Discordance between 2D and 4D flow in the assessment of pulmonary regurgitation severity: a right ventricular remodeling follow-up study.

OBJECTIVES: Pulmonary regurgitation (PR) is common in adult congenital heart disease (ACHD). 2D phase contrast MRI is the reference method for the quantification of PR and helps in the decision of pulmonary valve replacement (PVR). 4D flow MRI can be an alternative method to estimate PR but more validation is still needed. Our purpose was to compare 2D and 4D flow in PR quantification using the degree of right ventricular remodeling after PVR as the reference standard. METHODS: In 30 adult patients with a pulmonary valve disease recruited between 2015 and 2018, PR was assessed using both 2D and 4D flow. Based on the clinical standard of care, 22 underwent PVR. The pre PVR estimate of PR was compared using the post-operative decrease in right ventricle end-diastolic volume on follow-up exam as reference. RESULTS: In the overall cohort, regurgitant volume (Rvol) and regurgitant fraction (RF) of PR measured by 2D and 4D flow were well correlated but with moderate agreement in the overall cohort (r = 0.90, mean diff. -14 ± 12.5 mL; and r = 0.72, mean diff. -15 ± 13%; all p < 0.0001). Correlations between Rvol estimates and right ventricle end-diastolic volume decrease after PVR was higher with 4D flow (r = 0.80, p < 0.0001) than with 2D flow (r = 0.72, p < 0.0001). CONCLUSIONS: In ACHD, PR quantification from 4D flow better predicts post-PVR right ventricle remodeling than that from 2D flow. Further studies are needed to evaluate the added value of this 4D flow quantification for guiding replacement decision. KEY POINTS: • Using 4D flow MRI allows a better quantification of pulmonary regurgitation in adult congenital heart disease than 2D flow when taking right ventricle remodeling after pulmonary valve replacement as a reference. • A plane positioned perpendicular to the ejected flow volume as allowed by 4D flow provides better results to estimate pulmonary regurgitation.

Volumetric Analysis of Progressive Remodeling of Isolated Mesenteric Artery Dissection Treated by Conservative Therapy.

PURPOSE: To characterize remodeling of conservatively treated isolated mesenteric artery dissection (IMAD) using 3-dimensional (3D) volumetric analysis. MATERIAL AND METHODS: Patients with Type I/II (classification of Yun) treated by conservative therapy between January 2018 and January 2020 were prospectively included. Semiautomatic morphological analysis of the superior mesenteric artery (SMA) included volumetric measurements of the true lumen (TL), false lumen (FL), and overall lumen (OL) and 3D aortomesenteric angles from computed tomography angiography data at admission (T0), 1 month (T1), and 12 months (T12). The SMA morphology of patients with IMAD (n = 15, mean age 53 years ± 7; 87% men) was also compared with that of control individuals (n = 51, mean age 56 years ± 4; 94% men). RESULTS: A significant reduction in OL volume was observed (P <.001), whereas TL volume remained stable (P =.23). The TL/OL volume ratio significantly increased over time (P =.001) from 53% at T1 to 78% at T12. Aortomesenteric 3D angles at 2, 4, and 6 cm from the ostium showed a progressive decrease toward values observed in the control group (P =.013, P =.002, and P =.027, respectively). At T12, 5 patients (33%) had complete remodeling, and aneurysmal change was observed in 2 patients (<20 mm). Smoking and SMA angle at a distance of 6 cm from the ostium (T0) were the only factors affecting remodeling negatively at T12. CONCLUSIONS: One-year remodeling in IMAD followed an overall decrease in OL volume related to a decrease in FL volume. Smokers and patients with larger SMA angles at baseline showed poorer remodeling. Spontaneous arterial remodeling in IMAD might favor conservative therapy.

Association of calcium density in the thoracic aorta with risk factors and clinical events.

