Pulmonary Valve Dysfunction Research Articles

Abstract 16787: Aneurysmal Dilatation of the Main Pulmonary Artery in Patients With Isolated Pulmonary Stenosis: An Intrinsic Arteriopathy or a Flow-Related Sequela?

Introduction: In patients with isolated pulmonary stenosis (iPS), dilatation of the MPA has been reported, sometimes developing into large aneurysms (giantPA). The incidence, aetiology, natural history, and its treatment. Methods: We identified all patients with iPS that attended our tertiary cardiac centre (one of the largest in the UK) between 2003 and 2018 and reviewed clinical notes, echocardiography and MRI data. We evaluated the incidence of MPA dilatation in patients with iPS and its relation to age and pulmonary valve (PV) function. Results: 197 patients (107 children, 90 adults) with iPS were identified. 122 (62%) underwent balloon dilatation of PV for severe stenosis (median age 0.65 IQR 0.08-5.18 years), 30 (15%) underwent PV repair or replacement (median age of 2.06 IQR 0.9-5.2 years) and 45 (22.8%) did not require any procedure. In patients that did not require a procedure, mean peak velocity on echocardiography was 2.55±0.65 m/sec. In patients that required an intervention, the MPA was normal to mildly dilated in most patients (mean z-score +1.2±2.6). In patients who did not undergo any procedure, the size of the MPA was only weakly correlated with age (R 2 .10 p <.01) and severity of PV stenosis ( p <.22). 12 patients (6% of total population) had giantPA (z-score > 4 in children, diameter > 50 mm in adults). Mean size of the largest diameter of the MPA was +5.8±1.9 z-score in children and 59±5 mm in adults. Of these patient 58% had undergone a procedure (mean age 11±14 yrs). Of note, while in the paediatric cohort the MPA size was easily obtained using echocardiography, in only 30% of adult patients the MPA was well visualized and there was a significant error (25±27%) in the provided measurements compared to 3D imaging obtained with MRI. In 7 of 8 adults with giantPA , diagnosis was made only with MRI. Conclusion: In patients with iPS, the incidence of giantPA is not negligible (at least 6%). MPA dilatation does not seem to correlate with PV function thus suggesting an underlying arteriopathy rather than a flow-related aetiology. In adults, MPA size is unreliably assessed using echocardiography. 3D imaging is therefore indicated in adults patients with iPS even in the presence of mild PV dysfunction. Total; word count : 1875 characters Figure 1: No impact of stenosis severity on MPA size in patient who did not undergo PV repair or replacement Figure 2: Aneurysmal dilatation of the MPA in a patient with isolated pulmonary stenosis (in this case mild stenosis).

Transcatheter valve replacement in congenital heart disease: the present and the future

### Learning objectives Survival into adulthood for patients with congenital heart disease (CHD) is expected in those that have access to specialty care. Many of them will need multiple valve...

Preprocedural Risk Assessment Prior to PPVI with CMR and Cardiac CT.

Percutaneous pulmonary valve intervention (PPVI) is a less invasive and less costly approach to pulmonary valve replacement compared with the surgical alternative. Potential complications of PPVI include coronary compression and pulmonary arterial injury/rupture. The purpose of this study was to characterize the morphological risk factors for PPVI complication with cardiac MRI and cardiac CTA. A retrospective review of 88 PPVI procedures was performed. 44 patients had preprocedural cardiac MRIs or CTAs available for review. Multiple morphological variables on cardiac MRI and CTA were compared with known PPVI outcome and used to investigate associations of variables in determining coronary compression or right ventricular-pulmonary arterial conduit injury. The most significant risk factor for coronary artery compression was the proximity of the coronary arteries to the conduit. In all patients with coronary compression during PPVI, the coronary artery touched the conduit on the preprocedural CTA/MRI, whilst in patients without coronary compression the mean distance between the coronary artery and the conduit was 4.9mm (range of 0.8-20mm). Multivariable regression analysis demonstrated that exuberant conduit calcification was the most important variable for determining conduit injury. Position of the coronary artery directly contacting the conduit without any intervening fat may predict coronary artery compression during PPVI. Exuberant conduit calcification increases the risk of PPVI-associated conduit injury. Close attention to these factors is recommended prior to intervention in patients with pulmonary valve dysfunction.

Right ventricular outflow tract endocarditis caused by brucellosis.

