Valve Annulus Research Articles

Echocardiogram-Guided Balloon Valvuloplasty of the Aortic Valve in Neonates and Infants Reduces Contrast Exposure with Maintained Efficacy and Less Aortic Regurgitation.

Balloon aortic valvuloplasty (BAV) is performed in children with significant aortic stenosis (AS). Traditionally, contrast angiography measures the annulus and assesses aortic regurgitation (AR) after each dilation. Echocardiographic guidance is hypothesized to reduce contrast and radiation exposure, without compromising efficacy or safety. Patients < 10kg undergoing BAV from 2013 to 2022 were retrospectively investigated. Agreement between echocardiographic and angiographic annulus measurements was assessed. Echocardiogram-guided (eBAV) and traditional angiogram-guided (tBAV) outcomes were compared controlling for weight, critical AS, and other congenital heart disease (CHD). Twelve eBAV and 19 tBAV procedures were performed. The median age was 33days, median weight was 4.3kg, 7 patients (23%) had critical AS, and 9 patients (29%) had other CHD. Annulus measurements by intraprocedural echocardiography and angiography displayed excellent correlation (ICC 0.95, p < 0.001). eBAV patients received less contrast (0.5 vs 3.5ml/kg, p < 0.01). Five recent eBAV procedures were performed contrast free. Radiation exposure was not statistically different between the eBAV and tBAV groups (155 vs 313µGy·M2, p = 0.12). One eBAV patient (8%) and 3tBAV patients (16%, p = 0.62) experienced serious adverse events. Technical success (gradient < 35mmHg and increase in AR by ≤ 1 grade) occurred in 11 eBAV patients (92%) and 16 tBAV patients (84%, p = 0.22). AR increased in 2 eBAV patients (17%) and 8 tBAV patients (44%, p = 0.02). eBAV was associated with similar efficacy and significantly lower contrast exposure and risk of aortic regurgitation. There was strong agreement between aortic valve annulus measurements by intraprocedural echocardiography and angiography, ultimately permitting contrast free BAV.

Comparison of De-Kay repair versus De Vega suture for functional tricuspid regurgitation: a preliminary experience.

In patients undergoing mitral valve surgery, restrictive suture annuloplasty (De Vega) for less-than-severe functional tricuspid regurgitation has been proven to be safe and effective. The aim of this study is to determine whether the adjunct of the plication of the posterior tricuspid leaflet with the same running suture (bicuspidized De Vega or "De Kay") is equally safe and effective. Single center, retrospective study on patients submitted to suture repair of the tricuspid valve during mitral valve surgery, with either conventional or De Kay, between January 2014 and December 2020. Comparison was based on degree of residual tricuspid valve regurgitation and right ventricular assessment at discharge. Over the course of the study period, 255 patients undergoing mitral valve surgery had a dilated (>40 mm or >20 mm/m2) tricuspid valve annulus, with less-than-severe tricuspid regurgitation. Conventional De Vega was employed in 166 patients (65.1%) and De Kay in the remaining 89 (34.9%). At discharge the adjunct of postero-septal commissure plication has similar outcomes to the classic De Vega repair. It seems to preserve right ventricular function. De Kay repair guarantees the same tricuspidal regurgitation reduction as compared with conventional De Vega early after surgery.

Relationship between mitral valve echocardiographic parameters and interventional septal reduction therapy success in patients with hypertrophic obstructive cardiomyopathy - a pilot study

Abstract Funding Acknowledgements Type of funding sources: None. Background The mitral valve (MV) has an important contribution to left ventricular outflow tract obstruction (LVOTO) in patients with hypertrophic obstructive cardiomyopathy (HOCM). Several parameters were described to be significantly different between obstructive and non-obstructive forms of HCM, like the aortomitral angle, anterior mitral leaflet (AML) and LVOT size, anterior displacement of the coaptation line, annular related parameters, etc. The redundant length of the AML beyond the coaptation point and the entire AML length are important in the decision to also approach the mitral valve when surgical septal reduction therapy (SRT) is considered, to increase the success rate. Data is scarce regarding mitral valve related predictors of interventional SRT response. This is important as certain patients have a suboptimal response regardless of the proper coronary anatomy and branch targeting. Purpose To evaluate the possible differences in certain mitral valve parameters in interventional SRT responders versus non-responders. Methods We retrospectively included in the study a number of 21 consecutive HOCM patients treated with alcohol septal ablation (ASA). All the procedures were guided with contrast echocardiography besides fluoroscopy and all patients had a proper distribution of at least 1 septal branch. They were divided in two groups- responder group (15 patients) with a non-significant residual LVOT PG (&amp;lt;50mmHg/&amp;gt;50% reduction) and non-responder group (6 patients) with a significant residual LVOT PG (&amp;gt;50mmHg/&amp;lt;50% reduction) and/or early rebound. We accounted for the residual LVOT PG evaluated by continuous Doppler at least 6 months after SRT. The groups were compared regarding LV dimensions and ejection fraction and mitral valve annulus/ leaflet size and displacement of the coaptation line, evaluated by bidimensional transthoracic echocardiography, before the intervention. Results The most hypertrophied part of the LV was the basal interventricular septum (IVS). The two groups were similar regarding age, comorbidities, LV dimensions and ejection fraction and baseline LVOT PG. Also, there was no significant difference between AML length, posterior mitral leaflet (PML) length, AML/PML, MV annulus. The redundant length of the AML was significantly lower in responders whereas anterior displacement of the coaptation point (projection of AML/projection of PML on the MV annulus) was less intense in responders and almost reached statistical significance. (Table) Interestingly, we found a baseline AML/PML projection &amp;lt;1 in all non-responder patients and only in 2 responder patients (13.33%) (p&amp;lt;0.001). Conclusion So far, significant anterior displacement of the coaptation point and the residual AML length may have an important impact on the response to ASA in HOCM patients. This pilot study could be an important start point for larger prospective studies to confirm and evaluated the prediction value of these parameters among others.

