Resumen: Consenso internacional para la nomenclatura y clasificación de la válvula aórtica bicúspide congénita y su aortopatía, con fines clínicos, quirúrgicos, intervencionistas y de investigación / Summary: International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes

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Abstract This consensus of nomenclature and classification for congenital bicuspid aortic valve and its aortopathy is evidence-based and intended for universal use by physicians (both pediatricians and adults), echocardiographers, advanced cardiovascular imaging specialists, interventional cardiologists, cardiovascular surgeons, pathologists, geneticists, and researchers spanning these areas of clinical and basic research. In addition, as long as new key and reference research is available, this international consensus may be subject to change based on evidence-based data1.

Pharmacist-Led Antimicrobial Stewardship Programme in Two Tertiary Hospitals in Malawi.

The ultimate goal of antimicrobial stewardship (AMS) programmes is to decrease the occurrence and spread of antimicrobial resistance (AMR). In response to this, a pharmacist partnership was established between Malawi and Wales (UK) with the aim of strengthening antimicrobial stewardship (AMS) activities in Malawi, with the initial project focusing on two tertiary referral hospitals. The Global Point Prevalence Survey (GPPS) was undertaken for the first time in Malawi at these sites and demonstrated a prescribing rate slightly lower than the African average, with ceftriaxone indicated for almost every bacterial infection. An educational intervention was also delivered, with a train-the-trainer approach upskilling pharmacists at the two sites, who then cascaded co-produced training sessions to an additional 120 multidisciplinary health professionals. A toolkit to support AMS at an individual patient level was also developed and disseminated to provide an ongoing reference to refer to. Both the trainings and toolkit were well received. Over the course of this project, significant progress has been made with the AMS programmes at the two sites, with local staff empowered to implement AMS activities. These interventions could be easily replicated and scaled and support the delivery of some of the AMS elements of the Malawi Ministry of Health National Action Plan for Antimicrobial Resistance.

Magic Angle Spinning Solid-State 13C Photochemically Induced Dynamic Nuclear Polarization by a Synthetic Donor-Chromophore-Acceptor System at 9.4 T.

Solid-state photochemically induced dynamic nuclear polarization (photo-CIDNP) is a nuclear magnetic resonance spectroscopy technique in which nuclear spin hyperpolarization is generated upon optical irradiation of an appropriate donor-acceptor system. Until now, solid-state photo-CIDNP at high magnetic fields has been observed only in photosynthetic reaction centers and flavoproteins. In the present work, we show that the effect is not limited to such biomolecular samples, and solid-state 13C photo-CIDNP can be observed at 9.4 T under magic angle spinning using a frozen solution of a synthetic molecular system dissolved in an organic solvent. Signal enhancements for the source molecule larger than a factor of 2300 are obtained. In addition, we show that bulk 13C hyperpolarization of the solvent can be generated via spontaneous 13C-13C spin diffusion at natural abundance.

Probing structural and dynamic properties of MAPbCl3 hybrid perovskite using Mn2+ EPR.

Hybrid methylammonium (MA) lead halide perovskites have emerged as materials exhibiting excellent photovoltaic performance related to their rich structural and dynamic properties. Here, we use multifrequency (X-, Q-, and W-band) electron paramagnetic resonance (EPR) spectroscopy of Mn2+ impurities in MAPbCl3 to probe the structural and dynamic properties of both the organic and inorganic sublattices of this compound. The temperature dependent continuous-wave (CW) EPR experiments reveal a sudden change of the Mn2+ spin Hamiltonian parameters at the phase transition to the ordered orthorhombic phase indicating its first-order character and significant slowing down of the MA cation reorientation. Pulsed EPR experiments are employed to measure the temperature dependences of the spin-lattice relaxation T1 and decoherence T2 times of the Mn2+ ions in the orthorhombic phase of MAPbCl3 revealing a coupling between the spin center and vibrations of the inorganic framework. Low-temperature electron spin echo envelope modulation (ESEEM) experiments of the protonated and deuterated MAPbCl3 analogues show the presence of quantum rotational tunneling of the ammonium groups, allowing to accurately probe their rotational energy landscape.

Axial-Equatorial Halide Ordering in Layered Hybrid Perovskites from Isotropic-Anisotropic 207 Pb NMR.

