Fully automated measurement of aortic root anatomy using Philips HeartNavigator computed tomography software: fast, accurate, or both?

Cardiac computed tomography (CT) is vital for safety and efficacy of transcatheter aortic valve implantation (TAVI). We aimed to determine the accuracy of fully automated CT analysis of aortic root anatomy before TAVI by Philips HeartNavigator software. This prospective, academic, single-centre study enrolled 128 consecutive patients with native aortic valve stenosis considered for TAVI. Automated HeartNavigator software was compared to the standard manual CT analysis by experienced operators using FluoroCT software. The sizing of the aortic annulus by perimeter and area significantly differed between both methods: mean perimeter was 76.43 mm vs. 77.52 mm (P < 0.0001) using manual FluoroCT vs. automated HeartNavigator software; mean area was 465 mm2 vs. 476 mm2 (P < 0.0001). Interindividual variability testing revealed mean differences between the two operators were 1.21 mm for the aortic annulus perimeter and 9 mm2 for the aortic annulus area. The hypothetical self-expandable transcatheter prosthesis sizing resulted in 80% agreement in 80% of cases. The time required to perform the automated CT analysis was significantly shorter than the time required for manual analysis (mean 17.8 min vs. 2.1 min, P < 0.0001). Philips HeartNavigator fully automated software for pre-TAVI CT analysis is a promising technology. Differences detected in aortic annulus dimensions are small and similar to the variability of manual CT analysis. Automated prediction of optimal fluoroscopic viewing angles is accurate. Correct transcatheter prosthesis sizing requires clinical oversight.

Intravascular haemolysis after transcatheter aortic valve implantation with self-expandable prosthesis: incidence, severity, and impact on long-term mortality.

We aimed to determine the incidence, severity, and long-term impact of intravascular haemolysis after self-expanding transcatheter aortic valve implantation (TAVI). We believe this should be evaluated before extending the indications of TAVI to younger low-risk patients. Prospective, academic, single centre study of 94 consecutive patients treated with supra-annular self-expandable TAVI prosthesis between April 2009 and January 2014. Haemolysis at 1-year post-TAVI was defined per the published criteria based on levels of haemoglobin, reticulocyte and schistocyte count, lactate dehydrogenase (LDH), and haptoglobin. All patients had long-term clinical follow-up (6 years). The incidence of haemolysis at 1-year follow-up varied between 9% and 28%, based on different haemolysis definitions. Haemolysis was mild in all cases, no patient had markedly increased LDH levels. The presence of moderate/severe paravalvular aortic regurgitation was associated with haemolysis (7.7% vs. 23.1%, P = 0.044) and aortic valve area post-TAVI did not differ between groups with or without haemolysis (1.01 vs. 0.92 cm2/m2, P = 0.23) (definition including schistocyte count). The presence of haemolysis did not have any impact on patient prognosis after 6 years with log-rank test P = 0.80. Intravascular haemolysis after TAVI with self-expandable prosthesis is present in 9-28% of patients depending on the definition of haemolysis. The presence of haemolysis is associated with moderate/severe paravalvular aortic regurgitation but not with post-TAVI aortic valve area. Haemolysis is mild with no impact on prognosis.

Serum Dickkopf-1 signaling and calcium deposition in aortic valve are significantly related to the presence of concomitant coronary atherosclerosis in patients with symptomatic calcified aortic stenosis.