Right-ventricular outflow tract (RVOT) endocarditis is a very rare presentation of right-sided infective endocarditis (RSIE) by brucellosis. RSIE occurs most commonly in immune-suppressed cases and illicit drug abuser. The patients with RSIE and an incompetent immune system usually have a prosthetic foreign body in blood circulation such as catheter, pacemakers, or central venous lines and may be accompanied with tricuspid or pulmonary valve dysfunction. The most common site for RSIE is the tricuspid valve. We describe an exceedingly rare condition of RVOT endocarditis in a patient with brucellosis in which vegetation is attached to a muscle bundle of the RVOT. Despite appropriate antibiotic therapy, the general condition of the patient deteriorated and was finally scheduled for open-heart surgery. The mass was resected and the patient recovered uneventfully and was discharged on the 9th day of surgery with appropriate oral antibiotics.

Evolving hybrid approaches: the preservation of the ‘neglected’ pulmonary valve function in patients with congenital heart disease

ABSTRACTThe involvement of the hemodynamic expertise in the operating room led to the development of new strategies aimed to improve both early and long-term outcome of patients with congenital heart disease. During the last decade, with the aim of preserving the pulmonary valve function, we embarked on a new surgical approach, which combines surgical and interventional techniques, which are performed in the operating room. We believe that the preservation of the pulmonary valve function can be extended to any patients with classic tetralogy of Fallot and other selected patients with congenital pulmonary valve hypoplasia and dysfunction.

Reintervenciones quirúrgicas en adultos con situación Fallot: una población emergente

Introduction-objectivesFallot has excellent post-surgical survival, although it has late morbidity including re-operations. Of all the Fallot patients currently followed-up in our Adult Congenital Heart Disease (ACHD) Unit, 26% needed re-operation. An analysis is performed on these late re-operations and the outcomes achieved. MethodsRetrospective study (1991-2014): 90 re-operations in 84 Fallot patients previously operated in the ACHD unit. ResultsMean age: 33±10 years, 59% males, 2±1 previous surgeries/patient. Preoperative functional NYHA class I-II: 46.4%, III-IV: 53.6%; arrhythmia: 45%. Main surgical indications: pulmonary insufficiency and/or stenosis (76.7%), aortic insufficiency (11.1%), residual septal defect (7.8%), and tricuspid insufficiency (4.4%). Re-operations were performed with extracorporeal circulation, and without clamping aorta in 34%. Surgical techniques employed: 81.1% received pulmonary surgery (68.9% bio-prosthesis), 50% septal defect closure, 25.5% tricuspid, and 18.9% aortic valve surgery. Hospital mortality: 4.4%. Mean follow-up: 5.9±6.2 years. During this period 3 patients died, 12 received new surgery, and there were 9 percutaneous interventions. Survival at 3 and 11 years was 96% and 90% respectively. Currently, 92.2% patients are in functional class I-II, and 82.3% in sinus rhythm. Pre- and post-operative cardiovascular magnetic resonance studies show that pulmonary bioprosthesis significatively improves pulmonary regurgitation and reduces right ventricle function (P=.001), without changing right ventricle function. ConclusionsMain indications for reintervention in Fallot in the ACHD Unit are pulmonary valve dysfunction requiring a bioprosthesis implant. Good survival was achieved in these re-operations, improving patients symptoms and reducing right ventricle volumes.

Right Ventricular Outflow Tract Reconstruction With a Polytetrafluoroethylene Monocusp Valve: A 20-Year Experience

In patients with tetralogy of Fallot (TOF), pulmonary atresia (PA), and other congenital right ventricular outflow tract (RVOT) malformations, polytetrafluoroethylene (PTFE) monocusp outflow tract patches (MOTP) relieve obstruction and provide pulmonary valve competence. The purpose of this study was to determine whether our PTFE-MOTP was an acceptable short- and mid-term remedy for patients with TOF or PA as assessed by freedom from severe pulmonary regurgitation and freedom from reoperation. From 1994-2014, 171 patients (mean age 1.5 ± 1.5 years; median 1.1 years) with TOF or PA underwent initial right ventricular outflow tract (RVOT) reconstruction with a PTFE-MOTP. Patients were studied intraoperatively and serially postoperatively using echocardiography and cardiac magnetic resonance imaging (CMR) to determine pulmonary valve dysfunction defined as a peak gradient >40mmHg or valve regurgitation>moderate. The mean follow-up duration was 10.9 ± 5.8 years (range: 1 month-20 years). There were 5 late deaths and 1 early death. There was a significant difference between the preoperative and postoperative peak RVOT gradients (74.0 vs 25.2mmHg). Of the 171 patients, 25 were lost to follow-up, and 42 have required replacement of their monocusp valves 10.1 ± 5.0 years (range: 5 months-19 years) after original monocusp insertion. At 10-year follow-up, severe pulmonary regurgitation was seen in less than 25% of patients, and severe pulmonary stenosis was seen in less than 10% of patients. Since 2007, CMR was used in 44 patients to characterize cardiac function in patients under consideration for PTFE-MOTP replacement. The average right ventricular-to-left ventricular (RV/LV) ratio on CMR was 1.7 ± 0.5 in these patients. CMR also showed that RV ejection fraction (52 ± 9%) and left ventricular ejection fraction (58 ± 7%) were both preserved in most patients. The PTFE-MOTP is an excellent short-term and mid-term option for initial RVOT reconstruction, particularly in children with TOF with nonsalvageable pulmonary valve or PA-ventricular septal defect.

