Preoperative Computed Tomography Angiography Reveals Leaflet-Specific Calcification and Excursion Patterns in Aortic Stenosis

2021 ◽  
Author(s):  
Ian Y. Chen ◽  
Vijay Vedula ◽  
Sachin B. Malik ◽  
Tie Liang ◽  
Andrew Y. Chang ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Aortic Valve ◽  
Linear Regression ◽  
Aortic Stenosis ◽  
Computed Tomography Angiography ◽  
Aortic Valve Area ◽  
Male Patients ◽  
Coronary Cusp ◽  
The Right ◽  
Valve Area

Background: Computed tomography–based evaluation of aortic stenosis (AS) by calcium scoring does not consider interleaflet differences in leaflet characteristics. Here, we sought to examine the functional implications of these differences. Methods: We retrospectively reviewed the computed tomography angiograms of 200 male patients with degenerative calcific AS undergoing transcatheter aortic valve replacement and 20 male patients with normal aortic valves. We compared the computed tomography angiography (CTA)-derived aortic valve leaflet calcification load (AVLC CTA ), appearance, and systolic leaflet excursion (LE sys ) of individual leaflets. We performed computer simulations of normal valves to investigate how interleaflet differences in LE sys affect aortic valve area. We used linear regression to identify predictors of leaflet-specific calcification in patients with AS. Results: In patients with AS, the noncoronary cusp (NCC) carried the greatest AVLC CTA (365.9 [237.3–595.4] Agatston unit), compared to the left coronary cusp (LCC, 278.5 [169.2–478.8] Agatston unit) and the right coronary cusp (RCC, 240.6 [137.3–439.0] Agatston unit; both P <0.001). However, LCC conferred the least LE sys (42.8º [38.8º–49.0º]) compared to NCC (44.8º [41.1º–49.78º], P =0.001) and RCC (47.7º [42.0º–52.3º], P <0.001) and was more often characterized as predominantly thickened (23.5%) compared to NCC (12.5%) and RCC (16.5%). Computer simulations of normal valves revealed greater reductions in aortic valve area following closures of NCC (−32.2 [−38.4 to −25.8]%) and RCC (−35.7 [−40.2 to −32.9]%) than LCC (−24.5 [−28.5 to −18.3]%; both P <0.001). By linear regression, the AVLC CTA of NCC and RCC, but not LCC, predicted LE sys (both P <0.001) in patients with AS. Both ostial occlusion and ostial height of the right coronary artery predicted AVLC CTA, RCC ( P =0.005 and P =0.001). Conclusions: In male patients, the AVLC CTA of NCC and RCC contribute more to AS than that of LCC. LCC’s propensity for noncalcific leaflet thickening and worse LE sys , however, should not be underestimated when using calcium scores to assess AS severity.

Abstract 16300: Preoperative Computed Tomography Angiography Reveals Leaflet-specific Contribution to Aortic Stenosis Influenced by Local Coronary Factors

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Ian Y Chen ◽  
Vijay Vedula ◽  
Sachin B Malik ◽  
Tie Liang ◽  
Kieran S Chung ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Computer Simulation ◽  
Regression Analysis ◽  
Aortic Valve ◽  
Aortic Stenosis ◽  
Severe Aortic Stenosis ◽  
Aortic Valve Area ◽  
Coronary Cusp ◽  
The Right ◽  
Proximal Occlusion

Background: Current computed tomography (CT)-based diagnosis of severe aortic stenosis (AS) using aortic valve calcification (AVC) load does not take into account interleaflet differences in calcification and leaflet dysfunction. Objectives: We sought to assess the functional impact of these differences and identify factors that can influence calcification load in a leaflet-specific manner. Methods: We retrospectively reviewed the CT angiograms (CTA) of 170 AS patients being considered for valvular intervention and 20 control normal-valve patients. We quantified AVC load, aortic valve leaflet calcification (AVLC) load, and systolic leaflet excursion (LE sys ), and used regression analysis to investigate their interrelationships. We further performed computer simulation to examine how interleaflet differences in LE sys affect aortic valve area (AVA). Lastly, we used regression analysis to identify contributors of leaflet-specific calcification. Results: We observed significant interleaflet differences in AVLC load in AS patients, with noncoronary cusp (NCC) carrying the most load (342.0 [220.3-603.1] AU), compared to the right coronary cusp (RCC) (278.5 [168.2-492.1] AU; P < 0.001) and the left coronary cusp (LCC) (240.6 [143.1-450.3] AU; P < 0.001). However, LCC, but not NCC, was associated with the least LE sys (43.0 [38.4-49.2] °), compared to both NCC (45.2 [41.2-49.9] °; P = 0.009) and RCC (47.8 [42.1-53.0] °; P < 0.001). Computer simulation of normal valve dynamics revealed that NCC and RCC contributed 10.4 [-1.6-15.7] % more ( P = 0.004) and 10.7 [4.9-20.4] % more ( P < 0.001) to AVA than LCC. In multiple regression analysis, only NCC and RCC AVLC loads predicted LE sys (b = -0.015, P < 0.001; b = -0.020, P < 0.001), but not LCC AVLC load (b = -0.008; P = 0.065). Both ostial/proximal occlusion and ostial height of right coronary artery predicted RCC AVLC load (b = 71.508, P = 0.007; b = 10.252, P = 0.008). Conclusions: NCC and RCC should be given more weight than LCC in the evaluation of AS because of their greater AVC loads, more predictable LE sys -AVLC relationships, and greater contributions to AVA. Ostial/proximal occlusion and large ostial height of RCA should signify risk for disease progression in RCC.

