Assessing teratogenic risks of gadolinium in freshwater environments: Implications for environmental health.

Gadolinium (Gd) is among the rare earth elements extensively utilized in both industrial and medical applications. The latter application appears to contribute to the rise in Gd levels in aquatic ecosystems, as it is excreted via urine from patients undergoing MRI scans and often not captured by wastewater treatment systems. The potential environmental and biological hazards posed by gadolinium exposure are still under investigation. This study aimed to assess the teratogenic risk posed by a gadolinium chelate on the freshwater cnidarian Hydra vulgaris. The experimental design evaluated the impact of pure Gadodiamide (25 µg/l, 50 µg/l, 100 µg/l, 500 µg/l) and its commercial counterpart compound (Omniscan®; 100 µg/l, 500 µg/l, 782.7 mg/l) at varying concentrations using the Teratogenic Risk Index (TRI). Here we showed a moderate risk (Class III of TRI) following exposure to both tested formulations at concentrations ≥ 100 µg/l. Given the potential for similar concentrations in aquatic environments, particularly near wastewater discharge points, a teratogenic risk assessment using the Hydra regeneration assay was conducted on environmental samples collected from three rivers (Tiber, Almone, and Sacco) in Central Italy. Additionally, chemical analysis of field samples was performed using ICP-MS. Analysis of freshwater samples revealed low Gd concentrations (≤ 0.1 µg/l), despite localized increases near domestic and/or industrial wastewater discharge sites. Although teratogenic risk in environmental samples ranged from high (Class IV of TRI) to negligible (Class I of TRI), the low Gd concentrations, particularly when compared to higher levels of other contaminants like arsenic and heavy metals, preclude establishing a direct cause-effect relationship between Gd and observed teratogenic risks in environmental samples. Nevertheless, the teratogenic risks observed in laboratory tests warrant further investigation.

Late/delayed gadolinium enhancement in MRI after intravenous administration of extracellular gadolinium-based contrast agents: is it worth waiting?

The acquisition of images minutes or even hours after intravenous extracellular gadolinium-based contrast agents (GBCA) administration ("Late/Delayed Gadolinium Enhancement" imaging; in this review, further termed LGE) has gained significant prominence in recent years in magnetic resonance imaging. The major limitation of LGE is the long examination time; thus, it becomes necessary to understand when it is worth waiting time after the intravenous injection of GBCA and which additional information comes from LGE. LGE can potentially be applied to various anatomical sites, such as heart, arterial vessels, lung, brain, abdomen, breast, and the musculoskeletal system, with different pathophysiological mechanisms. One of the most popular clinical applications of LGE regards the assessment of myocardial tissue thanks to its ability to highlight areas of acute myocardial damage and fibrotic tissues. Other frequently applied clinical contexts involve the study of the urinary tract with magnetic resonance urography and identifying pathological abdominal processes characterized by high fibrous stroma, such as biliary tract tumors, autoimmune pancreatitis, or intestinal fibrosis in Crohn's disease. One of the current areas of heightened research interest revolves around the possibility of non-invasively studying the dynamics of neurofluids in the brain (the glymphatic system), the disruption of which could underlie many neurological disorders.

Overview of the Current Knowledge and Conventional MRI Characteristics of Peri- and Para-Vascular Spaces.

Brain spaces around (perivascular spaces) and alongside (paravascular or Virchow-Robin spaces) vessels have gained significant attention in recent years due to the advancements of in vivo imaging tools and to their crucial role in maintaining brain health, contributing to the anatomic foundation of the glymphatic system. In fact, it is widely accepted that peri- and para-vascular spaces function as waste clearance pathways for the brain for materials such as ß-amyloid by allowing exchange between cerebrospinal fluid and interstitial fluid. Visible brain spaces on magnetic resonance imaging are often a normal finding, but they have also been associated with a wide range of neurological and systemic conditions, suggesting their potential as early indicators of intracranial pressure and neurofluid imbalance. Nonetheless, several aspects of these spaces are still controversial. This article offers an overview of the current knowledge and magnetic resonance imaging characteristics of peri- and para-vascular spaces, which can help in daily clinical practice image description and interpretation. This paper is organized into different sections, including the microscopic anatomy of peri- and para-vascular spaces, their associations with pathological and physiological events, and their differential diagnosis.

Go Green in Neuroradiology: towards reducing the environmental impact of its practice.

