Coronary Cusp Research Articles

Inter-operative determination of the aortic root and cusp geometry associated with the aortic regurgitation grade.

To perform successful aortic valve plasty (AVP) and valve-sparing root replacement (VSRR), a sufficient understanding of the aortic root and cusp geometry is required. Several key parameters of the aortic root and cusp geometry were, therefore, measured intraoperatively. Forty-nine patients (63.1 ± 16.6 y.o., 40 males) were measured during the surgeries. The patients were divided into 3 groups; including patients with no or mild aortic valve regurgitation (AR) (n = 13), moderate AR (n = 18), and severe AR (n = 18). There were no significant differences in the body surface area (1.72 ± 0.19m2) among the 3 groups (p = 0.858). The effective height (EH) and geometric height (GH) of right coronary cusp were smaller than those of the others (EH: p = 0.068, GH: p < 0.01). The insertion line length (ILL) and free margin length (FML) of each leaflet tended to be significantly longer according to the AR grade(ILL: p < 0.01, FML: p < 0.01). The FML/AVJ ratios were significantly different (p < 0.01). The FML/ILL ratios were constant with the ratio of 0.88 ± 0.1(p = 0.624). Although the ILL and FML tended to increase with the AR grade, the FML/ILL ratio remained constant. For successful AVP and VSRR, adequately maintaining the FML/ILL ratio is necessary to prevent remarkable cusp prolapse while also preserving its favorable cusp motion.

Association Between Bicuspid Aortic Valve and Ascending Aorta Morphology

Background: Bicuspid aortic valve (BAV) occurs in 2% of the population, and is divided into 3 morphological groups: right and leftcoronary cusp (RL), right coronary and non-coronary cusp (RN), and left coronary and non-coronary cusp (LN) fusion patterns.Objective: The aim of the study was to evaluate the association between bicuspid aortic valve morphology and ascending aortamorphology.Methods: This was a descriptive-analytical study carried out in 200 patients. A questionnaire collected echocardiographic findingsand variables. SPSS 22 was used for statistical analysis.Results: The study enrolled 139 men (69.5%) and 61 women (30.5%). Right and left coronary cusp fusion (69%) and total dilation ofthe ascending aorta (44.5%) were the most common morphologies.Conclusion: Right and left coronary cusp fusion was the most prevalent morphology and total dilation of the aorta and abnormalaortic valve function were more frequent in RL cusp fusion.

Short term clinical outcomes and analysis of risk factors for pacemaker implantation: a single center experience of self-expandable TAVI valves

ObjectivesTranscatheter aortic valve implantation is a recognized treatment for patients with severe aortic stenosis at all risk groups. However, permanent pacemaker rates remain high for self expandable transcatheter valves and permanent pacemaker implantation has been associated with increased morbidity. In this analysis we aim to evaluate short term clinical outcomes post self expandable transcatheter aortic valve implantation and determine risk factors for permanent pacemaker implantation.Methods88 patients with severe aortic stenosis with transcatheter aortic valve implantation performed between the year 2016–2018 were retrospectively analyzed. Outcomes of interest included 1- year all cause mortality, 30-day major adverse cardiovascular events, permanent pacemaker and paravalvular leak rates. Survival analysis was performed with Kaplan Meier analysis and risk factors for survival and permanent pacemaker rates were identified with log rank test and regression analysis.ResultsThe mean age of the cohort was 80.3 +/− 6.9 years. The mean STS score was 9.25. The 30 day all-cause mortality was 5.7% and 1-year all cause mortality was 16.7%. 80 patients had transfemoral transcatheter aortic valve implantation, and a majority of the patients (85.2%) were implanted with Corevalve Evolut R device. The device success rate was 88.6%. Multivariate analysis identified concomitant severe coronary artery disease (OR = 18.2 +/− 0.9; P = 0.002), pre transcatheter aortic valve implantation atrial fibrillation (OR = 8.6 +/− 0.91; P = 0.02) and post procedural disabling stroke (OR = 32.6 +/− 1.35; P = 0.01) as risk factors for 1-year mortality. The 30-day pacemaker rate was 17.6%. The presence of right bundle branch block (OR 11.1 +/− 0.86; P = 0.005), non-coronary cusp implantation depth (OR = 1.34 +/− 0.15; P = 0.05) and a non coronary cusp implantation depth / membranous septal length ratio of more than 50% were associated with post procedural pacemaker implantation (OR = 29.9 +/− 1.72; P = 0.05). Among the 15 patients with post procedural pacemaker implantation, 40% were found to be non-pacemaker dependent at 1 year.ConclusionShort term outcomes of transcatheter aortic valve implantation in severe aortic stenosis patients are promising. Pacemaker rates remain high. More studies are needed to evaluate the factors that influence pacemaker rates and dependence to further improve transcatheter aortic valve implantation outcomes.