Bandgap-tuneable mixed-halide 3D perovskites are of interest for multi-junction solar cells, but suffer from photoinduced spatial halide segregation. Mixed-halide 2D perovskites are more resistant to halide segregation and are promising coatings for 3D perovskite solar cells. The properties of mixed-halide compositions depend on the local halide distribution, which is challenging to study at the level of single octahedra. In particular, it has been suggested that there is a preference for occupation of the distinct axial and equatorial halide sites in mixed-halide 2D perovskites. 207 Pb NMR can be used to probe the atomic-scale structure of lead-halide materials, but although the isotropic 207 Pb shift is sensitive to halide stoichiometry, it cannot distinguish configurational isomers. Here, we use 2D isotropic-anisotropic correlation 207 Pb NMR and relativistic DFT calculations to distinguish the [PbX6 ] configurations in mixed iodide-bromide 3D FAPb(Br1-x Ix )3 perovskites and 2D BA2 Pb(Br1-x Ix )4 perovskites based on formamidinium (FA+ ) and butylammonium (BA+ ), respectively. We find that iodide preferentially occupies the axial site in BA-based 2D perovskites, which may explain the suppressed halide mobility.

[Summary: International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes]. / Resumen: Consenso internacional para la nomenclatura y clasificación de la válvula aórtica bicúspide congénita y su aortopatía, con fines clínicos, quirúrgicos, intervencionistas y de investigación.

This consensus of nomenclature and classification for congenital bicuspid aortic valve and its aortopathy is evidence-based and intended for universal use by physicians (both pediatricians and adults), echocardiographers, advanced cardiovascular imaging specialists, interventional cardiologists, cardiovascular surgeons, pathologists, geneticists, and researchers spanning these areas of clinical and basic research. In addition, as long as new key and reference research is available, this international consensus may be subject to change based on evidence-based data1.

Este consenso de nomenclatura y clasificación para la válvula aórtica bicúspide congénita y su aortopatía está basado en la evidencia y destinado a ser utilizado universalmente por médicos (tanto pediatras como de adultos), médicos ecocardiografistas, especialistas en imágenes avanzadas cardiovasculares, cardiólogos intervencionistas, cirujanos cardiovasculares, patólogos, genetistas e investigadores que abarcan estas áreas de investigación clínica y básica. Siempre y cuando se disponga de nueva investigación clave y de referencia, este consenso internacional puede estar sujeto a cambios de acuerdo con datos basados en la evidencia1.

Measurement of Abdominal Aortic Aneurysm Strain Using MR Deformable Image Registration: Accuracy and Relationship to Recent Aneurysm Progression.

BACKGROUND: Management of asymptomatic abdominal aortic aneurysm (AAA) based on maximum aneurysm diameter and growth rate fails to preempt many ruptures. Assessment of aortic wall biomechanical properties may improve assessment of progression and rupture risk. This study aimed to assess the accuracy of AAA wall strain measured by cine magnetic resonance imaging (MRI) deformable image registration (MR strain) and investigate its relationship with recent AAA progression. METHODS: The MR strain accuracy was evaluated in silico against ground truth strain in 54 synthetic MRIs generated from a finite element model simulation of an AAA patient's abdomen for different aortic pulse pressures, tissue motions, signal intensity variations, and image noise. Evaluation included bias with 95% confidence interval (CI) and correlation analysis. Association of MR strain with AAA growth rate was assessed in 25 consecutive patients with >6 months of prior surveillance, for whom cine balanced steady-state free-precession imaging was acquired at the level of the AAA as well as the proximal, normal-caliber aorta. Univariate and multivariate regressions were used to associate growth rate with clinical variables, maximum AAA diameter (Dmax), and peak circumferential MR strain through the cardiac cycle. The MR strain interoperator variability was assessed using bias with 95% CI, intraclass correlation coefficient, and coefficient of variation. RESULTS: In silico experiments revealed an MR strain bias of 0.48% ± 0.42% and a slope of correlation to ground truth strain of 0.963. In vivo, AAA MR strain (1.2% ± 0.6%) was highly reproducible (bias ± 95% CI, 0.03% ± 0.31%; intraclass correlation coefficient, 97.8%; coefficient of variation, 7.14%) and was lower than in the nonaneurysmal aorta (2.4% ± 1.7%). Dmax (ß = 0.087) and MR strain (ß= -1.563) were both associated with AAA growth rate. The MR strain remained an independent factor associated with growth rate (ß= -0.904) after controlling for Dmax. CONCLUSIONS: Deformable image registration analysis can accurately measure the circumferential strain of the AAA wall from standard cine MRI and may offer patient-specific insight regarding AAA progression.

