Three-dimensional volumetric measurement of the aortic root compared to standard two-dimensional measurements using cardiac computed tomography.

INTRODUCTION: Two-dimensional measurements are self-evidently limited when seeking accurately to represent the three-dimensional complexity of the aortic root. Volumetric measurement, therefore, seems an ideal alternative for a more accurate assessment. MATERIALS AND METHODS: We retrospectively analyzed 123 individuals undergoing cardiac computed tomography. We measured the dimensions of the sinuses of Valsalva using routine multiplanar short axis imaging. Three conventional two-dimensional methods were applied to measure the dimensions of the sinuses. These involved bisecting center of sinus-to-center of interleaflet triangle measures, along with center of sinus-to-center of sinus, and largest sinus-to-sinus measurements. We then quantified the volumes of the root using the volume-rendering method. RESULTS: The mean dimensions of the sinuses were significantly greater when measured using the largest sinus-to-sinus method as opposed to center of sinus-to-center of interleaflet triangle and center of sinus-to-center of sinus methods (33.6 ± 3.6 mm vs. 31.1 ± 3.1 mm and 30.9 ± 3.3 mm, p < .0001). The mean root volume of 13.6 ± 4.2 ml showed the strongest correlation with the mean dimensions of the sinuses of Valsalva measured using the bisecting method (R2 = .8401, p < .0001). CONCLUSIONS: By using two- and three-dimensional measurements, we have provided average data for the structurally normal aortic root. The differences and correlations encountered should be noted when evaluating and following changes in the diseased root.

Lesion characteristics between cryoballoon ablation and radiofrequency ablation with a contact force-sensing catheter: Late-gadolinium enhancement magnetic resonance imaging assessment.

BACKGROUND: Pulmonary vein isolation (PVI) lesions after cryoballoon ablation (CBA) are characterized as a wider and more continuous than that after conventional radiofrequency catheter ablation (RFCA) without the contact force (CF)-sensing technology. However, the impact on the lesion characteristics of ablation with a CF-sensing catheter has not been well discussed. We sought to assess the lesions using late-gadolinium enhancement magnetic resonance imaging (LGE-MRI) and to compare the differences between the two groups (CB group vs. RF group). METHODS: A total of 30 consecutive patients who underwent PVI were enrolled (CB group, 18; RF group, 12). The RF applications were delivered with a target lesion size index (LSI) of 5. The PVI lesions were assessed by LGE-MRI 3 months after the PVI. The region around the PV was divided into eight segments: roof, anterior-superior, anterior carina, anterior inferior, bottom, posterior inferior, posterior carina, and posterior superior segment. The lesion width and visual gap of each segment were compared between the two groups. The visual gaps were defined as no-enhancement site of >4 mm. RESULTS: The mean LSI was 4.7 ± 0.7. The lesion width was significantly wider but the visual gaps were more frequently documented at the bottom segment of right PV in the CBA group (lesion width: 8.1 ± 2.2 vs. 6.3 ± 2.2 mm; p = .032; visual gap at the bottom segment or right PV: 39% vs. 0%; p = .016). CONCLUSIONS: The PVI lesion was wider after CBA, while the visual gaps were fewer after RFCA with a CF-sensing catheter.

Ascending aortic elongation and correlative change in overall configuration of the proximal aorta in elderly patients with severe aortic stenosis.

BACKGROUND: Configurational changes in the proximal aorta are relevant to the procedural difficulty of transcatheter aortic valve implantation (TAVI). Among several morphological changes involving the ascending aorta, elongation is characteristics of elderly patients with aortic stenosis and can compromise the success and safety of TAVI. However, the effect of ascending aortic elongation on the overall morphology of the proximal aorta has not been established. AIMS: Our primary purpose was to investigate the effect of ascending aortic elongation on structural changes in the proximal aorta in TAVI candidates. MATERIALS & METHODS: In total, 121 consecutive patients with severe aortic stenosis (mean age, 84.5 ± 5.3 years; 69% women) who had undergone preprocedural computed tomography before TAVI were enrolled. We examined the structural anatomy of the proximal aorta in detail, focusing on its elongation, dilatation, tilting, rotation, and wedging. RESULTS: The mean length of the ascending aorta was 68.0 ± 9.2 mm, and the length was significantly correlated with dilatation (R = .278, p = .002), rightward tilting (R = .437, p < .001), clockwise rotation (R = .228, p = .018), and deep wedging (R = -.366, p < .001) of the proximal aorta. Elongation of the ascending aorta was correlated with dilatation, rightward tilting, clockwise rotation, and deep wedging of the proximal aorta in an elderly population with severe aortic stenosis. DISCUSSION: Appreciation of the clinical anatomy around the proximal aorta is required for clinicians involved in TAVI to estimate the procedural difficulty. CONCLUSION: Elongation of the ascending aorta was associated with dilatation, rightward tilting, clockwise rotation, and deep wedging of the proximal aorta.

