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Background: The goal of our study is to evaluate a method to quantify aortic valve calcification (AVC) in contrast-enhanced computed tomography for patients with suspected severe aortic stenosis pre-interventionally. Methods: A total of sixty-five patients with aortic stenosis underwent both a native and a contrast-enhanced computed tomography (CECT) scan of the aortic valve (45 in the training cohort and 20 in the validation cohort) using a standardized protocol. Aortic valve calcification was semi-automatically quantified via the Agatston score method for the native scans and was used as a reference. For contrast-enhanced computed tomography, a calcium threshold of the Hounsfield units of the aorta plus four times the standard deviation was used. Results: For the quantification of aortic valve calcification in contrast-enhanced computed tomography, a conversion formula (691 + 1.83 x AVCCECT) was derived via a linear regression model in the training cohort. The validation in the second cohort showed high agreement for this conversion formula with no significant proportional bias (Bland–Altman, p = 0.055) and with an intraclass correlation coefficient in the validation cohort of 0.915 (confidence interval 95% 0.786–0.966) p < 0.001. Conclusions: Calcium scoring in patients with aortic valve stenosis can be performed using contrast-enhanced computed tomography with high validity. Using a conversion factor led to an excellent agreement, thereby obviating an additional native computed tomography scan. This might contribute to a decrease in radiation exposure. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The aim of this study was to investigate whether balloon-expandable and self-expandable transcatheter heart valves (THVs) differ in terms of the incidence of early subclinical leaflet thrombosis (LT). METHODS: Electrocardiographic-gated cardiac dual-source computed tomography angiography was performed at a median of 5 days after transcatheter aortic valve implantation and assessed for evidence of LT. RESULTS: Of the 629 consecutive patients, 538 (86%) received a balloon-expandable THV and 91 (14%) a self-expandable THV. LT was documented in 77 (14%) patients with a balloon-expandable valve and in 16 (18%) with a self-expandable valve (P = 0.42). Similarly, LT was not significantly related to THV size (P = 0.62). Corresponding to a lower rate of atrial fibrillation in the group with LT [25 (27%) vs 222 (41%), P = 0.01], anticoagulation at the time of computed tomography angiography was less frequent in this group [21 (23%) vs 183 (34%), P = 0.03]. Among the other potentially relevant covariables, there was no significant difference in the clinical baseline and the procedural characteristics between patients with and without LT (age 82 ± 6 years vs 82 ± 6 years, P = 0.51; ejection fraction 49 ± 10% vs 50 ± 10%, P = 0.47). In multivariate logistic regression analysis, including potentially relevant covariables, valve type was not significantly associated with LT (P = 0.36). In the univariate and multivariate analyses, only the lack of anticoagulation at the time of computed tomography angiography was predictive of thrombus formation [0.563 (0.335-0.944), P = 0.03; 0.576 (0.343-0.970), P = 0.04]. CONCLUSIONS: In this large retrospective study of 629 patients, the type and the size of THV was not predictive of early LT. [ABSTRACT FROM AUTHOR]

Abstract: ACE inhibition has been shown to improve left ventricular (LV) and myocardial blood flow. Previous data regarding changes in capillary density and angiogenesis during ACE inhibition are controversial. The aim of the following study was to determine myocardial microcirculation and heart function in the rat after coronary stenosis using non invasive MR imaging techniques. MR spin labeling and cine techniques have been performed in female Wistar rats 2weeks after coronary artery stenosis. In one group, animals were treated with quinapril in a dose of 6mg/kg/day. Perfusion, relative blood volume (RBV), LV mass and function were determined non-invasively 2weeks after treatment. Finally, fibrosis and capillary density were analyzed histologically. Additionally, hemodynamic measurements were realized in a further group in order to calculate systemic vascular resistance (SVR). Quinapril resulted in a significant increase in perfusion at rest in the remote and the poststenotic myocardium with improved systolic function and a decrease in SVR compared to the non treated control group. Additionally, maximum perfusion and RBV were slightly elevated whereas capillary density was unchanged among the groups. MRI allows for non-invasive quantification of functional microcirculation and heart function. In addition to the well known effect of ACE inhibition on systolic function, treatment with the tissue specific ACE inhibitor quinapril revealed an important microvascular improvement, especially at arteriolar level. These findings may support the use of tissue ACE inhibitors to improve cardiac microcirculation after ischemia. [Copyright &y& Elsevier]

