Commissural alignment and the ACURATE neo2 transcatheter aortic valve: Impact on valve performance.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly being used to treat severe aortic stenosis in younger patients. Accordingly, lifetime management regarding future reintervention and coronary access is a concern. AIMS: To assess the impact of commissural alignment on ACURATE neo2 transcatheter aortic valve (TAV) performance. METHODS: COMALIGN-neo2 was an observational, retrospective study enrolling consecutive TAVR patients treated with the ACURATE neo2 (October 2021 to October 2022). The degree of commissural (mis)-alignment (CMA) with the native aortic valve commissures was determined and transvalvular gradient, effective orifice area, patient-prosthesis mismatch (PPM), and aortic regurgitation (AR) were assessed. RESULTS: Among 825 patients, the mean age was 80.7 years and 42% were female. Commissural alignment was achieved in 60% of cases; mild (26%), moderate (9%), and severe misalignment (5%) were found less often. Severe PPM occurred more frequently in patients with severe CMA (14.7%) compared to aligned valves (p = 0.034). By multivariate analysis, severe CMA (odds ratio [OR]: 3.12, 95% confidence interval [CI] [1.09-8.90]; p = 0.033) and lack of postdilatation (OR: 3.85, [1.33-11.1]; p = 0.012) were associated with severe PPM. Higher rates of ≥mild AR (51.4%) were found in TAVs implanted with severe CMA compared to aligned (34.3%), mildly (38.1%) or moderately (36.0%) misaligned TAVs (p = 0.030). Multivariate analysis identified severe CMA (OR: 2.05, [1.05-4.02]; p = 0.037) to be an independent predictor of ≥mild AR. CONCLUSIONS: COMALIGN-neo2 is the largest study to date assessing the impact of commissural alignment on acute TAV performance. Severe CMA with the ACURATE neo2 platform was associated with worse valve hemodynamics and increased risk for mild AR.

CT in Transcatheter-delivered Treatment of Valvular Heart Disease.

Minimally invasive strategies to treat valvular heart disease have emerged over the past 2 decades. The use of transcatheter aortic valve replacement in the treatment of severe aortic stenosis, for example, has recently expanded from high- to low-risk patients and became an alternative treatment for those with prohibitive surgical risk. With the increase in transcatheter strategies, multimodality imaging, including echocardiography, CT, fluoroscopy, and cardiac MRI, are used. Strategies for preprocedural imaging strategies vary depending on the targeted valve. Herein, an overview of preprocedural imaging strategies and their postprocessing approaches is provided, with a focus on CT. Transcatheter aortic valve replacement is reviewed, as well as less established minimally invasive treatments of the mitral and tricuspid valves. In addition, device-specific details and the goals of CT imaging are discussed. Future imaging developments, such as peri-procedural fusion imaging, machine learning for image processing, and mixed reality applications, are presented.

Comparison of DVB-T Passive Radar Simulated and Measured Bistatic RCS Values for a Pilatus PC-12 Aircraft.

Passive radar is a technology that has huge potential for airspace monitoring, taking advantage of existing transmissions. However, to predict whether particular targets can be measured in a particular scenario, it is necessary to be able to model the received signal. In this paper, we present the results of a campaign in which a Pilatus PC-12 single-engine aircraft was measured with a passive radar system relying on DVB-T transmission from a single transmitter. We then present our work to simulate the bistatic RCS of the aircraft along its flight track, using both the method of moments and the shooting and bouncing ray solvers, assess the uncertainty in the simulations, and compare against the measurements. We find that our simulated RCS values are useful in predicting whether or not detection occurs. However, we see poor agreement between simulated and measured RCS values where measurements are available, which we attribute primarily to the difficulties in extracting RCS measurements from the data and to unmodeled transmission and received path effects.

Prognostic impact of echocardiographic mean transvalvular gradients in patients with aortic stenosis and low flow undergoing transcatheter aortic valve implantation.