Right ventricular strain by speckle tracking echocardiography in patients with systemic scleroderma and absence of pulmonary hypertension

Abstract Funding Acknowledgements Type of funding sources: None. Introduction In patients with scleroderma the morphological remodeling and alteration of right ventricular (RV) function begins even before the setting of pulmonary artery hypertension (PAH). These alterations are associated with worse outcomes and high mortality rate as 30% of deaths are attributed to cardiovascular causes followed by respiratory causes (17%). Purpose Early detection of RV dysfunction is possible using advanced imaging techniques and can lead to specific therapeutic management before installation of PAH and clinical signs and symptoms of heart failure . Purpose of this study is to evaluate new indices, based on speckle tracking echocardiography, for identification of subclinical RV systolic failure. Methods Thirty (30) scleroderma patients without any signs or symptoms of PAH and forty (40) healthy subjects were included in the present study. Two-dimensional echocardiography (2DE) and two-dimensional speckle-tracking echocardiography (2DSTE) were performed. All the usual 2DE, Doppler and tissue Doppler imaging measurements were obtained for the evaluation of RV function. Moreover, TAPSE, maximum systolic myocardial velocity from TDI of lateral tricuspid valve annulus (SRV), auto RV global longitudinal strain (aRVGLS) and auto RV free wall longitudinal strain (aRVFWLS) by 2DSTE were measured. aRVGLS and aRVFWLS are new indices, with appropriate RV function echo logistics in new technology echo systems, independent from known manual measurements. Results In scleroderma patients significantly higher systolic pulmonary artery pressure was recorded, although it remained within normal limits in both groups (24.6+-5.4mmHg vs 19.2+-5.9 mmHg) . Scleroderma patients had significant decreased RV systolic function with significantly lower TAPSE and SRV. Both aRVGLS and aRVFWLS were also lower in scleroderma patients compared to the control group (−18.6+-2.7 vs −23.1+-2.3 % and −25.4+-3.1 vs −26.4+-2.2 % respectively). aRVGLS was the best significant predictor of early RV systolic impairment in patients with scleroderma.The difference in aRVFWLS was not significant. Conclusions Scleroderma is a severe systematic disease associated with high mortality rates. RV remodeling, dysfunction, and progressive pulmonary artery hypertension are among the most important internal organ manifestations of this disease. Early detection of RV dysfunction before installation of pulmonary hypertension is possible by 2DSTE, and may be helpful to guide further therapy in these patients.

Validation of a three-dimensional trans-esophageal echocardiography analysis software to assess mitral valve annulus and predicted Neo-LVOT before trans-catheter mitral valve replacement

Abstract Funding Acknowledgements Type of funding sources: None. Background Trans-catheter mitral valve replacement (TMVR) procedures had emerged as an alternative solution for patients who have surgical high risk for mitral valve surgery. One of the main challenges faced during the percutaneous approach is the degree of left ventricular outflow tract (LVOT) narrowing after implanting the new percutaneous mitral prosthesis. The remaining LVOT area (NeoLVOT) can be estimated by a commercially available CT analysis software that allows the insertion of a virtual valve within the CT dataset in the native annulus and/or the degenerated bioproshesis and hence allows measurement of the NeoLVOT using the multi-planar reconstruction (MPR) mode. Due to the radiation as well as intravenous contrast risk of the CT scans, a new 3DTEE based software was developed, using the same concept of the virtual valve implantation within the 3DTEE dataset to measure the NeoLVOT using the MPR mode. Using this 3DTEE based software avoids the risks associated with CT (radiation &amp; contrast) and can be a reasonable alternative for patients with impaired renal function or a screening test and/or filter for all patients before proceeding to a detailed CT scan if found suitable based on the 3DTEE analysis. Purpose To validate the 3DTEE based software in mitral valve annulus (MA) and NeoLVOT assessment using the CT based software as a gold standard. Methods A retrospective observational single center study, including 49 patients (age 57± 6 years, 60% men), who had undergone Cardiac computed tomography (CT) and three-dimensional trans-esophageal echocardiography (3DTEE) within one month from each other for any clinical indication. We excluded patients who had previous mitral or aortic valve surgeries. CT analysis was done using the commercially available software, (3mensio Structural Heart, Pie Medical Imaging, The Netherlands). 3DTEE analysis was done using the newly available software (3mensio Structural Heart 10.1–3mSH, Pie Medical Imaging, Bilthoven, Netherlands) Figure 1 Measurements done on both software were; mitral annulus (MA) antero-posterior (AP) diameter, inter-commissural (IC) diameter, annulus area (Area), annulus perimeter (Peri) and the NeoLVOT. Excellent correlation was found between 3D-TEE and CT measurements for MA AP diameter (r= 0.96), IC diameter (r=0.92), MA area (r =0.96), MA perimeter (r= 0.94) and NeoLVOT area (r= 0.96), (all P-values &amp;lt;0.0001). Virtual valve sizing was based on annulus measurement and was identical between CT and 3DTEE. Interobserver and intraobserver agreements were excellent for all the measurements with ICCs &amp;gt;0.80. Figure2 Conclusions Mitral annulus dimensions and Neo-LVOT assessment using this 3DTEE based analysis software is feasible and reliable compared to CT analysis. This can offer a good screening test or a filter for TMVR candidates and can also be a good alternative for patients who have a contraindication for CT.

