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Recent data indicate that left atrial (LA) function assessment by cardiac computed tomography (CT) is closely related to diastolic dysfunction (DD). Therefore, we aimed to perform a direct comparison between CT and echocardiography for diagnosis of advanced DD and prediction of future heart failure or cardiovascular death. We identified 340 patients who had both spiral cardiac CT and a proximate echocardiogram. LA total emptying fraction (LATEF), a measure of global LA function, was automatically calculated from CT data, as a surrogate for diastolic function and was compared with echocardiographic grades of diastolic function. The area under the receiver operating characteristic curve for LATEF to differentiate between advanced DD (grades 2 and 3) and all other grades was 0.84 (0.79 to 0.88). Over a median of 4 years, 69 events (admissions for heart failure and cardiovascular deaths) occurred. By multivariate Cox analysis, LATEFlt;40% provided incremental prognostic information after adjustments for advanced DD by echocardiography (hazard ratio 2.15, 95% confidence interval 1.13 to 3.94). There was a significant interaction (p = 0.03) between LATEF and echocardiography-based diastolic grades. Stratified analyses within the diastolic function groups revealed that LATEFlt;40% was equivalent to echocardiography in predicting events in the subgroup with advanced DD by echocardiography (p = 0.20) but was associated with a significantly higher event rates in patients with normal filling pressures (p = 0.0001) or indeterminate diastolic function (p = 0.04) by echocardiography. In conclusion, LA function derived from CT can accurately detect advanced DD diagnosed by echocardiography and has additive value to echocardiography-derived DD.

There is a growing interest in transcutaneous aortic valve implantation (TAVI) therapy among patients with bicuspid severe aortic stenosis (BAV). Conduction disturbances remain a frequent complication of TAVI, and new-onset permanent LBBB (NOP-LBBB) post-TAVI may be a marker of worse outcomes. We aimed to evaluate the rate of NOP-LBBB following TAVI among patients with BAV as compared to tricuspid severe aortic stenosis (TAV). Patients enrolled in the multicenter (5 centers) Bicuspid AS TAVI Registry were reviewed and compared with patients with TAV. Patients with previous aortic valve replacement, other valve morphologies and those with preprocedural LBBB or pacemaker were excluded. NOP-LBBB was defined as LBBB first detected and persisting 30-days following TAVI. A total of 387 patients (66 with BAV, 321 with TAV), age 80.3 ± 7.3, 47% females were analyzed. The device success rates were 95% in both groups without any conversions to surgery. The rate of NOP-LBBB was significantly higher among patients with BAV versus TAV (29.2% vs 16.9%, p = 0.02). However, the rate of post procedural pacemaker implantation was similar (14.8% vs 12.5%; respectively, p = 0.62). In BAV and TAV groups, 1-year mortality (6.1% vs 7.2%; respectively, p = 0.75) and stroke rates (6.1% vs 3.5%; respectively, p = 0.30) were not significantly different. Multivariate analysis identified BAV as an independent predictor of NOP-LBBB (AdjOR = 2.7, 95%CI 1.3 to 5.4). Furthermore, BAV subtypes with raphe (type 1) were identified as independent predictors of NOP-LBBB (AdjOR = 3.2, 95%CI: 1.5 to 6.7). In conclusion, patients with BAV undergoing TAVI have greater risk for developing NOP-LBBB compared with patients with TAV and the presence of raphe was associated with increased risk of NOP-LBBB. The prognostic significance for this finding warrants further evaluation in future studies.

We sought to evaluate cardiac CT angiography (CCTA)–based assessment of left atrial (LA) function as a predictor of hospitalizations for heart failure (HF) and cardiovascular (CV) mortality. LA function was evaluated using automatic derivation of LA volumes to calculate LA total emptying fraction (LATEF) in 788 consecutive patients with normal sinus rhythm who had undergone spiral CT scans. The relationship between LATEF evaluated by CCTA and the composite endpoint of admission for HF or CV mortality was analyzed using Cox models. During a median follow-up of 4 years, there were 100 events, 62 HF hospitalizations, and 38 cardiovascular deaths. Mean LATEF was 30.7 ± 10.7% and 40.5 ± 11.2% in patients with and without events, respectively (p 46%) was associated with a very low event rate (3.5% at 6 years [95% CI 1.7–7.1%]). The adjusted HR for HF or CV mortality was 4.37 (95% CI 1.99–9.60) in the lowest LATEF tertile, and 2.29 (95% CI 1.03–5.14) in the middle tertile, relative to the highest tertile. For the endpoint of HF alone, adjusted HR for the lowest LATEF tertile was 5.93 (95% CI 2.23–15.82) and for the middle tertile 2.89 (95% CI 1.06–7.86). The association of LATEF with outcome was similar for patients with both reduced and preserved left ventricular (LV) ejection fraction (Pinteraction = 0.724). Reduced LATEF was associated with a high event rate, even when coupled with normal LA volume. CCTA-derived LA function is a predictor of HF hospitalization or CV death, independent of clinical risk factors, LA volume, and LV systolic function. • Left atrial function can be automatically derived from cardiac CTA scans. • Cardiac CTA-derived left atrial function is a predictor of hospitalization for heart failure and cardiovascular death. • Evaluation of left atrial function could be useful in identifying patients at risk of heart failure.