Idiopathic right ventricular arrhythmias requiring additional ablation from the left-sided outflow tract: ECG characteristics and efficacy of an anatomical approach.

Despite the characteristic electrocardiogram (ECG) findings of early activation during ventricular tachyarrhythmias (VAs) and/or excellent pacemapping in the right ventricular outflow tract (RVOT), some VAs may require additional, left-sided ablation for a cure. This study included five patients with idiopathic VAs whose QRS morphologies were highly suggestive of an RVOT origin. The ECG characteristics and intracardiac electrocardiograms during catheter ablation were assessed. In all patients, the clinical VAs had an LBBB QRS morphology and inferior axis with a precordial R/S transition through leads V3-V5, and negative components in lead I. The earliest activation during the VAs (local electrogram-QRS interval = -34 ± 6.8 ms) and excellent pacemapping were obtained at the posterior portion of the RVOT just beneath the pulmonary valve. However, ablation at those sites failed, and the QRS morphology of the VAs changed. During left-sided OT mapping, the earliest activation was found at sites just contralateral to the initially ablated sites of the RVOT (junction of the left and right coronary cusps = 2, left coronary cusp = 3). In spite of the late activation time and poor pacemapping scores, catheter ablation at those sites cured the VAs. Those successful sites were also near the transitional zone from the great cardiac vein to the anterior interventricular vein (GCV-AIV). Some VAs, highly suggestive of having RVOT origins, require catheter ablation in the left-sided OT near the initially ablated RVOT site. Those VAs have the same ECG characteristics and might have intramural origins in the superobasal LV surrounded by the RVOT, LVOT, and GCV-AIV.

Electrocardiographic localization of ventricular arrhythmias successfully ablated from the distal great cardiac vein.

Idiopathic ventricular arrhythmias (IVAs) from the left ventricular (LV) summit may be successfully ablated from the distal great cardiac vein (dGCV). Using a 12-lead electrocardiogram (ECG) to localize IVAs that can be ablated from the dGCV is valuable for ablation planning. To determine if a "w" wave, a notch in the Q wave in lead I, and other ECG features can identify IVAs that can be successfully ablated from the dGCV. We reviewed outflow tract premature ventricular contraction (PVC) ablations performed at two centers between September 2010 and June 2018. Successful PVC ablations, in which the PVCs were mapped from the right ventricular outflow tract, coronary cusps, commissures, endocardial LV, and the coronary venous system including the dGCV were included. ECG characteristics were compared between patients with successful ablations in the dGCV and non-dGCV sites. Of the 120 patients (age 56.8 ± 13.8 years, 45% female) that met the inclusion criteria, the dGCV was the successful ablation site in 18 patients (15%). Multivariate analysis with binary logistic regression showed that a "w" in lead I in combination with an early precordial pattern break and a maximum deflection index (MDI) ≥ 0.5 had sensitivity and specificity for a successful ablation in the dGCV of 94.4% and 96.1%, respectively. Combining a "w" wave in lead I with an early precordial pattern break and an MDI ≥ 0.5 is highly sensitive and specific for identifying the dGCV as a successful ablation site for PVCs.

A single, shared origin for all three coronary arteries from the right coronary cusp: a case report

BackgroundAnomalous coronary arteries occur in less than 1% of the population and have been implicated in sudden cardiac and exercise-related death. The most common variant involves the left circumflex artery arising from a separate ostium than the left coronary artery. This case demonstrates a rare variation in which all three coronary arteries arise from a shared, single, ostium originating from the right coronary cusp.Case presentationWe report the case of a 63-year-old Caucasian man with a history of myocardial infarction, congestive heart failure, and atrial fibrillation who presented for syncope. Inpatient ischemic workup, including coronary angiography, demonstrated a rare coronary anomaly which included all three coronary arteries arising from a shared, single, ostium originating from the right coronary cusp. Our patient was treated conservatively with an option for coronary bypass if symptomatic.ConclusionSurgical management is indicated in high-risk patients, but the optimal management for a nonmalignant, shared origin for all three coronary arteries has not been explored in detail.