OBJECTIVES: In the ascending aorta, calcification density was independently and inversely associated with cardiovascular disease (CVD) risk prediction. Until now, the density of thoracic aorta calcium (TAC) was estimated as the Agatston score divided by the calcium area (DAG). We thought to analyze TAC density in a full Hounsfield unit (HU) range and to study its association with TAC volume, traditional risk factors, and CVD events. METHODS: Non-enhanced CT images of 1426 patients at intermediate risk were retrospectively reviewed. A calcium density score was estimated as the average of the maximum HU attenuation in all calcified plaques of the entire thoracic aorta (DAV). RESULTS: During a mean 4.0 years follow-up, there were 26 events for a total of 674 patients with TAC > 0. TAC volume and DAV were positively correlated (R = 0.72). The median DAV value was 457 HU (IQ 323-603 HU) and was exponentially related to DAG (R = 0.86). DAV was inversely associated with systolic pressure (p < 0.05), pulse pressure (p < 0.01), hypertension (p < 0.05), and 10-year FRS (p < 0.001) after adjusting for TAC volume. When TAC volume and DAV were included in a logistic model, a significant improvement was shown in CVD risk estimation beyond coronary artery calcium (CAC) (AUC = 0.768 vs 0.814, p < 0.05). In multivariable Cox models, TAC volume and DAV showed an independent association with CVD. CONCLUSIONS: In intermediate risk patients, TAC density was inversely associated with several risk factors after adjustment for TAC volume. A significant improvement was observed over CAC when TAC volume and density were added into the risk prediction model. KEY POINTS: • Calcifications in the aorta can be non-invasively assessed using CT images • A higher calcium score is associated with a higher cardiovascular risk • Measuring the calcifications size and the density separately can improve the risk prediction.

Urinary Bladder Matrix Scaffolds Promote Pericardium Repair in a Porcine Model.

Pericardium closure after cardiac surgery is recommended to prevent postoperative adhesions to the sternum. Synthetic materials have been used as substitutes, with limited results because of impaired remodeling and fibrotic tissue formation. Urinary bladder matrix (UBM) scaffolds promote constructive remodeling that more closely resemble the native tissue. The aim of the study is to evaluate the host response to UBM scaffolds in a porcine model of partial pericardial resection. Twelve Landrace pigs were subjected to a median sternotomy. A 5 × 7 cm pericardial defect was created and then closed with a 5 × 7 cm multilayer UBM patch (UBM group) or left as an open defect (control group). Animals were survived for 8 wk. End points included gross morphology, biomechanical testing, histology with semiquantitative score, and cardiac function. The UBM group showed mild adhesions, whereas the control group showed fibrosis at the repair site, with robust adhesions and injury to the coronary bed. Load at failure (gr) and stiffness (gr/mm) were lower in the UBM group compared with the native pericardium (199.9 ± 59.2 versus 405.3 ± 99.89 g, P = 0.0536 and 44.23 ± 15.01 versus 146.5 ± 24.38 g/mm, P = 0.0025, respectively). In the UBM group, the histology resembled native pericardial tissue, with neovascularization, neofibroblasts, and little inflammatory signs. In contrast, control group showed fibrotic tissue with mononuclear infiltrates and a lack of organized collagen fibers validated with a histologic score. Both groups had normal ultrasonography results without cardiac motility disorders. In this setting, UBM scaffolds showed appropriate features for pericardial repair, restoring tissue properties that could help reduce postsurgical adhesions and prevent its associated complications.

Biomechanical Features of Reinforced Esophageal Hiatus Repair in a Porcine Model.

Recurrence rates in the laparoscopic repair of the hiatal hernia range from 12% to 59%. Limitation of reinforcement has been principally the risk of adverse events caused by synthetic materials. Biologic and resorbable synthetic materials are valid alternatives. This study compares the host response to all these materials after hiatal hernia repair. A total of 20 Landrace pigs, underwent laparoscopic primary hiatal hernia repair and reinforced with a polypropylene mesh (PROLENE: polypropylene [PP]), an absorbable synthetic scaffold (GOREBIO-A: polyglycolic acid [PGA]), a urinary bladder matrix scaffold, (Gentrix: urinary bladder matrix [UBM]), or without reinforcement, control group (C). Animals were survived for 3 months. Endpoints included gross morphology, biomechanical testing, and histology. Pigs in PP and PGA groups showed fibrosis at the repair site, with robust adhesions. In UBM and C groups, only mild adhesions were found. Load at failure (gr) and stiffness (gr/mm) of PP were higher than C group (PP:2103 ± 548.3 versus C:951.1 ± 372.7, P = 0.02; PP:643.3 ± 301 versus C:152.6 ± 142.7, P = 0.01). PGA and UBM values for both parameters were in between PP and C samples. However, stiffness in UBM was tended to be lower than PP group, and approached a significant difference (643.3 ± 301 versus 243 ± 122.1, P = 0.0536). In UBM group, the histology resembled native tissue. By contrast, PP and PGA groups showed mononuclear infiltrates, fibroencapsulation, necrosis, remnants of mesh, and disorganized tissue that was validated with a histologic score. In this setting, UBM scaffolds showed the most appropriate features for hiatal hernia repair, recovering the tissue properties that can help reduce the possibility of early failure and prevent complications associated with the implanted material.