Objectives: To determine the diagnostic accuracy of ultra-high-resolution photon-counting detector CT angiography (UHR PCD-CTA) for evaluating coronary stent patency compared to invasive coronary angiography (ICA). Methods: Consecutive, clinically referred patients with prior coronary stent implantation were prospectively enrolled between August 2022 and March 2023 and underwent UHR PCD-CTA (collimation, 120 × 0.2 mm). Two radiologists independently analyzed image quality of the in-stent lumen using a 5-point Likert scale, ranging from 1 ("excellent") to 5 ("non-diagnostic"), and assessed all coronary stents for the presence of in-stent stenosis (≥ 50% lumen narrowing). The diagnostic accuracy of UHR PCD-CTA was determined, with ICA serving as the standard of reference. Results: A total of 44 coronary stents in 18 participants (mean age, 83 years ± 6 [standard deviation]; 12 women) were included in the analysis. In 3/44 stents, both readers described image quality as non-diagnostic, whereas reader 2 noted a fourth stent to have non-diagnostic image quality. In comparison to ICA, UHR PCD-CTA demonstrated a sensitivity, specificity, and accuracy of 100% (95% CI [confidence interval] 47.8, 100), 92.3% (95% CI 79.1, 98.4), and 93.2% (95% CI 81.3, 98.6) for reader 1 and 100% (95% CI 47.8, 100), 87.2% (95% CI 72.6, 95.7), and 88.6% (95% CI 75.4, 96.2) for reader 2, respectively. Both readers observed a 100% negative predictive value (36/36 stents and 34/34 stents). Stent patency inter-reader agreement was 90.1%, corresponding to a substantial Cohen's kappa value of 0.72. Conclusions: UHR PCD-CTA enables non-invasive assessment of coronary stent patency with high image quality and diagnostic accuracy. Clinical relevance statement: Ultra-high-resolution photon-counting detector CT angiography represents a reliable and non-invasive method for assessing coronary stent patency. Its high negative predictive value makes it a promising alternative over invasive coronary angiography for the rule-out of in-stent stenosis. Key Points: • CT-based evaluation of coronary stent patency is limited by stent-induced artifacts and spatial resolution. • Ultra-high-resolution photon-counting detector CT accurately evaluates coronary stent patency compared to invasive coronary angiography. • Photon-counting detector CT represents a promising method for the non-invasive rule-out of in-stent stenosis. [ABSTRACT FROM AUTHOR]

Background: We aimed to evaluate the feasibility of a non-contrast time-of-flight magnetic resonance angiography (TOF-MRA) protocol for the pre-procedural access route assessment of transcatheter aortic valve implantation (TAVI) in comparison with contrast-enhanced cardiac dual-source computed tomography angiography (CTA). Methods and Results: In total, 51 consecutive patients (mean age: 82.69 ± 5.69 years) who had undergone a pre-TAVI cardiac CTA received TOF-MRA for a pre-procedural access route assessment. The MRA image quality was rated as very good (median of 5 [IQR 4–5] on a five-point Likert scale), with only four examinations rated as non-diagnostic. The TOF-MRA systematically underestimated the minimal effective vessel diameter in comparison with CTA (for the effective vessel diameter in mm, the right common iliac artery (CIA)/external iliac artery (EIA)/common femoral artery (CFA) MRA vs. CTA was 8.04 ± 1.46 vs. 8.37 ± 1.54 (p < 0.0001) and the left CIA/EIA/CFA MRA vs. CTA was 8.07 ± 1.32 vs. 8.28 ± 1.34 (p < 0.0001)). The absolute difference between the MRA and CTA was small (for the Bland–Altman analyses in mm, the right CIA/EIA/CFA was −0.36 ± 0.77 and the left CIA/EIA/CFA was −0.25 ± 0.61). The overall correlation between the MRA and CTA measurements was very good (with a Pearson correlation coefficient of 0.87 (p < 0.0001) for the right CIA/EIA/CFA and a Pearson correlation coefficient of 0.9 (p < 0.0001) for the left CIA/EIA/CFA). The feasibility agreement between the MRA and CTA for transfemoral access was good (the right CIA/EIA/CFA agreement was 97.9% and the left CIA/EIA/CFA agreement was 95.7%, Kohen's kappa: 0.477 (p = 0.001)). Conclusions: The TOF-MRA protocol was feasible for the assessment of the access route in an all-comer pre-TAVI population. This protocol might be a reliable technique for patients at an increased risk of contrast-induced nephropathy. [ABSTRACT FROM AUTHOR]

