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This article, published in the journal Thoracic & Cardiovascular Surgeon, explores the impact of surgical ventricular restoration (SVR) on intracardiac hemodynamics. The study analyzes cardiac computed tomography (CCT) data from 10 patients before and after SVR to assess changes in ventricular function and shape. The results show a reduction in mitral valve regurgitation and improvements in end-diastolic volume and ejection fraction. The study also suggests a correlation between improved washout and ejection fraction, indicating a lower risk of thrombus formation and embolic events after surgery. The authors propose that this methodology could be used to predict outcomes of SVR procedures in the future. [Extracted from the article]

Speckle-tracking echocardiography (STE) parameters are an integral part of the assessment of left ventricular (LV) function. We aimed to evaluate established and novel STE parameters of LV diastolic function and their prognostic role in patients with LV anteroapical aneurysm undergoing surgical ventricular repair (SVR). We retrospectively examined the data of 137 patients with anteroapical LV aneurysm who underwent SVR. In 27 patients, the correlation of STE parameters with invasive hemodynamic parameters was evaluated. Preoperative echocardiographic parameters were assessed for their association with outcome, defined as all-cause mortality, LV assist device implantation, or heart transplantation. The late diastolic strain rate (GLSRa) showed a stronger correlation with mean pulmonary artery pressure (r =  - 0.75, p < 0.001) than all other parameters. GLSRa was also significantly correlated with mean pulmonary capillary wedge pressure and LV end-diastolic pressure. In the multivariate model, GLSRa and the ratio of early diastolic filling velocity to GLSRa demonstrated incremental prognostic value in addition to clinical and echocardiographic parameters. Patients with GLSRa < 0.59 s -1 had significantly shorter event-free survival than those with GLSRa > 0.59 s -1 (6.7 vs. 10.9 years, p < 0.001). Peak reservoir left atrial strain showed a weaker association with hemodynamic parameters and outcome compared to GLSRa. In patients with LV aneurysm, late diastolic strain rate and left atrial strain can be used for the assessment of LV diastolic function and have a predictive value for the outcome after surgical ventricular restoration., (© 2024. The Author(s).)

Background: Obesity is a known cardiovascular risk factor and associated with higher postoperative complication rates in patients undergoing cardiac surgery. In heart failure (HF), conflicting evidence in terms of survival has been reported, whereas sarcopenia is associated with poor prognosis. An increasing number of HF patients require left ventricular assist device (LVAD) implantations. The postoperative mortality has improved in recent years but is still relatively high. The impact of body composition on outcome in this population remains unclear. The aim of this investigation was to examine the preoperative computed tomography (CT) body composition as a predictor of the postoperative outcome in advanced HF patients, who receive LVAD implantations., Methods: Preoperative CT scans of 137 patients who received LVADs between 2015 and 2020 were retrospectively analysed using an artificial intelligence (AI)-powered automated software tool based on a convolutional neural network, U-net, developed for image segmentation (Visage Version 7.1, Visage Imaging GmbH, Berlin, Germany). Assessment of body composition included visceral and subcutaneous adipose tissue areas (VAT and SAT), psoas and total abdominal muscle areas and sarcopenia (defined by lumbar skeletal muscle indexes). The body composition parameters were correlated with postoperative major complication rates, survival and postoperative 6-min walk distance (6MWD) and quality of life (QoL)., Results: The mean age of patients was 58.21 ± 11.9 years; 122 (89.1%) were male. Most patients had severe HF requiring inotropes (Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS] profile I-III, 71.9%) secondary to coronary artery diseases or dilated cardiomyopathy (96.4%). Forty-four (32.1%) patients were obese (body mass index ≥ 30 kg/m 2 ), 96 (70.1%) were sarcopene and 19 (13.9%) were sarcopene obese. Adipose tissue was associated with a significantly higher risk of postoperative infections (VAT 172.23 cm 2 [54.96, 288.32 cm 2 ] vs. 124.04 cm 2 [56.57, 186.25 cm 2 ], P = 0.022) and in-hospital mortality (VAT 168.11 cm 2 [134.19, 285.27 cm 2 ] vs. 135.42 cm 2 [49.44, 227.91 cm 2 ], P = 0.033; SAT 227.28 cm 2 [139.38, 304.35 cm 2 ] vs. 173.81 cm 2 [97.65, 254.16 cm 2 ], P = 0.009). Obese patients showed no improvement of 6MWD and QoL within 6 months postoperatively (obese: +0.94 ± 161.44 months, P = 0.982; non-obese: +166.90 ± 139.00 months, P < 0.000; obese: +0.088 ± 0.421, P = 0.376; non-obese: +0.199 ± 0.324, P = 0.002, respectively). Sarcopenia did not influence the postoperative outcome and survival within 1 year after LVAD implantation., Conclusions: Preoperative AI-based CT body composition identifies patients with poor outcome after LVAD implantation. Greater adipose tissue areas are associated with an increased risk for postoperative infections, in-hospital mortality and impaired 6MWD and QoL within 6 months postoperatively., (© 2023 The Authors. Journal of Cachexia, Sarcopenia and Muscle published by Wiley Periodicals LLC.)

