Utility of CT and MRI in Tricuspid Valve Interventions.

Transcatheter tricuspid valve interventions (TTVIs) comprise a variety of catheter-based interventional techniques for treatment of tricuspid regurgitation (TR) in patients at high surgical risk and those with failed previous surgeries. Several TTVI devices with different mechanisms of action are either currently used or in preclinical evaluation. Echocardiography is the first-line modality for evaluation of tricuspid valve disease that provides information on tricuspid valve morphology, mechanism of TR, and hemodynamics. Cardiac CT and MRI have several advantages for a comprehensive preprocedure evaluation. CT and MRI provide complementary information to that of echocardiography on the mechanism and cause of TR. MRI can quantify the severity of TR using indirect or direct techniques that involve two-dimensional or four-dimensional flow sequences. MRI and CT can also accurately quantify right ventricular volumes and function, which is crucial for timing of intervention. CT provides comprehensive three-dimensional information on the morphology of the valve, annulus, subvalvular apparatus, and adjacent structures. CT is the procedure of choice for evaluation of several device-specific measurements, including tricuspid annulus dimensions, annulus-to-right coronary artery distance, leaflet morphology, coaptation gaps, caval dimensions, and cavoatrial-to-hepatic vein distance. CT allows evaluation of the vascular access as well as optimal procedure fluoroscopic angles and catheter trajectory. Postprocedure CT and MRI are useful in detection of complications such as paravalvular leak, pseudoaneurysm, thrombus, pannus, infective endocarditis, and device migration. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Exploring the landscape of model representations.

The success of any physical model critically depends upon adopting an appropriate representation for the phenomenon of interest. Unfortunately, it remains generally challenging to identify the essential degrees of freedom or, equivalently, the proper order parameters for describing complex phenomena. Here we develop a statistical physics framework for exploring and quantitatively characterizing the space of order parameters for representing physical systems. Specifically, we examine the space of low-resolution representations that correspond to particle-based coarse-grained (CG) models for a simple microscopic model of protein fluctuations. We employ Monte Carlo (MC) methods to sample this space and determine the density of states for CG representations as a function of their ability to preserve the configurational information, I, and large-scale fluctuations, Q, of the microscopic model. These two metrics are uncorrelated in high-resolution representations but become anticorrelated at lower resolutions. Moreover, our MC simulations suggest an emergent length scale for coarse-graining proteins, as well as a qualitative distinction between good and bad representations of proteins. Finally, we relate our work to recent approaches for clustering graphs and detecting communities in networks.

Pre- and Postprocedure Imaging of Transcatheter Pulmonary Valve Implantation.

Transcatheter pulmonary valve replacement (TPVR) is a minimally invasive procedure for treatment of right ventricular outflow tract (RVOT) dysfunction in surgically repaired congenital heart diseases. TPVR is performed in these patients to avoid the high risk and complexity of repeat surgeries. Several TPVR devices are now available to be placed in the right ventricle (RV) to pulmonary artery (PA) conduit, native RVOT, or surgical bioprosthetic valves. Imaging is used before TPVR to determine patient eligibility and optimal timing, which is critical to avoid irreversible RV dilatation and failure. Imaging is also required for evaluation of contraindications, particularly proximity of the RVOT to the left main coronary artery and its branches. Cross-sectional imaging provides details of the complex anatomy in which the TPVR device will be positioned and measurements of the RVOT, RV-PA conduit, or PA. Echocardiography is the first-line imaging modality for evaluation of the RVOT or conduit to determine the need for intervention, although its utility is limited by the complex RVOT morphology and altered anatomy after surgery. CT and MRI provide complementary information for TPVR, including patient eligibility, assessment of contraindications, and key measurements of the RVOT and PA, which are necessary for procedure planning. TPVR, performed using a cardiac catheterization procedure, includes a sizing step in which a balloon is expanded in the RVOT, which also allows assessment of the risk for extrinsic coronary artery compression. Follow-up imaging with CT and MRI is used for evaluation of postprocedure remodeling and valve function and to monitor complications. ©RSNA, 2022 Online supplemental material is available for this article.

Pre- and Postprocedural CT of Transcatheter Left Atrial Appendage Closure Devices.

