Search

Transcatheter aortic valve replacement (TAVR) is preferred therapy for elderly patients with severe aortic stenosis (AS) and increasingly used in younger patient populations with good safety and efficacy outcomes. However, cardiac conduction abnormalities remain a frequent complication after TAVR ranging from relative benign interventriculair conduction delays to prognostically relevant left bundle branch block and complete atrio-ventricular (AV) block requiring permanent pacemaker implantation (PPI). Although clinical, procedural and electrocardiographic factors have been identified as predictors of this complication, there is a need for advanced strategies to control the burden of conduction defects particularly as TAVR shifts towards younger populations. This state of the art review highlights the value of ECG-synchronized computed tomographic angiography (CTA) evaluation of the aortic root to better understand and manage conduction problems post-TAVR. An update on CTA derived anatomic features related to conduction issues is provided and complemented with computational framework modelling. This CTA-derived 3-dimensional anatomical reconstruction tool generates patient-specific TAVR simulations enabling operators to adapt procedural strategy and implantation technique to mitigate conduction abnormality risks. [ABSTRACT FROM AUTHOR]

Objectives: The Ross procedure is currently receiving renewed interest. Its function and durability depend on preservation of pulmonary valve anatomy; limited data exists on normal pulmonary valve geometry. The objective was to compare aortic and pulmonary root and cusp dimensions in adults with normal tricuspid aortic and pulmonary valves., Methods: We reviewed 507 coronary computed tomography studies, selecting those with adequate visibility of both pulmonary and aortic roots for further analysis. Diastolic aortic and pulmonary root and cusp dimensions were measured. Root dimensions at different phases of the cardiac cycle were measured in three patients., Results: We analysed studies of 50 patients with the mean age of 54 years (SD : 16). In end-diastole, pulmonary root had a smaller sinutubular to basal ring ratio than the aortic root (0.82 (SD : 0.09) vs 1.14 (SD : 0.12), P < 0.001). Aortic and pulmonary cusps had similar dimensions; however, pulmonary cusp effective height was lower (5.9 mm (SD : 1.6) vs 8.4 mm (SD : 1.2), P < 0.001). Pulmonary basal ring perimeter was largest at end-diastole and smallest at end-systole, with the relative difference of 23.5% (SD : 2.7)., Conclusions: The pulmonary root has a similar cusp size compared to the aortic root, but a different shape, resulting in a lower pulmonary cusp effective height. The perimeter of the pulmonary basal ring changes during the cardiac cycle. These findings suggest that stabilising the autograft to normal aortic, rather than pulmonary, root dimensions should result in normal autograft cusp configuration. CTA could become a tool for personalized planning of the Ross procedure., Meeting Presentation: Presented at the 38th EACTS meeting in October 2024 in Lisbon., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background and Aim of the Study: The aim of this study was to use coronary computed tomography in patients with normal tricuspid aortic valves to perform detailed aortic root and aortic valve geometric analysis with a focus on the asymmetry of the three leaflets. Methods: Retrospective analysis of anonymized coronary computed tomography angiograms was performed using dedicated software, where manual aortic root segmentation and marking of several points of interest were followed by automated measurements of aortic root and leaflets. Asymmetry of the three leaflets in individual patients was assessed by calculating absolute and relative differences between the largest and the smallest of the three leaflets. Results: We analyzed 70 aortic valves, the mean patient age was 53 ± 11 years, and 50% (n = 35) of patients were female. All aortic valves were tricuspid, without calcifications and aortic roots were of normal dimensions. Some degree of asymmetry was present in all analyzed valves. Absolute and relative differences for free margin length were 3.2 ± 1.4 mm and 9.3 ± 3.8%, respectively. The largest relative difference was noted in the coaptation area (36.5 ± 16.5%) and the smallest in leaflet effective height (6.1 ± 4.8%). Using predefined cutoff criteria for absolute differences in leaflet dimensions, 86% of the valves were classified as asymmetric. Conclusions: Most normal tricuspid aortic valves show some degree of asymmetry. Equal free margin length of the three leaflets is not needed for normal tricuspid aortic valve function. Leaflet effective height showed the least amount of asymmetry confirming its importance in keeping the aortic valve competent. [ABSTRACT FROM AUTHOR]

