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ObjectivesThe effect of subclinical leaflet thrombosis, characterised by hypoattenuated leaflet thickening (HALT), on the valve haemodynamic function and durability of the bioprosthetic valve, is not yet determined. We determined the impact of HALT on valve haemodynamics after transcatheter aortic valve replacement (TAVR) and the predictors of haemodynamic structural valve deterioration (SVD).MethodsThe Anticoagulation vs Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization after Transcatheter Aortic Valve Replacement(ADAPT-TAVR) trial is a multicenter, randomised trial that compared edoxaban and dual antiplatelet therapy in patients who had undergone successful TAVR. The presence of HALT was evaluated by four-dimensional CT at 6 months and serial echocardiography performed at baseline, immediately post-TAVR and after 6 months. SVD was defined as at least one of the following: (1) mean transprosthetic gradient ≥20 mm Hg, (2) change in the mean gradient ≥10 mm Hg from baseline, or (3) new or increase in intraprosthetic aortic regurgitation of at least ≥1 grade, resulting in moderate or greater regurgitation.ResultsAt 6 months, HALT was found in 30 of 211 (14.2%) patients. The presence of HALT did not significantly affect aortic valve mean gradients (with vs without HALT; 14.0±4.8 mm Hg vs 13.7±5.5 mm Hg; p=0.74) at 6 months. SVD was reported in 30 of 206 patients (14.6%) at 6-month follow-up echocardiography. Older age (OR: 1.138; 95% CI: 1.019 to 1.293; p=0.033), use of aortic valve size ≤23 mm (OR: 6.254; 95% CI: 2.230 to 20.569; p=0.001) and mean post-TAVR pressure gradient (OR: 1.233; 95% CI: 1.123 to 1.371; p<0.001) were independent predictors of haemodynamic SVD; however, the presence of HALT was not identified as a predictor of SVD.ConclusionsIn patients who had undergone successful TAVR, aortic valve haemodynamic status was not influenced by the presence of HALT. Although HALT was not a predictor of haemodynamic SVD at 6 months, it warrants further longer-term follow-up to evaluate the effect on long-term valve durability.Trial registration numberNCT03284827(https://www.clinicaltrials.gov).

BackgroundSome patients have severe aortic valve stenosis (AS) despite a lower degree of aortic valve calcification (AVC). This study compared the clinical features and prognosis of patients undergoing aortic valve replacement (AVR) for severe AS with a low AVC score compared with those with higher AVC scores.MethodsThis study included 1002 Korean patients with symptomatic severe degenerative AS who underwent AVR. We measured AVC score before AVR and defined low AVC as AVC score of <2000 units for male patients and <1300 units for female patients. Patients with bicuspid or rheumatic aortic valve disease were excluded.ResultsThe mean age was 75.6±7.9 years and 487 patients (48.6%) were female. Mean left ventricular ejection fraction was 59.4%±10.4%, and concomitant coronary revascularisation was performed in 96 patients (9.6%). The median aortic valve calcium score was 3122 units (IQR 2249–4289 units) among male patients and 1756 units (IQR 1192–2572) among female patients. A total of 242 patients (24.2%) had low AVC; they were significantly younger (73.5±8.7 years vs 76.3±7.5 years, p<0.001) and were more likely to be female (59.5% vs 45.1%, p<0.001) and on haemodialysis (5.4% vs 1.8%, p=0.006) than those with high AVC. During a follow-up (median: 3.8 years), the patients with low AVC had significantly higher risk of death from any cause (adjusted HR 1.60, 95% CI 1.02 to 2.52, p=0.04), mostly non-cardiac cause.ConclusionsPatients with low AVC exhibit distinct clinical characteristics and a higher risk of long-term mortality compared with those with high AVC.

In patients with symptomatic obstructive hypertrophic cardiomyopathy, tailored preoperative planning—using multiphase cardiac CT with postprocessing methods to simulate surgical myectomy—can guide successful therapeutic surgical myectomy with minimal risk of complications.

By enabling quantification of the ratio of encroachment by pannus, cardiac CT may help in differentiating which subprosthetic panni might lead to substantial flow limitation in the prosthetic aortic valve.

Stress myocardial perfusion CT is an accurate method for detecting myocardial ischemia, as defined by invasive fractional flow reserve measurement, and provides an incremental value over CT angiography in patients with a high calcium score.

The 3-dimensional relationship between aortic root and cusp is essential to understand the mechanism of aortic regurgitation (AR) because of aortic root dilatation (ARD). We sought to test the hypothesis that the stretched cusps in ARD enlarge to compensate for ARD.