Raising public awareness about the relevance of supporting sustainable practices is required owing to the phenomena of global warming caused by the rising production of greenhouse gases. The healthcare sector generates a relevant proportion of the total carbon emissions in developed countries, and radiology is estimated to be a major contributor to this carbon footprint. Neuroradiology markedly contributes to this negative environmental effect, as this radiological subspecialty generates a high proportion of diagnostic and interventional imaging procedures, the majority of them requiring high energy-intensive equipment. Therefore, neuroradiologists and neuroradiological departments are especially responsible for implementing decisions and initiatives able to reduce the unfavourable environmental effects of their activities, by focusing on four strategic pillars-reducing energy, water, and helium use; properly recycling and/or disposing of waste and residues (including contrast media); encouraging environmentally friendly behaviour; and reducing the effects of ionizing radiation on the environment. The purpose of this article is to alert neuroradiologists about their environmental responsibilities and to analyse the most productive strategic axes, goals, and lines of action that contribute to reducing the environmental impact associated with their professional activities.

Extrahepatic abscess and dropped gallstones: a case report and a narrative review of an unusual delayed complication of laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is the most common minimally invasive abdominal surgery procedure performed in Western countries; it offers several advantages over laparotomy but still carries some risks, such as intraoperative spillage of bile and gallstones. Diagnosis of dropped gallstones could be challenging, it is frequently delayed, and this can lead to further complications such as abscesses formation. METHODS: We report the history of a 51-year-old male with persistent dull abdominal pain in association to appetite loss, vomiting episodes and changes in regular bowel habits, a past medical history of laparoscopic cholecystectomy for biliary lithiasis (1.5 years earlier) and minimum elevation of inflammatory markers and gamma-GT values. RESULTS: Ultrasound examination showed perihepatic stones and magnetic resonance imaging revealed the presence of multiple perihepatic abscesses, findings compatible with fibrotic-inflammatory phenomena from 'dropped gallstones'. A re-laparoscopy was then performed with an abscess collection containing multiple gallstones; a liver wedge resection was also required due to strong adhesions. At follow up, the patient had improved both on clinical and biochemical perspective. CONCLUSION: Dropped gallstones are an underreported cause of morbidity and diagnostic dilemmas in subjects who underwent to laparoscopic cholecystectomy, in relation to infectious complications that can occur even several months or years after surgery. Imaging represents a valuable aid in the correct non-invasive diagnostic process, but proper awareness of this insidious condition is necessary. Surgeons and radiologists should always consider this eventuality in the differential diagnosis of a patient presenting with abdominal abscesses and history of cholecystectomy.

The role of gadolinium-based contrast agents in magnetic resonance imaging structured reporting and data systems (RADS).

Among the 28 reporting and data systems (RADS) available in the literature, we identified 15 RADS that can be used in Magnetic Resonance Imaging (MRI). Performing examinations without using gadolinium-based contrast agents (GBCA) has benefits, but GBCA administration is often required to achieve an early and accurate diagnosis. The aim of the present review is to summarize the current role of GBCA in MRI RADS. This overview suggests that GBCA are today required in most of the current RADS and are expected to be used in most MRIs performed in patients with cancer. Dynamic contrast enhancement is required for correct scores calculation in PI-RADS and VI-RADS, although scientific evidence may lead in the future to avoid the GBCA administration in these two RADS. In Bone-RADS, contrast enhancement can be required to classify an aggressive lesion. In RADS scoring on whole body-MRI datasets (MET-RADS-P, MY-RADS and ONCO-RADS), in NS-RADS and in Node-RADS, GBCA administration is optional thanks to the intrinsic high contrast resolution of MRI. Future studies are needed to evaluate the impact of the high T1 relaxivity GBCA on the assignment of RADS scores.

Interrater reliability of Brain Tumor Reporting and Data System (BT-RADS) in the follow up of adult primary brain tumors: a single institution experience in Italy.