Despite excellent procedural results in a broad clinical population, certain anatomical or clinical conditions are still challenging for transcatheter aortic valve replacement (TAVI). Whether the adherence to the instructions for use (IFU) or the use of a clinically suitable device is a prerequisite for procedural success has not been well characterized. The anatomical and clinical suitability of new-generation transcatheter heart valves (THV) was evaluated in an all-comers population (n = 540) at a high-volume center. Conformity with anatomical IFU criteria was evaluated in each implanted THV. In addition, the suitability of the implanted THV was verified in each case according to clinical and anatomical criteria, which had been previously defined according to the results of an international survey including 20 renowned TAVI operators. Furthermore, criteria of clinical suitability and adherence to IFU of each THV were applied to the overall cohort to analyze the proportion of patients in whom the use of the respective THV would have been judged to be unsuitable or off-label. An off-label use of THV based on anatomical considerations was found in 20% of all procedures, whereas the implantation of a THV deemed to be clinically unsuitable was noted in 16.3% of all procedures. Clinical suitability and conformity with IFU were present to a varying extent across the THV systems. Neither clinical suitability, nor conformity with IFU were associated with device failure or periprocedural mortality. On multivariable analysis, aortic tortuosity, mean transaortic gradient and ascending aorta diameter were identified as independent predictors of device failure (VARC-3). Off-label TAVI and the use of clinically unsuitable THVs were common, but did not affect procedural outcomes. The variety of clinical and anatomical coverage of the different THV systems emphasizes the importance of an individualized THV selection. • The majority of anatomical and clinical conditions in a contemporary TAVI population can be treated properly with new-generation THVs. • Vast differences exist in the anatomical coverage and clinical eligibility among all four THVs examined. • An off-label or clinically unsuitable THV use was common in this all-comers TAVI population. • Off-label use and the use of a "clinically unsuitable" THV were not associated with device failure after transfemoral TAVI. [ABSTRACT FROM AUTHOR]

Objective: By assessing the normal dimensions and the relationship between the aortic root and leaflets in Chinese population, the objective of this three-dimensional computed tomography (3DCT)-based study was to establish a matching reference for leaflets and aortic root for aortic valve (AV) repair.Method: Electrocardiogram-gated multi-detector CT was performed on 168 Chinese participants with a normal aortic valve. Measurements of the aortic annuli and leaflets were obtained. The correlations between and the ratios of the specific root and leaflet measurements were analyzed. The references for the leaflet and root dimensions were suggested based on geometric height (gH) using a linear regression equation. The utility of the ratios was tested with CT images of 15 patients who underwent aortic valve repair.Result: The mean annulus diameter (AD), sino-tubular junction (STJ) diameter, geometric height (gH), effective height (eH), free margin length (FML), commissural height (ComH), inter-commissural distance (ICD), and coaptation height (CH) were 22.4 ± 1.7 mm, 27.3 ± 2, 0.4 mm, 15.5 ± 1.7 mm, 8.9 ± 1.2 mm, 32.0 ± 3.4 mm, 17.9 ± 1.9 mm, 23.1 ± 2.3 mm, and 3.1 ± 0.6 mm, respectively. The gH/AD, FML/ICD, and eH/ComH ratios were 0.69 ± 0.07, 1.38 ± 0.08, and 0.50 ± 0.07, respectively. The gH correlated with all other leaflet and root measurements (P < 0.01), whereas the FML demonstrated a better correlation with ICD compared with gH (R2 = 0.75, and R2 = 0.37, respectively). The FML/ICD and eH/ComH ratios might be used to assess leaflet-root mismatch and post-repair leaflet billowing.Conclusion: The normal aortic valve measurements based on 3DCT revealed a specific relationship between the root and leaflets; and this will guide the development of an objective method of aortic valve repair.

Objectives: In patients with aortic root aneurysm, the aortic basal ring is frequently dilated. It has been speculated that the muscular part of the basal ring dilates most. The purpose of this study was to analyse the segmental dilatation of the basal ring, comparing normal and dilated roots in patients with tricuspid aortic valves., Methods: Retrospective analysis of computed tomography studies in patients with normal and dilated aortic roots was performed. Lengths of segments of the basal ring corresponding to each of the 3 sinuses, and to the muscular and fibrous parts were measured. Fractions of these segments relative to the total basal ring perimeter were calculated., Results: We analysed 152 normal and 126 dilated aortic roots and 86 propensity-matched pairs. Basal ring dilatation was present in all segments of dilated aortic roots with subtle differences between the segments corresponding to the 3 sinuses. The muscular part of the basal ring dilated proportionately to its fibrous part, with no difference in fractions of measured muscular part in normal and dilated roots [42.2% (interquartile range 4.3%) vs 42.1% (interquartile range 6.3%)]., Conclusions: Basal ring dilatation was present in all segments corresponding to the 3 sinuses in dilated aortic roots. Both muscular and fibrous parts dilated equally, supporting the need to stabilize the entire basal ring when performing aortic valve repair surgery., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