Analysis of aortic pressure fields from 4D flow MRI in healthy volunteers: Associations with age and left ventricular remodeling.

BACKGROUND: Aging-related arterial stiffness is associated with substantial changes in global and local arterial pressures. The subsequent early return of reflected pressure waves leads to an elevated left ventricular (LV) afterload and ultimately to a deleterious concentric LV remodeling. PURPOSE: To compute aortic time-resolved pressure fields of healthy subjects from 4D flow MRI and to define relevant pressure-based markers while investigating their relationship with age, LV remodeling, as well as tonometric augmentation index (AIx) and pulse wave velocity (PWV). STUDY TYPE: Retrospective. POPULATION: Forty-seven healthy subjects (age: 49.5 ± 18 years, 24 women). FIELD STRENGTH/SEQUENCE: 3 T/4D flow MRI. ASSESSMENT: Spatiotemporal pressure fields were computed by integrating velocity-derived pressure gradients using Navier-Stokes equations, while assuming zero pressure at the sino-tubular junction. To quantify aortic pressure spatiotemporal variations, we defined the following markers: 1) volumetric aortic pressure propagation rates ΔP E1 /ΔV and ΔP E2 /ΔV, representing variations of early and late systolic relative pressure peaks along the aorta, respectively, according to the cumulated aortic volume; 2) ΔA PE1-PE2 defined in four aortic regions as the absolute difference between early and late systolic relative pressure peaks amplitude. STATISTICAL TESTS: Linear regression, Wilcoxon rank sum test, Bland-Altman analysis, and intraclass correlation coefficients (ICC). RESULTS: Spatiotemporal variations of aortic pressure peaks were moderately to highly reproducible (ICC ≥0.50) and decreased significantly with age, in terms of absolute magnitude: ΔP E1 /ΔV (r = 0.70, P < 0.005), ΔP E2 /ΔV (r = -0.45, P < 0.005) and ΔA PE1-PE2 (|r| > 0.39, P < 0.005). ΔP E1 /ΔV was associated with LV remodeling (r = 0.53, P < 0.001) and ascending aorta ΔA PE1-PE2 was associated with AIx (r = -0.59, P < 0.001). Both associations were independent of age and systolic blood pressures. Only weak associations were found between pressure indices and PWV (r ≤ 0.40). DATA CONCLUSION: 4D flow MRI relative aortic pressures were consistent with physiological knowledge as demonstrated by their significant volumetric and temporal variations with age and their independent association with LV remodeling and augmentation index. Level of Evidence 2 Technical Efficacy Stage 3 J. Magn. Reson. Imaging 2019;50:982-993.

Comparison of different methods for the estimation of aortic pulse wave velocity from 4D flow cardiovascular magnetic resonance.

BACKGROUND: Arterial pulse wave velocity (PWV) is associated with increased mortality in aging and disease. Several studies have shown the accuracy of applanation tonometry carotid-femoral PWV (Cf-PWV) and the relevance of evaluating central aorta stiffness using 2D cardiovascular magnetic resonance (CMR) to estimate PWV, and aortic distensibility-derived PWV through the theoretical Bramwell-Hill model (BH-PWV). Our aim was to compare various methods of aortic PWV (aoPWV) estimation from 4D flow CMR, in terms of associations with age, Cf-PWV, BH-PWV and left ventricular (LV) mass-to-volume ratio while evaluating inter-observer reproducibility and robustness to temporal resolution. METHODS: We studied 47 healthy subjects (49.5 ± 18 years) who underwent Cf-PWV and CMR including aortic 4D flow CMR as well as 2D cine SSFP for BH-PWV and LV mass-to-volume ratio estimation. The aorta was semi-automatically segmented from 4D flow data, and mean velocity waveforms were estimated in 25 planes perpendicular to the aortic centerline. 4D flow CMR aoPWV was calculated: using velocity curves at two locations, namely ascending aorta (AAo) and distal descending aorta (DAo) aorta (S1, 2D-like strategy), or using all velocity curves along the entire aortic centreline (3D-like strategies) with iterative transit time (TT) estimates (S2) or a plane fitting of velocity curves systolic upslope (S3). For S1 and S2, TT was calculated using three approaches: cross-correlation (TTc), wavelets (TTw) and Fourier transforms (TTf). Intra-class correlation coefficients (ICC) and Bland-Altman biases (BA) were used to evaluate inter-observer reproducibility and effect of lower temporal resolution. RESULTS: 4D flow CMR aoPWV estimates were significantly (p < 0.05) correlated to the CMR-independent Cf-PWV, BH-PWV, age and LV mass-to-volume ratio, with the strongest correlations for the 3D-like strategy using wavelets TT (S2-TTw) (R = 0.62, 0.65, 0.77 and 0.52, respectively, all p < 0.001). S2-TTw was also highly reproducible (ICC = 0.99, BA = 0.09 m/s) and robust to lower temporal resolution (ICC = 0.97, BA = 0.15 m/s). CONCLUSIONS: Reproducible 4D flow CMR aoPWV estimates can be obtained using full 3D aortic coverage. Such 4D flow CMR stiffness measures were significantly associated with Cf-PWV, BH-PWV, age and LV mass-to-volume ratio, with a slight superiority of the 3D strategy using wavelets transit time (S2-TTw).

