Sarah Ghulam Ali

Carotid stenting through the right brachial approach for left internal carotid artery stenosis and bovine aortic arch configuration.

Unfavorable complex anatomy or congenital anomalies of supra-aortic vessel take-off may increase carotid artery stenting (CAS) procedural difficulties and complications through the femoral route. We assessed the feasibility, safety, and efficacy of CAS through the right brachial approach in patients in whom left internal carotid artery stenosis and bovine aortic arch configuration were identified with computed tomography (CT) angiography. Bovine configuration of the aortic arch and left carotid artery stenosis were easily identified by CT angiography and successfully treated through the right brachial approach technique.

Feasibility and accuracy of three-dimensional transthoracic echocardiography vs. multidetector computed tomography in the evaluation of aortic valve annulus in patient candidates to transcatheter aortic valve implantation

AIMS Proper measurement of the aortic annulus (AoA) is crucial for the success of transcatheter aortic valve implantation (TAVI). Transthoracic echocardiography (TTE) is the first step to assess AoA diameter, but a two-dimensional TTE (2DTTE) measurement is no longer accepted as the sole determinant of prosthetic size. The aims of the study were to evaluate feasibility and accuracy of three-dimensional TTE (3DTTE) estimation of AoA dimensions in comparison with multidetector computer tomography (MDCT). METHODS AND RESULTS We enrolled 100 consecutive patients referred for TAVI. Feasibility of AoA evaluation was 91% for 3DTTE and in 90% for MDCT. In 81 of 100 patients, AoA maximum diameter (max-D), minimum diameter (min-D), and area were measured and compared using 2DTTE, 3DTTE, and MDCT. Image quality of 3DTTE was sufficient in 47, good in 46 and optimal in 7%. High correlations (P < 0.001) were found between MDCT and 3DTTE (max-D: r = 0.89; min-D r = 0.86; area: r = 0.93), and between MDCT and 2DTTE (min-D: r = 0.81; area 0.78). The 3DTTE measurements were found to be highly reproducible on intra- and interobserver variability analyses. Regarding the choice of prosthesis size, agreement between 3DTTE and MDCT was very good (k = 0.84, P < 0.001) while it was poor between 2DTTE and MDCT (k = 0.36, P < 0.001). CONCLUSIONS 3DTTE may be a valid imaging alternative in patients unsuitable for MDCT during the preoperative evaluation for TAVI. Evaluation of AoA through 3DTTE is feasible, and measurements closely approximate those of MDCT thus improving TTE accuracy in identifying the correct prosthesis size.

Dysfunction of bileaflet aortic prosthesis: Accuracy of echocardiography versus fluoroscopy

OBJECTIVES The authors sought to investigate the accuracy of transthoracic echocardiography (TTE)-derived parameters in the identification of bileaflet aortic prosthesis dysfunction, compared with fluoroscopy (FL). BACKGROUND Identification of bileaflet aortic prosthesis dysfunction is challenging, because high mean pressure gradient (MPG >20 mm Hg) is not proof of prosthetic obstruction (AVPO), and may be due to prosthesis-patient mismatch (PPM). Conversely, high gradients may not be manifest in AVPO and low cardiac output. METHODS TTE and FL were prospectively performed in 100 nonconsecutive patients with bileaflet aortic prosthesis. TTE included the estimation of MPG, indexed effective orifice area (EOAi), Doppler velocity index (DVI), intraprosthetic regurgitation, acceleration time (AT), ejection time (ET), AT/ET, and the difference (dA) between the expected prosthetic orifice area and EOA. FL allowed the calculation of opening and closing angles, and the discrimination of AVPO from normal (NL) and PPM. RESULTS On the basis of FL examination and MPG and EOAi at TTE, patients were classified as NL (42%), PPM (32%), and AVPO (26%). High MPG (>20 mm Hg) was present in 65% of the patients, with higher values in PPM (36 ± 8 mm Hg) and AVPO (43 ± 16 mm Hg) than in NL (16 ± 6 mm Hg). DVI was reduced in PPM (0.30 ± 0.05) and AVPO (0.25 ± 0.04) compared with NL (0.42 ± 0.09). In AVPO, dA (0.59 ± 0.32 cm(2)), AT (108 ± 20 ms), and AT/ET (0.35 ± 0.05) significantly differed from NL (dA = -0.12 ± 0.43 cm(2), AT = 74 ± 15 ms, AT/ET = 0.25 ± 0.05) and PPM (dA = 0.15 ± 0.24 cm(2), AT = 78 ± 13 ms, AT/ET = 0.26 ± 0.04). Moderate or severe intraprosthetic regurgitation was observed only in AVPO. All considered TTE-derived parameters were found related to obstruction, and dA (accuracy = 87%), AT (94%), and AT/ET (89%) showed the highest accuracy in discriminating normofunctioning prostheses from AVPO. CONCLUSIONS In the presence of high MPG, TTE parameters play a key role in aortic prosthesis examination. Especially time indices and dA add to the functional assessment of prosthetic aortic valves. However, the TTE discrimination between AVPO and PPM may be suboptimal, and fluoroscopy is a complementary and essential diagnostic step.