Extrapolation of CT aortic annulus derived diameter/CT aortic annulus area from 2D echocardiography aortic annulus diameter in TAVR: not a reliable tool

Abstract Funding Acknowledgements Type of funding sources: None. Background Computed tomography (CT) aortic annulus area, CT area derived diameter and two-dimensional echocardiography (2D ECHO) diameters are used for valvular sizing in transcutaneous aortic valve replacement (TAVR). According to our previous study, 2D ECHO annulus diameter was smaller in comparison to CT derived diameter (22.6±2.9 vs 25.0±5.5mm, p = 0.013), but both CT aortic annulus area derived diameter/CT aortic annulus and 2D ECHO diameter predicted correct valve size selection with the same accuracy of 79–80%. However, CT requires radiation and iodine contrast administration, which might be the limitation in patients with chronic kidney disease or history of iodine allergy. Purpose To determine if 2D ECHO diameter can be used for reliable estimation of CT area derived diameter/CT aortic annulus area. Methods 139 consecutive patients with favourable outcome of Sapien XT/Sapien S3 TAVR (no more than mild aortic regurgitation, only one valve implanted) were included in the study. 2D ECHO diameter was measured from mid oesophageal three-chamber view (110–135°) just below the anatomical aortic valve annulus. CT aortic annulus was obtained as double oblique plane by manual multiplanar reconstruction of CT dataset, defined by three lowest attachment points of valvular leaflets. Aortic annulus area was measured by manual tracking of lumen contours, area derived diameter as 2*√(area/π). Linear regression analysis between pre-implant CT area derived diameter and 2D ECHO diameter was performed; extrapolated CT annulus area diameter and CT aortic annulus area [π*(d/2)2] were calculated from 2D ECHO diameter. Concordance of valve size selection based on extrapolated CT area derived diameter vs original CT area derived diameter and extrapolated CT aortic annulus area vs original CT aortic annulus area was determined on patients where CT aortic annulus area/annulus derived diameter were falling outside the overlap of the manufacturer recommended ranges for neighbouring valve sizes. Results Significant relationship between CT aera derived diameter and 2D ECHO diameter was found (r=0.720, p&amp;lt;0.001, Fig 1,2). Extrapolated CT area derived diameter would have led to inappropriate size selection in 33/100 more cases (undersizing in 16%, oversizing in 17%), similar to extrapolated aortic annulus area, where both undersizing and oversizing was observed in 18/106 (17%) more cases in comparison to original CT based parameters. Conclusion Extrapolation of CT aortic annulus area/area derived diameter from 2D ECHO diameter is not a reliable tool in valvular sizing for balloon expandable Sapien valve. In patients with chronic kidney disease or history of iodine allergy, three-dimensional (3D) ECHO aortic annulus assessment remains the only viable alternative tool.

A uniform strategy of primary repair of tetralogy of Fallot: Transventricular approach results in low reoperation rate in the first decade