Background: In 2018, a new system was proposed for classifying and reporting post-treatment adult brain tumor on magnetic resonance imaging, named as Brain Tumor Reporting and Data System (BT-RADS), that needs a validation by means of agreement studies. Methods: A retrospective study was designed with the aim of identifying contrast-enhanced magnetic resonance imaging (MRI) of adult patients on follow-up for primary brain tumor at Fondazione Policlinico Campus Bio-Medico. Four radiologists (2 radiology residents, 1 general radiologist, 1 neuroradiologist) read and scored each study using the BT-RADS scoring tool, blinded to the MRI original report. Interobserver agreement and Fleiss' k were calculated to assess the level of diagnostic agreement. It was assessed how many times the assignment of different scoring of BT-RADS would have led to a different patient management. Results: The total number of patients included in the study was 23 with 147 MRIs and a total of 588 BT-RADS scores retrospectively evaluated. The two most frequent tumor types were astrocytoma grade 4 (62%) and oligodendroglioma grade 3 (21%). The overall agreement rate for all 4 radiologists was 82% with a Fleiss' k of 0.70. The overall agreement rate between general radiologist and neuroradiologist was 91% with a Fleiss' k of 0.86. The overall agreement rate between 2 radiology residents and neuroradiologist was 80% with a Fleiss' k of 0.66. Astrocytoma grade 3 (k: 0.51) and oligodendroglioma grade 2 (k: 0.32) showed a poor agreement while higher values of agreement were found for astrocytoma grade 4 (k: 0.70), astrocytoma grade 2 (k: 0.78) and oligodendroglioma grade 3 (k: 0.78). All the radiologists agreed on BT-RADS assignment in 70% patients, three radiologists agreed in 17% and two radiologists agree in 13%. In no cases there was a complete disagreement among the readers. In 18% of cases the discrepancy in the estimated BT-RADS would have led to a different follow-up management. Conclusions: BT-RADS can be considered a valid tool for neuroradiologists and radiologists even with little experience in the interpretation of patients' images during follow-up for adult primary brain tumors supporting standardized interpretation, reporting and clinical management.

Relationship between chronic kidney disease and cerebral white matter hyperintensities: a systematic review.

Background: This systematic review summarizes available evidence on the relationship between white matter hyperintensities (WMH) volumetric quantification on brain MRI scans and chronic kidney disease (CKD). Methods: The literature search was performed in March 2022 using MEDLINE PubMed Central, Scopus and Web of Science - Publons as search engines. Relevant articles investigating, with a quantitative volumetric approach, the link between WMH and CKD patients were selected. Results: The database search strategy found 987 articles, after excluding duplicates, the titles and abstracts of the remaining 320 articles were examined. Subsequently 276 articles were excluded as they were not relevant to the topic. Of the 44 articles evaluated for eligibility, 36 were excluded because the quantitative analysis of WMH was not volumetric. Finally, 8 articles were included in this systematic review. Conclusions: Literature on this topic is extremely heterogeneous in terms of methodology and samples. However, evidence shows that there is a relationship between CKD and WMH volume of the brain. We recommend that quantifiable biomarkers such as estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (UACR) should be included in studies dealing with cerebrovascular disease. The biological and molecular mechanisms underlying cerebrovascular damage in patients with chronic renal failure deserve to be further explored.

The role of iodinated contrast media in computed tomography structured Reporting and Data Systems (RADS): a narrative review.

Background and Objective: In recent years, there has been a large-scale dissemination of guidelines in radiology in the form of Reporting & Data Systems (RADS). The use of iodinated contrast media (ICM) has a fundamental role in enhancing the diagnostic capabilities of computed tomography (CT) but poses certain risks. The scope of the present review is to summarize the current role of ICM only in clinical reporting guidelines for CT that have adopted the "RADS" approach, focusing on three specific questions per each RADS: (I) what is the scope of the scoring system; (II) how is ICM used in the scoring system; (III) what is the impact of ICM enhancement on the scoring. Methods: We analyzed the original articles for each of the latest versions of RADS that can be used in CT [PubMed articles between January, 2005 and March, 2023 in English and American College of Radiology (ACR) official website]. Key Content and Findings: We found 14 RADS suitable for use in CT out of 28 RADS described in the literature. Four RADS were validated by the ACR: Colonography-RADS (C-RADS), Liver Imaging-RADS (LI-RADS), Lung CT Screening-RADS (Lung-RADS), and Neck Imaging-RADS (NI-RADS). One RADS was validated by the ACR in collaboration with other cardiovascular scientific societies: Coronary Artery Disease-RADS 2.0 (CAD-RADS). Nine RADS were proposed by other scientific groups: Bone Tumor Imaging-RADS (BTI-RADS), Bone­RADS, Coronary Artery Calcium Data & Reporting System (CAC-DRS), Coronavirus Disease 2019 Imaging-RADS (COVID-RADS), COVID-19-RADS (CO-RADS), Interstitial Lung Fibrosis Imaging-RADS (ILF-RADS), Lung-RADS (LU-RADS), Node-RADS, and Viral Pneumonia Imaging-RADS (VP-RADS). Conclusions: This overview suggests that ICM is not strictly necessary for the study of bones and calcifications (CAC-DRS, BTI-RADS, Bone-RADS), lung parenchyma (Lung-RADS, LU-RADS, COVID-RADS, CO-RADS, VP-RADS and ILF-RADS), and in CT colonography (C-RADS). On the other hand, ICM plays a key role in CT angiography (CAD-RADS), in the study of liver parenchyma (LI-RADS), and in the evaluation of soft tissues and lymph nodes (NI-RADS, Node-RADS). Future studies are needed in order to evaluate the impact of the new iodinated and non-iodinate contrast media, artificial intelligence tools and dual energy CT in the assignment of RADS scores.

