Automatic Aortic Valve Cusps Segmentation from CT Images Based on the Cascading Multiple Deep Neural Networks

Accurate morphological information on aortic valve cusps is critical in treatment planning. Image segmentation is necessary to acquire this information, but manual segmentation is tedious and time consuming. In this paper, we propose a fully automatic aortic valve cusps segmentation method from CT images by combining two deep neural networks, spatial configuration-Net for detecting anatomical landmarks and U-Net for segmentation of aortic valve components. A total of 258 CT volumes of end systolic and end diastolic phases, which include cases with and without severe calcifications, were collected and manually annotated for each aortic valve component. The collected CT volumes were split 6:2:2 for the training, validation and test steps, and our method was evaluated by five-fold cross validation. The segmentation was successful for all CT volumes with 69.26 s as mean processing time. For the segmentation results of the aortic root, the right-coronary cusp, the left-coronary cusp and the non-coronary cusp, mean Dice Coefficient were 0.95, 0.70, 0.69, and 0.67, respectively. There were strong correlations between measurement values automatically calculated based on the annotations and those based on the segmentation results. The results suggest that our method can be used to automatically obtain measurement values for aortic valve morphology.

Mural Endocarditis and Embolic Pneumonia Due to Trueperella pyogenes in an Adult Cow with Ventricular Septal Defect

Bacterial endocarditis represents one of the most frequently acquired cardiac diseases in adult cattle. Congenital heart diseases as a ventricular septal defect can facilitate bacterial endocarditis as a consequence of turbulent blood flow through the defect, causing damage to the endocardium. We describe a case of mural endocarditis associated with a ventricular septal defect in an eight-year-old female Holstein Friesian cow. The cow’s history revealed that she had presented dysorexia and a sudden decrease of milk production in the last 10 days prior to the examination. On clinical examination, jugular pulses, tachycardia with irregular heart rate and tachypnea with harsh bronchovesicular sounds were evident. Electrocardiographic examination allowed the diagnosis of an atrial fibrillation with high ventricular response rate. Transthoracic echocardiography revealed a large vegetation originating from the endocardium between the tricuspid and pulmonic valves in the right ventricle outflow. On post-mortem examination, a small muscular septal defect under the right coronary cusp of the aortic valve and a mural vegetative endocarditis were found. An abscess in the chondro-costal junction of the third right rib and metastatic pneumonia were also observed. This case report describes a rare consequence of a small ventricular septal defect that had not been previously diagnosed in an adult cow.

Percutaneous closure of ventricular septal defect using LifeTechTM Konar-MF VSD Occluder: initial and short-term multi-institutional results

Background: Transcatheter ventricular septal defect closure remains a complex procedure with potential complications like complete heart block and aortic regurgitation. The ideal device design for such intervention is still evolving. Aim: To assess the safety, efficacy, and short-term outcome of ventricular septal defect closure using LifeTechTM multifunctional (KONAR-MFTM) VSD Occluder. Patients and methods: In a multicenre study, 44 patients with haemodynamically significant, restrictive ventricular septal defects underwent closure with the KONAR-MFTM device from April, 2019 to March, 2020. Clinical, echocardiographic, and angiographic data were collected and reviewed. Patients were followed up at 1, 3, 6, and 12 months. Results: The median age and weight were 8 (1.7–36) years and 20 (11–79) kg. Of 44 patients, 8 (18%) had a high muscular and 36 (82%) had a perimembranous defect, of which 6 had mild prolapse of the right coronary cusp. The median ventricular septal defect size was 8.8 (3.9–13.4) mm. A retrograde approach was adopted in 39 (88.6%) patients. Nine patients (20.5%) had a small residual leak and there was a slight increase in aortic regurgitation in one patient. One device, which embolised to pulmonary artery was retrieved, and the defect was closed with a larger device. At a median follow-up of 13 (5–18) months, the residual leak persisted in 1 (2.3%) patient. Mild aortic regurgitation in one patient remained unchanged. There were no major complications. Conclusion: Percutaneous closure of ventricular septal defect using KONAR-MFTM device is safe and effective in short and midterm follow-up including selected patients with perimembranous defect and mild prolapse of the right coronary cusp.

Nonsurgical Management of a Papillary Fibroelastoma of the Aortic Valve

We report the case of a 63-year-old woman who had an incidental echocardiographic diagnosis of papillary fibroelastoma (PFE) of the right coronary cusp of the aortic valve. The patient was informed about the embolic risk due to the pedunculated mass located on the aortic valve but she refused the proposed surgical removal. She was followed up yearly, and each follow-up included an echocardiographic evaluation of the mass. The lady is taking lysine acetylsalycilate 160 mg daily, and after more than 19 years later, she does not complain any symptoms or complications as a result of possible embolic episodes. If on one hand, our report is provocative for PFE nonsurgical management; on the other, we do believe that in symptomatic patients PFE located in the left heart chambers, the standard of care remains surgical excision after diagnosis. Anyway, our analysis shows that further data in this issue are needed in asymptomatic patients, and surgical indication should be proposed considering carefully the risk-benefit balance.

Selective Proximal Left Anterior Fascicle Pacemapping for Guiding narrow QRS Premature Ventricular Complex ablation from the Right Coronary Cusp

Premature ventricular complexes (PVC) ablation has increased over the past decades. The morphology of PVCs arising from left anterior fascicle (LAF) is typically a right bundle branch block-like morphology with an inferior axis showing a qR or qRs complex in the inferior leads and an rS or RS complex in leads I and aVL. We describe the case of a 38 years old woman with symptomatic, high burden PVCs, despite of beta blockers treatment. The PVC’s ECG morphology suggested an origin in the LAF. This case illustrates how ablation from the right coronary cusp for PVC arising from the LAF could be accurately guided by pace-mapping. At this location, pacing at different outputs can result in both a selective and a non-selective capture of the left anterior fascicle.

Etiologies of Hemodynamically Significant Aortic Regurgitation and Coronary Cusp Bending: Evaluation by Transesophageal Echocardiography

Background: While the number of patients with aortic regurgitation (AR) has been increasing in the aging society, its etiologies remain to be fully elucidated. Methods: We studied consecutive 126 patients with chronic moderate or severe AR who underwent TEE. After the study subjects were divided into 2 groups by the age of 65 years, AR etiology was examined in each group. Results: In the older group (n = 85), cusp bending was the most frequent cause of AR (48.2%), and right coronary cusp (RCC) was the most common (90.2%). In the younger group (n=41), bicuspid valve was the most frequent cause (36.5%), and cusp bending was less frequent (16.5%). Multivariate analysis revealed that age was the only factor associated with cusp bending. Conclusion: Cusp bending of RCC was the most frequent etiology of AR in the elderly. Because AR caused by cusp bending has a possibility to be mended by aortic plasty, it is important to detect it by TEE especially in the older patients.

Double Vessel Coronary Angioplasty in a Patient with Anomalous Single Coronary Artery Arising from the Right Cusp and Premature Atherosclerotic Coronary Artery Disease: A Case Report and Review of the Literature

We report a rare case of a 39-year-old male who presented with acute inferior wall myocardial infarction (IWMI). Coronary angiography revealed an anomalous single coronary artery arising from the right coronary cusp. Premature atherosclerotic coronary artery disease (CAD) with critical stenosis in the mid right coronary artery (RCA), proximal posterior left ventricular (PLV) artery, and distal left circumflex (LCX) artery was detected during angiography. The patient managed successfully by percutaneous coronary interventions (PCI) with drug-eluting stents (DESs) by radial approach.