A study on the prevalence, distribution and related factors of heart valve calcification using coronary CT angiography.

The concept of active atherosclerotic disease has been accepted for heart valve calcification (HVC). We investigated prevalence, distribution and related factors of HVC in patients who had undergone coronary CT angiography (CCTA). Subjects were consecutive 200 patients who underwent CCTA. The prevalence and the distribution of HVC using ECG gated non-contrast CT were investigated. Logistic regression analysis and simple regression analysis for factors associated with presence of the calcification and quantitative calcification in the aortic and mitral valve were conducted. HVC was detected in 48.0%. Aortic valve calcification (AVC) was found in 92 cases, the most, followed by mitral valve calcification (MVC) in 25 cases, pulmonary valve in 3 cases, and tricuspid valve in 1 case. Although the left coronary cusp showed the most in 65.2%, no statistic significant difference for Agatston score was detected among each cusp in AVC. Multiple logistic regression analysis showed that age (OR:1.211, 95%C.I.:1.0716-1.1728, p<0.0001) and coronary artery calcium score (CACS) grade (grade2 OR:7.3393, 95%C.I.:1.7699-30.4349, p=0.0060, grade3 OR:7.2214, 95%C.I.:1.4376-36.2762, p=0.0164) were significant factors associated with presence of AVC. The significant factors associated with quantitative AVC were age (p=0.0043), dyslipidemia (p=0.0117), and statin use (p=0.0221). Only age (OR:1.1589, 95%C.I.:1.0726-1.2520, p=0.0002) was significant factor related to presence of MVC. No significant related factor was found in quantitative MVC. There was an association between presence of AVC and CACS, but not a significant association with presence of MVC. Neither quantitative AVC nor MVC had a significant association with CACS or coronary artery disease.

Novel bicuspid aortic valve model with aortic regurgitation for hemodynamic status analysis using an ex vivo simulator

ObjectiveThe objective was to design and evaluate a clinically relevant, novel ex vivo bicuspid aortic valve model that mimics the most common human phenotype with associated aortic regurgitation. MethodsThree bovine aortic valves were mounted asymmetrically in a previously validated 3–dimensional-printed left heart simulator. The non-right commissure and the non-left commissure were both shifted slightly toward the left–right commissure, and the left and right coronary cusps were sewn together. The left–right commissure was then detached and reimplanted 10 mm lower than its native height. Free margin shortening was used for valve repair. Hemodynamic status, high-speed videography, and echocardiography data were collected before and after the repair. ResultsThe bicuspid aortic valve model was successfully produced and repaired. High-speed videography confirmed prolapse of the fused cusp of the baseline bicuspid aortic valve models in diastole. Hemodynamic and pressure data confirmed accurate simulation of diseased conditions with aortic regurgitation and the subsequent repair. Regurgitant fraction postrepair was significantly reduced compared with that at baseline (14.5 ± 4.4% vs 28.6% ± 3.4%; P = .037). There was no change in peak velocity, peak gradient, or mean gradient across the valve pre- versus postrepair: 293.3 ± 18.3 cm/sec versus 325.3 ± 58.2 cm/sec (P = .29), 34.3 ± 4.2 mm Hg versus 43.3 ± 15.4 mm Hg (P = .30), and 11 ± 1 mm Hg versus 9.3 ± 2.5 mm Hg (P = .34), respectively. ConclusionsAn ex vivo bicuspid aortic valve model was designed that recapitulated the most common human phenotype with aortic regurgitation. These valves were successfully repaired, validating its potential for evaluating valve hemodynamics and optimizing surgical repair for bicuspid aortic valves.

Aortic cusp ablation for premature ventricular contractions and ventricular tachycardia in children: a 5-year single-center experience.