Living Anatomy of the Ventricular Myocardial Crescents Supporting the Coronary Aortic Sinuses.

The aortic valvar sinuses are supported, in part, by ventricular myocardium, so-called myocardial crescents. We elucidated individual variation in the extent of the myocardial support. We assessed the extent of the crescents in 84 patients who underwent cardiac computed tomography. We measured their maximal width, their extent within the circumference of the aortic root, and the influence of rotation of the root itself within the ventricular base. The maximal widths, and rotational locations, of the crescents supporting the base of the left coronary aortic sinus were significantly smaller than those supporting the right coronary aortic sinus (2.9 ± 0.8 mm vs 6.4 ± 1.2 mm, P < 0.001; 54.2 ± 12.0° vs 70.4 ± 13.5°, P < 0.001, respectively). Overall, 42.7 ± 4.3% of the circumference of the virtual basal ring was supported by myocardium as opposed to fibrous tissue. Clockwise rotation of the aortic root was correlated with a decrease in the extent of myocardial crescent supporting the left coronary aortic sinus, but an increase in the myocardial support of the right coronary aortic sinus (R2 = 0.3899 and R2 = 0.2752, P < 0.001). Clockwise rotation of the root was correlated in negative fashion with the ratio of its myocardial as opposed to fibrous support (R2 = 0.0527, P = 0.0356). The extent of myocardial support of the left coronary aortic sinus, on average, is less than that of the right coronary aortic sinus. This difference becomes greater when the aortic root is rotated in clockwise fashion.

Visualization of Inflammation After Cryoballoon Ablation in Atrial Fibrillation Patients　- Protocol for Proof-of-Concept Feasibility Trial.

Background: Atrial fibrosis and inflammation play important roles in perpetuating and initiating atrial fibrillation (AF). Although the fibrotic area can be visualized as a delayed enhancement area on late gadolinium enhancement magnetic resonance imaging (LGE-MRI), atrial inflammation has not yet been visualized on any imaging modality. We describe the protocol for a feasibility study to visualize atrial inflammation on positron emission tomography/MRI (PET/MRI). Methods and Results: This is a single-arm, prospective, open-label proof-of concept trial, involving AF patients after cryoballoon ablation (CBA). A total of 30 paroxysmal AF patients will be enrolled and undergo simultaneous PET/MRI for the assessment of regional 18F-fluorodeoxyglucose (18F-FDG) uptake 1 day after the CBA. Furthermore, LGE-MRI will be performed before CBA, and at 1 and 4 weeks after assessing the regional LGE area. The main outcome measures will be (1) the feasibility of imaging inflammation in the left atrium on PET/MRI; and (2) the safety of the intervention. Conclusions: There are few data on the visualization of atrial inflammation using PET/MRI. Establishing the visualization methodology will contribute to elucidating the fundamental histopathologic findings of the progress to fibrosis, and to the planning and execution of a larger definitive trial to test the usefulness of PET/MRI.

Predominant Involvement of the Aortic Root in a Patient with Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis: Congestive Heart Failure due to Subacute Severe Aortic Regurgitation and Reversible Conduction Disturbance.

A 72-year-old woman was referred to our institution with decompensated congestive heart failure owing to subacute severe aortic regurgitation and mitral regurgitation. Her blood sample tested positive for myeloperoxidase anti-neutrophil cytoplasmic antibody (ANCA). Cardiac computed tomography revealed abnormal thickening and shortening of the aortic valvar leaflets as well as wall thickening of the sinuses of Valsalva. Based on the diagnosis of ANCA-associated vasculitis, predominantly involving the aortic root, prednisolone administration was initiated, which failed to improve the valvar dysfunction. The patient underwent aortic root replacement and mitral annuloplasty. Histopathology confirmed severe inflammation involving both the aortic valvar sinuses and leaflets.

