Right Coronary Cusp Research Articles

Anatomical Annulus Predictors of New Permanent Pacemaker Implantation Risk After Balloon-Expandable Transcatheter Aortic Valve Implantation

New-generation transcatheter-heart-valves (THV) have significantly improved technical success and procedural safety of transcatheter-aortic-valve-implantation (TAVI) procedures, but incidence of permanent pacemaker implantation (PPI) remains a concern.The study aimed to assess the role of anatomical annulus features in determining peri-procedural conduction disturbances leading to new-PPI following TAVI with the last generation Edwards Sapien balloon-expandable valves (BEV). In the context of a prospective single-center registry, we integrated clinical and procedural predictors of PPI with anatomical data derived from multi-slice-computed-tomography (MSCT). A total of 210 consecutive patients treated with balloon expandable Edwards THV were included in the study from 2015 to 2023. Technical success was achieved in 197 (93.8%) procedures, and 26 patients (12.4%) required new-PPI at 30-day follow-up (median time-to-implantation 3 days). At the univariable logistic-regression analysis, pre-procedural right bundle branch block (RBBB; OR:2.24 [95%CI:1.01-4.97], p=0.047), annulus eccentricity ≥0.25 (OR:5.43 [95%CI:2.21-13.36], p<0.001), calcium volume at annulus of the right coronary cusp (RCC) >48 mm3 (OR:2.60 [95%CI:1.13-5.96], p=0.024) and prosthesis implantation depth greater than membranous septum length (OR:2.17 [95%CI: 1.10-4.28], p=0.026) were associated with new-PPI risk. At multivariable analysis pre-procedural RBBB (OR:2.81 [95%CI:1.01-7.85], p=0.049), annulus eccentricity ≥0.25 (OR:4.14 [95%CI:1.85-9.27], p<0.001), and annulusRCC calcium >48 mm3 (OR:2.89 [95%CI:1.07-7.82], p=0.037) were confirmed as independent predictors of new-PPI. In conclusion, specific anatomical features of the aortic valve annulus might have an additive role in determining the occurrence of conduction disturbances in patients undergoing TAVI with BEV. This suggests the possibility to use the MSCT to improve the prediction of post-TAVI new-PPI risk.

Automatic and interpretable prediction of the site of origin in outflow tract ventricular arrhythmias: machine learning integrating electrocardiograms and clinical data.

The treatment of outflow tract ventricular arrhythmias (OTVA) through radiofrequency ablation requires the precise identification of the site of origin (SOO). Pinpointing the SOO enhances the likelihood of a successful procedure, reducing intervention times and recurrence rates. Current clinical methods to identify the SOO are based on qualitative analysis of pre-operative electrocardiograms (ECG), heavily relying on physician's expertise. Although computational models and machine learning (ML) approaches have been proposed to assist OTVA procedures, they either consume substantial time, lack interpretability or do not use clinical information. Here, we propose an alternative strategy for automatically predicting the ventricular origin of OTVA patients using ML. Our objective was to classify ventricular (left/right) origin in the outflow tracts (LVOT and RVOT, respectively), integrating ECG and clinical data from each patient. Extending beyond differentiating ventricle origin, we explored specific SOO characterization. Utilizing four databases, we also trained supervised learning models on the QRS complexes of the ECGs, clinical data, and their combinations. The best model achieved an accuracy of 89%, highlighting the significance of precordial leads V1-V4, especially in the R/S transition and initiation of the QRS complex in V2. Unsupervised analysis revealed that some origins tended to group closer than others, e.g., right coronary cusp (RCC) with a less sparse group than the aortic cusp origins, suggesting identifiable patterns for specific SOOs.

Transcatheter Aortic Valve-in-Valve Implantation within a Radiolucent Stentless Valve

An 84-year-old man with a Shelhigh Super Stentless valve presented for valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR). Given the lack of radiopaque markers and the presence of a non-coronary cusp (NCC) pseudoaneurysm, implant depth was guided by root aortography at the time of balloon aortic valvuloplasty (BAV) using a pigtail in the right coronary cusp (RCC).

Regional assessment of aortic valve calcification using topographic maps in contrast-enhanced CT: in-vivo sex and severity-based differences in calcific presentation.