ObjectivesTo review outcomes after a uniform strategy of transventricular repair of tetralogy of Fallot. MethodsA total of 244 consecutive patients underwent transventricular primary repair of tetralogy of Fallot from 2004 to 2019. Median age at operation was 71 days; 57 (23%) patients were premature; 57 (23%) patients had low birth weight (<2.5 kg), and 40 (16%) had genetic syndromes. The diameter of pulmonary valve annulus, right pulmonary artery (PA), and left PA were 6.0 ± 1.8 mm (z score, −1.7 ± 1.3), 4.3 ± 1.4 mm (z score, −0.9 ± 1.2) and 4.1 ± 1.5 mm (z score, −0.5 ± 1.3). ResultsThree (1.2%) operative deaths were recorded. Ninety patients (37%) underwent transannular patching. Postoperative echocardiographic peak right ventricular outflow tract gradient decreased from 72 ± 27 mm Hg to 21 ± 16 mm Hg. Median intensive care unit and hospital stay were 3 and 7 days. The survival rate at 10 years was 94.6% ± 1.8%. Reintervention was required 86 times (55 catheter interventions) in 56 patients following tetralogy of Fallot repair. The freedom from all-cause reintervention rate at 10 years was 70.5% ± 3.6%. Cyanotic spells (hazard ratio, 2.14; 95% CI, 1.22-3.90; P < .01) and smaller pulmonary valve annulus z score (hazard ratio, 1.26; 95% CI, 1.01-1.59; P = .04) were associated with increasing risk of all reinterventions. Freedom from redo surgery for right ventricular outflow tract obstruction and right ventricular dilatation at 10 years were, respectively, 85.0% ± 3.1% and 98.7% ± 0.9%. Freedom from valve implantation was 96.7% ± 1.5% at 10 years. ConclusionsA uniform strategy of primary repair of tetralogy of Fallot through a transventricular approach resulted in low reoperation rate in the first decade. The need of pulmonary valve implantation was limited to <4% at 10 years.

Iatrogenic coronary artery injuries during non-coronary artery adult cardiac surgery

: The close adjacency of the coronary ostia to the aortic valve, the left circumflex artery to the posterior mitral valve annulus, the right coronary artery to the tricuspid valve, and the septal branch of the left anterior descending artery to the pulmonary valve make them injury prone during surgical interventions on these valves. Iatrogenic coronary artery injuries during non-coronary artery adult cardiac surgery can endanger the myocardium and result in a substantial risk of morbidity and mortality. The clinical presentation of iatrogenic coronary injury is determined by the nature of injury. Acute injuries usually become apparent intraoperatively or immediately postoperatively. Chronic injuries mostly manifest within the first 6 postprocedural months, but they may occur as late as 30 months postoperatively. Prompt diagnosis and timely intervention can salvage the myocardium and improve the prognosis. Intraoperative detection of iatrogenic coronary artery injuries requires a high index of suspicion. The choice of therapeutic strategy, percutaneous coronary intervention or coronary artery bypass grafting, is dictated by the timing of detection as well as the clinical condition of the patient. This review article provides an overview of the incidence, mechanisms, diagnosis and therapeutic strategies to treat iatrogenic coronary artery injuries during non-coronary artery valvular surgery in adults.

Possible predictors of stroke in patients with atrial microfibrillation

Background Very short-lasting episodes of AF-like activity (micro-AF) may be precursors of undiagnosed silent episodes of atrial fibrillation. In this study, we examined the relationship between increased left atrial sphericity index (LASI) and stroke in patients with micro-AF.Material and Methods A total of 100 consecutive patients with micro-AF enrolled in this study. The histories, cranial magnetic resonance, and computed tomography images of these patients were scanned from the hospital database. The patients were divided into two groups according to whether or not they had a stroke. LASI was calculated as a fraction of the left atrial maximum volume to the left atrial volume of the sphere in a 4‑chamber view. Atrial electromechanical delay (AEMD) intervals were calculated from the atrial wall and atrioventricular valve annulus levels by using tissue Doppler imaging (TDI). These two groups were compared in terms of stroke predictors.Results A history of stroke was present in 25 (25 %) patients diagnosed with micro-AF (Group 1). 75 patients did not have stroke (Group 2). There was a significant difference between the two groups in terms of left atrial lateral wall electromechanical delay (LA lateral AEMD) times, left atrial volume index (LAVI), and left atrial sphericity index (LASI). Findings: LAVI, 40.9±3.72 vs. 29.9±3.84, p&lt;0.001; LASI, 0.84±0.07 vs. 0.66±0.07, p&lt;0.001; LA lateral AEMD, 77.2±4.85 vs. 66.5±3.66, p&lt;0.001.Conclusions Stroke precautions should be taken in patients with micro-AF. New predictive indexes should be given importance. Changes in LASI, LAVI and LA lateral AEMD values may be a predictor of stroke in patients with micro AF.

Tricuspid regurgitation in the setting of LVAD support.

Tricuspid valve regurgitation (TR) is a common complication of end-stage heart failure. Increased pulmonary venous pressures caused by left ventricular (LV) dysfunction can result in a progressive dilation of the right ventricle and tricuspid valve annulus, resulting in functional TR. Here, we review what is known about TR in the setting of severe LV dysfunction necessitating long-term mechanical support with left ventricular assist devices (LVADs), including the occurrence of significant TR, its pathophysiology, and natural history. We examine the impact of uncorrected TR on LVAD outcomes and the impact of tricuspid valve interventions at the time of LVAD placement, revealing that TR frequently improves after LVAD placement with or without concomitant tricuspid valve intervention such that the benefit of concomitant intervention remains controversial. We summarize the current evidence on which to base medical decisions and provide recommendations for future directions of study to address outstanding questions in the field.