BACKGROUND: The study aimed to assess serum RANKL:OPG ratio, Dkk-1 and deposition of calcium in aortic valve in relation to the presence of concomitant coronary atherosclerosis in patients with symptomatic calcified aortic stenosis (CAS). METHODS: OPG, soluble RANKL and Dkk-1 were measured in 218 consecutive patients who were undergoing cardiac catheterization because of symptomatic CAS. Values of studied compounds were compared between patients without (Group A) and with (Group B) coronary atherosclerosis. Computed tomography derived Agatston score was assessed by using 256-slice CT. RESULTS: Presence of coronary atherosclerosis was related to significantly (p = 0.007) higher OPG and to significantly (p = 0.004) lower Dkk-1. Coronary atherosclerosis was also associated with a trend towards a decrease of RANKL. RANKL/OPG Ratios (mean (95% C.I.)) were: 20.04 (16.58; 24.23) in Group A and 12.69 (9.96; 16.17) in Group B, resp., p = 0.018). After adjustment, the difference in RANKL:OPG ratios was no longer significant. Multivariable regression underscored the significance of difference in Dkk-1 (pafter adjustement = 0.020). Group A patients had significantly higher Dkk-1, significantly higher deposition of calcium in aortic valve and were symptomatic in significantly younger age (p < 0.001) as compared to group B patients: Agatston score (mean (95% C.I.)) 4069.9 (3211.8; 5134.5) and 2413.5 (1821.3; 3198.1), p = 0.007. CONCLUSIONS: Dkk-1 and deposition of calcium in aortic valve differ significantly in relation to the presence/absence of coronary atherosclerosis in patients with symptomatic CAS. A positive association was found between Dkk-1 and calcium load in aortic valve in patients with symptomatic CAS and angiographically normal coronary arteries.

A Comparison of Cardiac Computed Tomography, Transesophageal and Intracardiac Echocardiography, and Fluoroscopy for Planning Left Atrial Appendage Closure.

BACKGROUND: Left atrial appendage (LAA) closure (LAAC) is accompanied by a high risk of complications. Due to the complex anatomy of the LAA and the oval-shaped ostium, the proper sizing of the device is often difficult. PURPOSE: To assess individualized fluoroscopy viewing angles using pre-procedural CT analysis and to compare the results of landing zone measurements obtained from CT, transesophageal echocardiography (TEE), intracardiac echocardiography (ICE), and fluoroscopy. METHODS: Patients with indications for LAAC were enrolled. Cardiac CT and TEE were done before the procedure; ICE and fluoroscopy measurements were done peri-procedurally. Multiplanar reconstruction of CT images, using FluoroCT software, was done, and optimal "personalized" viewing angles for fluoroscopy were determined. Moreover, a mean (using multiplanar CT reconstruction, derived from the LAA perimetr) amd maximum (using all four imaging modalitities) landing zone (LZ) of the LAA were masured. RESULTS: Twenty-five patients were analyzed. Despite significant correlation between LZs obtained from different imaging modalities, the values of LZs differed significantly; the mean LZ diameter on CT was 20.60 ± 3.42 mm, the maximum diameters were 21.99 ± 4.03 mm (CT), 18.72 ± 2.44 mm (TEE), 18.20 ± 2.68 mm (ICE), and 17.76 ± 3.24 mm (fluoroscopy). The mean CT diameter matched with the final device selection in 92% patients, while fluoroscopy or TEE maximum diameters in only 72% patients. Optimal viewing angles differed significantly from the fluoroscopy projections usually recommended by the manufacturer in 3 patients. CONCLUSIONS: CT provides the best measurement of the LZ and the best prediction of the optimum fluoroscopy projections for the implantation procedure.

Multiple occurrence of premature polyarticular osteoarthritis in an early medieval Bohemian cemetery (Prague, Czech Republic).

OBJECTIVES: To highlight conditions that may cause early-onset degenerative joint disease, and to assess the possible impact of such diseases upon everyday life. MATERIAL: Four adults aged under 50 years from a medieval skeletal collection of Prague (Czechia). METHODS: Visual, osteometric, X-ray, and histological examinations, stable isotope analysis of bone collagen. RESULTS: All four individuals showed multiple symmetrical degenerative changes, affecting the majority of joints of the postcranial skeleton. Associated dysplastic deformities were observed in all individuals, including bilateral hip dysplasia (n = 1), flattening of the femoral condyles (n = 3), and substantial deformation of the elbows (n = 3). The diet of the affected individuals differed from the contemporary population sample. CONCLUSIONS: We propose the diagnosis of a mild form of skeletal dysplasia in these four individuals, with multiple epiphyseal dysplasia or type-II collagenopathy linked to premature osteoarthritis as the most probable causes. SIGNIFICANCE: Combining the skeletal findings with information from the medical literature, this paper defines several characteristic traits which may assist with the diagnosis of skeletal dysplasia in the archaeological record. LIMITATIONS: As no genetic analysis was performed to confirm the possible kinship of the individuals, it is not possible to definitively assess whether the individuals suffered from the same hereditary condition or from different forms of skeletal dysplasia. SUGGESTIONS FOR FURTHER RESEARCH: Further studies on premature osteoarthritis in archaeological skeletal series are needed to correct the underrepresentation of these mild forms of dysplasia in past populations.