Background Transcatheter aortic valve replacement (TAVR) is being increasingly performed in patients with bicuspid aortic valve stenosis (AS). Purpose This study sought to compare aortic root, aorta and iliofemoral artery anatomy in patients with bicuspid versus tricuspid AS. Methods 172 patients with bicuspid AS and 331 patients with tricuspid AS underwent pre-procedural computed tomography (CT) evaluation before TAVR. Dimensions, calcification, and tortuosity of the iliofemoral arteries were evaluated and the dimensions of aortic root, aorta, and left subclavian arteries were determined. Results Dimensions of aortic root, aorta, left subclavian, and iliofemoral arteries were consistently and significantly larger in bicuspid than in tricuspid AS (P Conclusions Bicuspid AS was associated with larger dimensions of aortic root, aorta, subclavian, and iliofemoral arteries compared with tricuspid AS. Low vascular calcification and decreased tortuosity index of iliofemoral arteries characterized bicuspid anatomy. Further studies are needed to evaluate the impact of bicuspid vascular anatomy on vascular complications after TAVR. Funding Acknowledgement Type of funding sources: None.

Evaluation of myocardial regional function is generally performed by visual "eyeballing" which is highly subjective. A robust quantifiable parameter of regional function is required to provide an objective, repeatable and comparable measure of myocardial performance. We aimed to evaluate the clinical utility of novel regional myocardial strain software from cardiac computed tomography (CT) datasets. 93 consecutive patients who had undergone retrospectively gated cardiac CT were evaluated by the software, which utilizes a finite element based tracking algorithm through the cardiac cycle. Circumferential (CS), longitudinal (LS) and radial (RS) strains were calculated for each of 16 myocardial segments and compared to a visual assessment, carried out by an experienced cardiologist on cine movies of standard "echo" views derived from the CT data. A subset of 37 cases was compared to speckle strain by echocardiography. The automated software performed successfully in 93/106 cases, with minimal human interaction. Peak CS, LS and RS all differentiated well between normal, hypokinetic and akinetic segments. Peak strains for akinetic segments were generally post-systolic, peaking at 50 ± 17% of the RR interval compared to 43 ± 9% for normokinetic segments. Using ROC analysis to test the ability to differentiate between normal and abnormal segments, the area under the curve was 0.84 ± 0.01 for CS, 0.80 ± 0.02 for RS and 0.68 ± 0.02 for LS. There was a moderate agreement with speckle strain. Automated 4D regional strain analysis of CT datasets shows a good correspondence to visual analysis and successfully differentiates between normal and abnormal segments, thus providing an objective quantifiable map of myocardial regional function.

OBJECTIVES We aimed to assess the agreement between cardiac computed tomography (CT) and echo for diagnosing advanced diastolic dysfunction (DD) and to assess the prognostic value of CT-based parameters. METHODS One hundred one consecutive patients who had both CT and echo-Doppler within 1 month were included. Diastolic function was assessed by CT using a previously validated method, based on left atrial volume changes, and compared with echocardiography grades 0 to 3. Patients were followed up for a combined outcome of cardiac death and hospitalization for heart failure. RESULTS By operating characteristic curve analysis, the best CT-based parameter for predicting advanced DD based on echo was left atrial total emptying fraction. Left atrial total emptying fraction

Background Transcatheter aortic valve implantation (TAVI) is being increasingly performed in patients with bicuspid aortic valve stenosis (AS). Objectives This study sought to compare aortic root and ilio-femoral artery characteristics and clinical outcomes in patients with bicuspid versus tricuspid AS from the Bicuspid AS TAVI multicenter registry. Methods 88 patients with bicuspid AS and 213 matched patients with tricuspid AS were referred for pre-procedural computed tomography (CT) evaluation before TAVI. We performed a detailed assessment of aortic root anatomy: size of the annulus, sinus of Valsalva (SoV), sino-tubular junction (STJ); we also determined the dimensions of aorta, left subclavian, and ilio-femoral arteries. Results Patients with bicuspid AS had significantly larger aortic root dimensions, (annulus mean diameter: 25.5±2.9 mm vs. 23.7±2.4 mm, SoV mean diameter: 35.3±4.7 mm vs. 32±4.4mm, STJ mean diameter: 31.5±4.9 mm vs. 27.6±3.5 mm; respectively) than patients with tricuspid AS (P value for all Conclusions Patients with bicuspid AS had significantly larger aortic root dimensions, larger ascending aorta, subclavian artery and ilio-femoral arteries even after adjustment for their BSA and height. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Rabin Medical Center

Background Bicuspid aortic valve (BAV) patients represent a significant minority of severe aortic stenosis (AS) patients undergoing transcutaneous aortic valve implantation (TAVI). These patients demonstrate anatomic differences compared to tricuspid aortic valve (TAV). Ethnicity is associated with different valve morphologies characterized by Siever's classification. Purpose We aim to evaluated the prevalence of BAV subtypes and the differences in valve morphology and aortic root dimensions between BAV and TAV in patients undergoing computed tomography (CT) before TAVI. Methods In five Israeli medical centers, 131 patients with BAV and 674 patients with TAV underwent CT angiography. BAV morphology was defined according to the number of commissures and raphe, following Siever's classification. Aortic root dimensions were measured at the level of the aortic annulus, sinus of Valsalva (SOV), and sino-tubular junction (STJ). Finally, Agatston score unit (AU) for valve calcification was evaluated. Results Type 0 accounted for 27% (36/131), Type IA for 63% (82/131), Type IC for 9% (12/131), and Type 2 for 1% (1/131). Calcium score in BAV patients was significantly higher compared to TAV patients, 4000±1897 vs. 2152±1216 AU; respectively (P Conclusion In Israel, AS patients showed more frequently type 1A BAV. BAV patients have larger aortic root dimensions and higher calcium burden than TAV patients. Funding Acknowledgement Type of funding source: None