Procedural planning for transcatheter aortic valve replacement (TAVR) is routinely performed using contrast computed tomography (CT) in patients with severe aortic stenosis (AS). Despite its potential, little investigation has been done into the possibility of aortic valve calcification (AVC) scoring in contrast-enhanced CT. Contrast CT has superior spatial and contrast resolution compared to the non-contrast Agatston score protocol, which would allow for development of better pattern and distribution descriptors of calcific lesions in the aortic valve (AV). We developed a new false positive rate (FPR) based method that can quantify leaflet calcification based on shape overlap metrics. We also introduce a novel regional scheme for quantifying the shape and structure of calcification using topographic maps. The study was designed to: (I) determine the feasibility of using a novel method based on FPR to detect AVC using contrast-enhanced CT images by assessing the volume scores measured using FPR versus non-contrast methods and alternative contrast methods for volume scoring based on fixed or dynamic HU thresholds. (II) Develop a new scheme for assessing calcific geometry and structure and evaluate patterns of calcification in the varied presentation of AS. Our results show a very strong correlation with non-contrast volume (r=0.919, P<0.001; n=178) and Agatston scores (r=0.913, P<0.001; n=178) that were evaluated using a standard calcium scoring technique. Finally, we analyzed the differences and similarities in the patterns of calcific deposition with respect to sex and degree of severity. The FPR method demonstrates the best overall agreement with non-contrast scores across both low and high ends of calcific density compared to luminal attenuation methods. In addition, we showed that leaflet calcific deposition follows distinctive patterns across the belly of the leaflet, with the rate of calcific progression peaking at the non-coronary cusp (NCC) leaflet and lowest for the right-coronary cusp. Females experience significantly lower calcific deposition compared to males despite showing similar patterns and symptoms. Our findings suggest that precise regional assessment of calcific progression could be an important tool for monitoring AS development as well as predicting peri-procedural complications in TAVR.

Ruptured sinus of Valsalva aneurysm coexisted with congenital ventricular septal defect: a case series

BackgroundRuptured sinus of Valsalva aneurysm (RSoVA) is an uncommon cardiac anomaly that may occasionally coexist with additional congenital heart disease (CHD). The presence of such congenital cardiac anomalies, frequently involving a ventricular septal defect (VSD), is of significant clinical importance and warrants vigilant detection during echocardiographic assessments to prevent oversight.Case presentationThree cases of RSoVA accompanied by VSD are presented in which all patients manifested symptoms of shortness of breath (SOB). In the first patient, right and left heart catheterization was undertaken; however, the images failed to reveal any evidence of VSD flow due to the occlusion of a small VSD by the prolapsed right coronary cusp (RCC). Prior to surgical intervention, multimodal imaging was conducted, revealing the presence of RSoVA extending into the right ventricle (RV) along with the VSD. The second patient had a prior childhood diagnosis of VSD but had not undergone further medical intervention. Transoesophageal echocardiography (TEE) was subsequently performed, identifying the presence of RSoVA, a small VSD, and valvular heart disease. The third patient presented with heart failure, exacerbated during her second pregnancy. TEE was also administered to this patient, revealing the presence of RSoVA accompanied by a small subaortic VSD with a left-to-right shunt. All three patients were scheduled for surgical repair of the ruptured sinus of Valsalva and closure of the VSD.ConclusionsThe coexistence of RSoVA and CHD, typically VSD, is frequently observed in patients experiencing symptoms of SOB. Recognizing the presence of CHD in individuals with RSoVA is of paramount importance, as it can significantly influence their medical management and treatment strategies.

Lead I R-wave indexes: A novel electrocardiographic criterion for distinguishing the origin of idiopathic premature ventricular contractions from the three subregions of the aortic sinus cusps

PurposeThe current study was conducted to investigate the electrocardiographic (ECG) characteristics of idiopathic premature ventricular contractions (PVCs) originating from the aortic sinus cusp (ASC) and establish a novel ECG criterion to discriminate PVCs originating from the right coronary cusp (RCC), left coronary cusp (LCC), and the left and right coronary cusp junction (LRJ). MethodsA retrospective analysis was performed on a total of 133 patients with idiopathic PVCs who underwent successful mapping and ablation. The sites of origin (SOO) were confirmed using fluoroscopy and a three-dimensional mapping system during radiofrequency catheter ablation (RFCA). Among the patients, 69 had PVCs originating from the LCC, 39 from the RCC, and 25 from the LRJ. Characteristics of surface 12‑lead electrocardiograms (ECGs) recorded during PVCs were analyzed. Q-, R-, S, and R'-wave amplitudes were measured in lead I, and the lead I R-wave indexes (IRa, IRb, IRc, IRd, and IRe) were derived by employing multiplication, subtraction, sum, and division operations on these ECG measurements. Notably, IRb and IRe demonstrated usefulness as ECG indexes for discriminating PVCs originating from RCC, LCC, and LRJ in the ASC. ResultsThe R- and S-wave amplitudes in lead I exhibited statistically significant differences among the three groups (P < 0.001 and P < 0.001, respectively). In discriminating PVCs originating from the RCC from the other two groups, IRb showed the largest area under the curve (AUC) of 0.813, as assessed by receiver operating characteristic (ROC) analysis, with a cutoff value of ≤0.5 indicating PVCs of RCC origin. The sensitivity and specificity were 80.3% and 78.7%, respectively. For discriminating PVCs arising from the LCC from those in the LRJ group, IRe exhibited the largest AUC of 0.801, with an optimal cutoff value of 0. An IRe value >0 indicated PVCs originating from the LRJ, while an IRe value ≤0 indicated PVCs originating from the LCC. The sensitivity and specificity of the IRe index were 84.0% and 70.7%, respectively. ConclusionLead I R-wave indexes provided simple and useful ECG criteria for discriminating PVCs originating from the LCC, RCC, and LRJ in the left ventricular outflow tract (LVOT).

