Rapid segmentation of computed tomography angiography images of the aortic valve: the efficacy and clinical value of a deep learning algorithm.

Objectives: The goal of this study was to explore the reliability and clinical value of fast, accurate automatic segmentation of the aortic root based on a deep learning tool compared with computed tomography angiography. Methods: A deep learning tool for automatic 3-dimensional aortic root reconstruction, the CVPILOT system (TAVIMercy Data Technology Ltd., Nanjing, China), was trained and tested using computed tomography angiography scans collected from 183 patients undergoing transcatheter aortic valve replacement from January 2021 to December 2022. The quality of the reconstructed models was assessed using validation data sets and evaluated clinically by experts. Results: The segmentation of the ascending aorta and the left ventricle attained Dice similarity coefficients (DSC) of 0.9806/0.9711 and 0.9603/0.9643 for the training and validation sets, respectively. The leaflets had a DSC of 0.8049/0.7931, and the calcification had a DSC of 0.8814/0.8630. After 6 months of application, the system modeling time was reduced to 19.83 s. Conclusion: For patients undergoing transcatheter aortic valve replacement, the CVPILOT system facilitates clinical workflow. The reliable evaluation quality of the platform indicates broad clinical application prospects in the future.

TAVI Under Pressure: Intra-balloon Pressure Profiles During Balloon-Expandable TAVR-First Data from a Feasibility Study.

Our study investigated the feasibility to measure pressure profiles inside the inflation balloon during direct implantation of Edwards Sapien 3 ultra-prostheses using an additional syringe with a digital pressure read-out. Pressure profiles of 15 patients for 26 mm valve size were analyzed. Uniform patterns were found for 5 patients similar to those of previously acquired in vitro curves. 10 patients showed strikingly different pressure profiles compared to the above-mentioned group, marked by an earlier pressure increase, single or multiple pressure drops or higher overall pressure. Measuring the percentage of under-expansion of the prostheses, using calibrated angiographic projections revealed a significant difference between both groups. Our data raises the hypothesis that the acquisition of pressure profiles might help to better understand not only the implantation procedure itself but also the highly individual patient-device interaction, offering new information and a new perspective on optimization of TAVR implantation in the future.

Protected Percutaneous Coronary Intervention of Unprotected Left Main Using Impella Ventricular Assist Device Before Transcatheter Aortic Valve Implantation: A Single-Center Experience.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is nowadays the optimal therapeutic strategy in patients with severe aortic valve stenosis (AS). Consequently, percutaneous coronary intervention (PCI) of concomitant complex coronary artery disease (CAD) has increased in the last decade to optimize patients with severe AS before TAVI. Although the Impella ventricular assist device (Abiomed) was considered as a relative contraindication in patients with AS, its usage has demonstrated promising results in selected patients. METHODS: All consecutive patients with severe AS who underwent staged approach with high-risk PCI of unprotected left main (ULM) using the Impella ventricular assist device before TAVI were retrospectively included. The primary endpoint was 30-day all-cause mortality, and secondary endpoints were peri-interventional mortality, vascular complication, and 30-day stroke rates. Due to the exploratory, observational intent of the study, no statistical analysis was performed. RESULTS: Twenty-one consecutive patients (14 men; age, 80 ± 6 years; log EuroScore, 17 ± 7; SYNTAX score, 27 ± 10) were included. All patients (21/21) survived to 30-day follow-up exam. Three patients (14%) had PCI of ULM and TAVI at the same session. Eighteen patients (86%) underwent TAVI in a staged approach after previous PCI (10 ± 10 days). No patient suffered from stroke up to 30-day follow-up. One patient (5%) developed Valve Academic Research Consortium-2 major vascular complication after PCI. TAVI was successfully performed in all patients. CONCLUSION: Temporary hemodynamic support with the Impella device during staged approach with high-risk protected PCI appears to be safe and technically feasible in patients with severe AS before undergoing TAVI.

Proof of Concept: Measuring Aortic Annulus Resistance by Means of Pressure-Volume Curves During Balloon Inflation to Guide Transcatheter Aortic Valve Implantation.

This study assessed the basic working principle to measure aortic annulus resistance during balloon inflation for transcatheter aortic valve implantation (TAVI), by acquisition of pressure-volume curve for a guided semi-automatic implantation. A modular bench-system was used which allows the incremental inflation of valvuloplasty balloons by means of a stepper-motor driven linear axis with simultaneous recording of the pressure changes inside the system. Different porcine aortic xenografts were assessed by use of a non-compliant valvuloplasty balloon. In a second step transcatheter aortic stents were implanted inside target sized xenografts. The recorded pressure volume-curves showed that the system can accurately differentiate between different xenografts and assess the quality of the tissue rendering real-time analysis of pressure-volume curves during balloon-inflation possible, which has the potential to optimize the implantation procedure by direct adaptation to the patient specific anatomy and characteristics. Further investigations and development are warranted.

A novel transcatheter aortic valve with a form-fitting anchor for self-alignment: feasibility in a chronic preclinical model.