BACKGROUND: Blunted left ventricular hemodynamics reflected by a low stroke volume index (SVI) ≤35 mL/m2 body surface area (low flow [LF]) in patients with severe aortic stenosis (AS) are associated with worse outcomes even after correction of afterload by transcatheter aortic valve implantation (TAVI). These patients can have a low or high transvalvular mean pressure gradient (MPG). We investigated the impact of the pre-interventional MPG on outcomes after TAVI. METHODS: Patients with LF AS were classified into those with normal (EF ≥ 50%; LF/NEF) or reduced ejection fraction (EF < 50%; LF/REF) and were then stratified according to an MPG < or ≥ 40 mmHg. Patients with SVI >35 mL/m2 (normal flow; NF) served as controls. RESULTS: 597 patients with LF/NEF, 264 patients with LF/REF and 975 patients with NF were identified. Among all groups those patients with a low MPG were characterized by higher cardiovascular risk. In patients with LF/REF, functional improvement post-TAVI was less pronounced in low-MPG patients. One-year survival was significantly worse in LF AS patients with a low vs. high MPG (LF/NEF 16.5% vs. 10.5%, p = 0.022; LF/REF 25.4% vs. 8.0%, p = 0.002), whereas no differences were found in NF patients (8.7% vs. 10.0%, p = 0.550). In both LF AS groups, a low pre-procedural MPG emerged as an independent predictor of mortality. CONCLUSIONS: In patients with LF AS, an MPG cut-off of 40 mmHg defines two patient populations with fundamental differences in outcomes after TAVI. Patients with LF AS and a high MPG have the same favorable prognosis as patients with NF AS.

Does the severity of low-gradient aortic stenosis classified by computed tomography-derived aortic valve calcification determine the outcome of patients after transcatheter aortic valve implantation (TAVI)?

OBJECTIVES: Aortic valve calcification (AVC) determined by computed tomography has emerged as a complementary measure of aortic stenosis (AS) severity and as a predictor of adverse events. Thus, AVC can guide further treatment decisions in patients with low-gradient AS (LG-AS). We compared the symptomatic and prognostic outcome of patients with low vs. high AVC after transcatheter aortic valve implantation (TAVI). METHODS: Patients with an aortic valve area index ≤ 0.6 cm2/m2 and a mean pressure gradient (MPG) < 40 mmHg were classified as low-flow, low-gradient AS (LFLG-AS; stroke volume index [SVI] ≤ 35 ml/m2, left ventricular ejection fraction [LVEF] < 50%, n = 173), paradoxical LFLG-AS (pLFLG-AS, SVI ≤ 35 ml/m2, LVEF ≥ 50%, n = 233), or normal-flow, low-gradient AS (NFLG-AS, SVI > 35 ml/m2, LVEF ≥ 50%, n = 244); patients with MPG ≥ 40 mmHg (n = 1142) served as controls. Patients were further categorized according to published AVC thresholds. RESULTS: Demographic characteristics and cardiovascular risk were not different between patients with high vs. low AVC in any of the subgroups. Patients with low AVC had a lower MPG. Symptom improvement at 30 days was observed in the majority of patients but was less pronounced in LFLG-AS patients with low vs. those with high AVC. Kaplan-Meier 1-year survival curves were identical between patients with low and high AVC in all three LG-AS groups. CONCLUSIONS: The severity of LG-AS based on AVC has no impact on 1-year prognosis once TAVI has been performed. KEY POINTS: • Aortic valve calcification (AVC) determined by computed tomography has emerged as a complementary measure of aortic stenosis (AS) severity and is of prognostic value in selected patients. • Patients with inconsistent echocardiographic measures can be classified as having severe or nonsevere AS by the computed tomography-derived AVC score. • The prognostic value of AVC in patients with low-gradient AS is abrogated after correction of afterload by TAVI.

Effects of Statins After Transcatheter Aortic Valve Implantation in Key Patient Populations.

ABSTRACT: Statin therapy after transcatheter aortic valve replacement (TAVI) is associated with better short-term and long-term outcomes. It is of interest to identify specific patient populations that may profit from statin therapy. In this retrospective, observational analysis of 2862 patients with symptomatic aortic stenosis after successful transfemoral TAVI, survival during a three-year observation period was characterized by Kaplan-Meier analyses according to statin therapy. Hazard ratios and potential interactions for specific subgroups of patients were determined by Cox regression analyses. At hospital discharge 1761 patients were on low-intensity or moderate-intensity statins, 246 patients were on high-intensity statins, and 855 patients did not take statins. Statin therapy adherence during the first 3 months post-TAVI was 91%. Mortality rates were 18.5%, 12.9%, and 6.9% for patients with no statin, low-intensity or moderate-intensity statins, and high-intensity statins (P < 0.001). Any statin therapy proved to be effective in patients in different classes of age, risk, and manifest cardiovascular disease and was independent of background medication. Statins were of particular benefit in high-risk patients with coronary artery disease [hazard ratio (HR) = 0.57], ejection fraction <40% (HR = 0.64), or low-flow low-gradient aortic stenosis (HR = 0.58) and showed additional benefit even in patients taking renin-angiotensin system blockers (HR = 0.74). Statins also reduced mortality in patients with malignant disease (HR = 0.47). Our analysis confirmed the beneficial effect of statins on survival after TAVI and documented this phenomenon in key patient subsets. The protective effect of statins in our study is consistent with the cardioprotective mechanisms but must be explained by other, yet undetermined pleiotropic effects of statins.