Optimal Fluoroscopic Projections of Coronary Ostia and Bifurcations Defined by Computed Tomographic Coronary Angiography.

OBJECTIVES: The aim of this study was to define the optimal fluoroscopic viewing angles of both coronary ostia and important coronary bifurcations by using 3-dimensional multislice computed tomographic data. BACKGROUND: Optimal fluoroscopic projections are crucial for coronary imaging and interventions. Historically, coronary fluoroscopic viewing angles were derived empirically from experienced operators. METHODS: In this analysis, 100 consecutive patients who underwent computed tomographic coronary angiography (CTCA) for suspected coronary artery disease were studied. A CTCA-based method is described to define optimal viewing angles of both coronary ostia and important coronary bifurcations to guide percutaneous coronary interventions. RESULTS: The average optimal viewing angle for ostial left main stenting was left anterior oblique (LAO) 37°, cranial (CRA) 22° (95% confidence interval [CI]: LAO 33° to 40°, CRA 19° to 25°) and for ostial right coronary stenting was LAO 79°, CRA 41° (95% CI: LAO 74° to 84°, CRA 37° to 45°). Estimated mean optimal viewing angles for bifurcation stenting were as follows: left main: LAO 0°, caudal (CAU) 49° (95% CI: right anterior oblique [RAO] 8° to LAO 8°, CAU 43° to 54°); left anterior descending with first diagonal branch: LAO 11°, CRA 71° (95% CI: RAO 6° to LAO 27°, CRA 66° to 77°); left circumflex bifurcation with first marginal branch: LAO 24°, CAU 33° (95% CI: LAO 15° to 33°, CAU 25° to 41°); and posterior descending artery and posterolateral branch: LAO 44°, CRA 34° (95% CI: LAO 35° to 52°, CRA 27° to 41°). CONCLUSIONS: CTCA can suggest optimal fluoroscopic viewing angles of coronary artery ostia and bifurcations. As the frequency of use of diagnostic CTCA increases in the future, it has the potential to provide additional information for planning and guiding percutaneous coronary intervention procedures.

Degenerative changes and immune response after transcatheter aortic valve implantation. Comparison with surgical aortic valve replacement.

BACKGROUND: Little is known about the valve degeneration process after transcutaneous aortic valve implantations (TAVI) that can have an important impact on patients' long-term prognosis. AIM: To evaluate degenerative changes of TAVI using computed tomography (CT) compared to findings in patients that underwent surgical aortic valve replacement (SAVR). Subsequently, to compare the level of immune and inflammatory markers in both groups and test their possible role in the valve degeneration process. METHODS AND RESULTS: 49 patients after TAVI and 29 patients in the control group after SAVR underwent 2 years of follow-up and 8 patients from the TAVI group and 7 patients after SAVR underwent five years of follow-up. CT was performed in all patients and calcifications on prosthesis cusps in both groups were measured using Agatson calcium score. TAVI patients were older compared to patients who underwent SAVR [82 (62;86) vs. 74 (64;84) years, p<0.001], and had more comorbidities - higher EuroScore I [21.0 (5.0;46.0) vs. 6.15 (2.54;11.17), p<0.001]. TAVI patients had more often concomitant coronary artery disease (69.4% vs. 13.8%, p<0.001) and previous history of cardiac surgery (32.7% vs. 0.0%, p<0.001). Slight calcifications (mean Agatson score 50.76) on prosthetic cusps were found in 2 patients 4-5 years after TAVI and in 1 patient 2 years after SAVR (p=NS). Even though significant differences were found in values of tumor necrosis factor-α and E-selectin before, 1 year, and 2 years after implantation, no significant changes in values of inflammatory markers were observed during follow-up period in both groups of patients. Detailed analysis revealed no significant difference between values of inflammatory markers of patients with and without calcifications present on CT. CONCLUSION: Minimal degenerative changes on TAVI prosthesis were observed in mid- and long-term follow-up. Systemic immune response did not differ between patients after TAVI and SAVR.