Distinct anatomical features predispose bicuspid AS patients to conduction disturbances after TAVR. This study sought to evaluate whether the incidence of permanent pacemaker implantation (PPMI) and left bundle branch block (LBBB) in patients with bicuspid aortic stenosis (AS) following transcatheter aortic valve replacement (TAVR) is related to an anatomical association between bicuspid AS and short membranous septal (MS) length.Sixty-seven consecutive patients with bicuspid AS from a Bicuspid AS TAVR multicenter registry and 67 propensity-matched patients with tricuspid AS underwent computed tomography before TAVR.MS length was significantly shorter in bicuspid AS compared with tricuspid AS (6.2 ± 2.5 mm vs. 8.4 ± 2.7 mm, respectively; p 0.001). In patients with bicuspid AS, MS length and aortic valve calcification were the most powerful pre-procedural independent predictors of PPMI or LBBB (odds ratio [OR]: 1.38, 95% confidence interval [CI]: 1.15 to 1.55, p = 0.003 and OR: 1.92, 95% CI: 1.1 to 3.34, p = 0.022, respectively). When taking into account pre- and post-procedural parameters, aortic valve calcification and the difference between MS length and implantation depth were the most powerful independent predictors of PPMI or LBBB in patients with bicuspid AS (OR: 1.82, 95%: 1.1 to 3.1, p = 0.027; OR: 1.25, 95% CI: 1.10 to 1.38, p = 0.003).MS length, which was significantly shorter in bicuspid AS compared with tricuspid AS, aortic valve calcification, and device implantation deeper than MS length predict PPMI or LBBB in bicuspid AS after TAVR.

Background Significant functional tricuspid regurgitation (TR) has been associated with higher risk for adverse cardiovascular outcomes. Left-sided heart disease (LHD) is a potentially important confounder of this association because it is strongly linked to both TR and to clinical outcome. Methods We studied 5886 patients who were followed for a period of 10-years after the index echocardiographic examination. The relationship between TR severity and the composite endpoint of admission for heart failure or cardiovascular mortality was analyzed using a Cox model. An additional analysis included a propensity-score-matching. To simplify the modeling of the severity of LHD, we calculated an additive score summing the number of LHD components as follows: reduced LVEF, LA enlargement ≥moderate, aortic or mitral valve disease (regurgitation or stenosis ≥moderate) and PASP≥50 mmHg. Results Higher TR grade was associated with markers of LHD including left ventricular systolic dysfunction, valvular heart disease ≥moderate, left atrial enlargement and pulmonary hypertension (All P Propensity score matching yielded 350 patient pairs, of which 88% had LHD. The HR for heart failure or cardiovascular mortality at 10-years was 0.78 (95% CI 0.56–1.08, P = 0.14) in the moderate/severe TR as compared with the trivial/mild TR. Conclusions Moderate or severe functional TR portends an increased risk for heart failure and cardiovascular mortality only when isolated, without concomitant LHD. Abstract 40 Figure. Interaction plot

Background Tricuspid regurgitation has been the focus of increasing interest and research in recent years. However, few data are available with regard to risk factors associated with the evolution of TR. purpose The aimed to determine the risk factors for the development of hemodynamically significant functional TR. Methods We studied 1552 subjects with an index echocardiogram demonstrating trivial or mild TR. Risk factors for TR progression to moderate or severe TR during a median follow-up time of 38 months (IQR 26 to 63 months), were determined using logistic regression. Results In the multivariable logistic regression model, older age, female gender, pacemaker electrode and indicators of left heart disease (LA enlargement, increased pulmonary artery pressure (PAP), atrial fibrillation, and left-sided valvular disease) were associated with future development moderate or severe TR (Table). The strongest predictors of TR progression were PAP, LA size, AF, and age. The final echocardiographic examination demonstrated a marked worsening in the severity of left-sided myocardial and valvular disease, that was more prominent in subjects with TR progression (Figure). Compared with subjects in whom TR did not progress, subjects with TR progression demonstrated an increase in PAP and in the severity of mitral and aortic valve disease, larger increases in LA and reductions in LVEF (Figure). Lager proportions of subjects progressing to significant TR developed AF, were implanted with pacemakers or defibrillators or underwent valvular interventions (Figure). The mean PAP change between the baseline and final echocardiographic examination was 16 ± 15 mm Hg and 3 ± 11 mm Hg with and without TR progression, respectively (P Conclusion Predictors of TR progression are mostly indicators of more advanced left heart disease. In addition, progression to significant TR is associated with a more acceleration course of left hear disease. Independent Predictors of TR Progression Characteristics HR (95% CI) P value Age (per 10 years increase) 1.35 (1.31-1.50) Abstract 44 Figure. Proportion of new abnormalities

Background Transcatheter aortic valve implantation (TAVI) has been shown safe and feasible in patients with bicuspid aortic valve (BAV) morphology. Evaluation of differences in valve morphology and aortic root dimensions in patients with BAV in comparison to patients with tricuspid aortic valve (TAV) is important for the spread of TAVI in patients with BAV. Purpose The present study evaluated the prevalence of BAV subtypes and the differences in valve morphology and aortic root dimensions between BAV and TAV in patients undergoing computed tomography (CT) before TAVI. Methods In five medical centers in Israel, 104 patients (69±13.5 years) with BAV and 105 patients (81±8.22 years) with TAV underwent CT angiography. BAV morphology was defined according to the number of commissures and raphe following Siever's classification. Functional BAV was defined as 3 cusps with focal fusion of 1, 2, or 3 commissures. Aortic root dimensions were measured at the level of the aortic annulus, sinus of Valsalva (SOV), sino-tubular junction (STJ), and ascending aorta (AA). Membranous septum (MS) length was measured in coronal view. The volume and agatston score of aortic valve calcification were evaluated. Results Type 0 account for 22% (23/104), type IA for 58% (60/104), Type IC for 9% (9/104), functional BAV for 11% (12/104). Type IB and II were not found in the studied population. As compared with TAV, patients with BAV have significantly larger aortic annulus area, SOV area, STJ area and AA Area; however, the ellipticity index of aortic annulus, SOV, STJ, and AA were similar. MS length was significantly smaller in patients with BAV compared to patients with TAV (6.4±2.3 mm vs. 8.1±2.7mm; retrospectively; P Conclusions In Israel, patients with BAV showed more frequently type 1A BAV. BAV patients have larger aortic root dimensions than patients with TAV without difference in regard to the ellipticity index. MS length was smaller and the amount of aortic leaflet calcifications was higher in patients with BAV. These findings may have important impact on procedural outcome.