Prospective validation of an acoustic-based system for the detection of obstructive coronary artery disease in a high-prevalence population.

Recent guidelines recommend a risk-adjusted, non-invasive work-up in patients presenting with chest discomfort to exclude coronary artery disease (CAD). However, a risk-adjusted diagnostic approach remains challenging in clinical practice. An acoustic detection device for analyzing micro-bruits induced by stenosis-generated turbulence in the coronary circulation has shown potential for ruling out CAD in patients with low-to-intermediate likelihood. We examined the diagnostic value of this acoustic detection system in a high-prevalence cohort. In total, 226 patients scheduled for clinically indicated invasive coronary angiography (ICA) were prospectively enrolled at two centers and examined using a portable, acoustic detection system. The acoustic analysis was performed in double-blinded fashion prior to quantitative ICA and following percutaneous coronary intervention (PCI). An acoustic detection result (CAD score) was obtained in 94% of all patients. The mean baseline CAD score was 41.2 ± 11.9 in patients with obstructive CAD and 33.8 ± 13.4 in patients without obstructive CAD (p < 0.001). ROC analysis revealed an AUC of 0.661 (95% CI 0.584-0.737). Sensitivity was 97.6% (95% confidence interval (CI) 91.5-99.7%), specificity was 14.5% (CI 9.0-21.7%), negative predictive value was 90.5% (CI 69.6-98.8%), and positive predictive value was 41.7% (CI 34.6-49.0%). Following PCI, the mean CAD score decreased from 40.5 ± 11.2 to 38.3 ± 13.7 (p = 0.039). Using an acoustic detection device identified individuals with CAD in a high-prevalence cohort with high sensitivity but relatively low specificity. The negative predictive value was within the predicted range and may be of value for a fast rule-out of obstructive CAD even in a high-prevalence population.

A fully automated software platform for structural mitral valve analysis.

OBJECTIVE: To evaluate a novel fully automated mitral valve analysis software platform for cardiac computer tomography angiography (CCTA)-based structural heart therapy procedure planning. METHODS: The study included 52 patients (25 women; mean age, 66.9 ± 12.4 years) who had undergone CCTA prior to transcatheter mitral valve replacement (TMVR) or surgical mitral valve intervention (replacement or repair). Therapeutically relevant mitral valve annulus parameters (projected area, circumference, trigone-to-trigone (T-T) distance, anterior-posterior (AP) diameter, and anterolateral-posteromedial (AL-PM) diameter) were measured. Results of the fully automated mitral valve analysis software platform with and without manual adjustments were compared with the reference standard of a user-driven measurement program (3mensio, Pie Medical Imaging). Measurements were compared between the fully automated software, both with and without manual adjustment, and the user-driven program using intraclass correlation coefficients (ICC). A secondary analysis included the time to obtain all measurements. RESULTS: Fully automated measurements showed a good to excellent agreement (circumference, ICC = 0.70; projected area, ICC = 0.81; T-T distance, ICC = 0.64; AP, ICC = 0.62; and AL-PM diameter, ICC = 0.78) compared with the user-driven analysis. There was an excellent agreement between fully automated measurement with manual adjustments and user-driven analysis regarding circumference (ICC = 0.91), projected area (ICC = 0.93), T-T distance (ICC = 0.80), AP (ICC = 0.78), and AL-PM diameter (ICC = 0.79). The time required for mitral valve analysis was significantly lower using the fully automated software with manual adjustments compared with the standard assessment (134.4 ± 36.4 s vs. 304.3 ± 77.7 s) (p < 0.01). CONCLUSION: The fully automated mitral valve analysis software, when combined with manual adjustments, demonstrated a strong correlation compared with the user-driven software while reducing the total time required for measurement. KEY POINTS: • The novel software platform allows for a fully automated analysis of mitral valve structures. • An excellent agreement was found between the fully automated measurement with manual adjustments and the user-driven analysis. • The software showed quicker measurement time compared with the standard analysis of the mitral valve.