4D Flow cardiovascular magnetic resonance consensus statement: 2023 update.

Hemodynamic assessment is an integral part of the diagnosis and management of cardiovascular disease. Four-dimensional cardiovascular magnetic resonance flow imaging (4D Flow CMR) allows comprehensive and accurate assessment of flow in a single acquisition. This consensus paper is an update from the 2015 '4D Flow CMR Consensus Statement'. We elaborate on 4D Flow CMR sequence options and imaging considerations. The document aims to assist centers starting out with 4D Flow CMR of the heart and great vessels with advice on acquisition parameters, post-processing workflows and integration into clinical practice. Furthermore, we define minimum quality assurance and validation standards for clinical centers. We also address the challenges faced in quality assurance and validation in the research setting. We also include a checklist for recommended publication standards, specifically for 4D Flow CMR. Finally, we discuss the current limitations and the future of 4D Flow CMR. This updated consensus paper will further facilitate widespread adoption of 4D Flow CMR in the clinical workflow across the globe and aid consistently high-quality publication standards.

Dynamic nuclear polarisation of 1H in Gd-doped In(OH)3.

Dynamic nuclear polarisation (DNP) of solids doped with high-spin metal ions, such as Gd3+, is a useful strategy to enhance the nuclear magnetic resonance (NMR) sensitivity for these samples. Spin diffusion can relay polarisation throughout a sample, which is most effective for dense 1H networks, while the efficiency of DNP using Gd3+ depends on the symmetry of the metal site. Here, we investigate cubic In(OH)3 as a high-symmetry, proton-containing material for endogenous Gd DNP. A 1H enhancement of up to 9 is demonstrated and harnessed to measure the 17O spectrum at natural abundance. The enhancement is interpreted in terms of clustering of the Gd3+ dopants and the local reduction in symmetry of the metal site induced by proton disorder, as demonstrated by quadrupolar 115In NMR. This is the first example of 1H DNP using Gd3+ dopants in an inorganic solid.

Optically Enhanced Solid-State 1H NMR Spectroscopy.

Low sensitivity is the primary limitation to extending nuclear magnetic resonance (NMR) techniques to more advanced chemical and structural studies. Photochemically induced dynamic nuclear polarization (photo-CIDNP) is an NMR hyperpolarization technique where light is used to excite a suitable donor-acceptor system, creating a spin-correlated radical pair whose evolution drives nuclear hyperpolarization. Systems that exhibit photo-CIDNP in solids are not common, and this effect has, up to now, only been observed for 13C and 15N nuclei. However, the low gyromagnetic ratio and natural abundance of these nuclei trap the local hyperpolarization in the vicinity of the chromophore and limit the utility for bulk hyperpolarization. Here, we report the first example of optically enhanced solid-state 1H NMR spectroscopy in the high-field regime. This is achieved via photo-CIDNP of a donor-chromophore-acceptor molecule in a frozen solution at 0.3 T and 85 K, where spontaneous spin diffusion among the abundant strongly coupled 1H nuclei relays polarization through the whole sample, yielding a 16-fold bulk 1H signal enhancement under continuous laser irradiation at 450 nm. These findings enable a new strategy for hyperpolarized NMR beyond the current limits of conventional microwave-driven DNP.

Ascending thoracic aortic aneurysm elongation occurs in parallel with dilatation in a nonsurgical population.