Objectives The objective of this study was to determine risk factors for progression to hemodynamically significant tricuspid regurgitation (TR) and the population burden attributable to these risk factors. Background Few data are available with regard to risk factors associated with the development of hemodynamically significant functional TR. Methods A total of 1,552 subjects were studied beginning with an index echocardiogram demonstrating trivial or mild TR. Risk factors for progression to moderate or severe TR were determined by using logistic regression and classification trees. Population attributable fractions were calculated for each risk factor. Results During a median follow-up time of 38 (interquartile range [IQR]: 26 to 63) months, 292 patients (18.8%) developed moderate/severe TR. Independent predictors of TR progression were age, female sex, heart failure, pacemaker electrode, atrial fibrillation (AF), and indicators of left heart disease, including left atrial (LA) enlargement, elevated pulmonary artery pressure (PAP), and left-sided valvular disease. Classification and regression tree analysis demonstrated that the strongest predictors of TR progression were PAP of ≥36 mm Hg, LA enlargement, age ≥60 years, and AF. In the absence of these 4 risk factors, progression to moderate or severe TR occurred in ∼3% of patients. Age (28.4%) and PAP (20.5%) carried the highest population-attributable fractions for TR progression. In patients with TR progression, there was a marked concomitant increase of incident cases of elevated PAP (40%); mitral and aortic valve intervention (12%); reductions in left ventricular ejection fraction (19%), and new AF (32%) (all p Conclusions TR progression is determined mainly by markers of increased left-sided filling pressures (PAP and LA enlargement), AF, and age. At the population level, age and PAP are the most important contributors to the burden of significant TR. TR progression entails a marked parallel increase in the severity of left-sided heart disease.

Significant tricuspid regurgitation (TR) is associated with higher risk for adverse cardiovascular outcomes. Left-sided heart disease (LHD) is a potentially important confounder of this association because it is strongly linked to both TR and clinical outcome.We studied 5,886 patients who were followed for a period of 10 years after the index echocardiographic examination. The relationship between TR severity and the end point of admission for heart failure or cardiovascular mortality was analyzed using competing risk analysis, Cox model, and propensity score matching.Higher TR grade was associated with markers of LHD including left ventricular systolic dysfunction, valvular heart disease ≥ moderate, left atrial enlargement, and pulmonary hypertension (all P .001). There was a significant interaction between TR and the presence of LHD with regard to the end point of heart failure in the competing risks model (P = .01) and the combined end point of heart failure and cardiovascular mortality (P = .02). In both models, moderate/severe TR was associated with higher risk for heart failure (hazard ratio [HR] = 3.10; 95% CI, 1.41-6.84; P = .005) and the combined end point of heart failure or cardiovascular mortality (HR = 2.75; 95% CI, 1.33-5.63, P = .006) only in patients without LHD. Propensity score matching yielded 350 patient pairs, of which 88% had LHD. The HR for heart failure or cardiovascular mortality at 10 years was 0.78 (95% CI, 0.56-1.08; P = .14) in the moderate/severe TR group as compared with the trivial/mild TR.Moderate or severe functional TR portends an increased risk for heart failure and cardiovascular mortality only when isolated, without concomitant LHD.

Background: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation in both paroxysmal and persistent AF. However, this procedure is still challenging and time consuming. Objective: The aim of this study was to present our approach for PVI using a novel circular irrigated multielectrode mapping and ablation catheter (nMARQTM) and to present acute and mid-term results. Methods: The study included 31 consecutive patients with symptomatic AF (4 had persistent and 27 had paroxysmal AF) who underwent PVI using the nMARQTM catheter. Circular ablation was guided by CT image integrated into fast anatomical map and by intra cardiac echo. Isolation of pulmonary veins was identified using the nMARQTM catheter if it was possible to advance it into the veins, otherwise Lasso catheter was used. Patients were followed up to 20 months. Results: PVI was achieved in 119 (98%) out of 121 pulmonary veins identified, and final PVI was obtained in 30 (97%) out of 31 patients. Lasso catheter was needed for PVI confirmation in 16 (52%) patients. Touch up ablation using standard catheter guided by Lasso catheter was needed in 4 (13%) patients. Pericardial tamponade occurred in 1 patient who was treated with pericardiocentesis. No other major complications were detected. During follow-up (mean 15.9 ± 3.6 months, range 9 - 20 months), 4 (13%) patients had recurrence of atrial tachyarrhythmia. Conclusion: PVI using the novel nMARQTM catheter is safe with good acute and mid-term efficacy. Long term follow up trials are needed.