Biomechanics and clinical outcomes of various conduit configurations in valve sparing aortic root replacement.

Several conduit configurations, such as straight graft (SG), Valsalva graft (VG), anticommissural plication (ACP), and the Stanford modification (SMOD) technique, have been described for the valve-sparing aortic root replacement (VSARR) procedure. Prior ex vivo studies have evaluated the impact of conduit configurations on root biomechanics, but the mock coronary artery circuits used could not replicate the physical properties of native coronary arteries. Moreover, the individual leaflet's biomechanics, including the fluttering phenomenon, were unclear. Porcine aortic roots with coronary arteries were explanted (n=5) and underwent VSARR using SG, VG, ACP, and SMOD for evaluation in an ex vivo left heart flow loop simulator. Additionally, 762 patients who underwent VSARR from 1993 through 2022 at our center were retrospectively reviewed. Analysis of variance was performed to evaluate differences between different conduit configurations, with post hoc Tukey's correction for pairwise testing. SG demonstrated lower rapid leaflet opening velocity compared with VG (P=0.001) and SMOD (P=0.045) in the left coronary cusp (LCC), lower rapid leaflet closing velocity compared with VG (P=0.04) in the right coronary cusp (RCC), and lower relative opening force compared with ACP (P=0.04) in the RCC. The flutter frequency was lower in baseline compared with VG (P=0.02) and in VG compared with ACP (P=0.03) in the LCC. Left coronary artery mean flow was higher in SG compared with SMOD (P=0.02) and ACP (P=0.05). Clinically, operations using SG compared with sinus-containing graft was associated with shorter aortic cross-clamp and cardiopulmonary bypass time (P<0.001, <0.001). SG demonstrated hemodynamics and biomechanics most closely recapitulating those from the native root with significantly shorter intraoperative times compared with repair using sinus-containing graft. Future in vivo validation studies as well as correlation with comprehensive, comparative clinical study outcomes may provide additional invaluable insights regarding strategies to further enhance repair durability.

Baseline CT-Based Risk Factors for Atrioventricular Block after Surgical AVR

We aimed to evaluate the impact of membranous interventricular septum (MIS) length and calcifications of the native aortic valve (AV), via preoperative multidetector computed tomography (MDCT) scan, on postoperative atrioventricular block III (AVB/AVB III) and permanent pacemaker implantation in surgical aortic valve replacement (SAVR). We retrospectively analyzed preoperative contrast-enhanced MDCT scans and procedural outcomes of patients affected by AV stenosis who underwent SAVR at our center (June 2016-December 2019). The study population was divided into two groups (AVB and non-AVB), and variables were compared with a Mann-Whitney's U-test or chi-square test. Data were further analyzed using point biserial correlation and logistic regression. A total of 155 (38% female) patients (mean age of 71.2 ± 6 years) were enrolled in our study: conventional stented bioprosthesis (N = 99) and sutureless prosthesis (N = 56) were implanted. A postoperative AVB III was observed in 11 patients (7.1%). AVB patients had significant greater calcifications in left coronary cusp (LCC) -AV (non-AVB = 181.0 mm3 [82.7-316.9] vs. AVB = 424.8 mm3 [115.9-563.2], p = 0.044), LCC left ventricular outflow tract (LVOT) (non-AVB = 2.1 mm3 [0-20.1] vs. AVB = 26.0 mm3 [0.1-138.0], p = 0.048), right coronary cusp (RCC) -LVOT (non-AVB = 0 mm3 [0-3.5] vs. AVB = 2.8 mm3 [0-29.0], p = 0.039), and consequently in total LVOT (non-AVB = 2.1 mm3 [0-20.1] vs. AVB = 26.0 mm3 [0.1-138.0], p = 0.02), while their MIS was significantly shorter than in non-AVB patients (non-AVB = 11.3 mm [9.9-13.4] vs. AVB = 9.44 mm [6.98-10.5]; p=0.014)). Partially, these group differences correlated positively (LCC -AV, r = 0.201, p = 0.012; RCC -LVOT, r = 0.283, p ≤ 0.001) or negatively (MIS length, r = -0.202, p = 0.008) with new-onset AVB III. We recommend including an MDCT in preoperative diagnostic testing for all patients undergoing surgical AVR for further risk stratification.

Papillary fibroelastoma of the aortic valve: occlusion of the left main coronary artery.