Transcatheter left atrial appendage (LAA) closure is an alternative to long-term anticoagulation therapy in selected patients with nonvalvular atrial fibrillation who have an increased risk for stroke. LAA closure devices can be implanted by means of either an endocardial or a combined endocardial and epicardial approach. Preprocedural imaging is key to identifying contraindications, accurately sizing the device, and minimizing complications. Transesophageal echocardiography (TEE) has been the reference standard imaging modality to assess the anatomy for LAA closure and to provide intraprocedural guidance. However, CT has emerged as a less-invasive alternative to TEE for pre- and postprocedural imaging. CT is comparable to TEE for exclusion of thrombus but is superior to TEE for the delineation of complex LAA anatomy, measurement for device sizing, and evaluation of pulmonary venous and extracardiac structures. CT provides accurate measurements of the LAA ostial diameter, landing zone diameter, and LAA length, which are vital for accurate sizing of the device. CT allows evaluation of the relationship with the pulmonary veins and other adjacent structures that can be injured during the procedure. CT also simulates procedural fluoroscopic angles and provides evaluation of the interatrial septum, which is punctured during LAA closure. CT also provides a more convenient method for the evaluation of postprocedural complications such as incomplete closure, peridevice leaking, device-related thrombus, and device dislodgement. Online supplemental material is available for this article. ©RSNA, 2021.

CT for Pre- and Postprocedural Evaluation of Transcatheter Mitral Valve Replacement.

Transcatheter mitral valve replacement (TMVR) is a catheter-based interventional technique for treating mitral valve disease in patients who are at high risk for open mitral valve surgery and with unfavorable anatomy for minimally invasive edge-to-edge transcatheter mitral valve repair. There are several TMVR devices with different anchoring mechanisms, delivered by either transapical or transseptal approaches. Transthoracic echocardiography is the first-line imaging modality used for characterization and quantification of mitral valve disorders. CT is complementary to echocardiography and has several advantages, including high isotropic spatial resolution, good temporal resolution, large field of view, multiplanar reconstruction capabilities, and rapid turnaround time. CT is essential for multiple aspects of preprocedural planning. Accurate and reproducible techniques to prescribe the mitral annulus at CT have been described from which important measurements such as the area, perimeter, trigone-trigone distance, intercommissural distance, and septolateral distance are obtained. The neo-left ventricular outflow tract (LVOT) can be simulated by placing a virtual prosthesis in the CT data to predict the risk of TMVR-induced LVOT obstruction. The anatomy of the landing zone and subvalvular apparatus as well as the relationship of the virtual device to adjacent structures such as the coronary sinus and left circumflex coronary artery can be evaluated. CT also stimulates procedural fluoroscopic angles. CT can be used to evaluate the chest wall for transapical access and the atrial septum for transseptal access. Follow-up CT is useful in identifying complications such as LVOT obstruction, paravalvular leak, pseudoaneurysm, and valve embolization. Online supplemental material is available for this article. ©RSNA, 2020.

Patterns of ascending aortic dilatation and predictors of surgical replacement of the aorta: A comparison of bicuspid and tricuspid aortic valve patients over eight years of follow-up.

BACKGROUND: Predictors of thoracic aorta growth and early cardiac surgery in patients with bicuspid aortic valve are undefined. Our aim was to identify predictors of ascending aorta dilatation and cardiac surgery in patients with bicuspid aortic valve (BAV). METHODS: Forty-one patients with BAV were compared with 165 patients with tricuspid aortic valve (TAV). All patients had LV EF > 50%, normal LV dimensions, and similar degree of aortic root or ascending aorta dilatation at enrollment. Patients with more than mild aortic stenosis or regurgitation were excluded. A CT-scan was available on 76% of the population, and an echocardiogram was repeated every year for a median time of 4 years (range: 2 to 8 years). Patterns of aortic expansion in BAV and TAV groups were analyzed by a mixed-effects longitudinal linear model. In the time-to-event analysis, the primary end point was elective or emergent surgery for aorta replacement. RESULTS: BAV patients were younger, while the TAV group had greater LV wall thickness, arterial hypertension, and dyslipidemia than BAV patients. Growth rate was 0.46 ±â€¯0.04 mm/year, similar in BAV and TAV groups (p = 0.70). Predictors of cardiac surgery were aorta dimensions at baseline (HR 1.23, p = 0.01), severe aortic regurgitation developed during follow-up (HR 3.49, p 0.04), family history of aortic aneurysm (HR 4.16, p 1.73), and history of STEMI (HR 3.64, p < 0.001). CONCLUSIONS: Classic baseline risk factors were more commonly observed in TAV aortopathy compared with BAV aortopathy. However, it is reassuring that, though diagnosed with aneurysm on average 10 years earlier and in the absence of arterial hypertension, BAV patients had a relatively low growth rate, similar to patients with a tricuspid valve. Irrespective of aortic valve morphology, patients with a family history of aortic aneurysm, history of coronary artery disease, and those who developed severe aortic regurgitation at follow-up, had the highest chances of being referred for surgery.