Mitral annular disjunction prevalence and its association with ventricular arrythmias in Upper Egypt

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Mitral annular disjunction (MAD) was first described more than 3 decades ago as an abnormal atrial displacement of the hinge point of the mitral valve away from the ventricular myocardium. MAD was associated with ventricular arrythmias and sudden cardiac death, yet some studies suggested that the presence of MAD can be potentially normal physiological function . (1) Purpose Our primary end point was assessment of the incidence of mitral annular disjunction among the cohort of mitral valve prolapse at our center and the secondary end point was the incidence and predictors of ventricular arrythmias(VAs) in our cohort. Methods It is an observational cross section study where we recruited all the patients who were diagnosed to have MAD at our center representing the area of Upper Egypt, MAD was defined as distinct separation of the mitral valve annulus and the left atrial wall and myocardial continuum, and it was initially diagnosed by the means of transthoracic echocardiography. All patients’ demographics and family history (FH) of sudden cardiac death (SCD) were collected,symptoms were assessed as regard palpitations, shortness of breathing, chest pain, pre syncope and syncope, data from echocardiography including LV internal dimensions, leaflets affection, degree of mitral regurgitation, careful ECG analysis was done extracting the data for PR interval, corrected QTc, T wave inversion, PVCs in surface ECG and in 24 hours Holter, cardiac MRI parameters including late gadolinium enhancement, its distribution and systolic curling. Results We analyzed the data of 300 patients with mitral valve prolapse, 7 % of them showed mitral annular disjunction, 33 % of the cohort were female patients, the mean age was 34 years old, the mean follow up period was 3 years, main presenting complain was palpitations with an incidence of 66 %, FH of SCD was noticed in 9 % of our cohort, Mean QRS width was 81 mseconds, mean QTc was 423 mseconds, the mean EF was 60 %, mean displacement distance was 3 mm, while the mean LA volume was 36 cm3, 80 % of the cohort showed bileaflet affection, while only 19 % of them had late gadolinium enhancement, 50 % of them had fibrosis in the papillary muscles, while systolic curling was noticed in only 9 %.VAs were defined as having premature ventricular complexes in the surface ECG or documented monomorphic ventricular tachycardia and it was noticed in 19 % of our cohort with an average burden of 10 % during a 24 hours Holter.There was a positive correlation between the FH of SCD and the Prescence of PVCs in surface ECG with a significant P value of 0.02, while there was no correlation between fibrosis and the incidence of ventricular arrythmias. Conclusions Incidence of MAD was 7 % among the MVP population at our center. Only FH of SCD was a predictor of the incidence of VAs, while ECG, echo and cardiac MRI parameters couldn`t be proved to be positively correlated with the VAs.

Mitral annular electrogram morphology - a balanced signal does not identify the anatomical annulus

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Background Electrogram morphology is used to identify the atrio-ventricular annuli during catheter ablation procedures with a "balanced" signal considered to represent the annuli. However, anatomical studies highlight a significantly greater mass of ventricular myocardium compared to atrial myocardium at the valve plane suggesting the correct electrical signature of the anatomical annulus may not be a balanced signal. Purpose To identify the relationship between atrial and ventricular electrogram components at the anatomically defined mitral valve annulus. Methods Mapping of the mitral annulus was performed in patients undergoing ablation for paroxysmal atrial fibrillation. Following femoral venous access and trans-septal puncture, left atrial anatomy was defined using rotational angiography performed using a 100ml contrast injection 4 seconds prior to X-ray acquisition, during rapid pacing and apnoea while covering 200 degrees at 40 degrees/s. A SmartTouch SF ablation catheter (Biosense Webster) was advanced into the left atrium and used to record intracardiac electrograms at four positions around the mitral annulus and at five predetermined levels ranging from ventricular to atrial (Figure, panel A). Data analysis was performed using OpenEP (https://openep.io). For each electrogram, the distance to the mitral valve plane and the amplitudes of atrial and ventricular electrogram components were calculated (Figure, panel B and C). Mean electrogram component amplitudes were calculated including all points recorded within ±2.5mm of the mitral valve plane. For each patient, a linear regression model was fitted and used to identify the atrial/ventricular ratio at the anatomically defined mitral valve annulus (Figure, panel D). Results The protocol was completed in 9 patients, including analysis of 240 atrial or ventricular electrogram components. Within ±2.5mm of the anatomically defined mitral valve annulus, the mean recorded amplitudes of atrial and ventricular electrogram components was 0.15±0.17mV and 1.35±1.27mV, respectively (A/V ratio 1:9). Using the linear regression model, the ventricular electrogram component was calculated to be 16.5±11.6 times greater in amplitude than the atrial electrogram component at the mitral valve plane (A/V ratio 1:16). The use of a balanced signal to identify the mitral valve annulus resulted in a positional error of -7.9±9.5mm (i.e. identifying a level which is approximately ~8mm too "atrial" compared to the anatomically defined annulus). Conclusion The conventional use of a "balanced" electrogram signal does not identify the anatomical mitral valve annulus. An atrial/ventricular electrogram ratio between 1:9 and 1:16 best approximates the mitral valve annular plane determined by left atrial rotational angiography. These findings have relevance in target site selection for an accessory pathway and the ventricular extent of linear ablation at the mitral isthmus.