Automatic correction of background phase offset in 4D-flow of great vessels and of the heart in MRI using a third-order surface model.

OBJECTIVE: To evaluate an automatic correction method for velocity offset errors in cardiac 4D-flow acquisitions. MATERIALS AND METHODS: Velocity offset correction was done in a plane-by-plane scheme and compared to a volumetric approach. Stationary regions were automatically detected. In vitro experiments were conducted in a phantom using two orientations and two encoding velocities (Venc). First- to third-order models were fit to the time-averaged images of the three velocity components. In vivo experiments included realistic ROIs in a volunteer superimposed to a phantom. In 15 volunteers, blood flow volume of the proximal and distal descending aorta, of the pulmonary artery (Qp) and the ascending aorta (Qs) was compared. RESULTS: Offset errors were reduced after correction with a third-order model, yielding residual phantom velocities below 0.6 cm/s and 0.4% of Venc. The plane-by-plane correction method was more effective than the volumetric approach. Mean velocities through superimposed ROIs of a volunteer vs phantom were highly correlated (r2 = 0.96). The significant difference between proximal and distal descending aortic flows was decreased after correction from 8.1 to - 1.4 ml (p < 0.001) and Qp/Qs reduced from 1.08 ± 0.09 to 1.01 ± 0.05. DISCUSSION: An automatic third-order model corrected velocity offset errors in 4D-flow acquisitions, achieving acceptable levels for clinical applications.

Urinary bladder matrix scaffolds strengthen esophageal hiatus repair.

BACKGROUND: Laparoscopic repair of the hiatal hernia is associated with a recurrence rate between 12% and 42% depending on the defect size. Although the impact of hiatal reinforcement on long-term recurrence remains controversial, the main limitation of this approach has been the risk of adverse events related with the use of synthetic materials in the vicinity of the esophagus. METHODS: A total of 14 female domestic pigs underwent laparoscopic primary hiatal hernia repair of a simulated defect in the esophageal hiatus. Seven of the hiatal repairs were reinforced with an extracellular matrix (ECM) scaffold, whereas the remaining seven served as primary repair controls. Animals were survived for 8 wk. At necropsy, after gross morphologic evaluation, samples were sent for mechanical testing and histology. RESULTS: The repaired defect site reinforced with ECM scaffolds showed a robust closure of the crura in all cases with a smooth peritoneal-like structure covering the entire repair. Average load at failure of the treated group was found to be significantly stronger than that of the controls (185.8 ± 149.7 g versus 57.5 ± 57.5 g, P < 0.05). Similarly, the stiffness was significantly higher in the treated animals (57.5 ± 26.9 g/mm versus 19.1 ± 17.5 g/mm; P < 0.01). Interestingly, there was no difference in elongation at failure (7.62 ± 2.02 mm versus 7.87 ± 3.28 mm; P = 0.44). CONCLUSIONS: In our animal survival model, we have provided evidence that the addition of an ECM to augment a primary hiatal repair leads to tissue characteristics that may decrease the possibility of early failure of the repair. This may translate to decreased recurrence rates. Further study is necessary.

Stroke and Neurodegeneration Induce Different Connectivity Aberrations in the Insula.

BACKGROUND AND PURPOSE: Stroke and neurodegeneration cause significant brain damage and cognitive impairment, especially if the insular cortex is compromised. This study explores for the first time whether these 2 causes differentially alter connectivity patterns in the insular cortex. METHODS: Resting state-functional magnetic resonance imaging data were collected from patients with insular stroke, patients with behavioral variant frontotemporal dementia, and healthy controls. Data from the 3 groups were assessed through a correlation function analysis. Specifically, we compared decreases in connectivity as a function of voxel Euclidean distance within the insular cortex. RESULTS: Relative to controls, patients with stroke showed faster connectivity decays as a function of distance (hypoconnectivity). In contrast, the behavioral variant frontotemporal dementia group exhibited significant hyperconnectivity between neighboring voxels. Both patient groups evinced global hypoconnectivity. No between-group differences were observed in a volumetrically and functionally comparable region without ischemia or neurodegeneration. CONCLUSIONS: Functional insular cortex connectivity is affected differently by cerebral ischemia and neurodegeneration, possibly because of differences in the cause-specific pathophysiological mechanisms of each disease. These findings have important clinical and theoretical implications.