OBJECTIVES: Rapid diameter growth is a criterion for ascending thoracic aortic aneurysm repair; however, there are sparse data on aneurysm elongation rate. The purpose of this study was to assess aortic elongation rates in nonsyndromic, nonsurgical aneurysms to understand length dynamics and correlate with aortic diameter over time. METHODS: Patients with <5.5-cm aneurysms and computed tomography angiography imaging at baseline and 3-5 years follow-up underwent patient-specific three-dimensional aneurysm reconstruction using MeVisLab. Aortic length was measured along the vessel centreline between the annulus and aortic arch. Maximum aneurysm diameter was determined from imaging in a plane normal to the vessel centreline. Average rates of aneurysm growth were evaluated using the longest available follow-up. RESULTS: Over the follow-up period, the mean aortic length for 67 identified patients increased from 118.2 (95% confidence interval: 115.4-121.1) mm to 120.2 (117.3-123.0) mm (P = 0.02) and 15 patients (22%) experienced a change in length of ≥5% from baseline. The mean annual growth rate for length [0.38 (95% confidence interval: 0.11-0.65) mm/year] was correlated with annual growth rate for diameter [0.1 (0.03-0.2) mm/year] (rho = 0.30, P = 0.01). Additionally, annual percentage change in length [0.3 (0.1-0.5)%/year] was similar to percentage change in diameter [0.2 (0.007-0.4)%/year, P = 0.95]. CONCLUSIONS: Aortic length increases in parallel with aortic diameter at a similar percentage rate. Further work is needed to identify whether elongation rate is associated with dissection risk. Such studies may provide insight into why patients with aortic diameters smaller than surgical guidelines continue to experience dissection events.

Dynamic Nuclear Polarization of Inorganic Halide Perovskites.

The intrinsic low sensitivity of nuclear magnetic resonance (NMR) experiments limits their utility for structure determination of materials. Dynamic nuclear polarization (DNP) under magic angle spinning (MAS) has shown tremendous potential to overcome this key limitation, enabling the acquisition of highly selective and sensitive NMR spectra. However, so far, DNP methods have not been explored in the context of inorganic lead halide perovskites, which are a leading class of semiconductor materials for optoelectronic applications. In this work, we study cesium lead chloride and quantitatively compare DNP methods based on impregnation with a solution of organic biradicals with doping of high-spin metal ions (Mn2+) into the perovskite structure. We find that metal-ion DNP provides the highest bulk sensitivity in this case, while highly surface-selective NMR spectra can be acquired using impregnation DNP. The performance of both methods is explained in terms of the relaxation times, particle size, dopant concentration, and surface wettability. We envisage the future use of DNP NMR approaches in establishing structure-activity relationships in inorganic perovskites, especially for mass-limited samples such as thin films.

Light-Induced Halide Segregation in 2D and Quasi-2D Mixed-Halide Perovskites.

Photoinduced halide segregation hinders widespread application of three-dimensional (3D) mixed-halide perovskites. Much less is known about this phenomenon in lower-dimensional systems. Here, we study photoinduced halide segregation in lower-dimensional mixed iodide-bromide perovskites (PEA2MA n-1Pb n (Br x I1-x )3n+1, with PEA+: phenethylammonium and MA+: methylammonium) through time-dependent photoluminescence (PL) spectroscopy. We show that layered two-dimensional (2D) structures render additional stability against the demixing of halide phases under illumination. We ascribe this behavior to reduced halide mobility due to the intrinsic heterogeneity of 2D mixed-halide perovskites, which we demonstrate via 207Pb solid-state NMR. However, the dimensionality of the 2D phase is critical in regulating photostability. By tracking the PL of multidimensional perovskite films under illumination, we find that while halide segregation is largely inhibited in 2D perovskites (n = 1), it is not suppressed in quasi-2D phases (n = 2), which display a behavior intermediate between 2D and 3D and a peculiar absence of halide redistribution in the dark that is only induced at higher temperature for the quasi-2D phase.

Contrast-enhanced CT radiomics improves the prediction of abdominal aortic aneurysm progression.