Right Condylar Jugular Diverticulum: Contrast-enhanced Computed Tomography Findings of a Rare Anatomical Variant of Jugular Bulb.

This is the first description of condylar jugular diverticulum (CJD) by means of contrast-enhanced computed tomography scan in the medical literature. CJD is a rare anatomical variant of jugular bulb that should be known to avoid radiological and surgical errors and achieve an appropriate pre-surgical planning of skull base pathologies.

Oxidative Stress in Postmenopausal Women with or without Obesity.

Oxidative stress, a key mediator of cardiovascular disease, metabolic alterations, and cancer, is independently associated with menopause and obesity. Yet, among postmenopausal women, the correlation between obesity and oxidative stress is poorly examined. Thus, in this study, we compared oxidative stress states in postmenopausal women with or without obesity. Body composition was assessed via DXA, while lipid peroxidation and total hydroperoxides were measured in patient's serum samples via thiobarbituric-acid-reactive substances (TBARS) and derivate-reactive oxygen metabolites (d-ROMs) assays, respectively. Accordingly, 31 postmenopausal women were enrolled: 12 with obesity and 19 of normal weight (mean (SD) age 71.0 (5.7) years). Doubled levels of serum markers of oxidative stress were observed in women with obesity in women with obesity compared to those of normal weight (H2O2: 32.35 (7.3) vs. 18.80 (3.4) mg H2O2/dL; malondialdehyde (MDA): 429.6 (138.1) vs. 155.9 (82.4) mM in women with or without obesity, respectively; p < 0.0001 for both). Correlation analysis showed that both markers of oxidative stress increased with an increasing body mass index (BMI), visceral fat mass, and trunk fat percentage, but not with fasting glucose levels. In conclusion, obesity and visceral fat are associated with a greater increase in oxidative stress in postmenopausal women, possibly increasing cardiometabolic and cancer risks.

Tricuspid Valve Geometrical Changes in Patients with Functional Tricuspid Regurgitation: Insights from a CT Scan Analysis Focusing on Commissures.

BACKGROUND: Cardiac computed tomography (CT) provides important insights into the geometrical configuration of the tricuspid valve (TV). The purpose of the present study was to assess the geometrical changes of TV in patients with functional tricuspid regurgitation (TR) using novel CT scan parameters and to correlate these findings with echocardiography. METHODS: This single-center study enrolled 86 patients undergoing cardiac CT and divided them into two groups according to the presence or not of severe TR (43 patients with TR ≥ 3+ and 43 controls). The measurements collected were as follows: TV annulus area and perimeter, septal-lateral and antero-posterior annulus diameters, eccentricity, distance between commissures, segment between the geometrical centroid and commissures, and the angles of commissures. RESULTS: We found a significant correlation between all annulus measurements and the grade of TR, except in regard to angles. TR ≥ 3+ patients had significantly larger TV annulus area and perimeter, larger septal-lateral, and antero-posterior annulus dimensions, as well as larger commissural distance and centroid-commissural distance. In patients with TR ≥ 3+ and controls, the eccentricity index predicted a circular shape and an oval shape of the annulus, respectively. CONCLUSIONS: These novel CT variables focusing on commissures increase the anatomical understanding of the TV apparatus and the TV geometrical changes in patients with severe functional TR.

Imaging findings in a case of leptomeningeal myelomatosis, a rare but critical central nervous system complication of multiple myeloma.