Background: In addition to manual compression, various vascular closure devices (VCD) are available to seal the puncture site following arterial vascular procedures. Purpose: To evaluate the efficacy and safety of the extravascular MYNX CONTROL closure system for achieving primary hemostasis after femoral arterial access following peripheral arterial procedures, compared to the intravascular FemoSeal Aclosure system. Patients and Methods: A retrospective analysis of consecutive patients who underwent endovascular intervention between April and November 2022 was performed. The primary endpoint was the incidence of significant puncture site complication defined as a complication resulting in medical treatment. Secondary endpoints included peri-interventional incidence of hematoma, peri-interventional changes in hemoglobin, incidence of emergency diagnostics and predictors for closure system failure. Results: Five hundred and forty-eight patients were included in this analysis. False aneurysm occurred in 18/273 cases (6.6%) following the use of the MYNX closure system, compared to 6/275 cases after using the FemoSeal closure system (2.2%, p = 0.006). The incidence of post-interventional hematoma was not significantly different (28 (10.3%) in the MYNX group versus 32 (11.6%) in the FemoSeal group, p = 0.358). Peri-interventional hemoglobin drop did not differ between groups (p = 0.449). Emergency diagnostics were not significantly performed more often in the MYNX group (14 (5.1%) versus 8 (2.9%), p = 0.134). A post-interventional duplex sonography showed stenosis at the puncture site in one patient after use of the MYNX system. For the entire cohort, oral anticoagulation was the only predictor for the failure of the closure device (p = 0.036). Conclusions: Device failure was more common after using the extravascular MYNX CONTROL system than after using the intravascular FemoSeal system. However, the need for surgical or interventional therapy due to device failure was low. [ABSTRACT FROM AUTHOR]

Background: The impact of transcatheter heart valve (THV) position on the occurrence of paravalvular leakage and permanent pacemaker implantation caused by new-onset conduction disturbances is well described. The purpose of this study was to investigate the influence of the geometry of the thoracic aorta on the implantation depth after TAVI (transcatheter heart valve implantation) using self-expanding valve (SEV) types. Methods: We evaluated three-dimensional geometry of the thoracic aorta based on computed tomography angiography (CTA) in 104 subsequently patients receiving TAVI with SEV devices (Evolut R). Prosthesis position was determined using the fusion imaging method of pre- and post-procedural CTA. An implantation depth of ≥4 mm was defined as the cut-off value for low prosthesis position. Results: The mean implantation depth of the THV in the whole cohort was 4.3 ± 3.0 mm below annulus plane. THV position was low in 66 (63.5%) patients and high in 38 (36.5%) patients. After multivariate adjustment none of the aortic geometry characteristics showed an independent influence on the prosthesis position—neither the Sinus of Valsalva area (p = 0.335) nor the proximal aortic arch diameter (p = 0.754) or the distance from annulus to descending aorta (p = 0.309). Conclusion: The geometry of the thoracic aorta showed no influence on the positioning of self-expanding TAVI valve types. [ABSTRACT FROM AUTHOR]