Pulmonary hypertension worsens outcome in left heart disease. Stiffening of the pulmonary artery may drive this pathology by increasing right ventricular dysfunction and lung vascular remodeling. Here we show increased stiffness of pulmonary arteries from patients with left heart disease that correlates with impaired pulmonary hemodynamics. Extracellular matrix remodeling in the pulmonary arterial wall, manifested by dysregulated genes implicated in elastin degradation, precedes the onset of pulmonary hypertension. The resulting degradation of elastic fibers is paralleled by an accumulation of fibrillar collagens. Pentagalloyl glucose preserves arterial elastic fibers from elastolysis, reduces inflammation and collagen accumulation, improves pulmonary artery biomechanics, and normalizes right ventricular and pulmonary hemodynamics in a rat model of pulmonary hypertension due to left heart disease. Thus, targeting extracellular matrix remodeling may present a therapeutic approach for pulmonary hypertension due to left heart disease., (© 2023. The Author(s).)

Objectives: In aortic valve replacement (AVR), the treatment strategy as well as the model and size of the implanted prosthesis have a major impact on the postoperative hemodynamics and thus on the clinical outcome. Preinterventional prediction of the hemodynamics could support the treatment decision. Therefore, we performed paired virtual treatment with transcatheter AVR (TAVI) and biological surgical AVR (SAVR) and compared hemodynamic outcomes using numerical simulations., Methods: 10 patients with severe aortic stenosis (AS) undergoing TAVI were virtually treated with both biological SAVR and TAVI to compare post-interventional hemodynamics using numerical simulations of peak-systolic flow. Virtual treatment procedure was done using an in-house developed tool based on position-based dynamics methodology, which was applied to the patient's anatomy including LVOT, aortic root and aorta. Geometries were automatically segmented from dynamic CT-scans and patient-specific flow rates were calculated by volumetric analysis of the left ventricle. Hemodynamics were assessed using the STAR CCM+ software by solving the RANS equations., Results: Virtual treatment with TAVI resulted in realistic hemodynamics comparable to echocardiographic measurements (median difference in transvalvular pressure gradient [TPG]: -0.33 mm Hg). Virtual TAVI and SAVR showed similar hemodynamic functions with a mean TPG with standard deviation of 8.45 ± 4.60 mm Hg in TAVI and 6.66 ± 3.79 mm Hg in SAVR (p = 0.03) while max. Wall shear stress being 12.6 ± 4.59 vs. 10.2 ± 4.42 Pa (p = 0.001)., Conclusions: Using the presented method for virtual treatment of AS, we were able to reliably predict post-interventional hemodynamics. TAVI and SAVR show similar hemodynamics in a pairwise comparison., (© 2022 The Authors. Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Background: Double outlet right ventricle (DORV) describes a group of congenital heart defects where pulmonary artery and aorta originate completely or predominantly from the right ventricle. The individual anatomy of DORV patients varies widely with multiple subtypes classified. Although the majority of morphologies is suitable for biventricular repair (BVR), complex DORV anatomy can render univentricular palliation (UVP) the only option. Thus, patient-specific decision-making is critical for optimal surgical treatment planning. The evolution of image processing and rapid prototyping techniques facilitate the generation of detailed virtual and physical 3D models of the patient-specific anatomy which can support this important decision process within the Heart Team., Materilas and Methods: The individual cardiovascular anatomy of nine patients with complex DORV, in whom surgical decision-making was not straightforward, was reconstructed from either computed tomography or magnetic resonance imaging data. 3D reconstructions were used to characterize the morphologic details of DORV, such as size and location of the ventricular septal defect (VSD), atrioventricular valve size, ventricular volumes, relationship between the great arteries and their spatial relation to the VSD, outflow tract obstructions, coronary artery anatomy, etc. Additionally, physical models were generated. Virtual and physical models were used in the preoperative assessment to determine surgical treatment strategy, either BVR vs. UVP., Results: Median age at operation was 13.2 months (IQR: 9.6-24.0). The DORV transposition subtype was present in six patients, three patients had a DORV-ventricular septal defect subtype. Patient-specific reconstruction was feasible for all patients despite heterogeneous image quality. Complex BVR was feasible in 5/9 patients (55%). Reasons for unsuitability for BVR were AV valve chordae interfering with potential intraventricular baffle creation, ventricular hypoplasia and non-committed VSD morphology. Evaluation in particular of qualitative data from 3D models was considered to support comprehension of complex anatomy., Conclusion: Image-based 3D reconstruction of patient-specific intracardiac anatomy provides valuable additional information supporting decision-making processes and surgical planning in complex cardiac malformations. Further prospective studies are required to fully appreciate the benefits of 3D technology., 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 © 2022 Brüning, Kramer, Goubergrits, Schulz, Murin, Solowjowa, Kuehne, Berger, Photiadis and Weixler.)