OBJECTIVES: Our goal was to assess the viability of an alternative anchoring design for a transcatheter aortic valve based on a form-fitting principle with a self-expanding nitinol frame to reduce issues related to excess radial force. METHODS: A 26-mm outer diameter prototype of a self-expanding nitinol frame was developed to reduce the amount of necessary radial force by utilizing additional anchoring via protruding arms in each aortic sinus, thus allowing for a form-fitting principle as well as the coaxial self-alignment of the valve inside the native anatomy. The prototype valve was implanted via a transapical approach in the orthotopic position in 2 sheep. Follow-up examinations were performed at regular intervals during a 3-month period to confirm adequate function and anchoring. RESULTS: Observation demonstrated secure, facilitated positioning with perfect alignment of the stent in the aortic sinuses. Repeated transthoracic echocardiography showed adequate valve function over the entire period with no change in the valve position, gradients or regurgitation. The animals remained in sinus rhythm during the entire period. CONCLUSIONS: The prototype frame with its form-fitting properties has the potential to resolve issues related to malpositioning and excess radial force for transcatheter aortic valves as well as to extend the treatment possibilities to pure aortic insufficiencies. The stent is presently being tested in vitro for its long-term durability.

Erroneous measurement of the aortic annular diameter using 2-dimensional echocardiography resulting in inappropriate CoreValve size selection: a retrospective comparison with multislice computed tomography.

OBJECTIVES: This study sought to assess the differential adherence to transcatheter heart valve (THV)-oversizing principles between transesophageal echocardiography (TEE) and multislice computed tomography (CT) and its impact on the incidence of paravalvular leak (PVL). BACKGROUND: CT has emerged as an alternative to 2-dimensional TEE for THV sizing. METHODS: In our early experience, TEE-derived aortic annular diameters determined THV size selection. CT datasets originally obtained for vascular screening were retrospectively interrogated to determine CT-derived annular diameters. Annular dimensions and expected THV oversizing were compared between TEE and CT. The incidence of PVL was correlated to TEE- and CT-based oversizing calculations. RESULTS: Using TEE-derived annulus measurements, 157 patients underwent CoreValve implantation (23 mm: n = 66; 29 mm: n = 91). The estimated THV oversizing on the basis of TEE was 20.1 ± 8.2%. Retrospective CT analysis yielded larger annular diameters than TEE (p < 0.0001). When these CT diameters were used to recalculate the percentage of oversizing achieved with the TEE-selected CoreValve, the actual THV oversizing was only 10.4 ± 7.8%. Consequently, CT analysis suggested that up to 50% of patients received an inappropriate CoreValve size. When CT-based sizing criteria were satisfied, the incidence of PVL was 21% lower than that with echocardiography (14% vs. 35%; p = 0.003). Adherence to CT-based oversizing was independently associated with a reduced incidence of PVL (odds ratio 0.36; 95% confidence interval: 0.14 to 0.90; p = 0.029); adherence to TEE-based sizing was not. CONCLUSIONS: Retrospective CT-based annular analysis revealed that CoreValve size selection by TEE was incorrect in 50% of patients. The percentage of oversizing with CT was one-half of that calculated with TEE resulting in the majority of patients receiving a THV that was too small.

Overlap syndrome consisting of PSC-AIH with concomitant presence of a membranous glomerulonephritis and ulcerative colitis.

The association of primary sclerosing cholangitis (PSC) and autoimmune hepatitis (AIH) is known as an overlap syndrome (OS). OS can also be described in the setting of concomitant presence of AIH and PSC. These diseases can in some cases be associated with ulcerative colitis. In this case report we describe, to our knowledge, the first case in the literature of a young Caucasian male suffering from ulcerative colitis and an overlap syndrome consisting of an association between PSC-AIH, with the concomitant presence of a membranous glomerulonephritis.

What is the potential increase in the heart graft pool by cardiac donation after circulatory death?

Heart transplantation remains the only definite treatment option for end-stage heart diseases. The use of hearts procured after donation after circulatory death (DCD) could help decrease the heart graft shortage. The aim of this study was to evaluate the potential increase in heart graft pool by developing DCD heart transplantation. We retrospectively reviewed our local donor database from 2006 to 2011, and screened the complete controlled DCD donor population for potential heart donors, using the same criteria as for donation after brain death (DBD) heart transplantation. Acceptable donation warm ischemic time (DWIT) was limited to 30 min. During this period 177 DBD and 70 DCD were performed. From the 177 DBD, a total of 70 (39.5%) hearts were procured and transplanted. Of the 70 DCD, eight (11%) donors fulfilled the criteria for heart procurement with a DWIT of under 30 min. Within the same period, 82 patients were newly listed for heart transplantation, of which 53 were transplanted, 20 died or were unlisted, and 9 were waiting. It could be estimated that 11% of the DCD might be heart donors, representing a 15% increase in heart transplant activity, as well as potential reduction in the deaths on the waiting list by 40%.

Liver transplantation for acute hepatic failure due to chemotherapy-induced HBV reactivation in lymphoma patients.

Hepatitis B (HBV) reactivation induced by chemotherapy is problem encountered recently in the management of malignant diseases. Chemotherapy-induced HBV reactivation may ultimately lead to terminal acute liver failure. Liver transplantation (LT) currently remains the only definitive treatment option for such cases, but is generally denied to patients suffering from malignancy. Here, the authors describe 2 cases of cancer-free and HBV graft re-infection-free survival after LT performed for terminal liver failure arising from HBV reactivation induced by chemotherapy for advanced stage lymphoma. These 2 cases, and some other reports in the literature, may suggest that patients suffering from hematologic malignancies and terminal liver disease can be considered for LT if the prognosis of their hematologic malignancy is good.