(1) Background: Early hypo-attenuated leaflet thickening (HALT) is diagnosed by computed tomography angiography (CTA) in approximately 15% of patients undergoing transcatheter aortic valve replacement (TAVR). We sought to investigate the diagnostic performance of CTA for the diagnosis of HALT, focusing on timing data assessment within the cardiac cycle. (2) Methods: The study enrolled 50 patients with and 50 without HALT with available post-TAVR-CTA. The primary objective was to compare the diagnostic performance of CTA readings at specific intervals and time points during the cardiac cycle (entire systole, entire diastole, end-systole, and mid-diastole) versus gold standard (consensus reading by two observers based on multiphase full cardiac cycle data sets). (3) Results: 100 CTAs were independently analysed by two observers blinded to clinical characteristics of the study population and the results from the gold standard reading. Sensitivity and specificity for the diagnosis of HALT were 84%/94% in systole, 87%/92% in diastole, 78%/95% at end-systole, and 80%/94% at mid-diastole. End-systole had the highest positive predictive value (0.88) and positive likelihood ratio (36). Cohen's kappa for interobserver reliability was 0.715 in systole, 0.578 in diastole, 0.650 at end-systole, and 0.517 at mid-diastole. (4) Conclusion: Limiting CTA reading to distinct intervals or time points during the cardiac cycle has good specificity but lowers sensitivity. For a reliable diagnosis of HALT, data sets from a multiphase CTA covering the entire cardiac cycle should be analysed. A double reader approach would be desirable in further studies investigating HALT. [ABSTRACT FROM AUTHOR]

To determine the diagnostic accuracy of volumetric interpolated breath-hold examination sequences with fat suppression in Dixon technique (VIBE-Dixon) for cardiac thrombus detection. From our clinical database, we retrospectively identified consecutive patients between 2014 and 2022 who had definite diagnosis or exclusion of cardiac thrombus confirmed by an independent adjudication committee, serving as the reference standard. All patients received 2D-Cine plus 2D-Late-Gadolinium-Enhancement (Cine + LGE) and VIBE-Dixon sequences. Two blinded readers assessed all images for the presence of cardiac thrombus. The diagnostic accuracy of Cine + LGE and VIBE-Dixon was determined and compared. Among 141 MRI studies (116 male, mean age: 61 years) mean image examination time was 28.8 ± 3.1 s for VIBE-Dixon and 23.3 ± 2.5 min for Cine + LGE. Cardiac thrombus was present in 49 patients (prevalence: 35 %). For both readers sensitivity for thrombus detection was significantly higher in VIBE-Dixon compared with Cine + LGE (Reader 1: 96 % vs.73 %, Reader 2: 96 % vs. 78 %, p < 0.01 for both readers), whereas specificity did not differ significantly (Reader 1: 96 % vs. 98 %, Reader 2: 92 % vs. 93 %, p > 0.1). Overall diagnostic accuracy of VIBE-Dixon was higher than for Cine + LGE (95 % vs. 89 %, p = 0.02) and was non-inferior to the reference standard (Delta ≤ 5 % with probability > 95 %). Biplanar VIBE-Dixon sequences, acquired within a few seconds, provided a very high diagnostic accuracy for cardiac thrombus detection. They could be used as stand-alone sequences to rapidly screen for cardiac thrombus in patients not amenable to lengthy acquisition times. [ABSTRACT FROM AUTHOR]