Quantitative assessment of right ventricular structure and flow dynamics in pulmonary homograft obstruction.

The insertion of cryopreserved homograft conduit into the pulmonary outflow tract is an effective method of relieving severe pulmonary valve dysfunction. A certain proportion of the inserted homografts undergo late degeneration resulting in progressive right ventricular outflow obstruction. When severe, this obstruction needs repeat intervention. The timing of this intervention is critical and depends on a thorough assessment of symptoms, coupled with detailed evaluation of right ventricular structure and function as well as flow dynamics in the right ventricular outflow. We report a patient who illustrates many of the issues related to management of these patients with particular reference to the use of modern imaging followed by detailed image processing.

Surgical pulmonary valve replacement: A benchmark for outcomes comparisons

Patients with right heart obstructive lesions develop residual or recurrent right ventricle outflow tract pathology as a result of native or implanted pulmonary valve (PV) dysfunction. Until recently, the standard of care has been surgical placement of a PV or valved right ventricle to pulmonary artery conduit. Catheter-based options are being increasingly applied in patients with PV dysfunction. The purpose of our study was to evaluate outcomes of surgical pulmonary valve/conduit replacement (PVR) at a large pediatric hospital to provide contemporary benchmark data for comparison with developing technologies. Retrospective review of patients undergoing PVR not associated with complex concomitant procedures from July 1995 to December 2010 was completed. Inclusion criteria were designed to generally match those applied to patients promoted for catheter-based valve replacement based on age and weight (age≥5 years and weight≥30 kg). There were 148 PVRs with all patients having undergone ≥1 previous interventions (tetralogy of Fallot [53%] and pulmonary atresia [17%]). Surgical indications were PV insufficiency (60%), PV stenosis (26%), and both (13%). Valves used included bioprosthetic (n=108; 73%) and homografts (n=40; 27%). Time-to-extubation, intensive care unit stay, and hospital length of stay were <1 day (interquartile range, 0-1 day), 2 days (interquartile range, 1-2 days), and 5 days (interquartile range, 4-6 days), respectively, with no hospital deaths. Freedom from PV reintervention at 1, 3, and 5 years was 99%, 99%, and 94%, respectively. Multivariable analysis showed age<13 years (P=.003), and smaller valve size (P=.025) were associated with increased risk of valve reintervention. Patient survival at follow-up (mean, 5.0±3.9 years) was 99%. Surgical PVR is safe with low in-hospital and midterm follow-up mortality and reoperation rates. These outcomes provide a useful benchmark for treatment strategy comparisons.

Ten-Year Follow-Up of Carpentier-Edwards Perimount Valve in the Pulmonary Position in Adults With Corrected Tetralogy of Fallot Repair

The majority of adults with corrected Tetralogy of Fallot have significant pulmonary valve dysfunction. We sought to review our results of pulmonary valve replacement (PVR) using the Carpentier-Edwards (CE) Perimount prosthesis in this context and their effect on tricuspid regurgitation (TR).