Prevalence of Calcification of the Mitral Valve Annulus in Patients Undergoing Surgical Repair of Mitral Valve Prolapse

Factors correlating to mitral annulus calcification (MAC) include risk factors predisposing to atherosclerosis. In patients with mitral valve (MV) prolapse (MVP), other anatomic or mechanical factors have been supposed to facilitate MAC. The aims of this study were, in patients with MVP undergoing MV repair, (1) to describe the prevalence and characteristics of MAC, (2) to correlate MAC with clinical risk factors, coronary involvement, and aortic valve disease, and (3) to describe prevalence, site, and extension of MAC in fibroelastic deficiency (FED) versus Barlows disease (BD) and correlate MAC to surgical outcomes (repair vs replacement). In 410 consecutive patients with MVP suitable for surgical MV repair, detailed clinical and echocardiographic data were collected to characterize MAC in BD and FED. MAC was found in 99 patients (24%). Age, female gender, coronary artery disease, and cardiovascular risk factors were correlated with MAC. MAC was equally distributed in FED and BD groups despite patients with FED being older with more cardiovascular risk factors. The most common localization of MAC was annular involvement adjacent to P2 (75%), P1 (31%), and P3 (35%). The presence of MAC affected surgical outcomes in both groups (8% patients with MAC underwent replacement after a first attempt of repair vs 3% without MAC). MAC is a common finding in patients undergoing MV repair, and several clinical characteristics correlate with MAC either in FED or BD. In conclusion, despite very high percentage of repairability, MAC influences surgical outcomes and very detailed echo evaluation is advocated.

Feasibility and Accuracy of Automated Software for Transthoracic Three-Dimensional Left Ventricular Volume and Function Analysis: Comparisons with Two-Dimensional Echocardiography, Three-Dimensional Transthoracic Manual Method, and Cardiac Magnetic Resonance Imaging

Background Recently, a new automated software package (HeartModel) was developed to obtain three‐dimensional (3D) left ventricular (LV) volumes using a model‐based algorithm (MBA) with a “one‐button” simple system and user‐adjustable slider. The aims of this study were to verify the feasibility and accuracy of the MBA in comparison with other commonly used imaging techniques in a large unselected population, to evaluate possible accuracy improvements of free operator border adjustments or changes of the sliders default position, and to identify differences in method accuracy related to specific pathologies. Methods This prospective study included consecutive 200 patients. LV volumes and ejection fraction were obtained using the MBA and compared with the two‐dimensional biplane method, the 3D full‐volume (3DFV) modality, and, in 90 of 200 cases, cardiac magnetic resonance (CMR) measurements. To evaluate the optimal position of the slider with respect to the 3DFV and CMR modalities, a set of threefold cross‐validation experiments was performed. Optimized and manually corrected LV volumes obtained using the MBA were also tested. Linear correlation and Bland‐Altman analysis were used to assess intertechnique agreement. Results Automatic volumes were feasible in 194 patients (94.5%), with a mean processing time of 29 ± 10 sec. MBA‐derived volumes correlated significantly with all evaluated methods, with slight overestimation of two‐dimensional biplane and slight underestimation of CMR measurements. Higher correlations were found between MBA and 3DFV measurements, with negligible differences both in volumes (overestimation) and in LV ejection fraction (underestimation), respectively. Optimization of the user‐adjustable slider position improved the correlation and markedly reduced the bias between the MBA and 3DFV or CMR. The accuracy of MBA volumes was lower in some pathologies for incorrect definition of LV endocardium. Conclusions The MBA is highly feasible, reproducible, and rapid, and it correlates highly with the traditional 3DFV method. It may represent a valid alternative to 3DFV measurement for everyday clinical use. HighlightsThe authors analyzed the feasibility and accuracy of a new echocardiographic 3D automatic MBA for LV volume and functional evaluation.The new automatic method was applied in a large population and enabled LV volume and LVEF measurements in a few seconds.The authors tested and found the best setting of the slider position for the automatic definition of LV wall borders, optimizing correlation between the new method and 3D traditional full‐volume or CMR.