Aortic cusps might be the source of supraventricular or ventricular arrhythmias. For many years, aortic cusp ablation has been widely used to treat premature ventricular contractions (PVCs) and ventricular tachycardia (VT). However, the data on the outcomes of this procedure in children are limited. The study aimed to convey or describe our own aortic cusp ablation experiences in children and, thus, contribute to the literature. The focus was pediatric cases of ventricular arrhythmia in which the origin of the PVCs was ablated above the Valsalva. The sample comprised patients who underwent aortic cusp ablation between 2013 and 2018. The demographic characteristics, noninvasive test results, procedure details, and follow-up results for the patients were noted. The 3D EnSite Precision cardiac mapping system and limited fluoroscopy were used. A total of 26 procedures were performed on 22 patients. The mean age was 14.4 ± 3.0 (9-19)years, and the mean weight was 57.3 ± 17.5 (27-99)kg. The mean follow-up period after the first presentation was 38.6 ± 22.9 (3-72)months. There were significant differences in the values of the transition index, V2S/V3R, IIR/IIIR, aVRS/aVLS ratio, and QRS polarity in I at various locations. The most common ablation site was the left coronary cusp (LCC). Radio frequency (RF) ablation, cryoablation, and irrigated RF ablation were found to be effective energy sources in 15, 4, and 3 patients, respectively. Patients who underwent ablation at the LCC-right coronary cusp (RCC) commissure were more likely to present with only VT and to experience worsening symptoms. Twelve patients had previously undergone ablation of the right ventricular outflow tract (RVOT). Ablation in the RVOT had been previously performed in all the patients who eventually underwent ablation at the RCC and the LCC-RCC commissure. Aortic cusp ablation can be safely performed in children. The careful evaluation of previous noninvasive tests provides important data for determining the location. There might be significant differences in the signs and requirements on the basis of the locations during mapping and ablation.

Right ventricular outflow tract obstruction caused by a right coronary cusp prolapse: An unusual finding

Patients with large sub-pulmonic ventricular septal defect (VSD) present early as a results of their complications. Some present late, due to the restriction of VSD by the right coronary cusp (RCC) due to its prolapse. In this report, we present a rare case of sub-pulmonic VSD in a 33-year-old man who developed a sub-pulmonic stenosis due to the prolapse of the RCC into the right ventricular outflow tract.

Correction to: Ablation at Right Coronary Cusp as an Alternative and Favorable Approach to Eliminate Premature Ventricular Complexes Originating From the Proximal Left Anterior Fascicle.

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 13, No. 6Correction to: Ablation at Right Coronary Cusp as an Alternative and Favorable Approach to Eliminate Premature Ventricular Complexes Originating From the Proximal Left Anterior Fascicle Free AccessCorrectionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessCorrectionPDF/EPUBCorrection to: Ablation at Right Coronary Cusp as an Alternative and Favorable Approach to Eliminate Premature Ventricular Complexes Originating From the Proximal Left Anterior Fascicle Originally published16 Jun 2020https://doi.org/10.1161/HAE.0000000000000073Circulation: Arrhythmia and Electrophysiology. 2020;13:e000073This article corrects the followingAblation at Right Coronary Cusp as an Alternative and Favorable Approach to Eliminate Premature Ventricular Complexes Originating From the Proximal Left Anterior FascicleIn the article by Chen et al, “Ablation at Right Coronary Cusp as an Alternative and Favorable Approach to Eliminate Premature Ventricular Complexes Originating From the Proximal Left Anterior Fascicle,” which published online on April 17, 2020, and appeared in the May 2020 issue of the journal (Circulation: Arrhythmia and Electrophysiology. 2020;13:e008173. DOI: 10.1161/CIRCEP.119.008173), a correction is needed.The visual overview that published with the article was incorrect. The correct visual overview is below. We apologize for this error.Download figureDownload PowerPointThe correction has been made to the current online version of the article, which is available at https://www.ahajournals.org/doi/10.1161/CIRCEP.119.008173. Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesAblation at Right Coronary Cusp as an Alternative and Favorable Approach to Eliminate Premature Ventricular Complexes Originating From the Proximal Left Anterior FascicleSongwen Chen, et al. Circulation: Arrhythmia and Electrophysiology. 2020;13 June 2020Vol 13, Issue 6 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/HAE.0000000000000073PMID: 32543969 Originally publishedJune 16, 2020 PDF download Advertisement