The Ross procedure: Outcomes at 20 years

Our study examines the outcomes of the Ross procedure in a cohort of 212 patients prospectively followed with clinical and echocardiographic assessments. Patients' mean age was 34 ± 9 years; 66% were men and 82% had congenital aortic valve disease. The median follow-up was 13.8 years. Patients who had reoperations continued to be followed and entered into the survival analysis. There was 1 operative death as well as 9 late deaths (3 in patients who no longer had the Ross). Survival at 20 years was 93.6% and similar to the general population matched for age and sex. Fifteen patients required reoperations on the pulmonary autograft (4 repairs and 11 replacements), 8 on the pulmonary homograft, and 4other cardiac procedures. At 20 years the freedom from reoperation on the pulmonary autograft was 81.8% and on the pulmonary homograft was 92.7%, and in both was 79.9%. Preoperative aortic insufficiency, aortic annulus diameter ≥15 mm/m(2), and being a man were associated with increased risk of reoperation on the pulmonary autograft. Twenty-six patients developed aortic insufficiency greater than mild and 25 patients developed pulmonary homograft dysfunction (defined as moderate or severe insufficiency and/or peak systolic gradient of >40 mm Hg). At 20 years the freedom from aortic insufficiency was 62.6% and freedom from pulmonary valve dysfunction was 53.5%. Survival after the Ross procedure in this cohort was similar to the general population. Dilated aortic annulus and aortic insufficiency were associated with increased risk of developing aortic insufficiency. Pulmonary homograft dysfunction was common at 20 years.

Transcatheter pulmonary valve replacement: valves, techniques of implantation and outcomes

Transcatheter pulmonary valve replacement has changed the way we approach congenital and structural heart disease. In patients with a conduit between the right ventricle and pulmonary artery or a bioprosthetic pulmonary valve, there will eventually be pulmonary valve dysfunction. This leads to right ventricular failure and possibly arrhythmias. Due to prior operations and the comorbid conditions that these patients have, reoperation to replace the pulmonary valve is complicated and associated with greater morbidity and mortality than the initial operation. The percutaneous insertion of a stented bioprosthetic valve offers a less invasive option. The valve is inserted into the dysfunctional conduit/bioprosthetic valve via the femoral vein or internal jugular vein. Most patients are able to return home the following day without the prolonged recovery period that follows conventional open heart surgery. Both short- and long-term outcomes appear to be promising with freedom from reintervention over 90% at 1 y...

Abstract 9635: Percutaneous vs. Surgical Pulmonary Valve Implantation: How Does the Right Ventricle Fare?

Introduction. Percutaneous pulmonary valve implantation (PPVI) to non-invasively correct pulmonary valve dysfunction is a recent advancement. Cardiopulmonary bypass is known to have a negative impact on right ventricular (RV) function. This study was designed to assess RV recovery using echocardiographic parameters post surgical pulmonary graft placement versus PPVI. Methods. Retrospective study of consecutive adult patients who underwent PPVI and received graft bioprosthesis between 2007 and 2011. Echocardiographic parameters analyzed included tricuspid annular systolic excursion (TAPSE), RV tissue Doppler velocity (TDV), and myocardial performance index (MPI). Graphs of relative differences (between postoperative and preoperative values) for each parameter were constructed to compare preoperative, early (≤60 days) and late postoperative (≥6-12 months) measurements. Significance of results was determined using T-test. Results. Ten patients received PPVI and 26 underwent open heart surgery with graft insertion. Average patient age was 31±20 years. Pre-operative TDV (p=0.008), and MPI (p=0.05) were significantly higher for the surgical population than the percutaneous group. Postoperative, TDV and TAPSE were significantly lower early (p&lt;0.001) and late (p&lt;0.001) in the surgical group than preoperative measures. No significant differences were seen for the PPVI group. On comparison of relative differences in parameters between groups TDI was significantly higher both early (p&lt;0.001) and late (p&lt;0.006) postoperatively in the percutaneous group. Conclusion. RV systolic recovery as measured by TDV and TAPSE was significantly impaired post surgery but relatively unchanged post PPVI. On analysis of relative differences in RV parameters, TDI was significantly higher early and late post PPVI than open-heart surgery suggesting that surgery may impact RV function more significantly than its percutaneous counterpart.

Quadricuspid Pulmonary Valve

Quadricuspid pulmonary valve (QPV) is a rare congenital cardiac entity. The recognition of QPV has clinical significance as it can cause pulmonary valve dysfunction. It is also important to recognize this condition in patients undergoing the Ross procedure. We report a case of QPV diagnosed by computed tomography with associated pulmonary stenosis and right ventricular hypertrophy.