A 53-year-old woman with palpitations and respiratory distress as her main symptoms, which had resulted in a cardiac arrest, was referred to the emergency room. Coronary angiography (CAG) with percutaneous cardiopulmonary support (PCPS) was performed, but no severe stenosis was found. The patient was diagnosed with vasospastic angina, treated medically, and discharged to her home. Six months later, however, during hospitalization for sick sinus syndrome, she suddenly developed runs of ventricular tachycardia. Therefore, CAG with PCPS was again carried out and revealed an occlusion of the left main trunk (LMT) of the coronary artery (Panel A, arrow). Intravascular ultrasound imaging was also performed (Panel B), and a plausible thrombus formation associated with coronary spasm was diagnosed. An emergency surgical intervention was therefore carried out. Intraoperative transoesophageal echocardiography imaging showed both a large mass at the aortic valve that may have occluded the LMT (Panel C, Supplementary data online, Video S1), and a previously undiagnosed severe aortic valve regurgitation caused by the mass. Aortic cross-clamping and a cardiac arrest were conducted; a huge mass originating from the right coronary cusp (RCC) of the valve was found (Panels D and E, arrowheads) and resected. No thrombus formation in the coronary artery was observed. Post-operatively, the patient's angina resolved without any sign of aortic regurgitation. The pathology report revealed a papillary fibroelastoma (PFE). This series of symptoms was caused by embolization within the coronary artery and the presence of a huge PFE, which together caused this rare condition.

Pacing maneuvers from the aortic cusps: A useful technique during ablation of focal arrhythmias arising from the aortic root.

The ablation of arrhythmias arising near the His-bundle region in the non-coronary aortic cusp (NCAC) is challenging. Among the aortic sinuses of Valsalva, the NCAC is located between the right atrium and the left atrium. For this reason, pacing from the NCAC should result in atrial capture while pacing from the right and left coronary cusps (LCC) may result in ventricular capture. The objective of this study is to prove that atrial capture during pacing from the sinuses of Valsalva may be used to confirm a correct position in the non-coronary cusp. A total of 30 patients with structurally normal heart undergoing left sided ablation procedures, underwent electrophysiological study of the aortic cusps. Each of the aortic valve cusps was paced with increasing outputs and analyzed offline to determine their unique electrocardiographic characteristics. In the NCAC, we obtained an atrial capture in 29 out of 30 patients (96.6%). The atrial capture was highly specific for a position in the NCAC (p<.001). The median output required to capture from the cusp was 10mA (range 5-25mA) at a pulse width of 2ms. In the right coronary cusp (RCC) and LCC, we obtained ventricular capture in all patients (100%). The median output required to capture from the cusp was 10mA (range 10-25mA) in RCC and 25mA (range 10-25mA) in LCC at a pulse width of 2ms. Atrial capture during a pacemapping from the aortic cusps can be considered proof of a correct position in NCAC.

Usefulness of the synthesized 18-lead ECG in premature ventricular contractions from near the HIS bundle.