Predictive value of preprocedural procalcitonin for short- and long-term mortality after transfemoral transcatheter aortic valve implantation.

Current risk scores used for patients undergoing transcatheter aortic valve implantation (TAVI) do not reliably predict adverse events after TAVI. Procalcitonin (PCT) is associated with increased atherosclerotic burden and adverse outcomes in patients with cardiovascular disease. The aim of our study is to assess the predictive value of preprocedural serum PCT levels in comparison with established risk scores in TAVI patients. A total of 243 patients undergoing transfemoral TAVI at our institution were included prospectively in the study and 230 of these patients participated in the follow-up 1 year after TAVI. The primary endpoints were mortality at 30 days and 1 year. Multivariable analysis revealed that preprocedural PCT was the only independent predictor of 30-day mortality (HR 2.84; 95% CI 1.59-5.06; p < 0.001) and 1-year mortality (HR 1.90; 95% CI 1.17-3.11; p = 0.01), whereas high-sensitivity C-reactive protein showed no association with procedural outcomes. The results of ROC analysis showed good predictive power of PCT for both outcomes (AUC 0.75; p = 0.0003 for 30-day mortality and AUC 0.71; p < 0.0001 for 1-year mortality). An optimal cut-off value for PCT of 0.06 ng/ml for short- and long-term mortality was determined with the Youden index. A significantly higher mortality rate was observed in the high-PCT group (≥ 0.06 ng/ml) based on Kaplan-Meier analysis (log rank = 12.1; p = 0.001 at 30 days and log rank = 14.2; p = 0.0002 at 1 year). Patients in the high-PCT group also had a considerably worse clinical pro6file. In conclusion, preprocedural PCT is an independent predictor of 30-day and 1-year mortality after TAVI. In particular, a cut-off value of 0.06 ng/ml discriminates patients at higher risk of mortality within 30 days and 1 year of TAVI.

Coronary CT Angiography-derived Fractional Flow Reserve: Machine Learning Algorithm versus Computational Fluid Dynamics Modeling.

Purpose To compare two technical approaches for determination of coronary computed tomography (CT) angiography-derived fractional flow reserve (FFR)-FFR derived from coronary CT angiography based on computational fluid dynamics (hereafter, FFRCFD) and FFR derived from coronary CT angiography based on machine learning algorithm (hereafter, FFRML)-against coronary CT angiography and quantitative coronary angiography (QCA). Materials and Methods A total of 85 patients (mean age, 62 years ± 11 [standard deviation]; 62% men) who had undergone coronary CT angiography followed by invasive FFR were included in this single-center retrospective study. FFR values were derived on-site from coronary CT angiography data sets by using both FFRCFD and FFRML. The performance of both techniques for detecting lesion-specific ischemia was compared against visual stenosis grading at coronary CT angiography, QCA, and invasive FFR as the reference standard. Results On a per-lesion and per-patient level, FFRML showed a sensitivity of 79% and 90% and a specificity of 94% and 95%, respectively, for detecting lesion-specific ischemia. Meanwhile, FFRCFD resulted in a sensitivity of 79% and 89% and a specificity of 93% and 93%, respectively, on a per-lesion and per-patient basis (P = .86 and P = .92). On a per-lesion level, the area under the receiver operating characteristics curve (AUC) of 0.89 for FFRML and 0.89 for FFRCFD showed significantly higher discriminatory power for detecting lesion-specific ischemia compared with that of coronary CT angiography (AUC, 0.61) and QCA (AUC, 0.69) (all P < .0001). Also, on a per-patient level, FFRML (AUC, 0.91) and FFRCFD (AUC, 0.91) performed significantly better than did coronary CT angiography (AUC, 0.65) and QCA (AUC, 0.68) (all P < .0001). Processing time for FFRML was significantly shorter compared with that of FFRCFD (40.5 minutes ± 6.3 vs 43.4 minutes ± 7.1; P = .042). Conclusion The FFRML algorithm performs equally in detecting lesion-specific ischemia when compared with the FFRCFD approach. Both methods outperform accuracy of coronary CT angiography and QCA in the detection of flow-limiting stenosis.

Long-term verification of functional and structural renal damage after renal sympathetic denervation.