Patients selection for MitraClip: Time to move to transthoracic echocardiographic screening?

echocardiographic screening? Paola Gripari , Francesco Maffessanti ⁎, Gloria Tamborini , Manuela Muratori , Laura Fusini , Sarah Ghulam Ali , Cristina Ferrari , Francesco Alamanni , Antonio L. Bartorelli , Cesare Fiorentini , Mauro Pepi a a Centro Cardiologico Monzino, IRCCS, Milan, Italy b Department of Clinical Sciences and Community Health — Cardiovascular Section, University of Milan, Milan, Italy

Randomized trial of predilation versus direct stenting for treatment of carotid artery stenosis

BACKGROUND A controversial aspect of carotid artery stenting (CAS) is the placement of a stent with or without predilation. The study was designed to test the hypothesis that direct stenting (DS) was not inferior to CAS with predilation. METHODS Elective CAS with filter protection was performed in 205 consecutive, unselected patients with carotid artery stenosis (>50% if symptomatic and > or =75% if asymptomatic by Doppler assessment) who were randomly assigned to CAS with predilation (n=100) or direct stenting (DS, n=105). Filter and stent selection were left to the operators discretion. The study end-point was the angiographic success, defined as < or =30% angiographic residual stenosis after CAS without abnormal angiographic findings in cerebral circulation and without cross-over to predilation in the DS group. RESULTS At baseline, patient clinical characteristics and stenosis anatomic features did not differ between groups. Angiographic success was 99% and 97%, p=0.33, in predilation and DS, respectively. No cross-over to predilation occurred in the DS group. Procedural time was shorter in DS as compared to predilation (24.3+/-7% versus 19.9+/-6%, p=0.001) and visible debris were more frequently captured in predilation as compared to DS (50% versus 36%, p=0.003). No peri-procedural and 30-day death or major stroke occurred in both groups. Minor stroke and TIA rates were similar in either group (2% versus 0% and 8% versus 5.7%, p=ns, respectively). CONCLUSION In an unselected, consecutive series of patients submitted to CAS, DS is a feasible technique and is not inferior to CAS with predilation.

Five-year echocardiographic follow-up after TAVI: structural and functional changes of a balloon-expandable prosthetic aortic valve

Aims Scarce data are available on the long-term structural and functional changes of prosthetic valves after transcatheter aortic valve implantation (TAVI). The objective was to evaluate with echocardiography the long-term structural and functional changes of prosthetic valves after TAVI. Methods and results Structural valve deterioration (SVD) was defined as leaflet thickening ≥3mm, presence of calcification and abnormal leaflet motion. Five-year echocardiographic follow-up was available in 96 out of 318 patients who underwent TAVI with a balloon-expandable device between April 2008 and December 2011. At 1-year follow-up, no patient showed SVD. At 5-year follow-up, SVD were observed in 29 (30%) patients who showed also a significant reduction of aortic valve area (AVA) together with an increase of mean and peak aortic pressure gradients at the latest echocardiography evaluation. Moreover, rate of central aortic valve regurgitation ≥2 was higher in SVD patients as compared to those without SVD, while there was no difference in terms of paravalvular regurgitation. Despite SVD, one patient only reached the criteria for severe stenosis and no reintervention was needed at 5-year follow-up. Variables independently associated with SVD were female sex, small body surface area, use of a 23 mm valve, and small AVA at pre-discharge echocardiogram. Conclusion At 5-year follow-up, 30% of patients who underwent TAVI with a balloon-expandable valve showed initial SVD. However, SVD was not associated with severe stenosis in most of the patients and had no significant impact on and clinical outcome.

Right ventricular dimensions and function: Why do we need a more accurate and quantitative imaging?

The right ventricle plays an important role in the morbidity and mortality of patients presenting with symptoms and signs of cardiopulmonary disease. This cardiac chamber has a unique crescent shape, which adds complexity to the quantification of its size and function. Until recently, little uniformity in echocardiographic imaging of the right heart existed because of a lack of familiarity with various techniques, and the enormous attention directed towards left heart quantification. Three-dimensional (3D) echocardiography, a major technological breakthrough in the field of cardiovascular imaging, provides several advantages over two-dimensional (2D) imaging in the quantitative evaluations of right ventricle because of its independence from any geometrical assumption. In this review, we focus on the contribution of this new modality to the evaluation of right ventricle.

Direct closure of an asymptomatic right coronary sinus of Valsalva aneurysm

A 52-year-old man was referred for evaluation of palpitation. Transthoracic echocardiography revealed an extracardiac aneurysm of the right coronary sinus of Valsalva, and normal anatomy of the aortic valve with no regurgitation. Three-dimensional computed tomography confirmed the aneurysm with a diameter of 21 × 13.7 mm arising from the right coronary sinus of Valsalva under the right coronary artery. Surgical repair was performed without changing the normal anatomy of the aortic valve, preserving the right coronary ostium. Intraoperative and postoperative echocardiography showed complete closure of the aneurysm with normal functioning of the aortic valve.