Isolated premature ventricular complexes (PVCs) are the most common arrhythmias observed in patients even if without structural heart disease.1 Although most PVCs originate from the right ventricular outflow tract (RVOT), there are some PVCs that originate near the HIS bundle.2 The synthesized 18-lead ECG consists of right-sided thoracic (V3R, V4R, V5R) and dorsal (V7, V8, V9) ECG leads derived from a mathematical calculation of the 12-lead ECG, and the detailed mathematical formula is shown in Figure 1. The synthesized 18-lead ECG has been reported to be effective for PVCs of an RVOT origin, but the rest remains to be elucidated.3 The aim of this study was to investigate the characteristics of the synthesized 18-lead ECG in patients with PVCs originating from near the HIS bundle. The synthesized 18-lead ECGs of 13 consecutive patients who underwent radiofrequency catheter ablation (RFCA) of idiopathic PVCs from near the HIS bundle at the Japan Community Healthcare Organization Osaka Hospital, Osaka General Medical Center, and Nara Prefectural Seiwa Medical Center from January 2018 to December 2020 were included in this retrospective analysis. The origin of the PVCs was identified by a cardiologist using a 3D mapping system (CARTO 3: Biosense Webster Inc or EnSite: Abbott Medical Inc). We analyzed the QRS morphology pattern of the synthesized 18-lead ECG analyzed in those patients. This study was approved by the Ethics Committee of each hospital in accordance with the Declaration of Helsinki. The synthesized 18-lead ECG and ECG characteristics in 13 patients with PVCs from near the HIS bundle are shown in Figure 2 and Table 1. The mean QRS duration of the ECG was 142.5 ± 26.9 ms. In 12 of 13 patients, a left bundle branch block pattern (92.3%) was present, and 11 of 13 patients had inferior axis deviation (84.6%). Regarding the right-sided chest leads of the synthesized 18-lead ECG, in all patients, a QS pattern in lead V5R (100%) was observed, and in 12 of 13 patients, a QS pattern in leads V3R, V4R, and V5R (92.3%) was present. A comparison showed that the synthesized ECGs recorded during sinus rhythm and during PVCs were not consistent, as shown in Table 2. Several studies have shown that identifying PVCs originating from the vicinity of the ventricular septum remains complicated,4 and it is difficult to identify the origin of PVCs originating from near the HIS bundle based on the characteristics of the 12-lead ECG. Noteworthy among our results was that there was a QS pattern in lead V5R in 100.0%. Igarashi et al reported that in the synthesized 18-lead ECG recorded by pace mapping in the outflow tract, a QS pattern in lead V5R was observed in about 80% at the right coronary cusp (RCC), about 20% in the posterior RVOT, and nothing at the other sites.3 Combining the above study3 with our results, a QS pattern in lead V5R might have been specific to PVCs originating from near the HIS bundle and RCC. QRS morphology changes after RFCA are often observed in patients with idiopathic PVCs.5 In such cases, the use of the synthesized 18-lead ECG's right-sided chest leads may assist in the re-mapping process. Regarding the mechanism of the QS pattern in lead V5R, in general the HIS bundle is anatomically closer to the RCC, and electrical conduction may propagate with a vector away from the right-sided chest leads such as lead V5R. Based on the characteristics of the ECG, only case 7 was considered to have a PVC from the HIS bundle. An identification of PVCs originating from near the HIS bundle or from the HIS bundle was attempted based on the characteristics of the synthesized ECG, but was not possible due to an insufficient number of cases. Although a 3D mapping system was used in this study, the distance between the HIS bundle and the ablation site was not measured, and it was considered necessary to include the distance in future studies. A QS pattern recorded in lead V5R of the synthesized 18-lead ECG was characteristic of PVCs originating from near the HIS bundle. This observation might assist in identifying the origin of PVCs during RFCA. H Kida, R Nakanishi, and N Ogasawara participated in the design of the study and coordination and helped draft the manuscript. All authors read and approved the final manuscript. We would like to express our gratitude to Mr. John Martin for his linguistic revision of the manuscript. All authors declare no conflicts of interest associated with this manuscript. This study was approved by the Ethics Committee of Japan Community Healthcare Organization Osaka Hospital, Osaka General Medical Center, and Nara Prefectural Seiwa Medical Center in accordance with the Declaration of Helsinki. Since this study was a retrospective study, we used the opt-out system according to the ethics guidelines on human medical research by the Japanese government.

A Bayesian constitutive model selection framework for biaxial mechanical testing of planar soft tissues: Application to porcine aortic valves

A variety of constitutive models have been developed for soft tissue mechanics. However, there is no established criterion to select a suitable model for a specific application. Although the model that best fits the experimental data can be deemed the most suitable model, this practice often can be insufficient given the inter-sample variability of experimental observations. Herein, we present a Bayesian approach to calculate the relative probabilities of constitutive models based on biaxial mechanical testing of tissue samples. Forty-six samples of porcine aortic valve tissue were tested using a biaxial stretching setup. For each sample, seven ratios of stresses along and perpendicular to the fiber direction were applied. The probabilities of eight invariant-based constitutive models were calculated based on the experimental data using the proposed model selection framework. The calculated probabilities showed that, out of the considered models and based on the information available through the utilized experimental dataset, the May–Newman model was the most probable model for the porcine aortic valve data. When the samples were further grouped into different cusp types, the May–Newman model remained the most probable for the left- and right-coronary cusps, whereas for non-coronary cusps two models were found to be equally probable: the Lee–Sacks model and the May–Newman model. This difference between cusp types was found to be associated with the first principal component analysis (PCA) mode, where this mode’s amplitudes of the non-coronary and right-coronary cusps were found to be significantly different. Our results show that a PCA-based statistical model can capture significant variations in the mechanical properties of soft tissues. The presented framework is applicable to other tissue types, and has the potential to provide a structured and rational way of making simulations population-based.

ECHO ROUND: THREE DIMENSIONAL TRIMMING, THE FREE ANGLE ALTERNATIVE FOR MITRAL AND AORTIC VALVE VITIUM ASSESSMENT.