Leptomeningeal myelomatosis is a rare complication of multiple myeloma (<1% of the patients). There was an increase in the incidence of leptomeningeal myelomatosis during the last decade; the prognosis of leptomeningeal myelomatosis remains poor, (overall median survival from the time of diagnosis of 2 months). We discuss a rare case of a monoclonal gammopathy evolving into multiple myeloma and finally into a rapidly progressing leptomeningeal disease. A 76 year-old woman in hematologic follow-up for advanced stage multiple myeloma in sixth-line treatment had an episode of generalized tonic-clonic seizure with sphincter release followed by altered state of consciousness. The unenhanced head CT scan showed a mild enlargement of the ventricular system without intra-axial or extra-axial hemorrhages nor significant changes in brain parenchyma. The subsequent contrast-enhanced brain MRI revealed a widespread nodular leptomeningeal enhancement characterized by contrast-enhancement of the pia mater extended into the subarachnoid spaces of the sulci and cisterns, involving supra- and sub-tentorial regions and the statoacoustic nerve in the inner ear canal bilaterally. The fluid-attenuated inversion recovery MRI images demonstrated an abnormally elevated signal within the sulci in the parieto-occipital regions. The radiological diagnosis of leptomeningeal myelomatosis was made. The patient died 4 days after the examination. In patients with long-lasting multiple myeloma and onset of neurological signs or symptoms, a contrast-enhanced brain MRI should be performed to assess the actual burden of central nervous system involvement in leptomeningeal myelomatosis; CT may provide a clue to the diagnosis when progressive enlargement of the ventricles over time is noted.

A case of portal biliopathy in a young patient with portal cavernoma secondary to neonatal umbilical vein catheterization.

Portal biliopathy (PB) refers to biliary obstruction caused by cavernous transformation of the portal vein (CTPV). CTPV occurs most frequently in patients with liver cirrhosis or malignancy. Less common causes include congenital malformations and neonatal umbilical vein cannulation. We present a case of portal biliopathy in a 28-year-old man with CTPV secondary to umbilical vein catheterization in neonatal age. The case illustrates portal biliopathy as a late complication of neonatal invasive procedures and highlights the importance of a multimodality imaging approach to achieve a prompt diagnosis.

Cerebral Hemodynamics, Right-to-Left Shunt and White Matter Hyperintensities in Patients with Migraine with Aura, Young Stroke Patients and Controls.

Background: Migraine with aura (MA) patients present an increased risk of cerebrovascular events. However, whether these patients present an increased white matter hyperintensities (WMHs) load compared to the general population is still under debate. Our study aimed to evaluate the relationship between cerebral hemodynamics, right-to-left shunt (RLS) and WMHs in MA patients, young patients with cryptogenic stroke or motor transient ischemic attack (TIA) and controls. Methods: We enrolled 30 MA patients, 20 young (<60 years) patients with cryptogenic stroke/motor TIA, and 10 controls. All the subjects underwent a transcranial Doppler bubble test to detect RLS and cerebral hemodynamics assessed by the breath holding index (BHI) for the middle (MCA) and posterior (PCA) cerebral arteries. Vascular risk factors were collected. The WMHs load on FLAIR MRI sequences was quantitatively assessed. Results: The stroke/TIA patients presented a higher prevalence of RLS (100%) compared with the other groups (p < 0.001). The MA patients presented a higher BHI compared with the other groups in the PCA (p = 0.010) and higher RLS prevalence (60%) than controls (30%) (p < 0.001). The WMHs load did not differ across groups. BHI and RLS were not correlated to the WMHs load in the groups. Conclusions: A preserved or more reactive cerebral hemodynamics and the presence of a RLS are likely not involved in the genesis of WMHs in MA patients. A higher BHI may counteract the risk related to their higher prevalence of RLS. These results need to be confirmed by further studies to be able to effectively identify the protective role of cerebral hemodynamics in the increased RLS frequency in MA patients.

Analysis of Risk Factors of Soft Tissue Bleeding in COVID-19 Patients: A Point of View After Two Years of Pandemic.

