Thomas A. Foley

Three-dimensional Physical Modeling: Applications and Experience at Mayo Clinic

Radiologists will be at the center of the rapid technologic expansion of three-dimensional (3D) printing of medical models, as accurate models depend on well-planned, high-quality imaging studies. This article outlines the available technology and the processes necessary to create 3D models from the radiologists perspective. We review the published medical literature regarding the use of 3D models in various surgical practices and share our experience in creating a hospital-based three-dimensional printing laboratory to aid in the planning of complex surgeries.

CT and MR Imaging of the Mitral Valve: Radiologic-Pathologic Correlation

Computed tomography (CT) and magnetic resonance (MR) imaging are increasingly important adjuncts to echocardiography for the evaluation of mitral valve disease. The mitral valve may be involved in various acquired or congenital conditions with resultant regurgitation or stenosis, and many of these conditions can be identified with CT or MR imaging. In addition, CT is useful for detecting and monitoring postoperative complications after mitral valve repair or replacement. As the use of CT and MR imaging increases, awareness of the CT and MR imaging appearances of the normal mitral valve and the various disease processes that affect it may foster recognition of unsuspected mitral disease in patients undergoing imaging for other purposes. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.306105518/-/DC1.

CT and MRI assessment of the aortic root and ascending aorta.

OBJECTIVE We provide an outline of aortic anatomy and disease patterns, describe methods of aortic measurement, and highlight measurement thresholds for surgical intervention. We also discuss findings that can assist in preoperative planning and in detecting underlying connective tissue disorders. CONCLUSION A standardized approach to the measurement of the aorta is needed and features suggestive of an underlying connective tissue disorder should be recognized. Radiologists should be aware of the image limitations and clinical implications of reported measurements.

Computed Tomography of Cardiac Pseudotumors and Neoplasms

Important features of cardiac masses can be clearly delineated on cardiac computed tomography (CT) imaging. This modality is useful in identifying the presence of a mass, its relationship with cardiac and extracardiac structures, and the features that distinguish one type of mass from another. A multimodality approach to the evaluation of cardiac tumors is advocated, with the use of echocardiography, CT imaging and magnetic resonance imaging as appropriately indicated. In this article, various cardiac masses are described, including pseudotumors and true cardiac neoplasms, and the CT imaging findings that may be useful in distinguishing these rare entities are presented.

Tricuspid Valve Replacement: A Percutaneous Transfemoral Valve-in-Ring Approach.

We describe a percutaneous transcatheter tricuspid valve-in-ring implantation using the Sapien XT prosthesis (Edward Lifesciences, Irvine, California) [(1,2)][1]. A 68-year-old woman with rheumatic heart disease and 2 previous sternotomies including tricuspid valve repair with a 32-mm Carpentier-

Percutaneous Pulmonary Valve Implantation in a Native Outflow Tract: 3-Dimensional DynaCT Rotational Angiographic Reconstruction and 3-Dimensional Printed Model

A 15-year-old girl with D-transposition of the great arteries presented with combined neo-pulmonary stenosis and regurgitation following arterial switch operation as a neonate and neo-pulmonary valvectomy at 6 years of age. Echocardiography revealed right ventricular enlargement and severe neo-

Sex-related differences in calcific aortic stenosis: correlating clinical and echocardiographic characteristics and computed tomography aortic valve calcium score to excised aortic valve weight