128Non-invasive 3D mapping of earliest activation of premature ventricular complexes originating from intracardiac structures to guide catheter ablation

Abstract Funding Acknowledgements Research funding from Catheter Precision, Inc. Introduction Catheter ablation for ventricular arrhythmias such as premature ventricular complexes and ventricular tachycardia is an established management approach. Non-invasive mapping to localise the earliest activation (site of origin) on the myocardium may help guide ablation. Established ECGi methods using the inverse solution to reconstruct epicardial electrograms are unable to accurately locate arrhythmias from the endocardium or from intracardiac structures. VIVO™ (Catheter Precision) is a novel vectorcardiography based 3D mapping system that may be able to localise arrhythmias from any part of the ventricle. Methods We reviewed our initial experience utilising this mapping system to guide catheter ablation of ventricular ectopics from the inter-ventricular septum, coronary cusp or papillary muscle. A patient-specific 3D heart and torso model was created using semi-automated segmentation of MRI or CT scan images. A 3D topographic image of the patient’s torso was taken to accurately position surface ECG electrode locations onto the 3D heart-torso model. An ECG of the PVC was imported from LabSystemPro (Bard) into VIVO™ for analysis prior to ablation. The result was then compared with the site of earliest activation identified using invasive electro-anatomical (EA) mapping. Results VIVO™ was used in 12 cases where the PVC was localised to an intracardiac structure – six papillary muscle, four to the septum and two from the coronary cusp. VIVO™ was able to accurately localise the earliest activation site when compared to the invasive map in 5/6 papillary muscle cases, 3/4 septal cases and 2/2 coronary cusp cases. Ablation was acutely successful in all cases. One additional patient had a PVC localised non-invasively to the postero-medial papillary muscle, however an invasive 3D electro-anatomical map or ablation was not performed. In three cases we were able to merge the 3D geometry of the non-invasive map from VIVO™ into the Carto™ system to guide mapping and ablation in real time (see figure). Conclusion Our experience shows promising results for accurate non-invasive localisation of ventricular arrhythmias originating from intracardiac structures. Non-invasive localisation is of particular value in cases where the arrhythmia is infrequent, difficult to induce or poorly tolerated haemodynamically. The two cases where PVC localisation was inaccurate were performed using an older version of the software. With recent refinements, localisation is anticipated to be improved further. We also present the first experience of combining the VIVO™ geometry with the real-time invasive EA map. This has potential to significantly speed up mapping time and reduce the need for expensive multi-polar catheters by allowing the operator to see their target in real time 3D. Further work is ongoing to validate the accuracy of VIVO™ prospectively and quantitatively. Abstract Figure. VIVO map merged with Carto LV geometry

A novel 9-partition method using fluoroscopic images for guiding left bundle branch pacing

Left bundle branch (LBB) pacing is a novel pacing modality, but there is no standard fluoroscopic methodology. This study aimed to analyze the characteristics of His bundle (HB) and LBB pacing lead locations and establish a method to guide LBB pacing using fluoroscopic images. Seventy patients who underwent HB or LBB pacing were enrolled. The fluoroscopic image was recorded, and ventricular contraction ring in the right anterior oblique 30° projection was determined. The region between the apex and the ventricular contraction ring was divided into 9 partitions. All patients underwent postoperative computed tomography to confirm components of the ventricular contraction ring and to measure the distance from the lead tip to the junction of the noncoronary aortic cusp and right coronary cusp. HB and LBB pacing leads were successfully implanted in 11 and 35 patients, respectively. All HB pacing leads were distributed in the second partition, and 94.3% (33/35) of LBB pacing leads were in the junctional area of second and fifth partitions. The computed tomography image confirmed that the ventricular contraction ring was composed of cardiac valves. The distance from the lead tip to the junction of the noncoronary cusp and right coronary cusp of LBB and HB pacing leads was 3.8 ± 0.6 and 1.9 ± 0.2 cm, respectively. Under the guidance of the 9-partition method, the success rate of LBB pacing in 30 prospective patients increased from 58.3% (35/60) to 83.3% (25/30) (P = .03). The fluoroscopy time and the number of screwing sites also significantly decreased. The distributions of HB and LBB pacing leads exhibited unique imaging characteristics. A new 9-partition method is useful to guide successful LBB pacing.