C46 ELECTROPHYSIOLOGICAL ASSESSMENT OF ATRIAL TACHYCARDIA SUBSTRATES IN PATIENTS WITH REPAIRED TETRALOGY OF FALLOT

Abstract Introduction Adults with repaired tetralogy of Fallot (rToF) experience episodes of atrial tachycardia (AT) and radiofrequency catheter ablation (RFCA) is often required but systematic evaluation of the mechanisms and recurrences is lacking. Methods Between January 2013 and October 2021, 20 rToF patients with AT referred for catheter ablation were enrolled. Electrophysiologic study with 3D electroanatomic mapping with multi–electrode mapping catheters was done, with right atrial bipolar voltage and activation mapping of the AT. Three mechanisms were searched: intra–atrial re–entrant tachycardias (IART), focal (FAT), other. Critical isthmus (CI) for IART was identified with activation mapping. FATs were localized according to the earliest uni/bipolar signal. All induced AT were treated. RFCA was aimed at the earliest activation point for FAT and at the critical isthmus for IART, anchoring lesion to fixed obstacles (valve annuli or scar). Written informed consent was provided. Results Among 20 adult (age 46±14 years) and mainly females (n=11, 55%) enrolled pts, 36 AT were documented: 25 (70%) IART, 10 (27%) FAT and only 1 (3%) had a typical atrioventricular nodal reentrant tachycardia. Mean tachycardia cycle length was 307±95 ms. Two ATs were induced in 11 pts, 3 in 4 pts and 4 in 2 during index EPS. Among IART, cavo–tricuspid isthmus (CTI) was the prevalent CI (n=14, 60%), while incisional IART (IARTinc, atriotomy and superior and inferior vena cava orifices, SVC and IVC, respectively) was the second mechanism (n=9, 39%). In two pts, due to non–inducibility, a pre–emptive lesion set comprising in one case CTI and in the second case CTI+SVC–atriotomy–IVC line was performed. Among FAT, in 3 cases the AT was mapped in the coronary sinus, in two at the tricuspid annulus, other at the crista terminalis, right appendage base, posterolateral scar or between atriotomy and SVC. During a median follow–up of 23 months (interquartile range, 6–37) recurrence occurred in 8 pts (25% of pts, 22% of tachycardias). Pts with recurrences were younger (43±7 vs. 48±17 y, p=0.04); no differences were found according to critical isthmus location (4 CTI and 4 IARTinc, 50%, p=ns). Conclusions Among rToF pts with AT, IART is the prevalent mechanism and CTI is the prevalent CI; atriotomy scar, however, is involved in a substantial portion of the critical isthmuses of the IART; FAT location is much more variable. Long–term freedom from AT in this clinical setting is encouraging.

Surgery for mitral annular caseous calcification-related calcified amorphous tumor: a case report

BackgroundA calcified amorphous tumor (a non-neoplastic tumor) with caseous calcification of the mitral annulus is a rare pathology that causes severe embolic events. We present a rare case of mitral valve surgery for a mitral annular caseous calcification-related calcified amorphous tumor found in cerebral infarction.Case presentationA 69-year-old man was diagnosed with a mitral valve calcified amorphous tumor with mitral annular caseous calcification found in cerebral infarction. He was admitted because of acute multiple embolic cerebral infarctions. A search for the embolic source through transesophageal echocardiography revealed a mitral valve tumor raised from the posterior mitral valve leaflet on the side of the left ventricle. Computed tomographic cardiac angiography revealed a calcified mitral valve tumor invading the posterior mitral valve annulus and left ventricular muscle. Intraoperative findings revealed a mitral annular calcification-related calcified amorphous tumor with caseous calcification of the posterior leaflet and annulus, which was suspected. Therefore, we performed radical debridement of the mitral annular calcification and bioprosthetic mitral valve replacement with patch repair of the posterior mitral valve annulus 2 weeks after the onset of cerebral infarction. The patient recovered well post operation, without any embolic events.ConclusionsA calcified amorphous tumor with caseous mitral annulus calcification may be highly associated with embolic events. In this case, mitral valve replacement with annular patch repair may be a favorable procedure for preventing embolic events.

Reverse remodeling of the tricuspid valve complex by sinus rhythm restoration after catheter ablation

BackgroundAtrial fibrillation (AF) can cause right atrium enlargement and structural changes of the tricuspid valve annulus (TVA). The features of the structural changes and benefits obtained from rhythm-control therapy is unknown. ObjectivesWe investigated how the TVA changes and whether its size decreases after rhythm-control therapy. MethodsMulti-detector row computed tomography (MDCT) was performed before and after catheter ablation for AF. TVA morphology and right atrium (RA) volume was evaluated by MDCT. The features of TVA morphology in patients with AF after rhythm-control therapy were analyzed. ResultsMDCT was performed in 89 patients with AF. The 3D perimeter was more correlated with diameter in the anteroseptal-posterolateral (AS-PL) direction than in the anterior-posterior direction. Seventy patients showed 3D perimeter reduction owing to rhythm-control therapy and the change was associated with the rate of change in the AS-PL diameter. Rate of change of the 3D perimeter was associated with that of the AS-PL diameter among TVA morphology and RA volume. We divided the subjects into three groups according to the tertiles of the TA perimeter. 3D perimeter in all groups was decreased after rhythm-control therapy. The AS-PL diameter in the 2nd and 3rd tertiles was decreased and increased TVA height in all groups. ConclusionTVA in patients with AF was enlarged and flattened in the early phase, and rhythm-control therapy resulted in reverse remodeling of the TVA and in the reduction of right atrial volume. These results suggest that early AF intervention can lead to the restoration of the TVA structure.