scholarly journals At what flow rate does aortic valve gradient become severely elevated? Implications for guideline recommendations on aortic valve area cutoffs

2021 ◽  
Author(s):  
Wilbert Aronow ◽  
Ayesha Salahuddin ◽  
Daniel Spevack
Keyword(s):  
Aortic Valve ◽  
Linear Regression ◽  
Aortic Stenosis ◽  
Flow Rate ◽  
Aortic Valve Area ◽  
Flow Rates ◽  
Wide Range ◽  
The Relationship ◽  
Valve Area

IntroductionSince many patients with AVA < 1.0 cm2 do not manifest a mAVG > 40 mmHg, we sought to determine the AVA at which mAVG tends to exceed 40 mmHg in a sample of subjects with varied transvalvular flow rates.Material and methodsWe selected 200 subjects with an AVA< 1.0 cm2. The sample was selected to include subjects with a varied mean systolic flow (MSF) rates. Linear regression was performed to determine the relationship between MSF and mAVG. Since this relationship varied by AVA, the regression was stratified by AVA (critical <0.6 cm2, severe 0.6-0.79 cm2 , moderately severe 0.8-0.99 cm2)ResultsThe study sample was 79 ± 12 years-old and was 60% female. The MSF rate at which mAVG tended to exceed 40 mmHg was 120 ml/s for critical AVA, 183 ml/s for severe AVA and 257 ml/s for moderately severe AVA. Those with moderately severe AVA rarely (8%) had a mAVG > 40 mmHg at a wide range of MSF. In contrast, those with severe AVA typically (75%) had mAVG > 40 mmHg when MSF was normal (>200 ml/s). Those with critical AVA frequently (44%) had mAVG > 40 mmHg, even when MSF was reduced.ConclusionsAVA > 0.8 cm2 was rarely associated with mAVG > 40 mmHg, even when transvalvular flow rate was normal. Consideration should therefore be given to either raising the cutoff AVA or lowering the mAVG at which aortic stenosis is considered severe.

scholarly journals P755 Aortic valve area calculation by 3D transesophageal echocardiography: new insights in severity grading of aortic stenosis

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
A Beneduce ◽  
C Capogrosso ◽  
S Stella ◽  
F Ancona ◽  
G Ingallina ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Aortic Valve ◽  
Aortic Stenosis ◽  
Transesophageal Echocardiography ◽  
3D Imaging ◽  
Imaging Modalities ◽  
Aortic Valve Area ◽  
Combined Approach ◽  
3D Transesophageal Echocardiography ◽  
Valve Area

Abstract Background Aortic stenosis (AS) grading is mainly based on aortic valve area (AVA) calculation by 2D transthoracic echocardiography (2D-TTE), using continuity equation (CE). However, 2D-TTE shows several limits, mainly due to left ventricular outflow tract (LOVT) underestimation. Different 3D imaging modalities have been proposed to overcome 2D-TTE limitations, including 3D transesophageal echocardiography manual and software measurements (3D-TEEm and 3D-TEEs) and multidetector computed tomography (MDCT). The AVA cut-off value generally used to define severe AS has been established and validated by outcome studies in which AVA was measured by 2D-TTE. This cut-off value cannot be directly extrapolated to the 3D-TEE combined approach that systematically measures larger LVOT compared with 2D-TTE. Purpose.To evaluate the diagnostic accuracy of 3D transesophageal echocardiography manual and software measurements (3D-TEEm and 3D-TEEs) in AS grading, compared with multidetector computed tomography (MDCT) as gold standard, and to identify a new cut-off for AS severity assessment. Methods 218 patients (81 ± 5.4 years, 54% male) with symptomatic normal-flow AS underwent 2D-TTE, 3D-TTEm, 3D-TEEs and MDCT within the same hospitalization. 3D-TEE LVOT reconstruction was performed manually and with semi-automated software (EchoPAC version 201). 3D-TEEm, 3D-TEEs and MDCT LVOT areas were combined with 2D-TTE Doppler parameters to calculate AVA by CE. Using Doppler parameters (Vmax &gt;4 m/s and MPG &gt;40 mmHg) to define AS severity, a receiving-operating curve (ROC) was calculated for AVA obtained with different 3D imaging modalities. Results There was a good correlation between both 3D-TEEm and 3D-TEEs and MDCT measurements (r = 0.800 and r = 0.814, respectively) and excellent agreement between 3D-TEEm and 3D-TEEs with minimum bias. 2D-TTE significantly underestimated AVA compared to 3D-TEEm, 3D-TEEs and MDCT. On the other hand, both 3D-TEEm and 3D-TEEs underestimated AVA compared to MDCT (mean AVA difference = 0.13 and =0.06 cm2, respectively). ROC curve analysis demonstrated 91% sensibility and 34% specificity for 2D-TTE AVA using a cut-off of 1 cm2 (AUC 0.732). For 3D-TEEm and 3D-TEEs, a 1 cm2cut-off resulted in 74% sensibility and 59% specificity, while a 1.2 cm2cut-off resulted in 91% sensibility and 31% specificity (AUC 0.715). MDCT showed 59% sensibility and 70% specificity using a 1 cm2 cut-off and 83% sensibility and 45% specificity using a 1.2 cm2 cut-off (AUC 0.708). Conclusion 3D-TEE represents a valuable tool for AS grading using a combined approach incorporating 3D LVOT measurements and 2D Doppler parameters in the CE. Both 3D-TEEm and 3D-TEEs AVA measurements demonstrated good correlation with MDCT and excellent reproducibility. 3D-TEE measurements underestimate AVA compared to MDCT. Given the multiparametric assessment of AS severity, a 1.2 cm2 AVA cut-off could be considered to define AS severity with emerging 3D imaging modalities.