Impact of aortic angle on transcatheter aortic valve implantation outcome with Evolut‐R, Portico, and Acurate‐NEO

To investigate paravalvular leak (PVL) and devices success rates according to aortic angle (AA) in patients undergoing transcatheter aortic valve implantation (TAVI) with three new-generation self-expanding devices. The impact of aortic angle (AA) on TAVI device success and PVL rates is controversial. This retrospective study included 392 patients submitted to TAVI for severe aortic stenosis with Portico, Evolut-R and Acurate-NEO, and available AA measurements at computed tomography (CT) angiography. AA was calculated from the implantation projection and was defined as the angle between the plane of aortic annulus and an ideal horizontal plane. Aorta was defined horizontal if AA>57° (75th percentile). In the horizontal group, the rates of moderate/severe PVL was higher in the Evolut-R group (20.8%), which was also characterized by a lower implant compared to that of Acurate-NEO, whereas device success was comparable among the three devices. AA was a significant predictor of moderate/severe PVLs (AUC 0.72, p = .002) only in the Evolut-R population. On multivariate analysis, calcium volume 850HU, bicuspid aortic valve, and implantation depth at the level of left coronary cusp were independent predictors of moderate/severe PVL. On univariate analysis in the horizontal aorta population, implantation depth was confirmed among the most significant predictors of moderate/severe PVL. Despite comparable device success rates, horizontal aorta represented a technical challenge only in the Evolut-R subgroup, which showed higher rates of moderate/severe PVL than Portico and Acurate-NEO, and was associated with a low implant.

Ablation at Right Coronary Cusp as an Alternative and Favorable Approach to Eliminate Premature Ventricular Complexes Originating From the Proximal Left Anterior Fascicle.

Premature ventricular complex (PVC) with narrow QRS duration originating from proximal left anterior fascicle (LAF) is challenging for ablation. This study was performed to evaluate the safety and feasibility of ablation from right coronary cusp (RCC) for proximal LAF-PVC and to investigate this PVC's characteristics. Mapping at RCC and left ventricle and ECG analysis were performed in 20 patients with LAF-PVC. The earliest activation site (EAS), with Purkinje potential during both PVC and sinus rhythm, was localized at proximal LAF in 8 patients (proximal group) and at nonproximal LAF in 12 patients (nonproximal group). The Purkinje potential preceding PVC-QRS at the EAS in proximal group (32.6±2.5 ms) was significantly earlier than that in nonproximal group (28.3±4.5 ms, P=0.025). Similar difference in the Purkinje potentials preceding sinus rhythm QRS at the EAS was also observed between proximal and nonproximal groups (35.1±4.7 versus 25.2±5.0 ms, P<0.001). In proximal group, the distance between the EAS to left His bundle and to RCC was shorter than that of nonproximal group (12.3±2.8 versus 19.7±5.0 mm, P=0.002, and 3.9±0.8 versus 15.7±7.8 mm, P<0.001, respectively). No difference in the distance from RCC to proximal LAF was identified between the 2 groups. PVCs were successfully eliminated from RCC for all proximal groups but at left ventricular EAS for nonproximal groups. The radiofrequency application times, ablation time, and procedure time of nonproximal group were longer than that of proximal group. Electrocardiographic analysis showed that, when compared with nonproximal group, the PVCs of proximal group had narrower QRS duration; smaller S wave in leads I, V5, and V6; lower R wave in leads I, aVR, aVL, V1, V2, and V4; and smaller q wave in leads III and aVF. The QRS duration difference (PVC-QRS and sinus rhythm QRS) <15 ms predicted the proximal LAF origin with high sensitivity and specificity. PVCs originating from proximal LAF, with unique electrocardiographic characteristics, could be eliminated safely from RCC.