Long-term outcomes of tetralogy of Fallot repair: A 30-year experience with 960 patients

ObjectiveThis study evaluates the long-term results of tetralogy of Fallot repair and assesses the risk factors for adverse outcomes. MethodsThis retrospective study included 960 patients who underwent transatrial transpulmonary tetralogy of Fallot repair between 1990 and 2020. ResultsA transannular patch was placed in 722 patients, and pulmonary valve preservation was achieved in 233 patients. The median age at tetralogy of Fallot repair was 9.4 (interquartile range, 6.2-14.2) months. The median follow-up duration was 10.6 (interquartile range, 5.4-16.3) years. There were 8 early deaths (0.8%) and 20 late deaths (2.1%). Genetic syndrome and pulmonary valve annulus Z score less than −3 were risk factors for mortality. The survival was 97.7% (95% confidence interval, 96.4-98.5) and 94.5% (95% confidence interval, 90.9-96.7) at 10 and 30 years, respectively. Freedom from any reoperation was 86.4% (95% confidence interval, 83.6-88.7) and 65.4% (95% confidence interval, 59.8-70.4) at 10 and 20 years, respectively. Postoperative right ventricular outflow tract peak gradient of 25 mm Hg or greater correlated with reoperation. Propensity score–matched analysis demonstrated that freedom from pulmonary valve replacement at 15 years was higher in the pulmonary valve preservation group compared with the transannular patch group (98.2% vs 78.4%, P = .004). Freedom from reoperation for right ventricular outflow tract obstruction at 15 years was lower in the pulmonary valve preservation group compared with the transannular patch group (P = .006). ConclusionsThe long-term outcomes of tetralogy of Fallot repair are excellent. A postoperative right ventricular outflow tract peak gradient less than 25 mm Hg appears to be optimal to prevent reoperation. If the pulmonary valve size is suitable, pulmonary valve preservation reduces the risk of pulmonary valve replacement, yet increases the reoperation rate for right ventricular outflow tract obstruction.

PO-04-158 INTRACARDIAC ECHOCARDIOGRAPHY GUIDES ANATOMICAL ISTHMUS ABLATION IN PATIENTS WITH VENTRICULAR TACHYCARDIA AND REPAIRED TETRALOGY OF FALLOT

Successful catheter ablation of monomorphic ventricular tachycardia (VT) in patients with repaired Tetralogy of Fallot (TOF) can be achieved by targeting one or more of four common anatomical isthmuses. However, variability in the size and location of surgical patches means careful mapping is required to design ablation lines to block the critical isthmus. Intracardiac echocardiography (ICE) may assist ablation by accurate identification of individual TOF anatomy. To determine whether the routine use of ICE aids linear ablation of VT isthmuses in patients with repaired TOF. Retrospective study of repaired TOF patients undergoing VT ablation at our centre from January 2017 to November 2022. Cases were divided into those which used ICE to assist anatomical mapping versus those which used voltage mapping to identify patches and valve annuli. Once anatomy was defined, we started with a VT stimulation study where haemodynamically stable VTs were mapped. Non-inducible or unstable VTs underwent substrate mapping in sinus rhythm. All cases underwent ablation and had no inducible monomorphic VT as the endpoint. Data are presented as median and [interquartile range]. Twenty-six patients were identified, of which 15 were guided by ICE. The baseline demographic data is presented in the table and a representative figure shows the use of ICE to identify surgical patches. The use of ICE allowed linear ablation of the critical anatomical isthmus in 12/15 patients (80%) compared to 4/11 (36%) without ICE (p=0.023). The remaining patients without linear ablation underwent substrate-based ablation only to sites of local abnormal ventricular activity. There was no significant difference in overall procedure time (ICE: 165 [60] minutes versus no ICE: 145 [50] minutes; p=0.24), nor in fluoroscopy time (ICE: 25 [17] minutes versus no ICE: 31 [16] minutes; p=0.9). Over time, the introduction of ICE was associated with improved workflow. When comparing the first and last five cases using ICE, both median procedure times (from 196 to 160 minutes) and fluoroscopy times (from 35 to 20 minutes) were shorter. Intracardiac echocardiography improves targeted linear ablation of the critical anatomical isthmus for VT in patients with repaired TOF. ICE provides real-time individualised identification of surgical patches and valve anatomy to guide optimal linear lesion sets across isthmuses, with routine use over time showing a trend towards shorter procedural and fluoroscopy times.Tabled 1Baseline demographicsICE (n=15)No ICE (n=11)Age (years)53 [26]41 [23]Male10 (67%)7 (64%)Number of sternotomies2 [1]3 [2]History of syncope5 (33%)1 (9%)QRS width (milliseconds)176 [59]172 [54]Left ventricular ejection fraction (%)50 [25]54 [9]Right ventricular ejection fraction (%)29 [8]27 [7]Implantable cardiac defibrillator7 (47%)5 (45%)History of sustained VT12 (80%)8 (73%)VT ablation15 (100%)11 (100%)Inducible VT at electrophysiology study11 (73%)6 (55%)Linear anatomical isthmus ablation12 (80%)4 (36%)Procedure time (minutes)165 [60]145 [50]Fluoroscopy time (minutes)25 [17]31 [16] Open table in a new tab

