measured and their association with cardiovascular diseases (CVDs), sudden cardiac death (SCD) and age at death was evaluated. Relationship between myocardial fibrosis in RVOT and CVDs was investigated. RVOT characteristics were recruited by machine learning algorithms for diagnosing CVDs. A total of 2370 cases were finally recruited. Perimeter of sub-valve plane (pSBV) in RVOT was positively associated with risk of CVDs and SCD (OR: 1.21, 95%CI: 1.07–1.37, p = 0.003; OR: 1.33, 95%CI: 1.16–1.52, p < 0.001). Compared with thickness of septum (tS) < 3.0 mm, tS ≥ 3.0 mm was associated with premature death in disease-dominant death (β=-0.16, 95%CI: -0.20 to -0.11, p < 0.001) and SCD (β=-0.15, 95%CI: -0.21 to -0.10, p < 0.001). Degree of myocardial fibrosis in the posterior septum was increased in coronary atherosclerosis (6.86%±2.48% vs. 4.91%±2.14%, p = 0.011) and cardiomyopathies (8.11%±3.24% vs. 4.88%±3.11%, p = 0.005). A logistic regression model, recruiting age, left and right ventricular wall thickness, pSBV, circumference of pulmonary annulus and aortic annulus, was elected as an optimal diagnostic model of CVDs, yielding AUC of 0.734 (95%CI: 0.705–0.763), 0.781 (0.740–0.821) and 0.763 (0.725-0.800) in training, validation and test sets. Increased pSBV significantly correlates with higher risk of CVDs and SCD. And tS ≥ 3.0 mm is an independent risk factor of premature death regardless of diseases.

Reference Ranges and Z-Score Equations for 19 Fetal Cardiac Biometry Structures From 18 to 34 Weeks' Gestation.

To determine equations for calculating the Z-scores of fetal cardiac structures between 18+0 and 34+6 weeks of gestation, create percentile reference tables and curves for the structures, and assess the intra- and inter-observer reproducibility of the measurements. A cross-sectional study was conducted involving 340 normal fetuses from singleton pregnancies between 18 and 34 weeks of gestational age (GA). Nineteen cardiac structures were evaluated: diameters of the mitral, tricuspid, aortic, and pulmonary valve annuli; length, diameter, and area of the left and right ventricles; cardiac area and circumference; and diameters of the ascending aorta, aortic isthmus, main pulmonary artery, right pulmonary artery, left pulmonary artery, and ductus arteriosus. Regression analysis was performed to determine the equations for the mean and standard deviation of all structures using GA, biparietal diameter (BPD), and femur length (FL) as independent variables. All equations had high coefficients of determination (R2). The best performance was achieved using the GA (R2 .819-.944), followed by FL (R2 .813-.937) and BPD (R2 .792-.934). The structure that demonstrated the highest R2 was the cardiac circumference and the smallest was the ductus arteriosus. Reference tables of percentiles 1, 5, 10, 50, 90, 95, and 99, and reference curves of Z-scores were created for all 19 cardiac structures, depending on the GA. All measurements demonstrated good and excellent reproducibility with an inter-observer intraclass correlation coefficient (ICC) of 0.774-0.972 and intra-observer ICC of 0.938-0.993. Equations were produced to calculate Z-scores as well as percentile tables and curves for 19 fetal heart structures. All the measurements demonstrated good reproducibility.

Comparative Assessment of Aortic Annulus Diameters between 3D Transesophageal Echocardiography and Cardiac MDCT in Patient with Sclerocalcific Aortic Stenosis

Comparative Assessment of Aortic Annulus Diameters between 3D Transesophageal Echocardiography and Cardiac MDCT in Patient with Sclerocalcific Aortic Stenosis

Aortic root parameter analysis for transcatheter aortic valve implantation in the Pakistani population: a retrospective study

