Study of aortic valve using multi slice computed tomography in patients presenting with chest pain

Objective: To determine aortic root dimensions in younger patients presenting with chest pain. Study Design: Descriptive cross sectional study Study Setting: CT Angiography Department of Armed Forces Institute of Cardiology & National Institute of Heart Diseases, Rawalpindi. Duration of study:6 months (from 12th September 2018 to 11th March 2019) Methods: MSCT angiography was performed over all the patients who met the inclusion and exclusion criteria after written informed consent .MSCT acquisition was performed in a single breath-hold of about 5–10 seconds, ECG gated synchronized data acquisition with 60-100ml contrast was done.Multiphase data sets were reconstructed followed by data analysis. Required measurements were recorded with software caliper and tracer. All data were analyzed in SPSS 23. Results: Recruited in the study were a total of 330 patients who fulfilled the inclusion criteria. Mean age (years) was45.5±7.9 and there were 236 (71.5%) male and 94 (28.5%) female patients in the study. Bicuspid aortic valve was found in 0.9%(n=3) of population whereas 99.1%(n=320) were tricuspid. The mean aortic valve area was 4.01±0.70cm2, mean aortic annular size was 21.9±2.37mm,Sinotubular junction diameter on average was found to 23.9±3.45mm, and mean sinotubular junction height was 21.09±2.77mm.The diameter at sinuses of Valsalva was found to be 33.0±3.99mm. Conclusion: The mean aortic root dimensions and general morphology of aortic valve was determined in our population to establish normal reference values, which will later help in therapeutic strategies in patients suffering from aortic valve disease. MSCT was utilized in the assessment of these parameters, also proves Continuous...

Acute liver failure in ruptured sinus of Valsalva aneurysm

A sinus of Valsalva aneurysm (SOVA) is a rare cardiac defect in which the aortic root area between the aortic annulus and the sinotubular junction is dilated. We present a case of acute liver failure (ALF) in a 21-year-old man secondary to ruptured SOVA inducing severe ischemic hepatitis. The patient presented clinically with classical ALF. The liver ultrasound reported hepatomegaly with pulsatile portal flow and dilated hepatic veins. A transthoracic echocardiogram revealed focal aneurysmal dilatation of the aortic root with flow across the aneurysm toward the right atrium and elevated right chambers pressures. The surgical repair of the non-coronary SOVA was successful, and post-operatively, liver transaminases improved, and ALF resolved. Given that ruptured SOVA can be surgically repaired, hepatologists should be aware of this diagnosis in a young patient with ALF.

Transthoracic echocardiographic reference values of the aortic root: results from the Hamburg City Health Study

Here we generate up-to-date reference values of transthoracic echocardiographic aortic root dimensions matched by sex, age, and body surface area (BSA) derived from the population-based Hamburg City Health Study (HCHS) cohort. In 1687 healthy subjects (mean age 57.1 ± 7.7, 681 male and 1006 female), derived from the first prospectively-recruited 10,000 HCHS participants, dimensions of the aortic root were measured in systole and diastole using state-of-the-art 2-dimensional transthoracic echocardiography. Diameters were assessed at four levels: aortic annulus, Sinus of Valsalva, sinotubular junction, and ascending aorta. Female sex was associated with significantly smaller absolute aortic root dimensions, while indexing for BSA resulted in a reverse effect at all levels. There was a strong age dependency of all aortic root diameters as well as aortic annulus/sinotubular junction ratio for both sexes. Multivariate analysis revealed age, sex, weight, height, and BSA to be significant determinants of aortic root size. Finally, formulas were generated for the calculation of individual aortic root reference values considering age, sex, weight, and height. We provide population-based reference values of aortic root diameters based on a standardized transthoracic echocardiographic protocol of the population-based HCHS which may support the diagnosis, monitoring, and treatment of aortic root disease.