Three-dimensional prototyping for procedural simulation of transcatheter mitral valve replacement in patients with mitral annular calcification.

INTRODUCTION: Three-dimensional (3D) prototyping is a novel technology which can be used to plan and guide complex procedures such as transcatheter mitral valve replacement (TMVR). METHODS: Eight patients with severe mitral annular calcification (MAC) underwent TMVR. 3D digital models with digital balloon expandable valves were created from pre-procedure CT scans using dedicated software. Five models were printed. These models were used to assess prosthesis sizing, anchoring, expansion, paravalvular gaps, left ventricular outflow tract (LVOT) obstruction, and other potential procedure pitfalls. Results of 3D prototyping were then compared to post procedural imaging to determine how closely the achieved procedural result mirrored the 3D modeled result. RESULTS: 3D prototyping simulated LVOT obstruction in one patient who developed it and in another patient who underwent alcohol septal ablation prior to TMVR. Valve sizing correlated with actual placed valve size in six out of the eight patients and more than mild paravalvular leak (PVL) was simulated in two of the three patients who had it. Patients who had mismatch between their modeled valve size and post-procedural imaging were the ones that had anterior leaflet resection which could have altered valve sizing and PVL simulation. 3D printed model of one of the latter patients allowed modification of anterior leaflet to simulate surgical resection and was able to estimate the size and location of the PVL after inserting a valve stent into the physical model. CONCLUSION: 3D prototyping in TMVR for severe MAC is feasible for simulating valve sizing, apposition, expansion, PVL, and LVOT obstruction.

The Various Applications of 3D Printing in Cardiovascular Diseases.

PURPOSE OF REVIEW: To highlight the various applications of 3D printing in cardiovascular disease and discuss its limitations and future direction. RECENT FINDINGS: Use of handheld 3D printed models of cardiovascular structures has emerged as a facile modality in procedural and surgical planning as well as education and communication. Three-dimensional (3D) printing is a novel imaging modality which involves creating patient-specific models of cardiovascular structures. As percutaneous and surgical therapies evolve, spatial recognition of complex cardiovascular anatomic relationships by cardiologists and cardiovascular surgeons is imperative. Handheld 3D printed models of cardiovascular structures provide a facile and intuitive road map for procedural and surgical planning, complementing conventional imaging modalities. Moreover, 3D printed models are efficacious educational and communication tools. This review highlights the various applications of 3D printing in cardiovascular diseases and discusses its limitations and future directions.

Van der Waals Perspective on Coarse-Graining: Progress toward Solving Representability and Transferability Problems.