Background: The aim of the study was to analyze the relationship between patient characteristics, including anagraphic and laboratoristic data and amount of adipose tissue measured in computed tomography (CT) scans in coronavirus disease 2019 (COVID-19) patients, and incidence of soft tissue bleeding requiring medical and/or interventional radiology management. Methods: A total of 132 patients hospitalized for COVID-19 pathology from October 2020 to May 2021 were included in the study and divided into two groups: a bleeding group of 70 cases with soft tissue bleeding occurring during hospitalization, and a control group of 62 hospitalized COVID-19 patients without bleeding events. In the bleeding group, two subgroups were considered: an embolization group including soft tissue bleeding cases requiring interventional radiology with transarterial embolization (TAE) (16/70; 22.9%) and a non-embolization group, clinically managed without TAE (54/70; 77.1%). Demographics and clinical data, visceral adipose tissue (VAT) area and subcutaneous adipose tissue (SAT) area measured on CT images and VAT/SAT ratio were compared between bleeding and control groups and between embolization and non-embolization subgroups. Results: Bleeding and control groups did not significantly differ for sex distribution, COVID-19, platelet (PLT) count, international normalized ratio (INR), SAT area, VAT area, and VAT/SAT ratio. Embolization and non-embolization groups did not significantly differ for age, COVID-19, PLT count, INR, SAT area, and VAT/SAT ratio. Bleeding group had lower body mass index (BMI) than control group as well as embolization group compared to non-embolization group. A statistically significant difference was observed between embolization and non-embolization groups for VAT area, with smaller values in embolization group (mean difference: 64.2 cm2, 95% confidence interval: 8.3 - 120.1; P < 0.05). Conclusion: Soft tissue bleeding in COVID-19 is more frequent and severe in patients with low amount of VAT, demonstrating that fat mass may have a containing function on bleeding, limiting its progression in surrounding structures. There are some other factors that influence the risk of bleeding, such as age, thromboprophylaxis therapy and BMI.

COVID-19 vaccination simulating lymph node progression in a patient with prostate cancer.

Several cases of cancer patients with 18-fluorodeoxyglucose (18FDG) Positron Emission Tomography/Computed Tomography (PET/CT) evidence of metabolically active axillary lymph nodes after COVID-19 vaccination have been described, creating a diagnostic dilemma and sometimes leading to further unnecessary examinations. A 62-year-old male, diagnosed with prostate cancer, treated with hormone-therapy and radiotherapy of the prostate 2 years before, underwent fluorine-18 choline (F-FCH) PET/CT for restaging purpose, less than 3 weeks after he had received the second dose of the Pfizer BioNTech-BNT162b2 mRNA COVID-19 vaccine. This exam showed an increased F-FCH uptake and an enlargement of the left axillary, paratracheal, para-aortic, subcarinal, and hilar bilateral lymph nodes. Fourteen weeks later, the patient underwent a new F-FCH PET-CT scan, displaying an almost complete regularization of the FCH uptake in all the previously involved regions. The patient was not treated after the first PET-CT scan, thus, the aforementioned PET/CT findings represented inflammatory vaccine-related lymph nodes. This case highlights the significance of knowing vaccination history to correctly interpret imaging findings and to avoid false-positive reports.

Novel Computed Tomography Variables for Assessing Tricuspid Valve Morphology: Results from the TRIMA (Tricuspid Regurgitation IMAging) Study.

BACKGROUND: Computed tomography (CT) is the recommended imaging technique for defining the anatomical suitability for current transcatheter technologies and planning tricuspid valve (TV) intervention. The aim of the Tricuspid Regurgitation IMAging (TRIMA) study was to assess the geometrical characteristics of the TV complex using novel CT parameters. METHODS: This prospective, single-center study enrolled 22 consecutive patients with severe tricuspid regurgitation, who underwent a cardiac CT study dedicated to the right chambers. The following variables were obtained: annulus area and perimeter, septal-lateral and antero-posterior diameters, tenting height, and anatomical regurgitant orifice area. Moreover, the following novel annular parameters were assessed: distance between commissures, distance between TV centroid and commissures, and angles between centroid and commissures. RESULTS: A significant phasic variability during the cardiac cycle existed for all variables except for eccentricity, angles, and distance between the postero-septal and antero-posterior commissure and distance between the centroid and antero-posterior commissure. There was a significant relationship between the TV annulus area and novel annular parameters, except for annular angles. Additionally, novel annular variables were found to predict the annulus area. CONCLUSIONS: These novel additional variables may provide an initial platform from which the complexity of the TV annular morphology can continue to be better understood for further improving transcatheter therapies.