Three-dimensional (3D) Technology provides real time dynamic assessment and allows for multiplanar reconstruction (MPR) for the different cardiac structures. However, it is much more demanding regarding the Echo device specification, and operator experience in both loop acquisition, enhancement and of course interpretation. Trimming function is one of the post-acquisition software tools, which can be used in step-by-step assessment of the Mitral valve (MV) and aortic valve (AV) vitrium. It didn't overcome the required experience required for the interpretation of 3D images. But when systematically done, it makes it more objective and allows for assessment of the coaptation line along the valve leaflets, even in cases where it is impossible to assess in 2D as between non-coronary and left coronary AV cusps. The loops in this poster were acquired with the Philips Affinity 70 and the X7-2T transoesophageal matrix array transducer. The basic requirement of the 3D loop acquisition is guided by the published recommendation as it is and when possible multibeat acquisition is used.1. In MV Our examination started in Midesophageal Intercommisural View with 3D Zoom function. We rotated the acquired loop to obtain the surgical view of the MV with the Aorta at 12 O'clock (Figure 1, Step 1). At this point we rotated the aorta to be positioned at 9 O'clock. (Figure 1 Step 2). Then, using the track ball, we rotated the 3D picture 90 degrees in the vertical axis to be facing the lateral annulus of the MV (Figure 1, Step 3) . Starting from this view, using the face Trimming function (figure 1 Step 4) we have adjusted the trimming level going deeper all through the MV from lateral to medial, examining the coaptation line all through all parts of the leaflets. What also helped to delineate the leaflets was to add more gain (in controversy to what is normally done to improve the 3D Image). For orientation, we recommend rotating the 3D loop back to surgical view to localize the trimming level. Color Flow Examination normally requires a multibeat acquisition to get a reasonable frame rate. We also trimmed from lateral to medial till we could see the Regurgitation Jet. (Figure 3) For AV we started with the Midesophageral AV short axis view and using loop was acquired using the 3D zoom function (Figure 4). Using the same technique we have adjusted the trimming line to go through the coaptation line needed to be examined between Non coronary cusp (NCC) – Right coronary cusp (RCC), RCC- Left coronary cusp (LCC) and NCC-LCC . (figure 5) .In each level we used the track ball to rotate the 3D image to get an inface view where we could see the coaptation. We could also measure coaptation height, coaptation length and identify single leaflet pathology. <b>Conclusion:</b> In contrast to 2D images the Trimming function allows a free angle generation of 2D images for angles difficult or sometimes impossible to be obtained with normal 2D cutting or even biplane.

Abstract 10744: Predictive Value of Calcium Volume Measurement Determined by Computed Tomography for Paravalvular Leakage After Transcatheter Aortic Valve Implantation

Background: Paravalvular leakage (PVL) is a frequent complication after transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS), and is related to adverse prognosis. We aimed to investigate whether aortic valve calcium volume (Ca-Vol) measured by preoperative cardiac computed tomography (CT) had a predictive value for PVL. Methods and Results: We analyzed consecutive 43 patients underwent TAVI using third-generation self-expandable valve (Evolut PRO ®︎ ) for severe AS with tricuspid valve. Among 43 patients, PVL was detected in 8 cases (18.6%) after TAVI. PVL was defined as moderate or severe regurgitation determined by transthoracic echocardiography. We analyzed preoperative cardiac CT (Fig 1), and measured total Ca-Vol in aortic valve and Ca-Vol in each cusp (non-coronary cusp [NCC], right-coronary cusp [RCC], and left-coronary cusp [LCC]). The threshold of CT value for calcium structure was determined at 500 Hounsfield Units as previously reported. Total Ca-Vol was significantly higher in the PVL group than in the non-PVL group (3.9 ± 2.8 vs. 2.1 ± 1.0 ml, P = 0.004). Ca-Vols in each cusp were also significantly higher in the PVL group than in the non-PVL group (NCC, 1.5 ± 1.0 vs. 0.8 ± 0.4 ml, P = 0.004; RCC, 1.2 ± 1.1 vs. 0.6 ± 0.3 ml, P = 0.007; and LCC, 1.1 ± 0.8 vs. 0.7 ± 0.4 ml, P = 0.021). Univariate logistic regression analysis for PVL indicated that total Ca-Vol and NCC Ca-Vol were predictors for PVL (total Ca-Vol, OR 2.0, 95% CI 1.0-4.1, P = 0.042; NCC Ca-Vol, OR 5.1, 95% CI 1.2-22.2, P = 0.031). By the receiver operating characteristic curve analysis of Ca-Vol for prediction of PVL, the optimal cut off values were 2.3 ml of total Ca-Vol and 0.8 ml of NCC Ca-Vol (Fig 2; AUC = 0.75 and 0.78, sensitivity 0.75 and 0.88, specificity 0.63 and 0.54, respectively). Conclusion: Total Ca-Vol and NCC Ca-Vol were significant predictors for PVL after TAVI. Ca-Vol can be measured routinely with preoperative CT and might be useful in predicting PVL.

A Four-Stepwise Electrocardiographic Algorithm for Differentiation of Ventricular Arrhythmias Originated from Left Ventricular Outflow Tract.