Previous studies of renal sympathetic denervation (RSD) excluded patients with impaired renal function to avoid potential RSD-related renal damage. Measurement of the highly sensitive biomarkers neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1) has shown that RSD does not aggravate renal damage during the early post-procedural period. The aim of the present study was to examine the effect of RSD on blood pressure (BP) reduction and renal function after a long-term follow-up. A total of 62 consecutive patients undergoing RSD were included in this study. Serum NGAL and KIM-1 were collected prior to RSD and at 24 hr, 48 hr, and 3 months after RSD. BP measurements, antihypertensive medication use, and safety events were followed over a three-year period. Follow-up data were available over 36.9[±3.4] months in 47 of 62 (75.8%) of the initially included patients. At this time point a significant systolic BP reduction of 23 mm Hg (P > 0.001) was documented, and there were no significant changes in serum creatinine (P = 0.14), blood urea nitrogen (P = 0.33), or estimated glomerular filtration rate (eGFR) (P = 0.2) values. There were also no significant changes documented in patients with impaired renal function (eGFR < 45 mL/min) during the early post- procedural period or the long-term follow-up (P = 0.34). The results of the present study show a sustained effect of RSD on BP reduction after a three-year follow-up, and there was no evidence of renal failure. These results provide verification of the long-term safety and effectiveness of RSD, even in patients with impaired renal function. © 2015 Wiley Periodicals, Inc.

Clinical feasibility of a myocardial signal intensity threshold-based semi-automated cardiac magnetic resonance segmentation method.

OBJECTIVES: To assess the accuracy and efficiency of a threshold-based, semi-automated cardiac MRI segmentation algorithm in comparison with conventional contour-based segmentation and aortic flow measurements. METHODS: Short-axis cine images of 148 patients (55 ± 18 years, 81 men) were used to evaluate left ventricular (LV) volumes and mass (LVM) using conventional and threshold-based segmentations. Phase-contrast images were used to independently measure stroke volume (SV). LV parameters were evaluated by two independent readers. RESULTS: Evaluation times using the conventional and threshold-based methods were 8.4 ± 1.9 and 4.2 ± 1.3 min, respectively (P < 0.0001). LV parameters measured by the conventional and threshold-based methods, respectively, were end-diastolic volume (EDV) 146 ± 59 and 134 ± 53 ml; end-systolic volume (ESV) 64 ± 47 and 59 ± 46 ml; SV 82 ± 29 and 74 ± 28 ml (flow-based 74 ± 30 ml); ejection fraction (EF) 59 ± 16 and 58 ± 17%; and LVM 141 ± 55 and 159 ± 58 g. Significant differences between the conventional and threshold-based methods were observed in EDV, ESV, and LVM mesurements; SV from threshold-based and flow-based measurements were in agreement (P > 0.05) but were significantly different from conventional analysis (P < 0.05). Excellent inter-observer agreement was observed. CONCLUSIONS: Threshold-based LV segmentation provides improved accuracy and faster assessment compared to conventional contour-based methods. KEY POINTS: • Threshold-based left ventricular segmentation provides time-efficient assessment of left ventricular parameters • The threshold-based method can discriminate between blood and papillary muscles • This method provides improved accuracy compared to aortic flow measurements as a reference.

A non-contrast self-navigated 3-dimensional MR technique for aortic root and vascular access route assessment in the context of transcatheter aortic valve replacement: proof of concept.

OBJECTIVES: Due to the high prevalence of renal failure in transcatheter aortic valve replacement (TAVR) candidates, a non-contrast MR technique is desirable for pre-procedural planning. We sought to evaluate the feasibility of a novel, non-contrast, free-breathing, self-navigated three-dimensional (SN3D) MR sequence for imaging the aorta from its root to the iliofemoral run-off in comparison to non-contrast two-dimensional-balanced steady-state free-precession (2D-bSSFP) imaging. METHODS: SN3D [field of view (FOV), 220-370 mm(3); slice thickness, 1.15 mm; repetition/echo time (TR/TE), 3.1/1.5 ms; and flip angle, 115°] and 2D-bSSFP acquisitions (FOV, 340 mm; slice thickness, 6 mm; TR/TE, 2.3/1.1 ms; flip angle, 77°) were performed in 10 healthy subjects (all male; mean age, 30.3 ± 4.3 yrs) using a 1.5-T MRI system. Aortic root measurements and qualitative image ratings (four-point Likert-scale) were compared. RESULTS: The mean effective aortic annulus diameter was similar for 2D-bSSFP and SN3D (26.7 ± 0.7 vs. 26.1 ± 0.9 mm, p = 0.23). The mean image quality of 2D-bSSFP (4; IQR 3-4) was rated slightly higher (p = 0.03) than SN3D (3; IQR 2-4). The mean total acquisition time for SN3D imaging was 12.8 ± 2.4 min. CONCLUSIONS: Our results suggest that a novel SN3D sequence allows rapid, free-breathing assessment of the aortic root and the aortoiliofemoral system without administration of contrast medium. KEY POINTS: • The prevalence of renal failure is high among TAVR candidates. • Non-contrast 3D MR angiography allows for TAVR procedure planning. • The self-navigated sequence provides a significantly reduced scanning time.