Low-resolution coarse-grained (CG) models provide the necessary efficiency for simulating phenomena that are inaccessible to more detailed models. However, in order to realize their considerable promise, CG models must accurately describe the relevant physical forces and provide useful predictions. By formally integrating out the unnecessary details from an all-atom (AA) model, "bottom-up" approaches can, at least in principle, quantitatively reproduce the structural and thermodynamic properties of the AA model that are observable at the CG resolution. In practice, though, bottom-up approaches only approximate this "exact coarse-graining" procedure. The resulting models typically reproduce the intermolecular structure of AA models at a single thermodynamic state point but often describe other state points less accurately and, moreover, tend to provide a poor description of thermodynamic properties. These two limitations have been coined the "transferability" and "representability" problems, respectively. Perhaps, the simplest and most commonly discussed manifestation of the representability problem regards the tendency of structure-based CG models to dramatically overestimate the pressure. Furthermore, when these models are adjusted to reproduce the pressure, they provide a poor description of the compressibility. More generally, it is sometimes suggested that CG models are fundamentally incapable of reproducing both structural and thermodynamic properties. After all, there is no such thing as a "free lunch"; any significant gain in computational efficiency should come at the cost of significant model limitations. At least in the case of structural and thermodynamic properties, though, we optimistically propose that this may be a false dichotomy. Accordingly, we have recently re-examined the "exact coarse-graining" procedure and investigated the intrinsic consequences of representing an AA model in reduced resolution. These studies clarify the origin and inter-relationship of representability and transferability problems. Both arise as consequences of transferring thermodynamic information from the high resolution configuration space and encoding this information into the many-body potential of mean force (PMF), that is, the potential that emerges from an exact coarse-graining procedure. At least in principle, both representability and transferability problems can be resolved by properly addressing this thermodynamic information. In particular, we have demonstrated that "pressure-matching" provides a practical and rigorous means for addressing the density dependence of the PMF. The resulting bottom-up models accurately reproduce the structure, equilibrium density, compressibility, and pressure equation of state for AA models of molecular liquids. Additionally, we have extended this approach to develop transferable potentials that provide similar accuracy for heptane-toluene mixtures. Moreover, these potentials provide predictive accuracy for modeling concentrations that were not considered in their parametrization. More generally, this work suggests a "van der Waals" perspective on coarse-graining, in which conventional structure-based methods accurately describe the configuration dependence of the PMF, while independent variational principles infer the thermodynamic information that is necessary to resolve representability and transferability problems.

Reducing Iodine Contrast Volume in CT Angiography of the Abdominal Aorta Using Integrated Tube Potential Selection and Weight-Based Method Without Compromising Image Quality.

OBJECTIVE: The purpose of this study is to determine whether image quality was maintained when a weight-based protocol incorporating tube potential selection was used to select lower iodine contrast volumes for aortic CT angiography (CTA). MATERIALS AND METHODS: Patients with potentially decreased renal function underwent CTA performed with the iodinated contrast volume determined using a table incorporating different tube potentials and patient weights. The image quality of CTA examinations performed with a reduced iodine volume (hereafter known as "low-iodine CTA examinations"), internal control CTA examinations (i.e., prior examinations), and size-matched control CTA examinations was evaluated in separate reading sessions conducted by three vascular radiologists who were blinded as to the contrast volume and tube potential used. Side-by-side unblinded comparison of the examinations was also performed. Aortic attenuation and the contrast-to-noise ratio were measured. Comparisons were performed using the Wilcoxon signed rank test. RESULTS: Fifty low-iodine CTA examinations, 36 internal control CTA examinations, and 50 size-matched control CTA examinations were performed. Contrast volumes were 63% lower when the protocol based on tube potential and patient weight was used (mean contrast volume, 49 mL for low-iodine CTA vs 133 mL for internal control CTA and 138 mL for size-matched control CTA). The mean volume CT dose index was 15.1 mGy for low-iodine CTA versus 18.8 mGy for internal control CTA (p < 0.001), and 15.3 mGy for low-iodine CTA versus 17.1 mGy for size-matched control CTA (p = 0.11). Of the image quality and diagnostic confidence evaluations for low-iodine CTA examinations, over 97% had acceptable image quality and diagnostic confidence for blinded (50/50) and unblinded (35/36) comparisons. Aortic attenuation was similar between groups (p = 0.13-0.71). CONCLUSION: A weight-based protocol that incorporates tube potential selection allows the use of substantially lower volumes of iodinated contrast material in aortic CTA while maintaining acceptable image quality.

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.

A comparison of infarct mass by cardiac magnetic resonance and real time myocardial perfusion echocardiography as predictors of major adverse cardiac events following reperfusion for ST elevation myocardial infarction.