Several electrocardiographic algorithms have been proposed to identify the site of origin for the ventricular arrhythmias (VAs) from the left ventricular outflow tract (LVOT) versus right ventricular outflow tract. However, the electrocardiographic criteria for distinguishing VAs originated from the different sites of LVOT is lacking. We aimed to develop a simple and efficient ECG algorithm to differentiate LVOT VAs originated from the aortic root, AMC and LV summit. We analyzed 12-lead ECG characteristics of 68 consecutive patients who underwent successful radiofrequency catheter ablation of symptomatic VAs from LVOT. Patients were divided into RCC (right coronary cusp) group (n = 8), the L-RCC (the junction between the LCC and RCC) group (n = 21), the LCC (left coronary cusp) group (n = 24), the aortomitral continuity (AMC) group (n = 9) and the LV summit group (n = 6) according to the final ablation sites. Measurements with the highest diagnostic performance were modeled into a 4-stepwise algorithm to discriminate LVOT VAs. The performance of this novel algorithm was prospectively tested in a validation cohort of 43 consecutive patients undergoing LVOT VAs ablation. Based on the accuracy of AUC, a 4-stepwise ECG algorithm was developed. First, the QS duration in aVL &gt; 134 ms was used to distinguish VAs from AMC, LV summit and VAs from aortic root (80% sensitivity and 76% specificity). Second, the R duration in II &gt; 155 ms was used to differentiate VAs from LV summit and VAs from AMC (67% sensitivity and 56% specificity). Third, the ratio of III/II &lt; 0.9 was used to discriminate VAs from RCC and VAs from LCC, L-RCC (82% sensitivity and 63% specificity). Fourth, the QS duration of aVR &gt; 130 ms was used to discern VAs from LCC and VAs from L-RCC (75% sensitivity and 62% specificity). In the prospective evaluation, our 4-stepwise ECG algorithm exhibited a good predictive value. We have developed a novel and simple 4-stepwise ECG algorithm with good predictive value to discriminate the AVs from different sites of LVOT.

Terminal end of retro-aortic root branch: An unrecognized origin for "proximal left anterior fascicle" premature ventricular complexes with narrow QRS duration.

Premature ventricular complexes (PVCs) with narrow QRS duration, inferior frontal plane QRS axis, and right bundle branch block (RBBB) pattern generally originate from the proximal segment of the left anterior fascicle (LAF). The purpose of this study was to investigate the exact origin of this category of PVCs. Twenty-two patients with assumed proximal LAF-PVCs were enrolled in the study. Detailed mapping of fascicular potentials (FPs) was performed during sinus rhythm (SR) and PVCs. During SR, a cluster of FPs could be found at the most superior portion of the left ventricle (LV). These FPs represented the terminal end of a discrete branch of the left fascicular system, which we named the "retro-aortic root branch" (RARB). The shortest distance between the proximal LAF and the terminal end of the RARB was 13.5 ± 4.2 mm. The earliest activation site (EAS) of PVCs in all patients were confirmed at the terminal end of the RARB, where the FP-V interval was 35.1 ± 4.3 ms during PVCs. The shortest distance from the right coronary cusp (RCC) to the EAS was 5.3 ± 3.5 mm. PVCs could be eliminated by ablation from the RCC in 45.5% (10/22) cases, in the remaining cases, ablation at the EAS in the LV endocardium successfully abolished PVCs. The terminal end of the retro-aortic root branch was the actual origin site for PVCs with inferior frontal plane axis, RBBB pattern and narrow QRS duration. Ablation in the RCC or at the EAS in the LV could both eliminate PVCs safely with high efficacy.

Aortic Valve Repair Following Ventriculo-septal Defect (VSD) and Severe Aortic Regurgitation: Surgical Techniques, Complications and Follow up Events

Background: Aortic regurgitation (AR) is a common sequel resulting from prolapsed of right coronary cusp (RCC), non-coronary cusp (NCC) or both, in the repair of ventricular septal defects (VSD). Objectives: The purpose of presenting these cases is to highlight the fact that aortic valve repair does not only end in addressing the cusp as this will result in moderate aortic regurgitation after surgery. Results: Our first case is a two and half year old male with alarge peri-membranous VSD with RCC prolapse causing co-optation failure and severe AR .The second case is a 12 year old male a large peri-membranous ventriculo-septal defect with RCC prolapsed with severe AR .The third case is a 12 year old female with a large peri-membranous VSD with a significant right coronary cusp prolapsed, severe aortic regurgitation due to non-cooptation of RCC with the remaining cusps with flow reversal in the descending aorta. The last case is a four year, 6-month-old male with a large peri-membranous VSD and severe AR from NCC and RCC prolapse. All had repair of aortic valve with mild regurgitation after several follow up. Conclusion: Aortic valve repair resulting from prolapse of RCC and NCC in children with VSD is expedient as it reduces morbidity and mortality post-operation.