Ablation of outflow flow ventricular arrhythmia (VA) originating from aortic cusps can be challenging. The aim of this study was to describe our approach for this ablation.All patients with outflow VA suspected to originate from aortic cusps according to ECG or after failed ablation from right ventricular outflow tract (RVOT) underwent cardiac CT and radiofrequency ablation. CT image of aortic cusps and coronary arteries was integrated into electroanatomic mapping system by point (left main ostium)-based registration. Ablation was performed at the earliest activation site.Ten patients were included in this case cohort. The ablation catheter was easily maneuvered above and below the aortic valve after registration. Two patients who had previous failed ablation of RVOT focus had successful ablation at right coronary cusp (RCC) and at left coronary cusp (LCC). A patient who had previous failed ablations of RVOT and LCC focuses had successful ablation at RCC-LCC junction. A patient who had previous failed ablation at LCC had successful ablation at RCC-LCC junction. Three patients had successful ablation at RCC-LCC junction, and one patient at LCC. One patient had successful ablation at anterior interventricular vein-great cardiac vein junction. One patient had successful ablation at non-coronary cusp. During follow-up (12-30 months), one patient had recurrence of VA controlled by flecainide. The remaining patients were free of VA without medications.Catheter ablation of VA originating from aortic cusps is safe and effective. CT image integration into electroanatomic mapping system can be helpful in this challenging ablation.

Left ventricular (LV) diastolic dysfunction (DD) often accompanies coronary artery disease but is difficult to assess since it involves a complex interaction between LV filling and left atrial (LA) emptying.To characterize simultaneous changes in LA and LV volumes using cardiac computed tomography (CT) in a group of patients with various grades of DD based on echocardiography.We identified 35 patients with DD by echocardiography, who had also undergone cardiac CT, and 35 age-matched normal controls. LV and LA volumes were measured every 10% of the RR interval, using semi-automatic software. From these, - systolic, early-diastolic and late-diastolic volume changes were calculated, and additional parameters of diastolic filling derived. Conduit volume was defined as the difference between the LV and LA early-diastolic volume change.Patients with DD had significantly larger LV mass, and LA volumes, reduced early emptying volumes and increased conduit volume as percent of early LV filling (All p0.001). LA function, manifesting as total emptying fraction (LATEF), decreased proportionately with worsening grades of DD (p0.001). LA contractile function was maintained until advanced grade-3 DD. By receiver operating characteristic analysis, LATEF had an AUC of 0.88 to separate between normals and DD. At a threshold of42.5%, LATEF has 97% sensitivity and 69% specificity to detect DD.DD is characterized by reduced LA function and an alteration in the relative contributions of the atrial emptying and conduit volume components of early LV filling. In patients undergoing cardiac CT, it is possible to identify the presence and severity of DD.

Symptomatic patients with severe aortic stenosis (AS) demonstrate abnormal left ventricular (LV) mechanics. The aim of this study was to compare mechanics in asymptomatic and symptomatic patients with severe AS using two-dimensional myocardial strain imaging.One hundred fifty-four patients with severe AS (aortic valve area ≤ 1.0 cm(2)) referred to a heart valve clinic from 2004 to 2011 were studied. Thirty patients were asymptomatic, with normal LV ejection fractions (≥ 55%), without other significant valvular disease or wall motion abnormalities. Thirty-two symptomatic patients who underwent early aortic valve replacement, with similar age, gender, LV ejection fraction, and aortic valve area, were selected for comparison. Both groups were also compared with 32 healthy subjects with similar age and gender distributions and normal echocardiographic results who served as controls. LV longitudinal and circumferential strain and rotation were measured using speckle-tracking software applied to archived echocardiographic studies. Conventional echocardiographic and myocardial mechanical parameters were compared among the study subgroups.Patients with asymptomatic severe AS demonstrated smaller reductions in longitudinal strain, higher (supernormal) apical circumferential strain (-38 ± 6% vs -35 ± 4%, P.05), and extreme (supernormal) apical rotation (12.2 ± 4.9° vs 2.9 ± 1.7°, P.0005) compared with symptomatic patients. Apical rotation6° was the single significant predictor of symptoms in logistic regression analysis of clinical, echocardiographic, and mechanical parameters. Twelve asymptomatic patients underwent eventual aortic valve replacement and showed decreases in strain and apical rotation compared with baseline values.Longitudinal strain was uniformly low in patients with severe AS and lower in those with symptoms. Compensatory circumferential myocardial mechanics (increased apical circumferential strain and rotation) were absent in symptomatic patients. Thus, myocardial mechanics may help in the follow-up of patients with severe AS and timing of valve surgery.

Eosinophilic myocarditis is a rare disease with an unknown etiology, that may be severe and even lethal. Early treatment based on steroids may prevent deterioration and even lead to complete cure, but it requires rapid diagnosis. The gold standard for diagnosis of the disease is by endomyocardial biopsy but this test has low sensitivity and involves risks to the patient. This case report presents a patient who was admitted with complaints of chest pain. During her workup, with the help of cardiac MRI, eosinophilic myocarditis with mild deterioration in heart function was diagnosed. Treatment with prednisone resulted in rapid improvement in patient complaints, laboratory indices and heart function.

Aim Significant tricuspid regurgitation (TR) is common in heart failure (HF) and portends poor prognosis. We sought to determine whether the poor outcome results from the TR itself, or whether the TR is a surrogate marker of advanced left-sided myocardial or valvular heart disease. Methods and results We studied 639 patients admitted for acute HF. The relationship between TR severity and the endpoint of readmission for HF or mortality was assessed after adjustment for multiple clinical and echocardiographic parameters. Higher TR grade was associated with higher congestion score and with other cardiac abnormalities including reduced left ventricular systolic function, moderate or severe mitral regurgitation, pulmonary hypertension (PH, defined as pulmonary artery systolic pressure ≥ 50 mmHg), and right ventricular dysfunction (all P

