Adam Berger

Incidence and Severity of Paravalvular Aortic Regurgitation With Multidetector Computed Tomography Nominal Area Oversizing or Undersizing After Transcatheter Heart Valve Replacement With the Sapien 3 : A Comparison With the Sapien XT

OBJECTIVES This study sought to compare the influence of the extent of multidetector computed tomography (MDCT) area oversizing on the incidence of paravalvular aortic regurgitation (PAR) between the Sapien 3 and the Sapien XT transcatheter heart valve (THV) to define a new MDCT sizing guideline suitable for the Sapien 3 platform. BACKGROUND The inverse relationship of PAR occurrence and oversizing has been demonstrated for the Sapien XT but the incidence of PAR with comparable oversizing with the Sapien 3 is not known. METHODS Sixty-one prospectively enrolled patients who underwent transcatheter aortic valve replacement with the Sapien 3 THV were compared with 92 patients who underwent transcatheter aortic valve replacement with the Sapien XT THV. Patients were categorized depending on the degree of MDCT area oversizing percentage: undersizing (below 0%), 0% to 5%, 5% to 10%, and above 10%. The primary endpoint was mild or greater PAR on transthoracic echocardiography. RESULTS Mild or greater PAR was present in 19.7% of patients (12 of 61) in the Sapien 3 group and in 54.3% of patients (50 of 92) in the Sapien XT group (p < 0.01). The Sapien 3 group, compared with the Sapien XT group, consistently demonstrated significantly lower rates of mild or greater PAR except for oversizing >10% (p for interaction = 0.54). Moderate or severe PAR rates were also lower in the Sapien 3 group than in the Sapien XT group (3.3% vs. 13.0%, p = 0.04). In the Sapien 3 group, a MDCT area oversizing percentage value of ≤4.17% was identified as the optimal cutoff value to discriminate patients with or without mild or greater PAR. CONCLUSIONS Our retrospective analysis suggests that the Sapien 3 THV displays significantly lower rates of PAR than does the Sapien XT THV. A lesser degree of MDCT area oversizing may be employed for this new balloon-expandable THV.

Mitral Annular Dimensions and Geometry in Patients With Functional Mitral Regurgitation and Mitral Valve Prolapse : Implications for Transcatheter Mitral Valve Implantation

OBJECTIVES The aims of this study were to determine D-shaped mitral annulus (MA) dimensions in control subjects without significant cardiac disease and in patients with moderate to severe mitral regurgitation (MR) being considered for transcatheter mitral therapy and to determine predictors of annular size, using cardiac computed tomography. BACKGROUND The recently introduced D-shaped method of MA segmentation represents a biomechanically appropriate approach for annular sizing prior to transcatheter mitral valve implantation. METHODS Patients who had retrospectively gated cardiac computed tomography performed at our institution (2012 to 2014) and were free of significant cardiac disease were included as controls (n = 88; 56 ± 11 years of age; 47% female) and were compared with patients with moderate or severe MR due to functional mitral regurgitation (FMR) (n = 27) or mitral valve prolapse (MVP) (n = 32). MA dimensions (projected area, perimeter, intercommissural, and septal-to-lateral distance), maximal left atrial (LA) volumes, and phasic left ventricular volumes were measured. RESULTS MA dimensions were larger in patients with FMR or MVP compared with controls (area index 4.7 ± 0.6 cm(2)/m(2), 6.0 ± 1.3 cm(2)/m(2), and 7.3 ± 1.7 cm(2)/m(2); perimeter index 59 ± 5 mm/m(2), 67 ± 9 mm/m(2), and 75 ± 10 mm/m(2); intercommissural distance index 20.2 ± 1.9 mm/m(2), 21.2 ± 3.1 mm/m(2), and 24.7 ± 3.2 mm/m(2); septal-to-lateral distance index 14.8 ± 1.6, 18.1 ± 3.3, and 19.5 ± 3.4 mm/m(2) in controls and patients with FMR and MVP, respectively; p < 0.05 between controls and MR subgroups). Absolute MA area was 18% larger in patients with MVP than patients with FMR (13.0 ± 2.9 cm(2) vs. 11.0 ± 2.3 cm(2); p = 0.006). Although LA and left ventricular volumes were both independently associated with MA area index in controls and patients with MVP, only LA volume was associated with annular size in patients with FMR. CONCLUSIONS Moderate to severe MR was associated with increased MA dimensions, especially among patients with MVP compared with control subjects without cardiac disease. Moreover, unlike in controls and patients with MVP, annular enlargement in FMR was more closely associated with LA dilation.

Sequential Right and Left Ventricular Assessment in Posttetralogy of Fallot Patients with Significant Pulmonary Regurgitation.