PURPOSE: Infarct mass as assessed by myocardial-delayed enhancement imaging on cardiac magnetic resonance (CMR) and myocardial blood flow as assessed by real time myocardial perfusion echocardiography (RT-MPE) have been shown to predict adverse events following ST elevation myocardial infarction (STEMI). There has been no published comparison of quantitative assessment using these modalities as predictors of clinical outcomes to date. We compared RT-MPE with CMR for prediction of cardiac events in reperfused STEMI patients. MATERIALS AND METHODS: Consecutive STEMI patients with early reperfusion were studied. RT-MPE and CMR were performed. Perfusion score indices (PSIRT-MPE and PSICMR ) were calculated [sum of segmental perfusion scores/number of segments]. CMR infarct mass (g) and RT-MPE myocardial blood flow (MBF dB/s) were quantified. Patients were followed for cardiac events (death, nonfatal MI, revascularization, angina, and heart failure). RESULTS: All 27 patients (age 62±14; follow-up 3.5±2.6 years) had thrombolysis in myocardial infarction (TIMI) grade 3 flow of infarct vessel. Cardiac events occurred in 17 (63%). Cardiac event patients had higher PSIRT-MPE , PSICMR , infarct mass, and lower MBF. PSIRT-MPE cutoff of 0.3 had an AUC of 0.856 (82% sensitivity, 70% specificity), while a PSICMR cutoff of 0.2 had an AUC of 0.765 (76% sensitivity, 60% specificity). Infarct mass and MBF were independent predictors of cardiac events after adjusting for risk factors (hazard ratios: 20.9 [95% CI 1.8-256] P=.02 and 8.1 [95% CI 1.5-78] P=.01, respectively). CONCLUSIONS: Quantitative RT-MPE performed comparably to CMR for prediction of MACE in STEMI patients supporting a prognostic role for this noninvasive, bedside imaging method.

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 radiologist's 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.

The impact of resolution upon entropy and information in coarse-grained models.

By eliminating unnecessary degrees of freedom, coarse-grained (CG) models tremendously facilitate numerical calculations and theoretical analyses of complex phenomena. However, their success critically depends upon the representation of the system and the effective potential that governs the CG degrees of freedom. This work investigates the relationship between the CG representation and the many-body potential of mean force (PMF), W, which is the appropriate effective potential for a CG model that exactly preserves the structural and thermodynamic properties of a given high resolution model. In particular, we investigate the entropic component of the PMF and its dependence upon the CG resolution. This entropic component, SW, is a configuration-dependent relative entropy that determines the temperature dependence of W. As a direct consequence of eliminating high resolution details from the CG model, the coarsening process transfers configurational entropy and information from the configuration space into SW. In order to further investigate these general results, we consider the popular Gaussian Network Model (GNM) for protein conformational fluctuations. We analytically derive the exact PMF for the GNM as a function of the CG representation. In the case of the GNM, -TSW is a positive, configuration-independent term that depends upon the temperature, the complexity of the protein interaction network, and the details of the CG representation. This entropic term demonstrates similar behavior for seven model proteins and also suggests, in each case, that certain resolutions provide a more efficient description of protein fluctuations. These results may provide general insight into the role of resolution for determining the information content, thermodynamic properties, and transferability of CG models. Ultimately, they may lead to a rigorous and systematic framework for optimizing the representation of CG models.

Medical consequences of Chernobyl with focus on the endocrine system: Part 1.

In the last 70 years, atomic disasters have occurred several times. The nuclear power plant accident at Chernobyl in 1986 in North-Central Ukraine was a unique experience in population exposures to radiation by all ages, and ongoing studies have brought a large amount of information on effects of radiation on human organism. Concerning the deteriorating global security situation and the strong rhetoric of some of the world leaders, the knowledge on the biological effects of ionizing radiation and the preventive measures designed to decrease the detrimental effects of radiation gains a new dimension, and involves all of us. This review focuses on the long-term effects of Chernobyl catastrophe especially on the endocrine system in children and in adults, and includes a summary of preventive measures in case of an atomic disaster.

Medical Consequences of Chernobyl with Focus on the Endocrine System - Part 2.

