Comparison of Non-Contrast Cardiovascular Magnetic Resonance Imaging to Computed Tomography Angiography for Aortic Annular Sizing Before Transcatheter Aortic Valve Replacement.

BACKGROUND: Accurate measurement of aortic annulus is crucial before transcatheter aortic valve replacement (TAVR). Computed tomography (CT) angiography is the most commonly utilized method, but requires contrast administration. Cardiovascular magnetic resonance (CMR) imaging is a promising alternative modality to provide aortic annulus measurements. Few studies have compared the clinical feasibility and accuracy of non-contrast CMR to contrast-enhanced computed tomography (CT) angiography in order to provide a non-contrast alternative to CT annular sizing. METHODS: Twenty-one consecutive patients (mean age, 85.7 ± 5.2 years) with severe aortic stenosis (mean aortic valve area, 0.6 ± 0.1 cm²) underwent pre-TAVR CT angiography and a non-contrast CMR at 1.5 T. CT measurements were performed during systole as the clinical non-invasive standard. CMR measurements were performed during systole and diastole and included three-dimensional (3D) and two-dimensional (2D) methods. Interobserver differences were assessed using intraclass correlation. We recorded scan time in each patient. RESULTS: The mean systolic annular area was not significantly different between CT and 3D-CMR (480.0 ± 77.9 mm² vs 479.4 ± 66.2 mm²; P=.98) in systole. There was no clinically relevant systematic difference between area measurements [mean difference, 0.6 mm²; limits of agreement -38.2 mm²; 39.3 mm²] using Bland-Altman analyses. Interobserver correlation was excellent. The diagnostic systolic 3D-CMR annular sizing scan was achieved in 4.4 ± 2.7 min. CONCLUSION: Non-contrast CMR protocol for the measurement of aortic annulus area is feasible and accurate. 3D-CMR could provide an alternative for annular sizing pre-TAVR assessment in patients who cannot undergo contrast-enhanced CT studies.

The functional aortic annulus in the 3D era: focus on transcatheter aortic valve replacement for the perioperative echocardiographer.

The functional aortic annulus represents a sound clinical framework for understanding the components of the aortic root complex. Recent three-dimensional imaging analysis has demonstrated that the aortic annulus frequently is elliptical rather than circular. Comprehensive three-dimensional quantification of this aortic annular geometry by transesophageal echocardiography and/or multidetector computed tomography is essential to guide precise prosthesis sizing in transcatheter aortic valve replacement to minimize paravalvular leak for optimal clinical outcome. Furthermore, three-dimensional transesophageal echocardiography accurately can quantify additional parameters of the functional aortic annulus such as coronary height for complete sizing profiles for all valve types in transcatheter aortic valve replacement. Although it is maturing rapidly as a clinical imaging modality, its role in transcatheter aortic valve replacement is seen best as complementary to multidetector computed tomography in a multidisciplinary heart team model.

Aortic and mitral valve replacement versus transcatheter aortic valve replacement in propensity-matched patients.

BACKGROUND: Recent studies have suggested that transcatheter aortic valve replacement (TAVR) may have superior outcomes compared with aortic valve replacement (AVR) for high-risk patients with significant mitral regurgitation (MR). Considering significant MR is frequently addressed with a mitral valve repair or replacement (MVR) at the time of open aortic valve replacement, this study compares TAVR and AVR/MVR in propensity-matched pairs of patients with significant MR. METHODS: We evaluated all patients presenting with moderate or greater MR undergoing either TAVR or AVR/MVR at a single institution from 2002 to 2012. Patients who underwent other cardiac operations or had preoperative endocarditis were excluded. Of 306 patients in the AVR/MVR group and 147 patients in the TAVR group, propensity analysis matched 40 pairs of patients. Standard univariate, logistic regression, and propensity matching techniques were used. RESULTS: There was no significant difference between TAVR patients and AVR/MVR patients, respectively, in preoperative average age (76 ± 7.4 versus 78 ± 6.9 years, p = 0.68), ejection fraction (53 ± 15 versus 51 ± 17, p = 0.68), The Society of Thoracic Surgeons score (9.9 ± 3.1 versus 9.3 ± 3.4, p = 0.61), or 30-day mortality (7.5% versus 2.5%, p = 0.6). Postoperative MR was significantly improved for both TAVR and AVR/MVR, but AVR/MVR showed significantly greater improvement (-2.33 ± 1.23 versus -0.88 ± 0.79, p < 0.001). Among 30-day survivors, midterm survival was significantly better in the AVR/MVR group compared with the TAVR group (log rank p = 0.04). CONCLUSIONS: In a propensity-matched analysis of patients with significant MR, AVR/MVR and TAVR had equivalent perioperative outcomes, but AVR/MVR had more reduction in MR and may have superior midterm survival when compared with TAVR among 30-day survivors.

Utilization patterns of single-photon emission cardiac tomography myocardial perfusion imaging studies in a rural tertiary care setting.