Aim: Two‐dimensional, transthoracic echocardiography does not account for the noncircular anatomy of the left ventricular outflow tract (LVOT) and may therefore underestimate LVOT area. Fusion of computed tomography (CT)‐derived LVOT area and Doppler‐derived flow data has been proposed to improve assessment of aortic valve area (AVA) and classification of aortic stenosis severity. For hemodynamic reasons, effective AVA has to be smaller than anatomic AVA. The aim of the study was to test the “fusion approach” by comparing effective CT‐derived AVA with anatomic AVA from CT planimetry. Methods and Results: Data of 244 consecutive patients (mean age 81 ± 5 years, 61% female) with aortic stenosis were retrospectively analyzed comparing effective AVA (calculated from the continuity equation using CT‐LVOT and transthoracic Doppler measurements) with anatomic AVA based on CT planimetry. Substituting the LVOT area from transthoracic echocardiography (TTE) by the CT‐LVOT resulted in an increase in AVA from 0.74 ± 0.15 to 0.92 ± 0.18cm² (P < .01), which was larger than anatomic AVA (0.82 ± 0.15cm²). Similar results were obtained based on planimetry from transesophageal echocardiography (TEE; AVA 0.79 ± 0.14cm², P < .01 vs CT‐LVOT) and in the subgroup presenting with low‐gradient severe aortic stenosis and preserved ejection fraction (n = 67, AVA from TTE 0.76 ± 0.09; from CT‐LVOT 0.97 ± 0.14; CT planimetry 0.86 ± 0.12; TEE planimetry 0.82 ± 0.13cm²). Conclusion: Fusion of CT‐derived LVOT area with Doppler echocardiography results in a calculated effective AVA that is larger than the corresponding anatomic AVA. Therefore, adjustment of partition values may be warranted when using this approach. [ABSTRACT FROM AUTHOR]

Background: Transcatheter aortic valve replacement (TAVR) is being increasingly performed in patients with bicuspid aortic valve stenosis (AS).Objectives: This study sought to compare the procedural and clinical outcomes in patients with bicuspid versus tricuspid AS from the Bicuspid AS TAVR multicenter registry.Methods: Outcomes of 561 patients with bicuspid AS and 4,546 patients with tricuspid AS were compared after propensity score matching, assembling 546 pairs of patients with similar baseline characteristics. Procedural and clinical outcomes were recorded according to Valve Academic Research Consortium-2 criteria.Results: Compared with patients with tricuspid AS, patients with bicuspid AS had more frequent conversion to surgery (2.0% vs. 0.2%; p = 0.006) and a significantly lower device success rate (85.3% vs. 91.4%; p = 0.002). Early-generation devices were implanted in 320 patients with bicuspid and 321 patients with tricuspid AS, whereas new-generation devices were implanted in 226 and 225 patients with bicuspid and tricuspid AS, respectively. Within the group receiving early-generation devices, bicuspid AS had more frequent aortic root injury (4.5% vs. 0.0%; p = 0.015) when receiving the balloon-expanding device, and moderate-to-severe paravalvular leak (19.4% vs. 10.5%; p = 0.02) when receiving the self-expanding device. Among patients with new-generation devices, however, procedural results were comparable across different prostheses. The cumulative all-cause mortality rates at 2 years were comparable between bicuspid and tricuspid AS (17.2% vs. 19.4%; p = 0.28).Conclusions: Compared with tricuspid AS, TAVR in bicuspid AS was associated with a similar prognosis, but lower device success rate. Procedural differences were observed in patients treated with the early-generation devices, whereas no differences were observed with the new-generation devices. [ABSTRACT FROM AUTHOR]

Background: Few studies have evaluated the clinical outcomes of transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic valve stenosis (AS). Particularly, limited data exist comparing the results of TAVR with new-generation devices versus early-generation devices.Objectives: This study sought to evaluate the clinical outcomes of TAVR for bicuspid AS with early- and new-generation devices.Methods: The Bicuspid TAVR Registry is an international multicenter study enrolling consecutive patients with bicuspid AS undergoing TAVR between April 2005 and May 2015.Results: Of 301 patients, 199 patients (71.1%) were treated with early-generation devices (Sapien XT [Edwards Lifesciences Corporation, Irvine, California]: n = 87; CoreValve [Medtronic, Minneapolis, Minnesota]: n = 112) and 102 with new-generation devices (Sapien 3 [Edwards Lifesciences Corporation]: n = 91; Lotus [Boston Scientific Corporation, Marlborough, Massachusetts]: n = 11). The mean Society of Thoracic Surgeons score was 4.7 ± 5.2 without significant differences between groups (4.6 ± 5.1 vs. 4.9 ± 5.4; p = 0.57). Overall, all-cause mortality rates were 4.3% at 30 days and 14.4% at 1 year. Moderate or severe paravalvular leak was absent and significantly less frequent with new-generation compared to early-generation devices (0.0% vs. 8.5%; p = 0.002), which resulted in a higher device success rate (92.2% vs. 80.9%; p = 0.01). There were no differences between early- and new-generation devices in stroke (2.5% vs. 2.0%; p > 0.99), life-threatening bleeding (3.5% vs. 2.9%; p > 0.99), major vascular complication (4.5% vs. 2.9%; p = 0.76), stage 2 to 3 acute kidney injury (2.5% vs. 2.9%; p > 0.99), early safety endpoints (15.1% vs. 10.8%; p = 0.30), and 30-day all-cause mortality (4.5% vs. 3.9%; p > 0.99).Conclusions: The clinical outcomes of TAVR in patients with bicuspid AS were favorable. New-generation devices were associated with less paravalvular leak and, hence, a higher device success rate than early-generation devices. (The Bicuspid Aortic Stenosis Following Transcatheter Aortic Valve Replacement Registry [Bicuspid TAVR]; NCT02394184). [ABSTRACT FROM AUTHOR]