Eleven Years After Scimitar Syndrome Repair With the Lugones Technique: Usefulness of Four-Dimensional Flow Magnetic Resonance Imaging.

Anatomic and physiologic assessment of surgical repair of scimitar syndrome can be challenging. We evaluated the first patient who underwent the Lugones procedure in 2012 using 4D flow magnetic resonance imaging. With this technology, we demonstrate that the reconstructed right pulmonary venous return drains into the left atrium with laminar flow, just as normal pulmonary veins do.

Automatic thoracic aorta calcium quantification using deep learning in non-contrast ECG-gated CT images.

Thoracic aorta calcium (TAC) can be assessed from cardiac computed tomography (CT) studies to improve cardiovascular risk prediction. The aim of this study was to develop a fully automatic system to detect TAC and to evaluate its performance for classifying the patients into four TAC risk categories. The method started by segmenting the thoracic aorta, combining three UNets trained with axial, sagittal and coronal CT images. Afterwards, the surrounding lesion candidates were classified using three combined convolutional neural networks (CNNs) trained with orthogonal patches. Image datasets included 1190 non-enhanced ECG-gated cardiac CT studies from a cohort of cardiovascular patients (age 57 ± 9 years, 80% men, 65% TAC > 0). In the test set (N = 119), the combination of UNets was able to successfully segment the thoracic aorta with a mean volume difference of 0.3 ± 11.7 ml (<6%) and a median Dice coefficient of 0.947. The combined CNNs accurately classified the lesion candidates and 87% of the patients (N = 104) were accurately placed in their corresponding risk categories (Kappa = 0.826, ICC = 0.9915). TAC measurement can be estimated automatically from cardiac CT images using UNets to isolate the thoracic aorta and CNNs to classify calcified lesions.

Morphological and dynamic analysis of the normal aortic valve with 4D computed tomography.

OBJECTIVES: To evaluate the precise dimensions of the normal aortic root, especially the true aortic annulus, during the cardiac cycle using an innovative reconstruction method based on multiphase cardiac computed tomography and to assess the feasibility and the reproducibility of this method for aortic root analysis. METHODS: Between January 2019 and June 2021, 30 optimal consecutive ECG-gated multiphase cardiac computed tomography of patients with normal tricuspid aortic valve were analysed using an in-house software. Aortic annulus border was pinpointed on 9 reconstructed planes and the 3D coordinates of the 18 consecutive points were interpolated into a 3D curve using a cubic spline. Three additional planes were generated at the level of the left ventricular outflow tract, the level of the Valsalva sinus and the level of the sinotubular junction. This procedure was repeated for all the 10 temporal phases of the RR interval. RESULTS: The aortic annulus mean 3D and 2D areas were 7.67 ± 1.51 and 5.16 ± 1.40 cm2, respectively. The mean 2D diameter was 2.51 ± 0.23 cm. The mean global area expansion was 11.8 ± 3.5% and the mean perimeter expansion of 7.1 ± 2.6%. During the cardiac cycle, the left ventricle outflow tract expands, reaching its maximum surface at the end of diastole, followed by the aortic annulus, the Valsalva sinuses and the sinotubular junction. The aorta changes from a clover-shaped cone during diastole to more cylindrical shape during systole. Compared to the 3D measurements, the analysis of the virtual basal ring significantly underestimates the annulus area, perimeter, and mean diameter. CONCLUSIONS: 4D morphometric analysis enables to have a precise and reproducible evaluation of the aortic annulus. The aortic annulus and root are deformable structures that undergo a unique expansion sequence during the cardiac cycle which should be considered for procedural planning.

Association of Impaired Left Ventricular Mitral Filling from 4D Flow Cardiac MRI and Prognosis of Hypertrophic Cardiomyopathy.

