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BACKGROUND Transesophageal echocardiography (TEE) is recommended for diagnosis in patients suspected of prosthetic valve dysfunction, but could be limited in its ability to identify the etiology of these dysfunctions and to assess extracardiac structures. Our objective is to examine the usefulness of multidetector computed tomography (MDCT) in establishing the etiology of the dysfunctions and its clinical utility in preoperative assessment in these patients. METHODS Twenty-two prosthetic heart valves from 20 consecutive patients who had a preoperative MDCT and underwent redo prosthetic valve procedures from December 2008 to February 2013 were examined retrospectively. Results from MDCT and TEE were compared to intraoperative findings. Extravalvular MDCT findings including coronary artery/bypass graft, high-risk features for reoperative cardiac surgery, and extracardiac findings were also assessed. RESULTS MDCT correctly identified 15 valve regurgitation and seven valve obstructions compared to intraoperative findings. Both TEE and MDCT were able to correctly identify the etiologies in 93% (14/15) of regurgitant valves. However, MDCT was better able to identify the etiology of obstructive valves than TEE (86% [6/7] vs. 43% [3/7]) compared to intraoperative findings. In patients who had preoperative invasive angiography, MDCT correctly identified two patients with significant coronary artery disease (CAD) and ruled out 11 without significant CAD. Furthermore, MDCT detected five high-risk features for postoperative complications and eight clinically relevant extracardiac findings. CONCLUSIONS MDCT displayed comparable or better diagnostic performance than TEE for identifying the type of dysfunction and its etiology, as well as providing additional coronary and other extravalvular evaluations useful for preoperative planning.

Transcatheter mitral valve-in-valve implantation (TMVIV) is an option for patients with mitral prosthetic valve dysfunction who are at high risk for surgical valve replacement. Efficacy and safety of TMVIV is at its infancy. We report a high-risk symptomatic dialysis-dependent end-stage renal disease patient with severe bioprosthetic mitral valve stenosis who had TMVIV performed successfully.

Obesity paradox has been described in various populations of coronary artery disease, mainly asymptomatic subjects. However, relationship between obesity and coronary artery calcification detected by cardiac CT in symptomatic patients has rarely been demonstrated. This study seeks to investigate whether the paradoxical relationship between obesity and coronary artery calcification exists in patients with acute chest pain. A final cohort of 1030 chest pain patients presenting at our emergency department who underwent coronary evaluation by multidetector cardiac CT were examined. With absent-to-mild coronary calcification (CAC score 0.002), body mass index (OR 0.945; 95% CI 0.920, 0.971; ), body weight (OR 0.987; 95% CI 0.979, 0.995; 0.001), and body surface area (OR 0.582; 95% CI 0.369, 0.920; 0.020) were inversely associated with moderate-to-severe coronary calcification (CAC score ≥ 100). This study extends the concept of obesity paradox to symptomatic patients undergoing coronary artery calcium score assessment. However, biological explanation(s) of this paradox remains unanswered.