A comparison was made between the accuracy of and time saved by using novel automated software for pre-procedural computed tomography (CT) planning before transcatheter aortic valve implantation (TAVI) and manual methods. Preprocedural CT to assess aortic annulus dimensions and predict the optimal C-arm implant angle before TAVI can reduce complications related to incorrect prosthesis sizing and positioning.A total of 61 consecutive patients underwent TAVI using either the SAPIEN XT or CoreValve prosthesis. Pre-procedural CT scans were analysed using three methods: automatic; semi-automatic; and manual. For each method, annular dimensions were measured and the optimal implantation angle was predicted. After TAVI the actual post-deployment angle orthogonal to the prosthesis was determined using aortic fluoroscopy. The difference between the predicted angle by CT and the measured post-deployment angle was calculated for each method.For all methods the mean angular difference with the actual post-deployment angle was similar at ~9 ± 7°. There was a significant difference between the SAPIEN XT (6.6 ± 5.8°) and CoreValve (11.5 ± 6.9°, p0.001) prostheses due to a consistently greater left anterior oblique and caudal angulation for the CoreValve. Although the annular area correlated well among all methods, 'automatic' results were consistently larger than 'manual' results. Interobserver variability was low for all measures. The fully automatic method saved 98 s, and the semiautomatic method 40 s per case.The use of automatic software enabled a rapid and accurate prediction of implantation angles, though results differed for specific manufacturers. Annular areas were overestimated by the automatic method, and thus required manual adjustments.

To test the feasibility of assessing mitral regurgitation (MR) severity using cardiac magnetic resonance (CMR) 4D velocity vectors to quantify regurgitant volume (RVol) by analysis of the proximal flow convergence, compared to Doppler based proximal isovelocity surface area (PISA) and CMR volume-based methods. In a prospectively designed study, 27 patients with various grades of MR underwent CMR and echo-Doppler on the same day. By CMR, multiple slices were obtained parallel to the mitral valve by phase-contrast imaging, using 3D velocity vectors, as well as short-axis cine images for left and right ventricular volume measurements. Using dedicated software developed in our laboratory, the perimeter of the proximal flow convergence region was semi-automatically measured for each temporal phase, and for each short-axis slice. The CMR-PISA RVol was calculated as the sum of PISA perimeters throughout systole, multiplied by slice width. For comparison, CMR-volumetric RVol was calculated by 2 methods: Volumetric (difference between left and right ventricular stroke volumes) and Flow-based (stroke volume -aortic flow). Echo-PISA RVol was calculated by echo-Doppler based PISA method. RVol by CMR-PISA correlated highly with echo-PISA (r = 0.87) and with CMR-volumetric (r = 0.86) and CMR-flow (r = 0.72). For comparison Doppler-RVol and CMR-volume-based RVol had r = 0.83. On average CMR-PISA was 16 ± 25 ml less than echo-PISA, but 12 ± 22 ml larger than CMR-volumetric RVol. The observed 3D shape of the PISA envelope by 4D-CMR resembled a hemiellipsoid rather than a hemisphere. This feasibility study suggests that CMR-based 4D-PISA may be able to assess MR severity quantitatively without any geometric assumptions.

Image registration is a central field in biomedical image analysis. Despite the large body of work on automatic image registration algorithms, in practice, results are often imperfect and can benefit from manual editing. In the current study, we propose a novel interactive registration tool that can be used for editing and refinement of automatic image registration results. The method is based on displacements to control points applied by the user to a finite element mesh representation of an organ of interest. The user-applied-displacements are translated to local forces using the organ’s elastic properties. The local user-derived forces are applied on the mesh and deform the image accordingly. We test the current method on 2D x-ray hand simulated data with non-continuous motion field and on 3D cardiac CT image data.

Background Pulmonary hypertension (PH) and right ventricular (RV) dysfunction have been associated with adverse outcome in patients with chronic heart failure. However, data are lacking in the setting of acute decompensated heart failure (ADHF). We sought to determine prognostic significance of PH in patients with ADHF and its interaction with RV function. Methods We studied 326 patients with ADHF. Pulmonary artery systolic pressure (PASP) and RV function were determined with the use of Doppler echocardiography, with PH defined as PASP >50 mm Hg. The primary end point was all-cause mortality during 1-year follow-up. Results PH was present in 139 patients (42.6%) and RV dysfunction in 83 (25.5%). The majority of patients (70%) with RV dysfunction had PH. Compared with patients with normal RV function and without PH, the adjusted hazard ratio (HR) for mortality was 2.41 (95% confidence interval [CI] 1.44–4.03; P = .001) in patients with both RV dysfunction and PH. Patients with normal RV function and PH had an intermediate risk (adjusted HR 1.78, 95% CI 1.11–2.86; P = .016). Notably, patients with RV dysfunction without PH were not at increased risk for 1-year mortality (HR 1.04, 95% CI 0.43–2.41; P = .94). PH and RV function data resulted in a net reclassification improvement of 22.25% (95% CI 7.2%–37.8%; P = .004). Conclusions PH and RV function provide incremental prognostic information in ADHF. The combination of PH and RV dysfunction is particularly ominous. Thus, the estimation of PASP may be warranted in the standard assessment of ADHF.

AIMS We aimed to test the feasibility of calculating SYNTAX score from coronary computed tomographic angiography (CCTA) compared to from invasive coronary angiography (ICA). METHODS AND RESULTS SYNTAX score was independently and blindly calculated from CCTA and from ICA in 104 patients, age 57±10, with significant (>50%) stenoses in 1.7±0.7 vessels. The level of agreement was assessed by Cohen's kappa. Agreement between ICA and CCTA for conventional vessel-based analysis (presence of >50% stenosis per vessel) was substantial with kappa=0.66 and sensitivity, specificity and accuracy of 74%, 90% and 80%, respectively. The mean SYNTAX score was 14.2±10.0 by ICA and 10.3±6.9 by CCTA, with a significant underestimation of 3.9±8.2 by CCTA (p