BackgroundTranscatheter aortic valve implantation (TAVI) is a growing treatment for aortic stenosis, but anatomical variations exist across populations. Asians tend to have smaller aortic annuli and higher bicuspid valve morphology compared to Westerners, potentially impacting TAVI valve selection and outcomes. This study analyzes aortic root parameters in Pakistani patients undergoing TAVI.ResultsWe conducted a retrospective analysis of 78 patients who underwent TAVI at the Peshawar Institute of Cardiology from January 2021 to March 2024. Pre-procedural CT scans were analyzed for aortic annulus diameters, area, and other relevant parameters. The mean age was 72.41 years (SD ± 11.99), and 61.5% were male. Aortic annulus diameters (minimum, mean, maximum) were 21.18 mm (SD ± 3.99), 24.21 mm (SD ± 3.93), and 27.49 mm (SD ± 4.43), respectively. Bicuspid aortic valves were present in 34.61% of patients.ConclusionsOur findings suggest that Pakistani patients undergoing TAVI may have aortic root dimensions comparable to Western populations, with a substantial prevalence of bicuspid valves. However, coronary heights were similar to those reported in Asian populations with smaller annuli. Further studies are needed to assess TAVI outcomes in Pakistani patients and determine if tailored valve sizing strategies are required.

Early severe paravalvular leak following mitral valve replacement with a prosthetic mechanical bileaflet valve

Abstract: A middle-aged woman developed severe breathlessness soon after mitral valve replacement for rheumatic heart disease with severe mitral stenosis and moderate mitral regurgitation. Echocardiography (two-dimensional and transesophageal) revealed a severe paravalvular leak into the left atrium between the mechanical bileaflet mitral valve and the aortic annulus. The patient was stabilized with intravenous nitroglycerin and torsemide, and the heart rate was controlled with tablet metoprolol. The patient was successfully treated with a redo surgery using a larger mechanical mitral bileaflet valve (size 29 mm) and interrupted sutures. A 25-mm mechanical bileaflet valve was used during index surgery.

Transcatheter Aortic Valve Implantation by Valve Type in Women With Small Annuli

Historically, women with aortic stenosis have experienced worse outcomes and inadequate recognition compared to men, being both underdiagnosed and undertreated, while also facing underrepresentation in clinical trials. To determine whether women with small aortic annuli undergoing transcatheter aortic valve replacement have better clinical and hemodynamic outcomes with a self-expanding valve (SEV) or balloon-expandable valve (BEV). The Small Annuli Randomized to Evolut or SAPIEN Trial (SMART) was a large-scale randomized clinical trial focusing on patients with small aortic annuli undergoing transcatheter aortic valve replacement, randomized to receive SEVs or BEVs and included 716 patients treated at 83 centers in Canada, Europe, Israel, and the US from April 2021 to October 2022. This prespecified secondary analysis reports clinical and hemodynamic findings for all 621 women enrolled in SMART. Data for this report were analyzed from February to April 2024. Transcatheter aortic valve replacement with an SEV or a BEV. The composite coprimary clinical end point comprised death, disabling stroke, or heart failure-related rehospitalization. The coprimary valve function end point was the incidence of bioprosthetic valve dysfunction, both assessed through 12 months. Secondary end points included the incidence of moderate or severe prosthesis-patient mismatch. A total of 621 women (mean [SD] age, 80.2 [6.2] years; 312 randomized to the SEV group and 309 to the BEV group) were included in the present analysis. At 12 months, there were no significant differences in the coprimary clinical end point between the SEV and BEV groups (9.4% vs 11.8%, absolute risk difference -2.3%; 95% CI -7.2 to 2.5, P = .35). However, SEV implantation was associated with less bioprosthetic valve dysfunction (8.4% vs 41.8%; absolute risk difference, -33.4%; 95% CI, -40.4 to -26.4; P < .001). SEV implantation resulted in lower aortic valve gradients and larger effective orifice areas at 30 days and 12 months and less mild or greater aortic regurgitation at 12 months compared to BEV implantation. Prosthesis-patient mismatch was significantly lower with SEVs, regardless of the definition used and adjustment for body mass index. Use of SEVs was associated with better quality of life outcomes as assessed by the Valve Academic Research Consortium-3 ordinal quality of life measure. Among women with severe symptomatic aortic stenosis and small aortic annuli undergoing transcatheter aortic valve replacement, the use of SEVs, compared to BEVs, resulted in similar clinical outcomes and a markedly reduced incidence of bioprosthetic valve dysfunction through 12 months, including a lower risk of prosthesis-patient mismatch and better 12-month quality of life. ClinicalTrials.gov Identifier: NCT04722250.

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

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