BACKGROUND The natural history of right ventricular (RV) and left ventricular (LV) size and function among adults with tetralogy of Fallot (TOF) repair and hemodynamically significant pulmonary regurgitation (PR) is not known. The main aim of this study was to determine changes in RV and LV size and function over time in an adult population with TOF repair and hemodynamically significant pulmonary regurgitation. METHODS Forty patients with repaired TOF and hemodynamically significant PR were included. These patients were identified on the basis of having more than one CMR between January 2008 and 2015. Patients with a prosthetic pulmonary valve or any cardiac intervention between CMR studies were excluded. Rate of progression (ROP) of RV dilation was determined for both indexed right ventricular end-systolic volume (RVESVi) and indexed right ventricular end-diastolic volume (RVEDVi), and calculated as the difference between the last and first volumes divided by the number of years between CMR#1 and CMR#2. Subjects were also divided into two groups based on the distribution of the ROP of RV dilation: Group I-rapid ROP (>50th percentile) and Group II-slower ROP (≤50th percentile). RESULTS The interval between CMR#1 and CMR#2 was 3.9 ± 1.7 years (range 1-8 years). We did find a significant change in RVEDVi and RVESVi over this time period, although the magnitude of change was small. Nine patients (23%) had a reduction in right ventricular ejection fraction (RVEF) by greater than 5%, 13 patients (33%) had an increase in RVEDVi by greater than 10 mL/m2 and seven patients (18%) had an increase in RVESVi by greater than 10 mL/m2 . Median ROP for RVEDVi was 1.8 (range -10.4 to 21.8) mL/(m2 year); RVESVi 1.1 (range -5.8 to 24.5) mL/(m2 year) and RVEF -0.5 (range -8 to 4)%/year. Patients with a rapid ROP had significantly larger RV volumes at the time of CMR#1 and lower RVEF as compared to the slow ROP group. There was no overall significant change in LVEDVi, LVESVi, or LVEF over this time period. CONCLUSIONS We have demonstrated, in a small population of patients with hemodynamically significant PR, that there is a small increase in RV volumes and decrease in RVEF over a mean 4-year period. We believe it to be reasonable practice to perform CMR at least every 4 years in asymptomatic patients with repaired TOF and hemodynamically significant PR. We found that LV volumes and function remained stable during the study period, suggesting that significant progressive LV changes are less likely to occur over a shorter time period. Our results inform a safe standardized approach to monitoring adults with hemodynamically significant PR post TOF repair and assist in planning allocation of this expensive and limited resource.

DOES PROGNOSIS CHANGE DEPENDING ON NUMBER AND COMPOSITION OF NON OBSTRUCTIVE PLAQUES? RESULTS FROM THE MULTINATIONAL CORONARY CT ANGIOGRAPHY EVALUATION FOR CLINICAL OUTCOME: AN INTERNATIONAL MULTICENTER REGISTRY (CONFIRM)

Obstructive coronary artery disease (CAD) has worse prognosis compare to non-obstructive CAD. However, non-obstructive plaques have been implicated in pathophysiology of sudden cardiac death and myocardial infarction (MI). It is not known whether there is an incremental risk of major adverse cardiac

LONG-TERM PROGNOSTIC VALUE OF CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY FINDINGS FOR ASYMPTOMATIC INDIVIDUALS: A 6-YEAR FOLLOW-UP OF 1,226 ASYMPTOMATIC INDIVIDUALS FROM THE PROSPECTIVE MULTICENTER INTERNATIONAL CONFIRM STUDY

The long-term prognostic benefit of coronary computed tomographic angiography (CCTA) findings of coronary artery disease (CAD) in asymptomatic population is unknown. From the prospective multicenter international CONFIRM long-term study (N=17,181), we evaluated asymptomatic subjects without known

INFLUENCE OF LEFT VENTRICULAR GEOMETRY AND BODY-SURFACE AREA ON MITRAL ANNULUS DIMENSIONS: ASSESSMENT BY COMPUTED TOMOGRAPHY

Kurzfassung: Die kardiale Schnittbilddiagnostik hat sich in der letzten Dekade rasant weiterentwickelt. In der Computertomographie (CT) sind in erster Linie eine Erhöhung der Anzahl der Detektorzeilen und damit ein größerer Abdeckungsbereich sowie eine Verkürzung der Rotationszeiten zu nennen. Dadurch hat sich die Bildqualität und insbesondere die diagnostische Genauigkeit deutlich gesteigert, denn die Mehrschicht-Computertomographie (MSCT) erlaubt eine präzise Quantifizierung von Koronarkalk basierend auf verschiedenen technologischen Verfahren (Volume Score, Mass Score, Agatston Score). Durch den methodischen Vorteil der CT-Koronarangiografie (CTA) zur Visualisierung der Koronargefäße stellt sie ein zur invasiven Katheterangiografie konkurrierendes Verfahren da. Die CTA ermöglicht unter anderem die Darstellung der Morphologie der Gefäßwand und damit verbundener Plaqueanalyse. Darüber hinaus kann ohne invasive Angiographie eine manifeste, asymptomatische KHK mit Wandkalzifikationen durchaus erfasst werden. Dies hat dazu geführt, dass die CTA der Koronararterien regelmäßig von Radiologen und Kardiologen in der klinischen Routine eingesetzt wird. Die Untersuchung ist allerdings mit einer Strahlenbelastung verbunden. Konsekutiv wurden technischen Neuerungen entwickelt, wie z.B. die iterative Rekonstruktion, prospektive EKG-Triggerung in Spiral-CT-Technik oder ein sog. “step-and-shot-Modus”, um die mit der Untersuchung verbundene Strahlenbelastung erheblich zu reduzieren. Allgemein sollte die Indikation zur CTA kritisch geprüft werden und eignet sich nicht bei jedem kardialen Krankheitsbild. Dies soll im Folgenden detailliert erläutert werden.

Use of Multidetector Computed Tomography for Planning Transcatheter Aortic Valve Sizing

Computed tomography (CT) has an increasingly important role in transcatheter aortic valve replacement (TAVR), offering noninvasive three-dimensional measurements of the aortic annulus which are used for transcatheter heart valve (THV) sizing. Accurate valve sizing is vital to reduce the risk of complications with TAVR, particular paravalvular aortic regurgitation, aortic annular rupture, and coronary occlusion. In this chapter, we review the anatomy of the aortic annulus, the historical move towards three-dimensional annular measurement, how to incorporate these measurements into valve sizing, and future perspectives of CT-based valve sizing.