AIMS Calcific aortic valve stenosis (AS) is purportedly associated with less calcium burden in women than in men. We sought to examine sex-related differences and correlates of surgically excised aortic valve weight (AVW) in pure AS. METHODS AND RESULTS Clinical and echocardiographic characteristics of 888 consecutive patients who underwent aortic valve replacement for severe AS were correlated to AVW, and in 126 patients, AVW was also correlated to computed tomography aortic valve calcium (AVC) score. Women and men had similar indexed valve area (0.42 ± 0.09 vs. 0.42 ± 0.07 cm (2)/m(2), P = 0.95) and mean systolic gradient (53 ± 15 vs. 52 ± 13 mmHg, P = 0.11), but women had higher New York Heart Association class (2.63 ± 0.70 vs. 2.50 ± 0.70, P = 0.01) and less prevalent coronary artery disease (38 vs. 52%, P < 0.0001). Aortic valve weight was lower in women (1.94 ± 0.88 vs. 3.08 ± 1.32 g, P < 0.0001) even when indexed to body surface area (1.09 ± 0.48 vs. 1.48 ± 0.62 g/m(2), P < 0.0001) or left ventricular outflow tract (LVOT) area (0.54 ± 0.23 vs. 0.71 ± 0.29 g/cm(2), P < 0.0001). Using multivariate analysis, male sex (P < 0.0001), bicuspid valve (P < 0.0001), and larger LVOT area (P < 0.0001) were the major determinants of increased AVW, along with current cigarette smoking (P = 0.007). Diabetes (P = 0.004) and hypertension (P = 0.03) were independently associated with lower AVW. Aortic valve calcium correlated well with AVW (r = 0.81, P < 0.0001) and was lower in women than in men (2520 ± 1199 vs. 3606 ± 1632 arbitrary units, P < 0.0001). CONCLUSIONS Despite the same degree of AS severity, women have less AVC and lower AVW compared with men, irrespective of valve morphology. Aortic valve calcium is correlated to excised AVW. Hypertension, diabetes, and current cigarette smoking were independently associated with AVW.

The role of imaging, deliberate practice, structure, and improvisation in approaching surgical perfection

From the Departments of Cardiovascular Surgery, Urology, and Radiology, Mayo Clinic, Rochester, Minn; Jazz Impact Appreciative Inquiry Consulting, New York, NY; Department of Psychology, Florida State University, Tallahassee, Fla; and Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Received for publication Dec 5, 2016; revisions received March 14, 2017; accepted for publication April 3, 2017; available ahead of print May 26, 2017. Address for reprints: Joseph A. Dearani, MD, Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (E-mail: jdearani@mayo.edu). J Thorac Cardiovasc Surg 2017;154:1329-36 0022-5223/

Imaging Pandora's Box: Incidental Findings in Elderly Patients Evaluated for Transcatheter Aortic Valve Replacement

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.04.045

Transthoracic Echocardiography versus Computed Tomography for Ascending Aortic Measurements in Patients with Bicuspid Aortic Valve

OBJECTIVE To determine the frequency and clinical impact of noncardiovascular incidental findings (IFs) detected on preoperative computed tomographic angiography (CTA) of the chest/abdomen/pelvis performed in elderly patients with severe aortic stenosis being considered for transcatheter aortic valve replacement (TAVR). PATIENTS AND METHODS The CTA studies for 424 consecutive patients being evaluated for TAVR between January 1, 2009, through January 24, 2012, were reviewed for noncardiovascular IFs (62.0% male; median ± SD age, 82 ± 8.3 years). The electronic medical record was reviewed to assess for subsequent clinical management and survival. RESULTS Potentially pathologic IFs (PPIFs) were present in 285 patients (67.2%). The mean ± SD number of PPIFs per patient was 1.1 ± 1.0 (range, 0-4). Factors associated with higher numbers of PPIFs were reduced ejection fraction (P=.02) and history of smoking (P=.06). Potentially pathologic incidental findings prompted clinical work-up in 39 patients (9.2%) and delayed or canceled treatment plans for aortic stenosis in 7 patients (1.7%). The number needed to image to diagnose a new malignancy or medical condition was 19. The number of PPIFs was predictive of poor overall survival before (hazard ratio, 1.58; 95% CI, 1.31-1.88) and after (hazard ratio, 1.45; 95% CI, 1.19-1.76) adjustment for baseline clinical variables (P<.001 for both). CONCLUSION This investigation found that PPIFs are common in elderly patients undergoing TAVR-CTA scans and, once discovered, commonly generate further clinical evaluation. Higher numbers of PPIFs may be predictive of poorer survival, but further study is required to guide the appropriateness of pursuing diagnostic evaluations for asymptomatic PPIFs in this elderly population.