Acute and Chronic Effects of Dysfunction of Right Ventricular Outflow Tract Components on Right Ventricular Performance in a Porcine Model: Implications for Primary Repair of Tetralogy of Fallot

This study investigates the contribution of infundibular versus pulmonary valve (PV) dysfunction on right ventricular (RV) function in a porcine model. Clinical outcome after repair of tetralogy of Fallot is determined by the adaptation of the right ventricle to the physiological sequelae of the right ventricular outflow tract (RVOT) reconstruction. Recent surgical techniques are pursuing a PV-versus infundibulum-sparing approach. In a porcine model, 3 types of RVOT dysfunction were created and compared with sham-operated controls: infundibular dysfunction (INF), PV insufficiency (PI), and combined infundibular-PV dysfunction (TAP). Both acute and chronic effects on RV function were studied by using conductance technology and magnetic resonance imaging. In animals with PI, pulmonary regurgitant fraction progressed more in the presence of concomitant INF (54% in TAP versus 14% in PI; p = 0.03). Subsequently, RV end-systolic and end-diastolic volume increased more in both groups, resulting in decreased ejection fraction after 3 months. Preload-independent systolic indices showed acute impairment of RV contractility in all treatment groups but most in animals with infundibular scarring (INF and TAP). Further chronic deterioration was observed in animals of the TAP group. RV compliance improved proportionally most in the PI and TAP groups in relation to the extent of RV dilation. Surgical RVOT dysfunction, whether it includes the infundibulum and/or the PV, has an immediate effect on RV performance. Although impaired RV contractility is due to intrinsic myocardial damage by infundibular distortion, it is chronically furthered by PI-related RV dilation. These findings support the adoption of a RVOT-sparing strategy to treat tetralogy of Fallot.

Strain Echocardiographic Assessment of Ventricular Function after Percutaneous Pulmonary Valve Implantation

Percutaneous pulmonary valve implantation (PPVI) is an emerging therapy for pulmonary valve dysfunction. Minimal data on the midterm effects of PPVI on ventricular function exist. We describe the effects of PPVI on right and left ventricular (RV, LV) function with speckle tracking echocardiography. Patients who met the inclusion criteria of the Food and Drug Administration Phase 1 Feasibility Clinical Trial PPVI were identified. Patients were studied with echocardiograms at baseline, post-PPVI (day of discharge), 3 months, and at 6 months. Patients were studied by cardiac magnetic resonance at baseline and at 6 months. Longitudinal strain was measured at the basal, mid, and apical portions of the RV, interventricular septum (IVS), and LV. Global RV and LV strain and strain rates were recorded. Paired t-tests were used for analysis. Ten patients were analyzed: nine patients were a variant of tetralogy of Fallot and one patient had complex LV outflow obstruction requiring a Ross and RV-pulmonary atresia conduit. Mean age was 24.4 ± 7.6 years. Indication for PPVI was pulmonary regurgitation in six patients, stenosis in two patients, and stenosis/regurgitation in two patients. After PPVI, both RV systolic pressure and RV to pulmonary artery pressure gradient significantly decreased. Cardiac magnetic resonance RV end-diastolic volume significantly decreased. IVS-mid, IVS-apical, and LV-global strain significantly increased and RV-basal decreased immediately after PPVI. Global RV a' strain rate significantly increased immediately after PPVI. However, RV, IVS, and LV strain/strain rate values between baseline and the 6 month echocardiographic study were either similar or significantly decreased. Despite improvement in RV hemodynamics, there was a decrease or no improvement in RV and LV function as measured by strain echocardiographic values at midterm follow-up. Larger studies with longer follow-up are needed to determine if these results remain consistent.

Comparison between homografts and Freestyle(R) bioprosthesis for right ventricular outflow tract replacement in Ross procedures

Although data from large series indicate the satisfactory performance of bioprosthetic valves in the right ventricular outflow tract (RVOT), replacement of the pulmonary valve in adult patients undergoing the Ross procedure is usually performed with pulmonary allografts. We evaluated the outcomes of homografts vs. bioprosthetic RVOT replacement after the Ross procedure in adults. Between 1996 and 2011, a total of 186 adult patients (141 male; mean age 44 ± 10 years) underwent aortic root replacement with a pulmonary autograft. The RVOT was replaced with a homograft in 113 patients and with stentless bioprostheses (Medtronic Freestyle(®)) in 73. Patients were followed for a mean of 6 years (range 1-15 years; 1106 patient years). Twelve patients required reintervention owing to dysfunction of the RVOT replacement, which was caused by endocarditis (n = 4), degeneration (n = 2) or stricture at the proximal suture line (n = 6). For homografts, the incidence of reintervention was 1 in 150 patient years, compared with 1 in 36 patient years for stentless bioprostheses (P = 0.007). The median gradient was 15 mmHg for the homograft group and 24 mmHg for bioprosthesis (P < 0.0001). The incidence of gradients >40 mmHg was 10-fold higher in the bioprosthetic group. Patients with bioprostheses in the RVOT position after the Ross procedure showed a significantly higher risk of reintervention or pulmonary valve dysfunction. The main problem, early development of a stricture at the proximal suture line, has to be solved to achieve satisfactory bioprosthetic function in the RVOT.