BACKGROUND: Appropriate use criteria (AUC) for single-photon emission computed tomographic myocardial perfusion imaging (SPECT MPI) were revised in 2009 to include 15 new clinical scenarios. We assessed multivariable predictors and overall appropriateness of MPI studies performed in a rural tertiary care setting. HYPOTHESIS: We hypothesized that appropriate utilization rates of SPECT MPI imaging in a rural tertiary care center are similar for cardiology and non cardiology providers. METHODS: We reviewed all SPECT MPI studies performed for over a 6-month period at our center. Using 67 scenarios in AUC, we categorized these studies as appropriate, inappropriate, uncertain, or unclassifiable. RESULTS: Of 328 MPI studies, 287 (88%) studies were classified as appropriate, 18 (5.5%) as inappropriate, 23 (7%) as uncertain, and none as unclassifiable. Preoperative testing accounted for 44% of the inappropriate studies; 61% of uncertain tests were ordered for cardiovascular risk assessment in patients with prior normal coronary angiography or normal stress tests. The ordering provider specialty did not show any relation with appropriateness of the test (P = 0.46). Patients with inappropriate and uncertain studies were younger than patients with appropriate studies (P = 0.007). CONCLUSIONS: We found that a majority of MPI studies are performed for appropriate indications regardless of ordering provider specialty. Few common scenarios accounted for the majority of the inappropriate or uncertain studies.

Open thoracic aortic repair for dysphagia in patients with Kommerell's diverticulum and right-sided aortic arch with aberrant left subclavian artery.

Kommerell's diverticulum of an aberrant left subclavian artery associated with a right-sided aortic arch is a rare congenital aortic anomaly. This communication reports two cases of this congenital anomaly leading to severe dysphagia. Both cases were successfully repaired with a staged open approach rather than an endovascular approach, which would not have addressed the presenting symptom of dysphagia.

Obesity and insulin resistance but not hyperandrogenism mediates vascular dysfunction in women with polycystic ovary syndrome.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is associated with biochemical evidence of early atherosclerosis; however, data regarding vascular function are controversial. We hypothesized that resistance vessel function (mediated by the endothelium or smooth muscle) would be impaired in women with PCOS and aimed to determine the contribution of hyperandrogenism, obesity, or insulin resistance to vascular dysfunction. DESIGN: Prospective study. SETTING: University practice. PATIENT(S): Women with PCOS (n = 24) and age/weight-matched controls (n = 22). INTERVENTION(S): Vascular function was assessed by measuring forearm vasodilatation in response to both endothelium-dependent (acetylcholine/bradykinin) and endothelium-independent dilators (nitroprusside/verapamil). MAIN OUTCOME MEASURE(S): Resistance vessel function. RESULT(S): Forearm vasodilatation to all four drugs was reduced (>50%) in obese PCOS compared to lean PCOS subjects. There was no significant difference in vascular function between obese or lean women with PCOS compared to corresponding controls. Androgen levels did not correlate with vascular function. Stepwise regression analysis showed that body mass index (BMI) contributed maximally to vascular dysfunction (R(2) = 0.47). CONCLUSION(S): This comprehensive study demonstrates for the first time that obese women with PCOS have markedly reduced vascular smooth muscle function compared to lean subjects with PCOS. In our study obesity and insulin resistance, but not hyperandrogenism, appeared to be significant modulators of vascular function.

Screening women with polycystic ovary syndrome for metabolic syndrome.

OBJECTIVE: Women with polycystic ovary syndrome (PCOS) are at an increased risk for insulin resistance and hyperlipidemia. Metabolic syndrome is a cluster of risk factors that confers an increased risk for cardiovascular disease. The objectives of this study were to compare the prevalence of metabolic syndrome in women with PCOS and controls and to identify the role of androgens or insulin resistance in the development of metabolic syndrome. METHODS: Women with PCOS (n = 129) and women with regular menses and no hirsutism seen for an annual examination (n = 177) were studied. RESULTS: The age-adjusted prevalence of metabolic syndrome was higher in women with PCOS (47.3%, 95% confidence interval 35.3-56.9%) compared with controls (4.3%, 95% confidence interval 1.9-7.6%, P < .001). Compared by age group, the risk of metabolic syndrome in women with PCOS was higher for all groups (P < .001). There were no significant differences in serum androgen levels between women with PCOS with or without metabolic syndrome. In contrast, all markers of insulin resistance were abnormal in women with PCOS with metabolic syndrome compared with those without metabolic syndrome (P < .001). We found serum triglyceride/high density lipoprotein cholesterol (TG/HDL-C) ratio correlated with insulin resistance in this population (P < .001). Serum TG/HDL-C > 3.2 has a high sensitivity and specificity for the detection of metabolic syndrome in women with PCOS. CONCLUSION: Women with PCOS have a 11-fold increase in the prevalence of metabolic syndrome compared with age-matched controls. The risk of metabolic syndrome is high even at a young age, highlighting the importance of early and regular screening. The TG/HDL-C ratio may serve as a screening tool and needs to be prospectively validated in this group. LEVEL OF EVIDENCE: II-2.

Unruptured sinus of Valsalva aneurysm in an asymptomatic patient.

A 75-year-old asymptomatic male patient was referred for transesophageal echocardiography after detection of a diastolic murmur on routine physical examination and widened mediastinum on a chest radiograph. Transesophageal echocardiography revealed a large, unruptured sinus of Valsalva aneurysm, filled with a thrombus and spontaneous echocontrast and protruding into the right atrium. Unruptured sinus of Valsalva aneurysms are rare, frequently asymptomatic, and not associated with any physical findings. The diagnosis was made by transesophageal echocardiography and was confirmed by angiography and at surgery. The need for corrective surgery of asymptomatic, incidentally diagnosed sinus of Valsalva aneurysm is not well defined in the absence of precise knowledge of its natural history. We provide a description of the natural history and rationale for early corrective surgery of sinus of Valsalva aneurysms in asymptomatic patients.