OBJECTIVES: To determine if three-dimensional (3D) radiomic features of contrast-enhanced CT (CECT) images improve prediction of rapid abdominal aortic aneurysm (AAA) growth. METHODS: This longitudinal cohort study retrospectively analyzed 195 consecutive patients (mean age, 72.4 years ± 9.1) with a baseline CECT and a subsequent CT or MR at least 6 months later. 3D radiomic features were measured for 3 regions of the AAA, viz. the vessel lumen only; the intraluminal thrombus (ILT) and aortic wall only; and the entire AAA sac (lumen, ILT, and wall). Multiple machine learning (ML) models to predict rapid growth, defined as the upper tercile of observed growth (> 0.25 cm/year), were developed using data from 60% of the patients. Diagnostic accuracy was evaluated using the area under the receiver operating characteristic curve (AUC) in the remaining 40% of patients. RESULTS: The median AAA maximum diameter was 3.9 cm (interquartile range [IQR], 3.3-4.4 cm) at baseline and 4.4 cm (IQR, 3.7-5.4 cm) at the mean follow-up time of 3.2 ± 2.4 years (range, 0.5-9 years). A logistic regression model using 7 radiomic features of the ILT and wall had the highest AUC (0.83; 95% confidence interval [CI], 0.73-0.88) in the development cohort. In the independent test cohort, this model had a statistically significantly higher AUC than a model including maximum diameter, AAA volume, and relevant clinical factors (AUC = 0.78, 95% CI, 0.67-0.87 vs AUC = 0.69, 95% CI, 0.57-0.79; p = 0.04). CONCLUSION: A radiomics-based method focused on the ILT and wall improved prediction of rapid AAA growth from CECT imaging. KEY POINTS: • Radiomic analysis of 195 abdominal CECT revealed that an ML-based model that included textural features of intraluminal thrombus (if present) and aortic wall improved prediction of rapid AAA progression compared to maximum diameter. • Predictive accuracy was higher when radiomic features were obtained from the thrombus and wall as opposed to the entire AAA sac (including lumen), or the lumen alone. • Logistic regression of selected radiomic features yielded similar accuracy to predict rapid AAA progression as random forests or support vector machines.

Dynamic Contrast-Enhanced MRI in Abdominal Aortic Aneurysms as a Potential Marker for Disease Progression.

BACKGROUND: Abdominal aortic aneurysms (AAAs) may rupture before reaching maximum diameter (Dmax ) thresholds for repair. Aortic wall microvasculature has been associated with elastin content and rupture sites in specimens, but its relation to progression is unknown. PURPOSE: To investigate whether dynamic contrast-enhanced (DCE) MRI of AAA is associated with Dmax or growth. STUDY TYPE: Prospective. POPULATION: A total of 27 male patients with infrarenal AAA (mean age ± standard deviation = 75 ± 5 years) under surveillance with DCE MRI and 2 years of prior follow-up intervals with computed tomography (CT) or MRI. FIELD STRENGTH/SEQUENCE: A 3-T, dynamic three-dimensional (3D) fast gradient-echo stack-of-stars volumetric interpolated breath-hold examination (Star-VIBE). ASSESSMENT: Wall voxels were manually segmented in two consecutive slices at the level of Dmax . We measured slope to 1-minute and area under the curve (AUC) to 1 minute and 4 minutes of the signal intensity change postcontrast relative to that precontrast arrival, and, Ktrans , a measure of microvascular permeability, using the Patlak model. These were averaged over all wall voxels for association to Dmax and growth rate, and, over left/right and anterior/posterior quadrants for testing circumferential homogeneity. Dmax was measured orthogonal to the aortic centerline and growth rate was calculated by linear fit of Dmax measurements. STATISTICAL TESTS: Pearson correlation and linear mixed effects models. A P value <0.05 was considered statistically significant. RESULTS: In 44 DCE MRIs, mean Dmax was 45 ± 7 mm and growth rate in 1.5 ± 0.4 years of prior follow-up was 1.7 ± 1.2 mm per year. DCE measurements correlated with each other (Pearson r = 0.39-0.99) and significantly differed between anterior/posterior versus left/right quadrants. DCE measurements were not significantly associated with Dmax (P = 0.084, 0.289, 0.054 and 0.255 for slope, AUC at 1 minute and 4 minutes, and Ktrans , respectively). Slope and 4 minutes AUC significantly associated with growth rate after controlling for Dmax . CONCLUSION: Contrast uptake may be increased in lateral aspects of the AAA. Contrast enhancement 1-minute slope and 4-minutes AUC may be associated with a period of recent AAA growth that is independent of Dmax . EVIDENCE LEVEL: 3. TECHNICAL EFFICACY: Stage 2.

Association of 3-Year All-Cause Mortality and Peak Wall Stresses of Ascending Thoracic Aortic Aneurysms in Veterans.