Application of computational simulations for percutaneous pulmonary valve implantation: (Percutaneous pulmonary valve computer analysis)

Percutaneous pulmonary valve implantation is an innovative, successful alternative to open-heart surgery for the treatment of pulmonary valve dysfunction. However, this minimally-invasive procedure still presents some limitations: stent fracture and availability to a limited group of patients with very specific anatomy. Computational simulations, together with advanced cardiovascular imaging techniques can be used to help understand these limitations in order to improve the success of percutaneous pulmonary valve implantation and ultimately to broaden the range of patients suitable for this procedure. In this review, we show how three-dimensional image reconstruction of patients' right ventricular outflow tract, derived from magnetic resonance data, can be used to assess implantation site anatomy, and define a morphological classification to analyse the criteria for subject selection and to outline the design and mechanical requirements for the next generation of percutaneous pulmonary valve devices. We also show how the finite element method can be used to virtually model different stents (current stent and new possible stent designs) to evaluate their mechanical performance, risk of fracture, and optimise the design of the next generation device. Finite element inflation of these stents into selected right ventricular outflow tract models allowed for the evaluation of the in-situ anchoring and performance of the stents in each individual patient specific implantation site. The engineering methodologies reviewed – patient-specific three-dimensional imaging elaboration and finite element modelling – can be used to characterize right ventricular outflow tract morphology, outline the requirements for the next generation percutaneous pulmonary valve device and enable better selection of patients for this procedure, thus enhancing their safety. Such methodologies have the potential to aid and accelerate the design of future stents for percutaneous pulmonary valve implantation, so that a much larger patient population requiring pulmonary valve dysfunction treatment might benefit from this minimally-invasive intervention.

Patient-specific reconstructed anatomies and computer simulations are fundamental for selecting medical device treatment: application to a new percutaneous pulmonary valve

Nowadays, percutaneous pulmonary valve implantation is a successful alternative to surgery for patients requiring treatment of pulmonary valve dysfunction. However, owing to the wide variety of implantation site morphology, size and dynamics, only about 15 per cent of cases are suitable for current devices. In order to increase the number of patients who could benefit from minimally invasive procedures, a new valved stent graft for percutaneous implantation has been designed recently. In this study, patient-specific computational analyses have been applied to investigate the suitability of new device designs, using real data from 62 patients who had undergone surgical pulmonary valve replacement. Magnetic resonance images of these patients before surgery were elaborated using imaging post-processing software to reconstruct the three-dimensional volume of each patient's implantation site. Three stent designs were created and tested in these patient outflow tracts using finite-element simulations: stent graft SG1 resembles the first device tested in animals; stent graft SG2 is a custom device tailored for a specific patient morphology; and stent graft SG3 represents a hypothetical larger device. The three devices showed an implantation success rate of 37 per cent, 42 per cent and 63 per cent, respectively. Using patient-specific simulations, we have shown that a percutaneous approach with these new devices may be possible for many patients who are currently referred for surgery. Furthermore, when the new devices become available, the methodologies described may help clinicians in the decision-making process, by enabling virtual implantation prior to the actual procedure.

Idiopathic Pulmonary Artery Aneurysm

Pulmonary artery aneurysm (PAA) is an uncommon lesion, which may be associated with different etiologies including congenital cardiovascular diseases, systemic vasculitis, connective tissue diseases, infections, and trauma. Idiopathic PAA is sporadically diagnosed by exclusion of concomitant major pathology. We report a case of a 56-year-old female with an idiopathic pulmonary artery dilatation identified fortuitously by echocardiography and confirmed by contrast-enhanced computed tomography. Neither significant pulmonary valve dysfunction nor pulmonary hypertension and other cardiac abnormalities which might contribute to the PAA development were found. Here, we describe echocardiographic and computed tomography findings and review the literature on PAA management.