scholarly journals P1692 The past returns after 20 years: a case report

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
S Habjan ◽  
D Cantisani ◽  
I S Scarfo` ◽  
M C Guarneri ◽  
G Semeraro ◽  
...  
Keyword(s):  
Heart Disease ◽  
Coronary Artery ◽  
Aortic Valve ◽  
Aortic Stenosis ◽  
Valvular Heart Disease ◽  
Radiation Treatment ◽  
Severe Aortic Stenosis ◽  
Aortic Valve Area ◽  
Radiation Induced ◽  
Valve Area

Abstract Introduction Radiation therapy is one of the cornerstones of treatment for many types of cancer. These patients can later in life develop cardiovascular complications associated with radiation treatment. Late cardiovascular effects of radiation treatment include coronary artery disease (CAD), valvular heart disease, congestive heart failure, pericardial disease and sudden death. The most common sign of radiation-induced valvular heart disease is the calcification of the intervalvular fibrosa between the aortic and mitral valve. Case presentation A 71-year-old male patient with a history of Non-Hodgkin lymphoma treated with radiotherapy and chemotherapy 20 years ago, CAD, arterial hypertension, diabetes type II, dyslipidemia, obesity and currently smoking presented in the emergency room in our medical facility with acute pulmonary edema. The patient had unstable angina pectoris in 2018, the coronary angiography showed two-vessel disease with a non-significant stenosis of the left main coronary artery (LMCA) and 70% stenosis of the left anterior descending artery (LAD), for which he refused the percutaneous coronary intervention. At the same time, a transthoracic echocardiography (TTE) showed severe aortic stenosis and moderately severe mitral stenosis, at that time the patient refused the operation. After the initial treatment for pulmonary edema, TTE and transesophageal echocardiography (TEE) were performed and showed a tricuspid aortic valve with calcification of the cusps and a very severe aortic stenosis (planimetric aortic valve area 0.74 cm², functional aortic valve area 0.55 cm², indexed functional aortic valve area 0.25 cm²/m², mean gradient 61 mmHg, peak gradient 100 mmHg, stroke volume (SV) 69 ml, stroke volume index (SVI) 31 ml/m², flow rate 221 ml/s, aortic annulus 20x26 mm). The left ventricle was severely dilated (end diastolic volume 268 ml) with diffuse hypokinesia and severe systolic dysfunction (ejection fraction 32%). We appreciated a calcification of the mitral-aortic intervalvular fibrosa and the mitral annulus, without mitral stenosis but with moderate mitral regurgitation. The calcification of the intervalvular fibrosa suggested our final diagnosis of radiation-induced valvular heart disease with a severe aortic stenosis in low-flow conditions. The patient was successfully treated with transcatheter aortic valve implantation (TAVI). Conclusion Radiation-induced heart disease is a common reality and is destinated to raise due to the increasing number of cancer survivors. Effects are seen also many years after the radiation treatment. The exact primary mechanism of radiation injury to the heart is still unknown. The treatment of radiation-induced valve disease is the same as the treatment of valve disease in the general population. Abstract P1692 Figure. Radiation-induced valvular heart disease

Quantitation of aortic valve area in aortic stenosis with multiplane transesophageal echocardiography: Comparison with monoplane transesophageal approach

1994 ◽  
Vol 128 (3) ◽  
pp. 526-532 ◽  
Author(s):  
Christophe Tribouilloy ◽  
Wei Feng Shen ◽  
Marcel Peltier ◽  
Anfani Mirode ◽  
Jean-Luc Rey ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Transesophageal Echocardiography ◽  
Aortic Valve Area ◽  
Valve Area
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