In the last 70 years, atomic disasters have occurred several times. The nuclear power plant accident at Chernobyl in 1986 in North-Central Ukraine was a unique experience in population exposures to radiation by all ages, and ongoing studies have brought a large amount of information effects of radiation on human organism. Concerning the deteriorating global security situation and the strong rhetoric of some of the world leaders, the knowledge on the biological effects of ionizing radiation and the preventive measures designed to decrease the detrimental effects of radiation gains a new dimension, and involves all of us. This review focuses on the long-term effects of Chernobyl catastrophe especially on the endocrine system in children and in adults, and includes a summary of preventive measures in case of an atomic disaster.

Computed tomography calcium scoring in aortic stenosis: bicuspid versus tricuspid morphology.

OBJECTIVE: CT aortic valve calcium score (AVCscore) and density (AVCdensity) thresholds have been recommended for aortic stenosis (AS) severity assessment in tricuspid aortic valve (TAV). We aimed to compare AVCscore and AVCdensity in bicuspid aortic valve (BAV) versus TAV. METHODS: Retrospective single-centre study of patients with echocardiographic AS-severity and CT-AVC assessments within 6 months, and left ventricular ejection fraction ≥50%, all referred for clinical AS evaluation.Severe AS was defined as aortic valve area (AVA) ≤1 cm2 or indexed AVA ≤0.6cm2/m2 plus mean gradient ≥40 mm Hg or peak velocity ≥4 m/s. AVC was assessed by Agatston method. RESULTS: Of the 1957 patients, 328 had BAV and 1629 had TAV, age 65±11 vs 80±9 years (p<0.001), men 65% vs 56% (p=0.006), respectively. BAV morphology was associated with higher AVCscore and AVCdensity independent of age, comorbidities and AS severity (p<0.001) in men only (sex and BAV interaction p<0.001). In patients with severe AS, mean AVCscore and AVCdensity were higher in BAV-men than that in TAV-men (both p<0.001), but similar in BAV-women and TAV-women (both p≥0.4). Such patterns remained the same after adjustment for clinical covariates and AS severity. Best thresholds for severe AS diagnosis in BAV-men were 2916 AU by AVCscore and 600 AU/cm2 by AVCdensity which were higher than the guideline-recommended thresholds, while thresholds in BAV-women (1036 AU and 282 AU/cm2) were similar to guideline-recommended ones. CONCLUSION: Valve calcification in AS differs according to valve morphology and sex. BAV-men with severe AS exhibit greater AVCscore and AVCdensity than TAV-men. This presents a diagnostic challenge to the current guidelines, which needs confirmation in larger studies.

Aortic valve cusp size and shape in dilated trileaflet aortic roots.

OBJECTIVES: The objective of the study was to quantify the differences in cusp size and shape in patients with normal and dilated trileaflet aortic roots and in dilated roots with or without aortic regurgitation. METHODS: A retrospective analysis of computed tomography studies in patients with normal and dilated trileaflet aortic roots was performed measuring root and cusp dimensions. Normal root size was defined as sinuses of Valsalva diameter less than 40 mm, dilated as 45 mm or greater. Root measurements normalized to basal ring diameter and cusp measurements normalized to geometric height were analyzed to assess the shape. Additionally, comparison of dilated roots with or without aortic regurgitation was made. RESULTS: We analyzed 146 normal and 104 dilated aortic roots and 73 propensity-matched pairs. Dilated roots were larger in all dimensions and had increased ratio between commissural and basal ring diameter (1.58 ± 0.23 vs 1.11 ± 0.10, P < .001). Cusps in dilated roots were larger in all measured dimensions and were elongated with increased normalized cusp insertion length (3.64 ± 0.39 vs 3.26 ± 0.20, P < .001) and normalized free margin length (2.53 ± 0.30 vs 2.16 ± 0.19, P < .001). In patients with dilated root and no cusp prolapse (n = 83), those with moderate or severe aortic regurgitation had larger commissural diameter but similar cusp dimensions compared with those with no or mild aortic regurgitation. CONCLUSIONS: The cusps in dilated roots elongate transversely and to a lesser degree radially. Functional aortic regurgitation is caused by extensive commissural dilatation and not by inadequate cusp adaptation.