Purpose To investigate whether the peak early filling rate normalized to the filling volume (PEFR/FV) estimated from four-dimensional (4D) flow cardiac MRI may be used to assess impaired left ventricular (LV) filling and predict clinical outcomes in individuals with hypertrophic cardiomyopathy (HCM). Materials and Methods Cardiac MRI with a 4D flow sequence and late gadolinium enhancement (LGE), as well as echocardiography, was performed in 88 individuals: 44 participants with HCM from a French prospective registry (ClinicalTrials.gov; NCT01091480) and 44 healthy volunteers matched for age and sex. In participants with HCM, a composite primary end point was assessed at follow-up, including unexplained syncope, new-onset atrial fibrillation, hospitalization for congestive heart failure, ischemic stroke, sustained ventricular arrhythmia, septal reduction therapy, and cardiac death. A Cox proportional hazard model was used to analyze associations with the primary end point. Results PEFR/FV was significantly lower in the HCM group (mean age, 51.8 years ± 18.5 [SD]; 29 male participants) compared with healthy volunteers (mean, 3.35 sec-1 ± 0.99 [0.90-5.20] vs 4.42 sec-1 ± 1.68 [2.74-11.86]; P < .001) and correlated with both B-type natriuretic peptide (BNP) level (r = -0.31; P < .001) and the ratio of pulsed Doppler early transmitral inflow to Doppler tissue imaging annulus velocities (E/E'; r = -0.54; P < .001). At a median follow-up of 2.3 years (IQR, 1.7-3.3 years), the primary end point occurred in 14 (32%) participants. A PEFR/FV of 2.61 sec-1 or less was significantly associated with occurrence of the primary end point (hazard ratio, 9.46 [95% CI: 2.61, 45.17; P < .001] to 15.21 [95% CI: 3.51, 80.22; P < .001]), independently of age, BNP level, E/E', LGE extent, and LV and left atrial strain according to successive bivariate models. Conclusion In HCM, LV filling evaluated with 4D flow cardiac MRI correlated with Doppler and biologic indexes of diastolic dysfunction and predicted clinical outcomes. Keywords: Diastolic Function, Left Ventricular Filling, Hypertrophic Cardiomyopathy, Cardiac MRI, 4D Flow Sequence Clinical trial registration no. NCT01091480 Supplemental material is available for this article. © RSNA, 2024.

Abdominal aortic calcium and geometry in patients with essential hypertension.

PURPOSE: Abdominal aorta calcium (AAC) burden and dilatation are associated with an increased risk of mortality. The purpose of this study was to investigate determinants of AAC and abdominal aorta size in patients with essential hypertension. MATERIALS AND METHODS: Patients with uncomplicated essential hypertension who had undergone non-enhanced abdominal CT to rule out secondary hypertension in addition to biological test were recruited between 2010 and 2018. A semi-automatic system was designed to estimate the aortic size (diameter, length, volume) and quantify the AAC from mesenteric artery to bifurcation using the Agatston score. Determinants of aortic size and those related to AAC were searched for using uni- and multivariables analyses. RESULTS: Among 293 randomly selected patients with hypertension (age 52 ± 11 [SD] years) included, 23% had resistant hypertension. Mean abdominal aorta diameter was 20.1 ± 2.1 (SD) mm. Eight (3%) patients had abdominal aorta aneurysm ≥ 30 mm and 58 (20%) had dilated abdominal aorta ≥ 27 mm. Median AAC score was 38 and calcifications were detected in the infra- and supra-renal abdominal aortic portions in 59% and 26% of the patients, respectively. After adjustment for age, male sex and body surface area, abdominal aorta diameter was positively associated with diastolic blood pressure (P = 0.0019). Smoking was the single variable associated with calcified abdominal aorta (P < 0.001) after adjustment for cofactors. In patients with calcifications of abdominal aorta, the score increased with smoking history (P < 0.001), statins treatment (P < 0.01), greater number of anti-hypertensive drugs (P < 0.01), larger abdominal aorta (P < 0.05) and greater systolic blood pressure (P < 0.05). Patients with resistant hypertension had more AAC in the supra-renal abdominal aorta portion than those without resistant hypertension (P < 0.01). CONCLUSION: In patients with essential hypertension, abdominal aorta dilation is related with diastolic blood pressure while AAC is associated with smoking history and resistant hypertension when located to the supra-renal abdominal aorta portion.

Computed tomographic analysis of the morphometrics and dynamics of the tricuspid annulus in secondary functional tricuspid regurgitation.