The impact of the aortic cusps fusion pattern and valve disease severity on the aortic wall mechanics in patients with bicuspid aortic valve

The ascending aorta dilatation in the bicuspid aortic valve (BAV) patients is often attributed to congenital abnormalities of the aortic wall, but it may be related to hemodynamic disturbances in the course of BAV disease. At present, ascending aortic diameter is used as almost sole but weak predictor of aortic dissection and rupture in BAV. We examined the association between aortic wall mechanics and severity of aortic valve disease including different cusps fusion patterns using conventional echocardiography and tissue Doppler imaging (TDI). We prospectively studied 106 BAV patients: 72 with right-left (R-L) coronary cusp fusion were matched 1:1 to 34 patients with right-noncoronary (R-N) cusp fusion obtaining 34 pairs of patients. Peak systolic radial velocity and acceleration of the ascending aortic wall, measured by TDI, were used as an index of hemodynamic stress imposed on the aorta. Paired analysis showed higher aortic wall radial velocity (4.71 ± 1.61 cm/s vs. 3.33 ± 1.44 cm/s, p = 0.001) and acceleration (1.08 ± 0.46 m/s2 vs. 0.80 ± 0.34 m/s2, p = 0.015) in-R-L compared to R-N fusion. Pearson correlation showed association of ascending tubular aortic diameter with age (r = 0.258, p = 0.012), weight (r = 0.323, p = 0.001), peak aortic valve gradient (r = 0.386, p = 0.0001), aortic root diameter (r = 0.439, p < 0.0001), and R-N fusion pattern (r = 0.209, p = 0.043). Aortic root diameter was related to male gender (r = 0.296, p = 0.003), weight (r = 0.381, p = 0.0001), ascending aortic diameter (r = 0.439, p < 0.0001), and severity of aortic regurgitation (r = 0.337, p = 0.0009). Regional differences in aortic wall motion between different BAV cusp fusion patterns and association of aortic diameters with the severity of aortic valve disease, both suggest a deleterious hemodynamic impact of cusp fusion patterns and aortic valve dysfunction on ascending aortic wall. Assessment of aortic hemodynamic by TDI is feasible and could be potentially used to improve prediction of acute aortic complications, thus helping to establish optimal timing of aortic surgery in BAV patients.

Non-invasive electroanatomic mapping to reduce mapping time during catheter ablation of outflow tract ventricular premature depolarizations.

Ventricular premature depolarizations (VPD) commonly arise from the septal anterior right ventricular outflow tract (sRVOT), the left coronary cusp (LCC), and the distal great cardiac vein (dGCV), and share common ECG characteristics. To assess the diagnostic accuracy of non-invasive electroanatomic mapping (NIEAM) in differentiating VPD origin between sRVOT, LCC and dGCV and quantify its clinical utility in eliminating unnecessary mapping and ablation. ECGs and NIEAMs (CardioInsight, Medtronic) from 32 patients (56.3 ± 15.2years) undergoing ablation for VPDs originating from sRVOT, LCC, or dGCV were blindly reviewed for their diagnostic accuracy in predicting the SOO. A 2-step algorithm using NIEAM-based activation timing of the superior basal septum of < 22.5ms and lateral mitral annulus of > 60.5ms was compared with subjective ECG evaluation, the maximum deflection index (MDI), and the V2 transitional ratio in predicting SOO. We calculated the mapping and ablation time that could have been avoided had the operators relied on activation timing by NIEAM in designing their mapping and ablation strategy. NIEAM was superior to subjective ECG evaluation, MDI, and V2 transition ratio in predicting the SOO yielding a sensitivity and specificity of 96.9% and 98.4% respectively. Using NIEAM in determining the SOO would have obviated 22 ± 4.5min of mapping in the wrong chamber and prevented unnecessary ablation of 4.5 ± 1.8min. NIEAM has high diagnostic accuracy in differentiating between sRVOT, LCC, and dGCV VPDs, and can significantly reduce mapping time, obviating the need for unnecessary access and ablation.

Distinguishing Ventricular Arrhythmias Originating from the Posterior Right Ventricular Outflow Tract, or Near the Right Coronary Cusp or Near the His-Bundle