Aims Respiratory changes in tricuspid regurgitation (TR) systolic velocities are occasionally demonstrated by Doppler echocardiography in patients with TR. We tested the hypothesis that excessive respiratory changes in TR velocities are diagnostic of severe TR. Methods and results The difference between the maximal (expiratory) and minimal (inspiratory) TR systolic velocities during spontaneous respiration was measured by Doppler echocardiography in 68 patients with severe TR and 68 patients with moderate TR. The diagnostic value of the respiratory changes in TR velocity for detecting severe TR was assessed. The respiratory differences in TR velocities were greater in patients with severe TR (0.72 ± 0.30 m/s), compared with patients with moderate TR (0.28 ± 0.18; P < 0.001). Using receiver-operating characteristics analysis, the area under the curve for the respiratory difference in TR velocities for diagnosing severe TR was 0.92 (95% confidence interval: 0.87–0.96; P < 0.001). A difference in TR velocity ≥0.6 m/s had a sensitivity of 66%, specificity of 94%, positive predictive value of 92%, and a negative predictive value of 74% for diagnosing severe TR. Among patients with severe TR, excessive values of TR velocity difference were associated with signs of more severe TR (greater right ventricular size and malcoaptation of the tricuspid valve leaflets). Conclusion Excessive respiratory changes in Doppler measurements of TR systolic velocities are a specific sign of severe TR.

OBJECTIVES Hypertrophic cardiomyopathy (HCM) is characterized by diastolic dysfunction, which is difficult to assess by noninvasive methods. We hypothesized that measurement of simultaneous left ventricular (LV) and left atrial (LA) volume changes by cardiac computed tomography would be useful in the assessment of diastolic function in HCM. METHODS We studied 21 patients with HCM and 21 age-matched controls. The LA and LV volumes were calculated and early and late diastolic volume changes derived. RESULTS The HCM patients had significantly larger LA volumes and reduced LA total emptying fraction (30 ± 7% vs 42 ± 6%; P < 0.0001). Conduit volume was increased (30 ± 6 vs 22 ± 4 mL/m; P < 0.0001) and contributed a significantly higher proportion of total LV diastolic filling, suggesting that passive filling of the LV compensates for LA dysfunction, but at the expense of increased pulmonary filling pressure. CONCLUSIONS This study suggests that simultaneous depiction of computed tomography-derived LV and LA volume changes can characterize diastolic dysfunction in HCM.

Background The clinical importance of right ventricular ( RV ) function in acute myocardial infarction is well recognized, but the impact of concomitant pulmonary hypertension ( PH ) has not been studied. Methods and Results We studied 1044 patients with acute myocardial infarction. Patients were classified into 4 groups according to the presence or absence of RV dysfunction and PH , defined as pulmonary artery systolic pressure >35 mm Hg: normal right ventricle without PH (n=509), normal right ventricle and PH (n=373), RV dysfunction without PH (n=64), and RV dysfunction and PH (n=98). A landmark analysis of early (admission to 30 days) and late (31 days to 8 years) mortality and readmission for heart failure was performed. In the first 30 days, RV dysfunction without PH was associated with a high mortality risk (adjusted hazard ratio 5.56, 95% CI 2.05–15.09, P no PH ). In contrast, after 30 days, mortality rates among patients with RV dysfunction were increased only when PH was also present. Compared with patients having neither RV dysfunction nor PH , the adjusted hazard ratio for mortality was 1.44 (95% CI 0.68–3.04, P =0.34) in RV dysfunction without PH and 2.52 (95% CI 1.64–3.87, P RV dysfunction with PH . PH with or without RV dysfunction was associated with increased risk for heart failure. Conclusion In the absence of elevated pulmonary pressures, the risk associated with RV dysfunction after acute myocardial infarction is entirely confined to the first 30 days. Beyond 30 days, PH is the stronger risk factor for long‐term mortality and readmission for heart failure.

To investigate the impact of using computed tomography (CT) and contact force (CF) technology on recurrence of atrial tachyarrhythmia after atrial fibrillation (AF) ablation.This non-randomized study included 2 groups of patients. All patients had symptomatic recurrent paroxysmal or persistent AF and were treated with at least 1 anti arrhythmic medication or intolerant to medication. The first group included 33 patients who underwent circumferential pulmonary veins isolation (PVI) for AF during 2012 and 2013 guided by CT image integration (Cartomerge, Biosense Webster, Diamond Bar, CA, United States) of left atrium and pulmonary veins into an electroanatomic mapping (EAM) system (CT group) using standard irrigated radiofrequency catheter (ThermoCool, Carto, Biosense Webster, Diamond Bar, CA, United States) or irrigated catheter with integrated CF sensor (Smart Touch, Carto, Biosense Webster, Diamond Bar, CA, United States). The second group included immediately preceding 32 patients who had circumferential PVI by standard irrigated catheter (ThermoCool) using only EAM (Carto) system (EAM group). Linear lesions were performed according to the discretion of operator.Sex, age, and persistent AF were not different between groups. PVI was achieved in all patients in both groups. Linear ablations including cavo-tricuspid isthmus and or roof line ablation were not different between groups. Free of atrial tachyarrhythmia during follow-up of 24 mo was significantly higher among CT group compared to EAM group (81% vs 55%; respectively; P = 0.027). When 11 patients from CT group who had ablation using Smart Touch catheter were excluded, the difference between CT group and EAM became non significant (73% vs 55%; respectively; P = 0.16). Sub analysis of CT group showed that patients who had ablation using Smart Touch catheter tend to be more free of atrial tachyarrhythmia compared to patients who had ablation using standard irrigated catheter during follow-up (100% vs 73%; respectively; P = 0.07). Major complications (pericardial effusion, cerebrovascular accident/transient ischemic attack, vascular access injury requiring intervention) did not occurred in both groups.These preliminary results suggest that CT image integration and CF technology may reduce the recurrence of atrial tachyarrhythmia after catheter ablation for AF.