Localized basal left ventricular dyssynchrony induced by manifest accessory pathway: Successful differentiation from cardiac involvement of sarcoidosis with administration of flecainide acetate.

We present a patient with non-cardiac sarcoidosis complicated with manifest ventricular preexcitation. Initially, cardiac involvement of sarcoidosis was suspected from the echocardiographic findings showing localized hypokinesia at the left ventricular basal inferior wall. We, however, considered that the hypokinesia was a preexcitation-induced mechanical dyssynchrony rather than cardiac sarcoidosis, because polarities of the delta-waves indicated a left ventricular inferior accessory pathway. Temporal administration of oral flecainide acetate eliminated the basal left ventricular motion abnormality. Accordingly, we could successfully differentiate the mechanism of hypokinesia. In this context, we could rule out cardiac sarcoidosis, and initiation of glucocorticoid therapy was reasonably withheld.

Three-Dimensional Understanding of Complexity of the Aortic Root Anatomy as the Basis of Routine Two-Dimensional Echocardiographic Measurements.

BACKGROUND: Because the aortic root anatomy is too complicated to evaluate only with 2D methodology, precise appreciation of its 3D anatomy is a prerequisite for all cardiologists and cardiac surgeons.Methods and Results:We provide comprehensive image panels reconstructed from CT datasets to understand the complexity of the aortic root by focusing on the representative longitudinal sections cut through the central zone of coaptation. CONCLUSIONS: The provided images will accelerate profound understanding of the 2D long-axis image of the aortic root commonly interrogated with 2D echocardiography, as well as correlated clinical measured values, including the geometric height, effective height, and coaptation length.

Lesion distribution after cryoballoon ablation and hotballoon ablation: Late-gadolinium enhancement magnetic resonance imaging analysis.

INTRODUCTION: Pulmonary vein isolation (PVI) lesions after cryoballoon ablation (CBA) are wide and continuous, however, the distribution can depend on the pulmonary vein (PV) size. We sought to assess the relationship between the lesion distribution and PV size after CBA and hotballoon ablation (HBA). METHODS AND RESULTS: A total of 80 consecutive patients who underwent PVI were enrolled (40 with CBA). The lesions were visualized by late-gadolinium enhancement magnetic resonance imaging. The lesion width, lesion gaps, and distance from the PV ostium (PVos) to distal lesion edge (DLE) were assessed. If the DLE extended inside the PV, the value was expressed as a negative value. Although the lesion width was significantly wider in the CB group (7.8 ± 2.0 vs 4.9 ± 1.0 mm, P < .001), the number of lesion gaps was significantly less in the HB group (2.9 ± 2.4 vs 1.3 ± 1.4 gaps, P = .001). The distance from the PVos to DLE was a negative value in both groups, but the impact was significantly greater (-1.5 ± 1.8 vs -0.2 ± 1.2 mm, P < .001) and negatively correlated with PV size in the CB group, but not in HB group (r = -0.27, P = .007). The AF recurrence 12 months after the procedure did not differ (5 [12.5%] of 40 in the CB group vs 4 [10%] of 40 in the HB group, P = .695). CONCLUSIONS: The PVI lesions after HBA were characterized by (a) narrower, but (b) more continuous, (c) smaller lesion inside the PV, and (d) irrespective of PV size as compared to that after CBA.

Percutaneous Pericardiocentesis With the Anterior Approach: Demonstration of the Precise Course With Computed Tomography.

OBJECTIVES: This study aimed to confirm the precise course of a pericardiocentesis with the anterior approach using post-procedural computed tomography (CT). BACKGROUND: Percutaneous epicardial ventricular tachycardia (VT) ablation has been increasingly performed. Although the inferior approach has been the common method, the feasibility of the anterior approach has subsequently been reported. However, the precise course of the anterior approach has not been presented. METHODS: An epicardial ablation with the anterior approach was performed in 15 patients. At the end of the procedure, the epicardial sheath was exchanged for a drainage tube to monitor bleeding. Of those patients, in 9 procedures in 8 patients a CT scan was performed just after the procedure to confirm the course of the drainage tube and to rule out any complications. Epicardial ablation was indicated for a failed endocardial VT ablation in 7 patients and epicardial substrate modification in 1 patient with Brugada syndrome. RESULTS: Volume-rendered images reconstructed from CT demonstrated each course of the drainage tubes and their relation to the surrounding organs. These images revealed that the tube had a curved trace, and did not penetrate the diaphragm or pass through the abdominal cavity. No injury to the surrounding organs was detected in any of the cases. CONCLUSIONS: The precise course of the drainage tube placed along the trajectory of the anterior approach was able to be confirmed using post-procedural CT images. These images support the safety and feasibility of the anterior approach from the anatomic standpoint with a low incidence of abdominal viscera injury.