Importance of complex blood flow in the assessment of aortic regurgitation severity using phase contrast magnetic resonance imaging

This study aimed to investigate if and how complex flow influences the assessment of aortic regurgitation (AR) using phase contrast MRI in patients with chronic AR. Patients with moderate (n = 15) and severe (n = 28) chronic AR were categorized into non-complex flow (NCF) or complex flow (CF) based on the presence of systolic backward flow volume. Phase contrast MRI was performed repeatedly at the level of the sinotubular junction (Ao1) and 1 cm distal to the sinotubular junction (Ao2). All AR patients were assessed to have non-severe AR or severe AR (cut-off values: regurgitation volume (RVol) ≥ 60 ml and regurgitation fraction (RF) ≥ 50%) in both measurement positions. The repeatability was significantly lower, i.e. variation was larger, for patients with CF than for NCF (≥ 12 ± 12% versus ≥ 6 ± 4%, P ≤ 0.03). For patients with CF, the repeatability was significantly lower at Ao2 compared to Ao1 (≥ 21 ± 20% versus ≥ 12 ± 12%, P ≤ 0.02), as well as the assessment of regurgitation (RVol: 42 ± 34 ml versus 54 ± 42 ml, P < 0.001; RF: 30 ± 18% versus 34 ± 16%, P = 0.01). This was not the case for patients with NCF. The frequency of patients that changed in AR grade from severe to non-severe when the position of the measurement changed from Ao1 to Ao2 was higher for patients with CF compared to NCF (RVol: 5/26 (19%) versus 1/17 (6%), P = 0.2; RF: 4/26 (15%) versus 0/17 (0%), P = 0.09). Our study shows that complex flow influences the quantification of chronic AR, which can lead to underestimation of AR severity when using PC-MRI.

Aortic root dimensions as a correlate for aortic regurgitation’s severity

To evaluate the prevalence of aortic regurgitation (AR) and associations between the individual aortic root components and AR severity in the general population. The study included the first 10,000 participants of the population-based Hamburg City Health Study (HCHS) of whom 8259 subjects, aged 62.23 ± 8.46 years (51.3% females), enrolled 2016–2018, provided echocardiographic data. 69 subjects with bicuspid valves and 23 subjects with moderate/severe aortic stenosis were excluded. Aortic root dimensions were measured using state-of-the-art cardiac ultrasound, including the aortic annulus, sinus of Valsalva, sinotubular junction (STJ), and ascending aorta, in diastole and systole. The distribution of AR was: 932 (11.4%) mild, 208 (2.5%) moderate, and 20 (0.24%) severe. Patients with moderate or severe AR were predominantly male at advanced age who had hypertension, coronary artery disease, atrial fibrillation, and renal dysfunction. Increasing AR severity correlated with higher absolute and indexed aortic root diameters (e.g., end-diastolic sinus of Valsalva for no-mild-moderate-severe AR in mm ± standard deviation: 34.06 ± 3.81; 35.65 ± 4.13; 36.13 ± 4.74; 39.67 ± 4.61; p < 0.001). In binary logistic regression analysis, all aortic root components showed significant associations with moderate/severe AR. Mid-systolic STJ showed the strongest association with moderate/severe AR (OR 1.33, 95% confidence interval 1.25–1.43, p < 0.001). AR was prevalent in 14.2%, of whom 2.8% showed moderate/severe AR. All assessed aortic root diameters correlated with the prevalence and severity of AR. STJ diameter had the strongest association with moderate/severe AR possibly reflecting the pathophysiological impact of an increasingly dilated STJ in the context of an ageing aorta.

Machine learning to automatically detect anatomical landmarks on phase-contrast enhanced magnetic resonance angiography

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Guala A. received funding from the Spanish Ministry of Science, Innovation and Universities Introduction The heterogeneous characteristic of the thoracic aorta implies that all biomarkers with potential for risk stratification need to be references to a specific location. This is the case, for example, of diameter [1], stiffness [2] and wall shear stress [3]. This is normally achieved by the manual identification of a limited number of key anatomic landmarks [4], which is a time-demanding task and may impact biomarkers accuracy and reproducibility. Automatic identification of these anatomic landmarks may speed-up the analysis and allow for the creation of fully automatic image analysis pipelines. Machine learning (ML) algorithms might be suitable for this task. Purpose The aim of this study was to test the performance of a ML algorithm in localizing key thoracic anatomical landmarks on phase-contrast enhanced magnetic resonance angiograms (PC-MRA). Methods PC-MRA of 323 patients with native aorta and aortic valve and a variety of aortic conditions (141 bicuspid aortic valve patients, 60 patients with degenerative aortic aneurysms, 82 patients with genetic aortopathy and 40 healthy volunteers) were included in this study. Four anatomical landmarks were manually identified on PC-MRA by an experienced researcher: sinotubular junction, the pulmonary artery bifurcation and the first and third supra-aortic vessel braches. A reinforcement learning algorithm (DQN), combining Q-learning with deep neural networks, was trained. The algorithm was tested in a separate set of 30 PC-MRA with similar distribution of aortic conditions in which human intra-observer reproducibility was quantified. The distance between points was used as quality metric and human annotation was considered as ground-truth. Repeated-measures ANOVA was used for statistical testing. Results ML algorithm resulted in performance similar to the intra-observer variability obtained by the experienced human reader in the identification of the sinotubular junction (11.1 ± 8.6 vs 11.0 ± 8.1 mm, p = 0.949) and first (6.8 ± 5.6 vs 6.6 ± 3.9 mm, p = 0.886) and third (8.4 ± 7.4 vs 6.8 ± 4.0 mm, p = 0.161) supra-aortic vessels branches. However, the algorithm did not reach human-level performance in the localization of the pulmonary artery bifurcation (15.2 ± 13.1 vs 10.2 ± 7.0 mm, p = 0.008). The time needed to the ML algorithm to locate all points ranged between 0.8 and 1.6 seconds on a standard computer while manual annotation required around two minutes to be performed. Conclusions The rapid identification of key aortic anatomical landmarks by a reinforced learning algorithm is feasible with human-level performance. This approach may thus be used for the design of fully-automatic pipeline for 4D flow CMR analysis.