Coronary CT angiography-derived fractional flow reserve correlated with invasive fractional flow reserve measurements--initial experience with a novel physician-driven algorithm.

OBJECTIVES: The present study aimed to determine the feasibility of a novel fractional flow reserve (FFR) algorithm based on coronary CT angiography (cCTA) that permits point-of-care assessment, without data transfer to core laboratories, for the evaluation of potentially ischemia-causing stenoses. METHODS: To obtain CT-based FFR, anatomical coronary information and ventricular mass extracted from cCTA datasets were integrated with haemodynamic parameters. CT-based FFR was assessed for 36 coronary artery stenoses in 28 patients in a blinded fashion and compared to catheter-based FFR. Haemodynamically relevant stenoses were defined by an invasive FFR ≤0.80. Time was measured for the processing of each cCTA dataset and CT-based FFR computation. Assessment of cCTA image quality was performed using a 5-point scale. RESULTS: Mean total time for CT-based FFR determination was 51.9 ± 9.0 min. Per-vessel analysis for the identification of lesion-specific myocardial ischemia demonstrated good correlation (Pearson's product-moment r = 0.74, p < 0.0001) between the prototype CT-based FFR algorithm and invasive FFR. Subjective image quality analysis resulted in a median score of 4 (interquartile ranges, 3-4). CONCLUSIONS: Our initial data suggest that the CT-based FFR method for the detection of haemodynamically significant stenoses evaluated in the selected population correlates well with invasive FFR and renders time-efficient point-of-care assessment possible. KEY POINTS: • CT-based FFR computation is a promising novel non-invasive application. • A novel prototype algorithm permits time-efficient point-of-care CT-based FFR assessment. • Initial results of the CT-based FFR prototype algorithm compare favourably with FFR.

Prognostic value of epicardial fat volume measurements by computed tomography: a systematic review of the literature.

OBJECTIVES: To perform a systematic review of the growing body of literature evaluating the prognostic value of epicardial fat volume (EFV) quantified by cross-sectional imaging. METHODS: Two independent reviewers performed systematic searches on both PubMed and Scopus using search terms developed with a medical librarian. Peer-reviewed articles were selected based on the inclusion of outcome data, utilization of epicardial fat volume and sufficient reporting for analysis. RESULTS: A total of 411 studies were evaluated with nine studies meeting the inclusion criteria. In all, the studies evaluated 10,252 patients. All nine studies were based on CT measurements. Seven studies evaluated the prognostic value of EFV unadjusted for calcium score, and six of these studies found a significant association between EFV and clinical outcomes. Seven studies evaluated the incremental value of EFV beyond calcium scoring, and six of these studies found a significant association. CONCLUSIONS: The majority of studies suggest that EFV quantification is significantly associated with clinical outcomes and provides incremental prognostic value over coronary artery calcium scoring. Future research should use a binary cutoff of 125 mL for evaluation of EFV to provide consistency with other research. KEY POINTS: • Epicardial fat volume (EFV) has prognostic value for adverse cardiac events • Establishment of standardized quantitative categories for EFV is needed • Quantification of EFV could improve risk assessment with calcium scoring.

Image quality and radiation dose of lower extremity CT angiography at 70 kVp on an integrated circuit detector dual-source computed tomography.