To investigate the capacity of manganese dipyridoxyl diphosphate (MnDPDP)-enhanced magnetic resonance imaging (MRI) to discriminate the injured myocardium from the normal myocardium in a cat model.

To compare manganese dipyridoxyl diphosphate (MnDPDP)-enhanced magnetic resonance imaging (MRI) with cine MRI for distinguishing the dysfunctional myocardium from the normal myocardium.

Background:Myocardial viability test to guide revascularization remains uncertain in patients with ischemic cardiomyopathy. We aimed to evaluate the different impacts of revascularization on cardiac mortality according to the extent of myocardial scar assessed by cardiac magnetic resonance with late gadolinium enhancement (LGE-CMR) in patients with ischemic cardiomyopathy.Methods:A total of 404 consecutive patients with significant coronary artery disease and an ejection fraction ≤35% were assessed by LGE-CMR before revascularization. Of them, 306 patients underwent revascularization and 98 patients received medical treatment alone. The primary outcome was cardiac death.Results:During a median follow-up of 6.3 years, cardiac death occurred in 158 (39.1%) patients. Revascularization was associated with a significantly lower risk of cardiac death than medical treatment alone in the overall population (adjusted hazard ratio [aHR], 0.29; 95% confidence interval [CI], 0.19-0.45; P < 0.001). There was a significant interaction between the number of segments with 76%-100% transmural LGE and revascularization on the risk of cardiac death (P = 0.037 for interaction). In patients with limited myocardial scar (< 6 segments with 76%-100% transmural LGE, N = 354), revascularization had a significantly lower risk of cardiac death than medical treatment alone (aHR, 0.24; 95% CI, 0.15-0.37; P < 0.001); in patients with extensive myocardial scar (≥ 6 segments with 76-100% transmural LGE, N = 50), there was no significant difference between revascularization and medical treatment alone regarding the risk of cardiac death (aHR, 1.33; 95% CI, 0.46-3.80; P = 0.60).Conclusions:Assessment of myocardial scar by LGE-CMR may be helpful in the decision-making process for revascularization in patients with ischemic cardiomyopathy.

Introduction:There is increasing interest of prediction models to identify patients at risk of major adverse cardiac event (MACE) following invasive coronary treatment using electronic medical record (EMR) data. However, robust models fully utilizing EMR data are limited.Hypothesis:The study aimed to develop machine-learning models utilizing diverse fields of EMR to predict 30-days MACE including death, repeat revascularization, or unplanned readmission after percutaneous intervention or bypass surgery.Methods:We used an EMR database including structured data and selected extracts of unstructured data from clinician? free-text notes via various data-mining methods between 2007 and 2016 at a tertiary hospital. The data was categorized into static data (e.g. demographics, and administration), dynamic features (e.g. medications, laboratory values, and vital signs) and cardiovascular-specific study data (e.g. echocardiography, and single photon emission computed tomography). The models were developed using logistic regression (LR), random forest (RF), gradient boosting (GB), and free-forward neural network (FFNN) and each model was validated with 5-fold cross-validation.Results:We identified 24,764 patients who received invasive treatment and MACE at 30 days occurred in 4,833 patients. The FFNN had the best performance after 5-fold cross-validation. Area under curves (AUCs) for prediction models were 0.827 ? 0.011, 0.853 ? 0.001, 0.829 ? 0.010, and 0.877 ? 0.001 for LR, RF, GB, and FFNN, respectively. In the FFNN model, the performance of MACE prediction gradually improved by adding dynamic features (0.012 of AUC [1.3%]) and cardiovascular-specific study data (0.007 with AUC [0.9%]). (Figure)Conclusions:Using an established EMR database, the FFNN demonstrated the robust performance for MACE prediction. The FFNN approach incorporating various fields of data can readily meet the demand of MACE prediction using rich EMR datasets.

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Sclerosing polycystic adenosis (SPA) is an uncommon salivary gland lesion similar to fibrocystic disease and adenosis of the mammary glands. To our knowledge, 51 cases of SPA have been reported in the literature to date. Sclerosing polycystic adenosis is well circumscribed, yet not encapsulated, and has sclerotic and irregularly defined lobules composed of abundant hyalinized collagen with ductal, acinar hyperplasia and areas of apocrine metaplasia. Focal cystic spaces within a dense fibrotic stroma are also characteristic features of this lesion. Most of the known cases occurred mainly in the parotid gland. In this article, we describe a case of SPA occurring in the parotid gland of a 47-year-old male patient.