Objectives: Secondary functional tricuspid regurgitation (FTR) management remains controversial mainly due to the lack of knowledge in its pathogenesis and the difficulties to measure the actual dimensions of tricuspid annulus (TA) with current imaging methods. Using a novel method based on multiphase cardiac computed tomography (CT) scan acquisition to accurately analyze the right atrioventricular junction size, we sought to explore modifications of TA morphometry and dynamics in secondary FTR. Methods: Echocardiographic and cardiac CT studies were obtained from 21 patients with severe mitral regurgitation (MR group) and 21 patients with dilated cardiomyopathy (DCMP group). Using an in-house software, a 3-dimensiontal (3D) semiautomated delineation of the TA perimeter was assessed. Modifications of diameters, 2-dimensional/3D areas and perimeters were analyzed through time. These 2 groups of patients were compared with 30 healthy subjects, considering the presence of a significant (≥2+) versus nonsignificant (<2+) FTR in each group. Results: Maximum TA 3D areas were 7.0 ± 1.2 cm2/m2 in healthy subjects at mid-to-late diastole and were smaller than in the MR group (9.8 ± 2.1 cm2/m2, P < .001) and the DCMP group (9.2 ± 3.0 cm2/m2, P < .001). In the MR group, patients with FTR <2+ had also larger TA areas and diameters than healthy patients (P < .01 for all 3D/2-dimensional parameters). TA shape was more circular only in the DCMP group with FTR ≥2+ compared with other patients (P < .05 for eccentricity). In multivariate analysis, both RA area (P < .001) and RV volume (P = .002) were independently related to TA dilatation. Conclusions: Based on multiphase CT image analyses, TA dilatation was directly related to RV and RA enlargement. Patients with severe mitral myxomatous disease and nondysfunctional tricuspid valve had yet dilated TA, which questioned the current cut-off recommendation for concomitant tricuspid annuloplasty in this specific population.

Case-Control Study of 3D Morphology in Isolated Mesenteric Artery Dissection.

INTRODUCTION: Isolated mesenteric artery dissection (IMAD) is uncommon and has not been investigated in detail. This study aimed to accurately identify the morphological differences of IMAD patients with control individuals using a detailed 3D volumetric analysis. METHODS: In this retrospective case-control study, cases were patients with acute symptomatic IMAD treated in a French intestinal stroke center between January 2016 and November 2019. Case-control matching was (1:3) by age, gender, and body mass index (BMI). The semi-automatic morphological analysis of the mesenteric artery included volumetric measurements of the true and false lumen size, the centerline curvature and the 3D aortomesenteric angles. RESULTS: Seventeen IMAD cases (mean age 56 ± 4 years, 94% men) were matched with 51 controls. The mean overall lumen (OL) volume was higher in IMAD patients as compared to controls (+ 64%, p < 0.001). In the same way, the mean OL cross-sectional area and diameters were higher in IMAD patients: + 77% for OL area (< 0.001) and + 34% for OL diameters (< 0.001). Meanwhile, no significant difference was found in terms of true lumen (TL) volume (p = 0.16) or cross-sectional area (p = 0.30) between IMAD patients and controls, whereas the mean TL diameter was lower in the IMAD group (p < 0.05). Patients with acute mesenteric ischemia had a lower [TL/OL volume] ratio (45% vs. 59%, p < 0.05) and longer dissections (63 mm vs. 48 mm, p < 0.01). The 3D aortomesenteric angle was significantly higher in IMAD patients at both 2 cm (p < 0.01) and 4 cm (p < 0.05) from the ostium. CONCLUSION: Using an original 3D semi-automated analysis, this study shows that IMAD induces significant morphological changes compared to control individuals: a larger aortomesenteric 3D angle, an increased overall volume and area. IMAD patients with acute mesenteric ischemia presented with a more severe morphological profile.

4D flow magnetic resonance imaging to assess right ventricular outflow tract in patients undergoing transcatheter pulmonary valve replacement.

INTRODUCTION AND OBJECTIVES: Magnetic resonance imaging (MRI) including 4D flow is used before percutaneous pulmonary valve implantation (PPVI). As PPVI is limited by the size of the right ventricular outflow tract (RVOT), accurate sizing is needed to plan the intervention. The aim of this study was to compare different MRI modalities and invasive angiography to balloon sizing of RVOT. METHODS: Single-center prospective study of patients who underwent PPVI for isolated pulmonary regurgitation assessed by 4D flow MRI, 3D steady-state free precession/gradient echo (3D SSFP/GRE) and contrast magnetic resonance angiography. Balloon sizing was considered as the reference. RESULTS: A total of 23 adults were included (mean age, 38.4±12.5 years). Eighteen patients underwent successful primary PPVI. The average of the narrowest RVOT diameter was 25.4±4.3 mm by balloon sizing. Compared to balloon sizing, RVOT diameters were better correlated when estimated by systolic 4D flow MRI (r=0.89, P<.001) than by diastolic 4D flow MRI (r=0.71, P <.001), 3D contrast magnetic resonance angiography (r=0.73; P <.001) and 3D SSFP/GRE (r=0.50; P=.04) and was not significantly correlated when estimated by 2D in diastole and systole. The mean difference between systolic 4D flow MRI and balloon sizing was 0.2 mm (95%CI, -3.5 to 3.9 mm), whereas it was wider with other techniques. CONCLUSIONS: Beyond the quantification of pulmonary valve regurgitation, 4D flow allows accurate estimation of RVOT diameters, especially in systole, which is fundamental before planning PPVI.