OBJECTIVES: Previous studies have found that standard echocardiographic measures of right ventricular (RV) function were impaired after surgical replacement of the aortic valve (SAVR), but not after transcatheter aortic valve implantation (TAVI). We used 3D echocardiography to gain further insight into the changes of RV performance in patient undergoing SAVR or TAVI. METHODS: We conducted a prospective non-randomized study with two parallel groups and performed echocardiographic evaluation in 20 patients with aortic stenosis undergoing SAVR (age 77 ± 4 years), and in 20 patients undergoing TAVI via the transfemoral approach (age 83 ± 6 years) 1 week before and between the fifth and seventh day after the procedure. RESULTS: Tricuspid annular plane systolic excursion was postoperatively markedly reduced in patients undergoing SAVR (13 ± 2 vs 26 ± 4 mm, post- vs preoperative, P < 0.001), but not in patients undergoing TAVI (24 ± 7 vs 24 ± 5 mm, P = 0.90). Fractional shortening of the RV midcavity transverse diameter, however, increased after SAVR (50 ± 8 vs 31 ± 11%, P < 0.001) in contrast to TAVI (33 ± 10 vs 34 ± 9%, P = 0.85). The RV ejection fraction, assessed by 3D echocardiography, remained unchanged in both patient groups (SAVR, 55 ± 6 vs 55 ± 7%, P = 0.52; TAVI, 56 ± 8 vs 54 ± 7%, P = 0.28). CONCLUSIONS: RV longitudinal contraction decreased after SAVR, whereas RV transverse contraction increased. Both parameters did not change after TAVI. RV ejection fraction and RV stroke volume remained constant irrespective of the technique of aortic valve replacement, thus indicating that global systolic RV function is not compromised after SAVR. [ABSTRACT FROM AUTHOR]

Background: Prior data suggest a correlation between the position of transcatheter heart valves (THV) and the occurrence of complications after transcatheter aortic valve implantation (TAVI) in patients with tricuspid aortic valves (TAV). However, data including a detailed analysis of prosthesis positioning in bicuspid aortic valves (BAV) are limited. Therefore, the purpose of this study was to investigate THV position after TAVI in BAV. Methods: We evaluated the THV position in 50 BAV and 50 TAV patients (all received the balloon-expandable Sapien 3 prosthesis) using fusion imaging of pre- and post-procedural computed tomography angiography. According to the manufacturers' recommendations, a low implantation position was defined as >30% of the prosthesis below the annulus. Results: THV position was appropriate in the majority of the patients within both groups (90.0% for BAV vs. 96.0% for TAV, p = 0.240). In BAV, we observed a more pronounced THV waist (7.4 ± 4.5% vs. 5.8 ± 3.0%, p = 0.043) and a lower average THV expansion (91.9 ± 12.2% vs. 95.5 ± 2.7% of nominal expansion, p = 0.044). Conclusions: Accurate positioning in relation to the aortic annulus of the TAVI Sapien 3 prosthesis is possible in patients with BAV with results comparable to TAV. However, there is a more pronounced prosthesis waist and a lower average THV expansion in BAV. [ABSTRACT FROM AUTHOR]