Dos and don'ts in large animal models of aortic insufficiency

Aortic insufficiency caused by paravalvular leakage (PVL) is one of the most feared complications following transcatheter aortic valve replacement (TAVI) in patients. Domestic pigs (Sus scrofa domestica) are a popular large animal model to study such conditions and develop novel diagnostic and therapeutic techniques. However, the models based on prosthetic valve implantation are time intensive, costly, and often hamper further hemodynamic measurements such as PV loop and 4D MRI flow by causing implantation-related wall motion abnormalities and degradation of MR image quality. This study describes in detail, the establishment of a minimally invasive porcine model suitable to study the effects of mild-to-moderate “paravalvular“ aortic regurgitation on left ventricular (LV) performance and blood flow patterns, particularly under the influence of altered afterload, preload, inotropic state, and heart rate. Six domestic pigs (Swiss large white, female, 60–70 kg of body weight) were used to establish this model. The defects on the hinge point of aortic leaflets and annulus were created percutaneously by the pierce-and-dilate technique either in the right coronary cusp (RCC) or in the non-coronary cusp (NCC). The hemodynamic changes as well as LV performance were recorded by PV loop measurements, while blood flow patterns were assessed by 4D MRI. LV performance was additionally challenged by pharmaceutically altering cardiac inotropy, chronotropy, and afterload. The presented work aims to elaborate the dos and don'ts in porcine models of aortic insufficiency and intends to steepen the learning curve for researchers planning to use this or similar models by giving valuable insights ranging from animal selection to vascular access choices, placement of PV Loop catheter, improvement of PV loop data acquisition and post-processing and finally the induction of paravalvular regurgitation of the aortic valve by a standardized and reproducible balloon induced defect in a precisely targeted region of the aortic valve.

Determination of Optimal Fluoroscopic Angulations for Left Main Coronary Artery Ostial Interventions: 3-Dimensional Computed Tomography Validation.

Background Current recommendations for the best views for the left main coronary artery (LMCA) ostium intervention are empirical. Objectives To determine the optimal projection to visualize the LMCA ostium using only fluoroscopy. Methods The optimal projection to visualize the LMCA ostium was determined using fluoroscopic images of superimposing the lowest points of the distal ends of two J tipped wires in the noncoronary cusp (NCC) and right coronary cusp (RCC). This was validated independently using 3-dimensional computed tomography (3D-CT) reconstruction. Results Satisfactory images of the overlapping wires in NCC and RCC could be obtained in 90% (45/50). Between the fluoroscopic and the 3D-CT reconstruction approaches, the mean difference for NCC and RCC overlapping at horizontal axes is -1.8 with a 95% limit of agreement between −3.94 and 0.34 (p=0.10) and at vertical axes −1.6 with a 95% limit of agreement between −3.46 and 0.26 (p=0.09); and the mean difference for the optimal projection to visualize the LMCA ostium at horizontal axes is −3.22 with a 95% limit of agreement between -7.26 and 0.81 (p=0.11) and at vertical axes −2.31 with a 95% limit of agreement between −5.83 and 1.21 (p=0.09). The 3D angulation deviation for the optimal projection to visualize the LMCA ostium was 8.5° ± 4.7° when the LMCA ostium faced the NCC-RCC commissure (n = 32) and 22.3° ± 16.0° (p=0.009) when it did not (n = 13). Conclusions The optimal projection for LMCA ostial intervention can be determined using fluoroscopic images of superimposing wires in the NCC and RCC when the LMCA ostium faces the NCC-RCC commissure, as was the case in 71% of the patients studied.

Experimental Findings and Clinical-Pathologic Correlation of Radiofrequency Catheter Ablation at the Left Ventricle Para-Hisian Region.

BackgroundCatheter ablation target at the site with large His activation in the left ventricle poses a high risk of atrioventricular (AV) block. We aimed to identify far-field (FF) and near-field (NF) His activation at left upper septum (LUS).MethodsThree-D mapping of the aortic root and left ventricle was performed in 12 dogs. Two sites located at either the base or apex of the triangle interposed between the hinges of the the noncornary coronary cusp (NCC) - right coronary cusp (RCC) were chosen for a single radiofrequency (RF) application. Bipolar and unipolar pacing with different outputs at both sites was attempted to discern NF and FF His activation.ResultsThe sites chosen for NF and FF ablation were located at the base and apex of the triangle, which were 8.03 ± 1.18 mm (group 1) and 3.42 ± 0.61 mm (group 2) away from the RCC-NCC junction. Lower A/V ratios were found in group 1. Pacing could not differentiate NF from FF His activation. In group 1, ablation resulted in III degree AV block in all 6 dogs, whereas neither PR prolongation nor AV block occurred in group 2. Pathologic examination of group 1 showed complete/partial necrosis of the His bundle (HB) and left bundle branch in all 6 dogs. In group 2, no necrosis of the HB was seen in the 6/6 dogs.ConclusionAnatomical localization in the triangle of RCC-NCC junction can help differentiate NF from FF His activation.