Early Diastolic Peak Velocity of Mitral Valve Annulus and Right Ventricular Systolic Tricuspid Annular Velocity as Predictors in Assessing Prognosis of Patients with Sepsis.

To analyze the epidemiological data of patients with septic cardiomyopathy and investigate the relationship between ultrasonic parameters and prognosis of patients with sepsis. In this study, we enrolled patients with sepsis who were treated at the Department of Critical Care Medicine in the Beijing Electric Power Hospital (No.1 Taipingqiao Xili, Fengtai District, Beijing) from January 2020 to June 2022. All patients received standardized treatment. Their general medical status and 28-day prognosis were recorded. Transthoracic echocardiography was performed within 24 hours after admission. We compared the ultrasound indexes between the mortality group and the survival group at the end of 28 days. We included parameters with significant difference in the logistic regression model to identify the independent risk factors for prognosis and evaluated their predictive value using receiver operating characteristic (ROC) curve. We included 100 patients with sepsis in this study; the mortality rate was 33% and the prevalence rate of septic cardiomyopathy was 49%. The peak e' velocity and right ventricular systolic tricuspid annulus velocity (RV-Sm) of the survival group were significantly higher than those of the mortality group (P < 0.05). Results of logistic regression analysis showed that the peak e' velocity and RV-Sm were independent risk factors for prognosis. The area under curve of the peak e' velocity and the RV-Sm was 0.657 and 0.668, respectively (P < 0.05). The prevalence rate of septic cardiomyopathy in septic patients is high. In this study, we found that the peak e' velocity and right ventricular systolic tricuspid annulus velocity were important predictors of short-term prognosis.

Venae Cavae Anatomic Characteristics in Severe Tricuspid Regurgitation: Implications for Transcatheter Interventions

Venae Cavae Anatomic Characteristics in Severe Tricuspid Regurgitation: Implications for Transcatheter Interventions

PO-02-109 FACILITATING LEFT BUNDLE BRANCH PACING BY IDENTIFYING THE TIP OF THE TRIANGLE OF KOCH WITH RIGHT ATRIAL SEPTOGRAM

Left bundle branch (LBB) pacing has emerged as an alternative to His bundle (HB) pacing for physiological stimulation of the ventricles. Current techniques to achieve LBB pacing can be challenging and time consuming, as they require the placement of a catheter/lead to reference the HB We sought to develop a method to facilitate the achievement of LBB pacing. Permanent LBB pacing was performed in 104 consecutive patients with symptomatic bradycardia. A right atrial septogram (RAS) was performed in all the patients to locate the His bundle region (HBR). Briefly, 8-10 cc of contrast were injected trough the Medtronic C315 His delivery sheath while fluoroscopy and cine runs were obtained in the RAO 20-degree projection. These images provided the visualization of an approximately 90-degree angle composed by the medial aspect of the tricuspid valve annulus (TV) anteriorly and the superior aspect of the interatrial septum (IAS) superiorly. The apex of this angle coincides with the tip of the triangle of Koch, where the HBR resides (Figure 1A). This area was referenced by placing a sticky paper arrow on the monitor screen (green arrow). The C315 sheath was then advanced approximately 2 cm anteriorly and 1 cm inferiorly from the level of the HBR to the right ventricular septum (RVS) in the location of the LBB area (LBBA) (Figure 1B). Subsequently, a 3830 Medtronic SelectSecure bipolar lead was advanced through the C315 sheath into the interventricular septum by turning the lead clockwise multiple times in the selected LBBA. The advancement of the lead was monitored by fluoroscopy visualization of the interventricular septum plane with intermittent injections of small amounts of contrast media in the LAO 30-degree projection (Figure 1C), by tracking the impedance measurements and analyzing morphology changes of the unipolar paced QRS morphology. LBB capture was confirmed by current ECG criteria. LBB pacing was successfully achieved in 96 % of the patients (100 out of 104 patients). Twenty nine female. Mean age 75 +/10 years. The mean procedure time for LBB lead insertion was 17.5 +/- 15 minutes. For LBB lead performance see table within figure 1. No acute complications were observed. This study demonstrates that the RAS guided technique provides a highly successful and safe approach to achieve LBB pacing by readily identifying the HBR.