Differentiation of outflow tract ventricular arrhythmias (OT-VAs) which originate from the posterior right ventricular outflow tract (RVOT), right coronary cusp (RCC) or near the His-bundle are still a challenge until now. This study was aimed to develop a stepwise electrocardiogram (ECG) algorithm to distinguish their locations. Seventy-five consecutive patients with VAs successfully ablated from the posterior RVOT (n = 57), near the His-bundle (n = 5) or RCC (n = 13) were enrolled in our study. Measurements with highest diagnostic performance were chosen to develop a diagnostic algorithm. Of all these ECG measurements, the R-wave amplitude in lead I and V2S/V3R index showed the best diagnostic performance to discriminate these anatomical sites. The optimal ECG discriminators were different combination of lead I and V2S/V3R index as follows: the posterior RVOT, Lead I R-wave amplitude <0.65 mV and V2S/V3R index>1.5 (96.2% sensitivity, 69.6% specificity); the near the His-bundle, lead I R-wave amplitude ≥0.65 mV and V2S/V3R index>1.5 (100% sensitivity, 70% specificity); RCC, lead I R-wave amplitude<0.65 mV and V2S/V3R index ≤1.5 (52.9% sensitivity, 93.1% specificity). Sequential algorithmic application of these criteria resulted in an overall accuracy of 83% in predicting site of OT-VA origin. A predominantly positive R-wave in lead I is seen in OT-VAs originated near the His-bundle. A stepwise ECG algorithm of combination with R-wave amplitude in lead I and V2S/V3R index could localize the origins of OT-VAs from the posterior RVOT, near the His-bundle and the RCC with a high accuracy.

Coronary ostial eccentricity in severe aortic stenosis: Guidance for BASILICA transcatheter leaflet laceration

BackgroundEccentricity of coronary ostial positions in relation to the aortic valve cusp may influence the target laceration location in BASILICA (Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Coronary Artery obstruction). Eccentricity of the coronary ostia in relation to coronary cusps of native and valve-in-valve transcatheter aortic valve replacement (TAVR) was not well described before. MethodsA total of 121 pre-TAVR patients’ CT data (72 native valves TAVR and 49 bioprosthetic surgical valves TAVR) was included and coronary ostial eccentricity angles were measured and compared. Coronary ostial angles were measured between mid-cusp line to coronary ostium in CT perpendicular images. ResultsIn the overall cohort, the right coronary artery (RCA) had an eccentric origin in the majority of cases, favoring the commissure between the right and the non coronary cusp (17.0°, IQR; 10–25). On the other hand, the left coronary artery (LCA) originated most commonly near center of the cusp position (0°, IQR; -8 -7.5) In comparison of native and bioprosthetic valves, RCA ostial angles were more eccentric in native valves (19.0°, IQR; 12–26) than in bioprosthetic valves (14.0°, IQR; 3–20) (p = 0.004). Whereas, LCA ostial angle has no significant differences between native valves (−2.0°, IQR;-7.75-5.75) and bioprosthetic valves (1°, IQR;-8-13), (p = 0.6). ConclusionRCA ostia often have an eccentric origin towards the non-coronary cusp, especially in native aortic valves, while LCA ostia commonly originate near the center of the cusp. This finding may contribute to better performance of BASILICA procedures.

Can the 12-lead ECG distinguish RVOT from aortic cusp PVCs in pediatric patients?

The ability to differentiate right ventricular outflow tract (RVOT) from coronary cusp (CC) site of origin (SOO) by 12-lead ECG in pediatric patients may impact efficacy and procedural time. The objective of this study was to predict RVOT versus CC SOO by ECG in pediatric patients. Pediatric patients (<21 years) without structural heart disease with RVOT or CC premature ventricular contraction (PVC) ablations performed (2014-2018) were evaluated through multi-institution retrospective review. Demographics, ECG PVC parameters, ablation site, recurrence, and repeat procedures were collected. Thirty-seven patients were evaluated (mean age 14.6 years, weight 60.6kg): 11 CC and 26 RVOT PVC SOO. CC PVCs were less likely to exhibit left bundle branch block (64%vs 100%, P=.005), had larger R-wave amplitude in V1 (0.27vs 0.11mV, P=.03), larger R/S ratio in V1 (0.37vs 0.09, P=.003), and had precordial transition in V3 or earlier (73%vs 15%, P=.002). A composite score was created with the following variables: isodiphasic or positive QRS in V1, R/S ratio in V1>0.05, S wave in V1<0.9mV, and precordial transition at or before V3. Composite score ≥ 2 was associated with a CC SOO (OR 42.0, P=.001, and AUC 0.86). 12-lead ECG of PVCs from the CC was associated with larger V1 R-wave amplitude, larger R/S ratio in V1, and precordial transition at or before V3. A composite score may help predict PVC/VT arising from the CC.