Background Despite advent of rapid arterial revascularization as 1st line treatment for acute myocardial infarction (AMI), incomplete restoral of flow at the microvascular level remains a problem and is associated with adverse prognosis, including pathological ventricular remodeling. We aimed to study the association between multidetector row computed tomography (MDCT) perfusion defects and ventricular remodeling post-AMI. Methods In a prospective study, 20 patients with ST-elevation AMI, treated by primary angioplasty, underwent arterial and late phase MDCT as well as radionuclide scans to study presence, size and severity of myocardial perfusion defects. Contrast echocardiography was performed at baseline and at 4 months follow-up to evaluate changes in myocardial function and remodeling. Results Early defects (ED), late defects (LD) and late enhancement (LE) were detected in 15, 7 and 16 patients, respectively and radionuclide defects in 15 patients. The ED area ( r = 0.74), and LD area ( r = 0.72), and to a lesser extent LE area ( r = 0.62) correlated moderately well with SPECT summed rest score. By univariate analysis, follow-up end-systolic volume index and ejection fraction were both significantly related to ED and LD size and severity, but not to LE size or severity. By multivariate analysis, end-systolic volume index was best predicted by LD area ( p Conclusions LD size and severity on MDCT are most closely associated with pathological ventricular remodeling after AMI and may thus play a role in early identification and treatment of this condition.

Pulmonary hypertension (PH) is usually perceived as a complication of established heart failure (HF) rather than as a predictor of HF or a marker of subclinical HF. PH may develop because of cardiac alterations that result in increased filling pressures after acute myocardial infarction (AMI). We hypothesized that PH might be a useful marker to predict the risk of HF after AMI. We studied 1,054 patients with AMI. Pulmonary artery systolic pressure (PASP) was estimated using echocardiography at the index admission and PH was defined as a PASP35 mm Hg. The primary end point was readmission for HF at 1 year. PH was present in 471 patients (44.6%) and was strongly associated with age, decreased ejection fraction, advanced diastolic dysfunction, and moderate/severe mitral regurgitation (p0.0001 for all comparisons). Area under the receiver operating characteristic curve was significantly higher for estimated PASP (0.74 ± 0.02) compared to other echocardiographic parameters (p = 0.02 to 0.0003). After adjustments for clinical and echocardiographic variables in a Cox model, PH was associated with a hazard ratio of 3.10 for HF (95% confidence interval 1.31 to 2.57, p0.0001). After adding estimated PASP to a model containing clinical and echocardiographic risk factors, net reclassification improvement was 0.21 (95% confidence interval 0.11 to 0.31, p0.0001). In conclusion, PASP integrates the severity of multiple hemodynamic determinants of increased left atrial pressures that lead to an increase in pulmonary venous pressure. In AMI, PH at the index admission is a useful marker in unmasking latent subclinical HF and predicting the development of overt HF.

Introduction The frequency, causes and prognostic implications of pulmonary hypertension (PHT) in patients with severe aortic stenosis (AS) are not well defined. The objectives of this study were to determine the frequency of PHT [pulmonary artery systolic pressure (PASP) >50 mm Hg] in patients with severe AS, identify the factors associated with PHT and assess the relationship between PHT and clinical outcome. Methods Patients with severe AS (aortic valve area ≤1.0 cm 2 ) and an echocardiographic estimate of PASP were identified by using the institutional echocardiography laboratory database. Patients with atrial fibrillation, mitral valve stenosis or a mitral prosthesis were excluded from analysis. The associations between clinical and echocardiographic parameters and PHT and the relationship between PHT and outcome were examined. Results During the study period, 216 patients fulfilled the inclusion criteria (age: 75 ± 11 years; 43% men), and PHT was present in 64 patients (29.6%). By multivariate analysis, reduced left ventricular (LV) systolic function (LV ejection fraction ≤45% and lower stroke volume) and impaired LV diastolic function (mitral inflow E/A ratio ≥1.5 and greater left atrium size) were independent predictors of PHT. Mortality was higher among patients with PHT managed medically (adjusted hazard ratio, 1.87; 95% confidence interval, 1.06–3.30; P = 0.011), whereas patients with PHT who underwent aortic valve replacement had an excellent outcome. Conclusions PHT is common in patients with AS and is related to the severity of LV systolic and diastolic dysfunction. PHT is associated with poorer outcome in medically treated patients.

Recently, model-based methods for the automatic segmentation of the heart chambers have been proposed. An important application of these methods is the characterization of the heart function. Heart models are, however, increasingly used for interventional guidance making it necessary to also extract the attached great vessels. It is, for instance, important to extract the left atrium and the proximal part of the pulmonary veins to support guidance of ablation procedures for atrial fibrillation treatment. For cardiac resynchronization therapy, a heart model including the coronary sinus is needed. We present a heart model comprising the four heart chambers and the attached great vessels. By assigning individual linear transformations to the heart chambers and to short tubular segments building the great vessels, variable sizes of the heart chambers and bending of the vessels can be described in a consistent way. A configurable algorithmic framework that we call adaptation engine matches the heart model automatically to cardiac CT angiography images in a multi-stage process. First, the heart is detected using a Generalized Hough Transformation. Subsequently, the heart chambers are adapted. This stage uses parametric as well as deformable mesh adaptation techniques. In the final stage, segments of the large vascular structures are successively activated and adapted. To optimize the computational performance, the adaptation engine can vary the mesh resolution and freeze already adapted mesh parts. The data used for validation were independent from the data used for model-building. Ground truth segmentations were generated for 37 CT data sets reconstructed at several cardiac phases from 17 patients. Segmentation errors were assessed for anatomical sub-structures resulting in a mean surface-to-surface error ranging 0.50-0.82mm for the heart chambers and 0.60-1.32mm for the parts of the great vessels visible in the images.