BACKGROUND: Despite the well-established requirement for radiation dose reduction there are few studies examining the potential for lower extremity CT angiography (CTA) at 70 kVp. PURPOSE: To compare the image quality and radiation dose of lower extremity CTA at 70 kVp using a dual-source CT system with an integrated circuit detector to similar studies at 120 kVp. MATERIAL AND METHODS: A total of 62 patients underwent lower extremity CTA. Thirty-one patients were examined at 70 kVp using a second generation dual-source CT with an integrated circuit detector (70 kVp group) and 31 patients were evaluated at 120 kVp using a first generation dual-source CT (120 kVp group). The attenuation and image noise were measured and signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Two radiologists assessed image quality. Radiation dose was compared. RESULTS: The mean attenuation of the 70 kVp group was higher than the 120 kVp group (575 ± 149 Hounsfield units [HU] vs. 258 ± 38 HU, respectively, P < 0.001) as was SNR (44.0 ± 22.0 vs 32.7 ± 13.3, respectively, P = 0.017), CNR (39.7 ± 20.6 vs 26.6 ± 11.7, respectively, P = 0.003) and the mean image quality score (3.7 ± 0.1 vs. 3.2 ± 0.3, respectively, P < 0.001). The inter-observer agreement was good for the 70 kVp group and moderate for the 120 kVp group. The dose-length product was lower in the 70 kVp group (264.5 ± 63.1 mGy × cm vs. 412.4 ± 81.5 mGy × cm, P < 0.001). CONCLUSION: Lower extremity CTA at 70 kVp allows for lower radiation dose with higher SNR, CNR, and image quality when compared with standard 120 kVp.

[Catheter-based and surgical treatment for aortic valve diseases]. / Katheterbasierte und operative Therapie bei Aortenvitien.

The pathophysiology of aortic valve diseases is of predominantly degenerative nature, characterized by calcific aortic valve stenosis, which is associated with a reduction in prognosis. The prevalence of aortic valve insufficiency also increases with advancing age. Timely causal treatment is crucial in the management of aortic valve diseases. Following the indication for intervention, the heart team plays a central role in evaluating the results and making therapeutic decisions that consider the patient's preferences. In the assessment of treatment options, considerations regarding the long-term perspective are particularly crucial, especially in younger patients. The most common therapeutic approach for aortic valve diseases is the introduction of a new valve prosthesis. In the majority of cases, this is now achieved through catheter-based implantation of a bioprosthetic heart valve, known as transcatheter aortic valve implantation (TAVI). Open surgical aortic valve replacement (AVR) is favored in younger patients with low surgical risk or in the case that TAVI is not feasible. In AVR, both biological and the longest-lasting mechanical prosthesis types are used. Surgical repair techniques are primarily applied in cases of aortic valve regurgitation. Notably, TAVI, as well as surgical procedures for the treatment of aortic valve diseases, have undergone significant advancements in recent years, including expanded indications for TAVI and, on the surgical side, in particular the development of minimally invasive surgical techniques.

ACURATE neo2 Versus SAPIEN 3 Ultra Transcatheter Heart Valve in Severe Aortic Valve Calcification: A Propensity-Matched Analysis.

BACKGROUND: Comparative data on transcatheter self-expanding ACURATE neo2 (NEO2) and balloon-expandable SAPIEN 3 Ultra prostheses in technically challenging anatomy of severe aortic valve calcified aortic annuli are scarce. METHODS: A total of 1987 patients with severe native aortic stenosis treated with the self-expanding NEO2 (n=1457) or balloon-expandable SAPIEN 3 Ultra (n=530) from January 2017 to April 2023 were evaluated. The primary end point was procedural outcome according to the Valve Academic Research Consortium 3 definitions. Propensity matching defined 219 pairs with severe calcification (calcium density cutoff, 758 AU/cm2) of the native aortic valve. RESULTS: Technical success (90.4% versus 91.8%; risk difference, 1.4% [95% CI, -4.4 to -7.2]; P=0.737) and device success at 30 days (80.8% versus 75.8%; risk difference, -5.0% [95% CI, -13.2 to 3.1]; P=0.246) were comparable between NEO2 and SAPIEN 3 Ultra. The rate of severe prosthesis-patient mismatch (1.1% versus 10.1%; risk difference, 10.0% [95% CI, 4.0-13.9]; P<0.001) and mean transvalvular gradient ≥20 mm Hg (2.8% versus 14.3%; risk difference, 11.5% [95% CI, 5.8-17.1]; P<0.001) was lower with NEO2. The rate of more-than-mild paravalvular leakage or valve-in-valve due to paravalvular leakage was significantly higher (6.2% versus 0.0%; risk difference, 6.2% [95% CI, -10.1 to -2.7]; P=0.002), and there was a tendency for a higher rate of device embolization or migration (1.8% versus 0.0%; risk difference, -1.8% [95% CI, -4.1 to 0.4]; P=0.123) with NEO2. Multivarate regression revealed no independent impact of transcatheter heart valve selection on device success (odds ratio, 0.93 [95% CI, 0.48-1.77]; P=0.817). CONCLUSIONS: In patients with severely calcified annuli, supraannular implantation of NEO2 showed hemodynamic advantages. Nevertheless, NEO2 was associated with a higher incidence of relevant paravalvular leakage and a numerically higher rate of device embolization than SAPIEN 3 Ultra in this particular patient group.