Circumferential extent of thinning of the basal muscular ventricular septum in a case of cardiac sarcoidosis.

Focal thinning of the basal muscular ventricular septum is a characteristic morphological finding in cases of cardiac sarcoidosis, usually detected on the parasternal long-axis image during echocardiography. Surprisingly, however, its circumferential extent has rarely been demonstrated and discussed. We present a case showing typical thinning of the basal ventricular septum. The extent of circumferential wall thinning was evaluated using both echocardiography and cardiac computed tomography. The present case highlights the importance of detailed multiplanar and three-dimensional evaluation of this characteristic abnormality, more so because its mechanism as well as the precise impact on conduction has not yet been elucidated.

A case of acute heart failure due to myocardial infiltration of mycosis fungoides.

Mycosis fungoides (MF) has been reported to be the most common cutaneous lymphoma with a good prognosis and myocardial infiltration is clinically rare. We hereby report a case of rapidly progressing acute heart failure due to myocardial infiltration by MF. Perfusion cardiac magnetic resonance imaging (MRI) demonstrated a massive perfusion defect in the left ventricle (LV) where multiple nodular enhancement areas by delayed enhancement MRI could be documented in the postero-lateral wall of the LV, which resulted in a deterioration of the LV function and mitral regurgitation. Autopsy confirmed the myocardial infiltration by the MF, which corresponded with the MRI findings. .

Serial observation of electrocardiographic responses to corticosteroid therapy in a patient with right ventricular-predominant cardiac sarcoidosis.

Predominant or isolated right ventricular involvement in cardiac sarcoidosis is uncommon, but should always be considered in a case of right ventricular hypertrophy combined with ventricular arrhythmia and/or conduction disturbance. Although improvement in right ventricular hypertrophy and atrioventricular conduction disturbance following corticosteroid therapy has been reported, the detailed serial electrocardiographic responses during corticosteroid therapy, as well as temporal changes in the electrocardiographic, biochemical, and morphological responses, have not been reported. We describe the clinical course and supportive imaging findings of reversible right ventricular hypertrophy and cardiac conduction disturbance in a case of right ventricular-predominant cardiac sarcoidosis.

Focal Myocardial Damage in Cardiac Sarcoidosis Characterized by Strain Analysis on Magnetic Resonance Tagged Imaging in Comparison with Fluorodeoxyglucose Positron Emission Tomography Accumulation and Magnetic Resonance Late Gadolinium Enhancement.

OBJECTIVE: The aims of this study were to characterize focal myocardial damage of cardiac sarcoidosis by strain analysis and to compare it with late gadolinium enhancement (LGE) and fluorodeoxyglucose (FDG) positron emission tomography. METHODS: We reviewed 208 segments from 13 cardiac sarcoidosis patients and measured the circumferential strain (Ecc) and the strain change per second (Ecc rate). The mean Ecc and Ecc rate values were compared between the FDG(+) and FDG(-), and the LGE(+) and LGE(-) segments using Welch's t test. RESULTS: The peak and max Ecc rates were better in the LGE(-) segments than in the LGE(+) segments (-11.8 vs -8.9%, 40.5 vs 29.7%/s, both P < 0.001). The max Ecc rate was higher in the FDG(-) segments than in the FDG(+) segments (39.2 vs 31.7%/s, P < 0.001), but the peak Ecc did not differ between the FDG(+) and FDG(-) segments (-11.2 vs -10.1%, P = 0.17). CONCLUSIONS: Strain analysis could reveal focal myocardial damage in the FDG(+) or the LGE(+) segments.

The lesion characteristics assessed by LGE-MRI after the cryoballoon ablation and conventional radiofrequency ablation.