During the last decade, special concerns have been raised about the anatomic relationships among the sinotubular junction, ventricular-aortic junction, and virtual basal ring to improve the results of root reconstruction. The aim of this study is to evaluate the in vivo anatomy of the aortic root after reimplantation with the Valsalva graft and the anatomic relationship between its components. We analyzed 10 consecutive patients with tricuspid aortic valves who underwent reimplantation with the Valsalva graft between September and December 2019. Surgical clips were applied as markers at the level of proximal annular knots and at the distal reimplanted commissures on the neo-sinotubular junction. Electrocardiogram-gated computed tomography scan of the aortic root was performed. Coordinates of the markers were exported on a 3-dimensional modeling software, and the distances between the virtual basal ring and the Dacron graft basal landmarks were measured. The mean heights of Dacron graft basal landmarks from virtual basal ring were right-left commissure 7.1 ± 5.1 mm; right sinus 4.7 ± 4.1 mm; right-noncoronary commissure 2.8 ± 2.2 mm; noncoronary sinus 1.4 ± 1.6 mm; left-noncoronary commissure 2.2 ± 2.3 mm; and left sinus 2.0 ± 0.9 mm. The mean planar distances of basal Dacron graft landmarks from virtual basal ring (thickness) were right-left commissure 5.3 ± 3.1 mm; right sinus 2.8 ± 1.4 mm; right-noncoronary commissure 2.2 ± 1.5 mm; noncoronary sinus 1.5 ± 1.5 mm; left-noncoronary commissure 1.3 ± 1.0 mm; and left sinus 3.4 ± 2.5 mm. After reimplantation, despite a complete dissection of the root, slight asymmetry of graft proximal seating exists. The inner annuloplasty is on the virtual basal ring, and the proximal edge of the Dacron graft is on the ventricular-aortic junction at a slightly different thickness and height along the annular circumference. At the level of the right sinus and left/right commissure, the Dacron graft is higher than the virtual basal ring and the relative wall thickness is increased. The annular stabilization is unaffected. The position of the markers on the Dacron graft after a reimplantation procedure (drawing), their visualization on the CT scan, and their 3D reconstruction (schematic). This sequence shows that the anatomic skeleton of the root after reimplantation is characterized by a slightly tilted position of the Dacron graft higher and farther from the VBR at the level of the right sinus and R/L commissure similar to the relationship between the natural VAJ and the VBR. [Display omitted] [ABSTRACT FROM AUTHOR]

Background To enhance the reproducibility of aortic valve–sparing reimplantation and annuloplasty, we analyzed the topographic relationship between the ventriculoaortic junction (VAJ), basal ring (BR), and sinotubular junction (STJ). The root base thickness is also quantified. Method Fifty-eight fresh human aortic valves were analyzed. The root was dissected to the limit where the aortic wall terminates into the cardiac structures (VAJ). Root height was measured externally from the STJ to the VAJ and internally from the STJ to the BR defined as the plane passing through the cusps nadir. The root base thickness was measured at the BR and orthogonal to the internal wall; except at the right coronary sinus, where it was measured between the BR internally and the VAJ externally. Measurements were taken at the middle of the 3 sinuses and commissures. Results The VAJ is at the same level as the BR from the noncoronary sinus (−0.1 ± 0.9 mm) to the left coronary sinus (0.5 ± 1.3 mm); it is above the BR from the left/right commissure (4.6 ± 1.4 mm) to the right/non commissure (2.5 ± 1.6 mm). The external root height was highest at the non/left commissure (21.5 ± 2.6 mm) followed by the right/non commissure (19.2 ± 2.3 mm) then the left/right commissure (15.7 ± 2.2 mm) ( P < .05). The mean root base thickness was 3.2 mm, ranging from 1 ± 0 mm at the left/non commissure to 6.2 ± 1.2 mm at the right coronary sinus ( P < .001). Conclusions The VAJ is not planar; it is above the level of the BR from the left/right to the right/non commissure. As a consequence, the external height of the non/left commissure is greater than the other 2 commissures. These findings should be taken into consideration when performing aortic valve–sparing reimplantation or external annuloplasty. [ABSTRACT FROM AUTHOR]

Objective: By assessing the normal dimensions and the relationship between the aortic root and leaflets in Chinese population, the objective of this three-dimensional computed tomography (3DCT)-based study was to establish a matching reference for leaflets and aortic root for aortic valve (AV) repair. Method: Electrocardiogram-gated multi-detector CT was performed on 168 Chinese participants with a normal aortic valve. Measurements of the aortic annuli and leaflets were obtained. The correlations between and the ratios of the specific root and leaflet measurements were analyzed. The references for the leaflet and root dimensions were suggested based on geometric height (gH) using a linear regression equation. The utility of the ratios was tested with CT images of 15 patients who underwent aortic valve repair. Result: The mean annulus diameter (AD), sino-tubular junction (STJ) diameter, geometric height (gH), effective height (eH), free margin length (FML), commissural height (ComH), inter-commissural distance (ICD), and coaptation height (CH) were 22.4 ± 1.7 mm, 27.3 ± 2, 0.4 mm, 15.5 ± 1.7 mm, 8.9 ± 1.2 mm, 32.0 ± 3.4 mm, 17.9 ± 1.9 mm, 23.1 ± 2.3 mm, and 3.1 ± 0.6 mm, respectively. The gH/AD, FML/ICD, and eH/ComH ratios were 0.69 ± 0.07, 1.38 ± 0.08, and 0.50 ± 0.07, respectively. The gH correlated with all other leaflet and root measurements ( P < 0.01), whereas the FML demonstrated a better correlation with ICD compared with gH (R 2 = 0.75, and R 2 = 0.37, respectively). The FML/ICD and eH/ComH ratios might be used to assess leaflet-root mismatch and post-repair leaflet billowing. Conclusion: The normal aortic valve measurements based on 3DCT revealed a specific relationship between the root and leaflets; and this will guide the development of an objective method of aortic valve repair., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Yang, Wen, El-Hamamsy, Ni, Sun and Zhu.)