Morphological and Dynamic Analysis of the Right Atrioventricular Junction in Healthy Subjects with 4D Computed Tomography.

PURPOSE: To improve knowledge of the tricuspid valve and right atrioventricular junction (RAVJ) coupling, four-dimensional (4D) imaging is mandatory (3D + time). Based on multiphase cardiac-volume computed tomography (CT) and innovative 4D analysis, we proposed to assess dynamical features of tricuspid annulus (TA) in relation to the right ventricle (RV) and right atrial (RA) functions. METHODS: Cardiac-volume CT data sets through time were obtained in 30 healthy patients (Male 57%, mean age 57 ± 11 years). Using an in-house software, 3D semi-automated delineation of 18 points around TA perimeter were defined through 10 cardiac phases within RR interval and used to calculate TA features such as 3D/2D areas, perimeters, 360°-diameters and vertical deformation. RV and RA inner contours were also delineated. Bi-dimensional parameters were compared with multiplanar reconstruction (MPR) measurements. RESULTS: TA was elliptical in horizontal projection with a maximal eccentricity index (EcImax) of 0.58 ± 0.12; and saddle-shaped in vertical projection with a horn nearby the antero-septal commissure. This feature remained throughout the cardiac cycle, but TA was more planar and less circular in late diastole (TA-height: 4.53 ± 1.06 mm, EcImax = 0.61 ± 0.14) when TA 3D area and perimeter reached a maximum of 7.05 ± 1.23 and 7.48 ± 0.93cm/m2, respectively. Correlations between minimal and maximal TA 3D areas and TA Projected 2D areas were excellent (r = 0.993 and r = 0.995, p < 0.001). TA 2D area measurements by MPR overestimated the projected values by 22 to 24%. Correlation between RV concentric strain and TA maximal diameter shortening was r = 0.452 (p = 0.01). CONCLUSIONS: Cardiac-volume CT improves physiological knowledge of the relationships between the RAVJ components in healthy subjects.

Echocardiographic Measurements of Left Heart Chamber Size in a Large Cohort of Subjects: Comparison of Body Surface Area and Height Indexing to Account for Effects of Obesity.

BACKGROUND: The assessment of cardiac chamber size in the obese population is a challenging subject. Values usually indexed to body surface area (BSA) are smaller in obese subjects and prone to overcorrection. The aims of this study were to find reference thresholds to account for the effects of obesity among a large cohort of patients and to evaluate indexing to height as an alternative to BSA. METHODS: The past 10 years of records from a single echocardiography unit were retrospectively analyzed, and 14,007 subjects without known cardiac disease were included (mean age, 45 ± 15 years; 54% women; 20% obese). Measurements included left atrial diameter, area, and volume, left ventricular (LV) end-diastolic and end-systolic diameters, aortic root diameter, and LV mass. Absolute, BSA-indexed, and height-indexed maximum thresholds (mean + 1.96 SDs) were calculated. Allometric indexing of the form variable/heightß was tested. Correlation coefficients between indexed and absolute values were calculated to evaluate their proportional association (ideally r = 1). Correlations between indexed values and body size represented residual associations to be minimized (ideally r = 0). RESULTS: The strongest association of echocardiographic measurements with body size was observed for BSA (r = 0.36-0.63), whereas the isometric and allometric height models showed lower comparable values (r = 0.28-0.48). Positive correlations with body mass index were mostly observed for left atrial size (r ≈ 0.36) and LV mass (r ≈ 0.36) measurements. Values of the scaling exponent ß for allometric height indexing were 1.72 for left atrial volume and 2.33 for LV mass. Correlations between indexed and absolute values were higher for height than BSA (0.80-0.98 vs 0.44-0.92). Correlations between indexed values and height were closer to 0 than for BSA, particularly using the allometric model. The overcorrection observed with increasing obesity class after BSA indexing was avoided after height indexing. CONCLUSIONS: Unlike BSA, height indexing provided adequate body size scaling of left heart chamber size, avoiding overcorrection using allometric models in particular.