Effects of high- versus low-intensity lipid-lowering treatment in patients undergoing serial coronary computed tomography angiography: results of the multi-center LOCATE study.

AIM: To evaluate the effects of lipid-lowering medications of different intensities on total, calcified, and non-calcified plaque volumes in patients undergoing serial cardiac computed tomography angiography (CCTA). METHODS: Individuals with chronic coronary syndromes from 11 centers were included in a retrospective registry. Total, calcified, and non-calcified plaque volumes were quantified and the relative difference in plaque volumes between baseline and follow-up CCTA was calculated. The intensity of lipid-lowering treatment was designated as low, moderate, or high, based on current recommendations. RESULTS: Of 216 patients (mean age 63.1 ± 9.7 years), undergoing serial CCTA (median timespan = 824.5 [IQR = 463.0-1323.0] days), 89 (41.2%) received no or low-intensity lipid-lowering medications, and 80 (37.0%) and 47 (21.8%) moderate- and high-intensity lipid-lowering agents, respectively. Progression of total and non-calcified plaque was attenuated in patients on moderate-/high- versus those on no/low-intensity treatment and arrested in patients treated with high-intensity statins or PCSK9 inhibitors (p < 0.001). Halted increase of non-calcified plaque was associated with LDL-cholesterol reduction (p < 0.001), whereas calcified plaque mass and Agatston score increased irrespective of the lipid-lowering treatment (p = NS). The intensity of lipid-lowering therapy robustly predicted attenuation of non-calcified plaque progression as a function of the time duration between the two CCTA scans, and this was independent of age and cardiovascular risk factors (HR = 3.83, 95% CI = 1.81-8.05, p < 0.001). CONCLUSION: The LOCATE multi-center observational study shows that progression of non-calcified plaques, which have been previously described as precursors of acute coronary syndromes, can be attenuated with moderate-intensity, and arrested with high-intensity lipid-lowering therapy. GERMAN CLINICAL TRIALS REGISTER: DRKS00031954.

Impact of Accidental High or Low Implantation Depth on Peri-Procedural Outcomes after Implantation with the Self-Expanding ACURATE neo2.

Background: Precise implantation could play a crucial role in the technical success of transcatheter aortic valve replacement (TAVR) for some prostheses. The impact of an accidental implantation depth (ID) outside the recommended range has not been assessed for the ACURATE neo2 (NEO2). Methods: Data from 1839 patients with severe native aortic stenosis treated with the NEO2 prosthesis were evaluated. We compared the results of prostheses implanted in an ID both inside and outside the recommendations. The outcome assessment followed the Valve Academic Research Consortium-3 criteria. Results: Patients were retrospectively divided into high (<3 mm; n = 412), optimal (3-7 mm; n = 1236), and low (>7 mm; n = 169) implantations. Technical success (94.7% vs. 94.7% vs. 91.7%, p = 0.296) and device success were high (90.1% vs. 89.3% vs. 84.6%, p = 0.112) without differences between groups. Rates of relevant paravalvular regurgitation (PVL; >mild or VinV due to PVL) were comparable (1.2% vs. 1.8% vs. 1.2%, p = 0.759). Even when hemodynamics were superior in the high-implantation group, with greater iEOA (1.01 cm2/m2 vs. 0.95 cm2/m2 vs. 0.92 cm2/m2, p < 0.001), spontaneous embolization or after post-dilatation was more common. Low implantation was associated with a higher rate of associated pacemaker implantation (PPI) (6.1% vs. 8.8% vs. 14.8%, p = 0.001). Conclusions: Implantation with the ACURATE neo2 showed excellent hemodynamic results, including low gradients and a small number of relevant PVL, in line with a high technical success rate that was irrespective of the ID. A favorable outcome can also be achieved in accidental low or high positions. Low implantation was associated with a higher rate of associated pacemaker implantation. Deliberately high implantation should be avoided due to the risk of embolization.