Early safety performance of a modified technique of aorta replacement with sinotubular stabilization

Background We sought to determine if a modified technique for ascending aorta replacement with sinotubular junction reduction and stabilization was safe. Methods This technique was performed by suspension of the three commissures, invagination of the aortic Dacron graft and advancing the graft into the ventricles. We included patients with dilatation of the ascending aorta, normal sinuses of Valsalva dimension (<45 mm), with or without aortic annulus enlargement (>25 mm) and with various degree of aortic insufficiency (from grade 1 to 3). Results From April to October 2019, 20 patients were recruited from two centers; mean age was 66.9 ± 12.8 years, 13 were male; grade 1, 2 and 3 was present in 12, 2 and 6 patients, respectively. All patients underwent ascending aorta replacement with modified technique; an additional open subvalvular ring was used in 8 patients with aortic insufficiency ≥ 2; cusps repair was performed in 6 patients (5 plicating central stitches/1 shaving); concomitant coronary artery bypass grafting was performed in 10 patients. There was no 30-day mortality. One patient was re-explored for bleeding. All patients completed six-month follow-up; at the transthoracic echocardiography, there was no aortic insufficiency ≥ 1 except one patient with aortic insufficiency grade 1 who underwent ascending aorta replacement and subvalvular ring; no patients underwent reintervention. Conclusions This modified technique for ascending aorta replacement and sinotubular junction stabilization was safe. It could be associated with other aortic valve sparing techniques. However, such remodeling approach has to be validated in a larger cohort of patients with longer follow-up.

Bicuspid aortic valve repair: outcomes after 17 years of experience

OBJECTIVES This study presents the results of 17 years of experience with bicuspid aortic valve (BAV) repair and the analysis of factors associated with repair failure and early echocardiographic outcome. METHODS Between 2003 and 2020, a total of 206 patients [mean age: 44.5 ± 15.2 years; 152 males (74%)] with BAV insufficiency with or without aortic dilatation underwent elective aortic valve repair performed by a single surgeon with a mean follow-up of 5 ± 3.5 years. The transthoracic echocardiography examinations were reported. RESULTS There were no deaths during the hospital stay, and all but 1 patient survived the follow-up period (99.5%). Overall, 10 patients (5%) developed severe insufficiency and 2 (1%) developed aortic dilatation requiring reoperation. Freedom from reoperation at 7 years reached 91.8%. Type 2 BAV configuration [hazard ratio (HR) 3.9; 95% confidence interval (CI): 1.01–60; P = 0.049], no sinotubular junction remodelling (HR 7; 95% CI: 1.7–23; P = 0.005), no circumferential annuloplasty (HR 3.9; 95% CI: 1.01–64; P = 0.047) and leaflet resection (HR 5.7; 95% CI 1.2–13. P = 0.017) have been identified as a risk factor of redo operation. Parameters of the postoperative left ventricle reverse remodelling improved significantly early after the operation and later at 2 years evaluation. CONCLUSIONS The repair of BAV offers good short- and mid-term results providing a significant reverse left ventricular remodelling. Type 0 BAV preoperative configuration, circumferential annuloplasty and sinotubular junction remodelling are associated with better repair durability.