Risk of aortic dissection in ascending thoracic aortic aneurysms is not sufficiently captured by size-based metrics. From a biomechanical perspective, dissection may be initiated when wall stress exceeds wall strength. Our objective was to assess the association between aneurysm peak wall stresses and 3-year all-cause mortality. Finite element analysis was performed in 273 veterans with chest computed tomography for surveillance of ascending thoracic aortic aneurysms. Three-dimensional geometries were reconstructed and models developed accounting for prestress geometries. A fiber-embedded hyperelastic material model was applied to obtain circumferential and longitudinal wall stresses under systolic pressure. Patients were followed up to 3 years following the scan to assess aneurysm repair and all-cause mortality. Fine-Gray subdistribution hazards were estimated for all-cause mortality based on age, aortic diameter, and peak wall stresses, treating aneurysm repair as a competing risk. When accounting for age, subdistribution hazard of mortality was not significantly increased by peak circumferential stresses (p = 0.30) but was significantly increased by peak longitudinal stresses (p = 0.008). Aortic diameter did not significantly increase subdistribution hazard of mortality in either model (circumferential model: p = 0.38; longitudinal model: p = 0.30). The effect of peak longitudinal stresses on subdistribution hazard of mortality was maximized at a binary threshold of 355kPa, which captured 34 of 212(16%) patients with diameter <5 cm, 11 of 36(31%) at 5.0-5.4 cm, and 11 of 25(44%) at ≥5.5 cm. Aneurysm peak longitudinal stresses stratified by age and diameter were associated with increased hazard of 3-year all-cause mortality in a veteran cohort. Risk prediction may be enhanced by considering peak longitudinal stresses.

A Complete Picture of Cation Dynamics in Hybrid Perovskite Materials from Solid-State NMR Spectroscopy.

The organic cations in hybrid organic-inorganic perovskites rotate rapidly inside the cuboctahedral cavities formed by the inorganic lattice, influencing optoelectronic properties. Here, we provide a complete quantitative picture of cation dynamics for formamidinium-based perovskites and mixed-cation compositions, which are the most widely used and promising absorber layers for perovskite solar cells today. We use 2H and 14N quadrupolar solid-state NMR relaxometry under magic-angle spinning to determine the activation energy (Ea) and correlation time (τc) at room temperature for rotation about each principal axis of a series of organic cations. Specifically, we investigate methylammonium (MA+), formamidinium (FA+), and guanidinium (GUA+) cations in current state-of-the-art single- and multi-cation perovskite compositions. We find that MA+, FA+, and GUA+ all have at least one component of rotation that occurs on the picosecond timescale at room temperature, with MA+ and GUA+ also exhibiting faster and slower components, respectively. The cation dynamics depend on the symmetry of the inorganic lattice but are found to be insensitive to the degree of cation substitution. In particular, the FA+ rotation is invariant across all compositions studied here, when sufficiently above the phase transition temperature. We further identify an unusual relaxation mechanism for the 2H of MA+ in mechanosynthesized FAxMA1-xPbI3, which was found to result from physical diffusion to paramagnetic defects. This precise picture of cation dynamics will enable better understanding of the relationship between the organic cations and the optoelectronic properties of perovskites, guiding the design principles for more efficient perovskite solar cells in the future.

Surface differences of oxide nanocrystals determined by geometry and exogenously coordinated water molecules.

Determining the different surfaces of oxide nanocrystals is key in developing structure-property relations. In many cases, only surface geometry is considered while ignoring the influence of surroundings, such as ubiquitous water on the surface. Here we apply 17O solid-state NMR spectroscopy to explore the facet differences of morphology-controlled ceria nanocrystals considering both geometry and water adsorption. Tri-coordinated oxygen ions at the 1st layer of ceria (111), (110), and (100) facets exhibit distinct 17O NMR shifts at dry surfaces while these 17O NMR parameters vary in the presence of water, indicating its non-negligible effects on the oxide surface. Thus, the interaction between water and oxide surfaces and its impact on the chemical environment should be considered in future studies, and solid-state NMR spectroscopy is a sensitive approach for obtaining such information. The work provides new insights into elucidating the surface chemistry of oxide nanomaterials.