Background: Rhythm outcomes after the pulmonary vein isolation (PVI) using the cryoballoon (CB) are reported to be excellent. However, the lesions after CB ablation have not been well discussed. We sought to characterize and compare the lesion formation after CB ablation with that after radiofrequency (RF) ablation. Methods: A total of 42 consecutive patients who underwent PVI were enrolled (29 in the CB group and 13 in the RF group). The PVI lesions were assessed by late gadolinium enhancement magnetic resonance imaging 1-3 months after the PVI. The region around the PVs was divided into eight segments: roof, anterior-superior, anterior-carina, anterior-inferior, bottom, posterior-inferior, posterior-carina, and posterior-superior segment. The lesion width and lesion gap in each segment were compared between the two groups. Lesion gaps were defined as no-enhancement sites of >4 mm. Results: As compared to the RF group, the overall lesion width was significantly wider and lesion gaps significantly fewer at the anterior-superior segment of the left PV (LAS) and anterior-inferior segment of the right PV (RAI) in the CB group (lesion width: 8.2 ± 2.2 mm vs 5.6 ± 2.0 mm, P = .001; lesion gap at LAS: 7% vs 38%, P = .02; lesion gap at RAI: 7% vs 46%, P = .006). Conclusions: The PVI lesions after CB ablation were characterized by extremely wider and more continuous lesions than those after RF ablation.

Optimal reconstruction of left ventricular outflow tract obstruction before surgical myectomy in a case with hypertrophic obstructive cardiomyopathy.

We present optimally reconstructed three-dimensional computed tomography images of left ventricular outflow obstruction, comprehensive left ventriculography, and comparable intraoperative transesophageal echocardiography, as well as serial operative pictures, to facilitate the understanding of live-heart anatomy of hypertrophic obstructive cardiomyopathy. As shown in this case, detailed morphological analysis around the left ventricular outflow tract using preoperative computed tomography would be feasible and useful. The present case highlights the importance of obtaining complete three-dimensional information present in the acquired computed tomography dataset because computed tomography is not entirely noninvasive or free of radiation exposure and contrast material.

Relationship between the membranous septum and the virtual basal ring of the aortic root in candidates for transcatheter implantation of the aortic valve.

Knowledge of the anatomy of the membranous septum, as a surrogate to the location of the atrioventricular conduction axis, is a prerequisite for those undertaking transcatheter implantation of the aortic valve (TAVI). Equally important is its relationship of the virtual basal ring. This feature, however, has yet to be adequately described in the living heart. We analyzed computed tomographic angiographic datasets from 107 candidates (84.1 ± 5.2 years, 68% women) for TAVI. Using multiplanar reconstructions, we measured the height and width of the membranous septum, and the distances of its superior and inferior margins from the virtual basal ring plane. We also assessed the extent of wedging of the aortic root between the mitral valve and the ventricular septum. Mean heights and widths of the membranous septum were 6.6 ± 2.0, and 10.2 ± 3.1 mm, respectively, with its size significantly associated with that of the aortic root (P < 0.05). Its superior and inferior margins were 4.5 ± 2.3 and 2.1 ± 2.1 mm, respectively, from the plane of the basal ring. The inferior distance, the surrogate for the adjacency of the atrioventricular conduction axis, was ≤ 5mm in 91% of the patients. Deeper wedging of the aortic root was independently correlated with a shorter inferior distance (ß = 0.0569, P = 0.0258). The membranous septum is appreciably closer to the virtual basal ring than previously appreciated. These findings impact on estimations of the risk of damage to the atrioventricular conduction axis during TAVI. Clin. Anat. 31:525-534, 2018. © 2018 Wiley Periodicals, Inc.

The first case of "locked-in leaflet" after transcatheter aortic valve replacement in a patient with bicuspid aortic stenosis.

This case report is about an 85-year-old woman with bicuspid aortic stenosis (AS). Although preoperative multimodality imaging showed challenging anatomical aspects, transcatheter aortic valve replacement (TAVR) was selected to be performed as a less invasive alternative treatment approach, owing to her comorbidity. Postoperative transesophageal echocardiography and multidetector-row computed tomography revealed the presence of "locked-in leaflet" caused by stent distortion due to pinching by calcified native leaflets, with nodular calcification preventing the full expansion of the valve, which resulted in moderate perivalvular leakage. This is the first reported case of bicuspid AS treated with TAVR that eventually resulted in "locked-in leaflet."