Background: Uneven hepatic venous blood flow distribution (HFD) to the pulmonary arteries is hypothesized to be responsible for the development of intrapulmonary arteriovenous malformations (PAVM) in patients with univentricular physiology. Thus, achieving uniform distribution of hepatic blood flow is considered favorable. However, no established method for the prediction of the post-interventional hemodynamics currently exists. Computational fluid dynamics (CFD) offers the possibility to quantify HFD in patient-specific anatomies before and after virtual treatment. In this study, we evaluated the potential benefit of CFD-assisted treatment planning., Materials and Methods: Three patients with total cavopulmonary connection (TCPC) and PAVM underwent cardiovascular magnetic resonance imaging (CMR) and computed tomography imaging (CT). Based on this imaging data, the patient-specific anatomy was reconstructed. These patients were considered for surgery or catheter-based intervention aiming at hepatic blood flow re-routing. CFD simulations were then performed for the untreated state as well as for different surgical and interventional treatment options. These treatment options were applied as suggested by treating cardiologists and congenital heart surgeons with longstanding experience in interventional and surgical treatment of patients with univentricular physiology. HFD was quantified for all simulations to identify the most viable treatment decision regarding redistribution of hepatic blood flow., Results: For all three patients, the complex TCPC anatomy could be reconstructed. However, due to the presence of metallic stent implants, hybrid models generated from CT as well as CMR data were required. Numerical simulation of pre-interventional HFD agreed well with angiographic assessment and physiologic considerations. One treatment option resulting in improvement of HFD was identified for each patient. In one patient follow-up data after treatment was available. Here, the virtual treatment simulation and the CMR flow measurements differed by 15%., Conclusion: The combination of modern computational methods as well as imaging methods for assessment of patient-specific anatomy and flow might allow to optimize patient-specific therapy planning in patients with pronounced hepatic flow mismatch and PAVM. In this study, we demonstrate that these methods can also be applied in patients with complex univentricular physiology and extensive prior interventions. However, in those cases, hybrid approaches utilizing information of different image modalities may be required., 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 © 2022 Schafstedde, Yevtushenko, Nordmeyer, Kramer, Schleiger, Solowjowa, Berger, Photiadis, Mykychak, Cho, Ovroutski, Kuehne and Brüning.)

Background: Cardiac computed tomography (CCT) based computational fluid dynamics (CFD) allows to assess intracardiac flow features, which are hypothesized as an early predictor for heart diseases and may support treatment decisions. However, the understanding of intracardiac flow is challenging due to high variability in heart shapes and contractility. Using statistical shape modeling (SSM) in combination with CFD facilitates an intracardiac flow analysis. The aim of this study is to prove the usability of a new approach to describe various cohorts., Materials and Methods: CCT data of 125 patients (mean age: 60.6 ± 10.0 years, 16.8% woman) were used to generate SSMs representing aneurysmatic and non-aneurysmatic left ventricles (LVs). Using SSMs, seven group-averaged LV shapes and contraction fields were generated: four representing patients with and without aneurysms and with mild or severe mitral regurgitation (MR), and three distinguishing aneurysmatic patients with true, intermediate aneurysms, and globally hypokinetic LVs. End-diastolic LV volumes of the groups varied between 258 and 347 ml, whereas ejection fractions varied between 21 and 26%. MR degrees varied from 1.0 to 2.5. Prescribed motion CFD was used to simulate intracardiac flow, which was analyzed regarding large-scale flow features, kinetic energy, washout, and pressure gradients., Results: SSMs of aneurysmatic and non-aneurysmatic LVs were generated. Differences in shapes and contractility were found in the first three shape modes. Ninety percent of the cumulative shape variance is described with approximately 30 modes. A comparison of hemodynamics between all groups found shape-, contractility- and MR-dependent differences. Disturbed blood washout in the apex region was found in the aneurysmatic cases. With increasing MR, the diastolic jet becomes less coherent, whereas energy dissipation increases by decreasing kinetic energy. The poorest blood washout was found for the globally hypokinetic group, whereas the weakest blood washout in the apex region was found for the true aneurysm group., Conclusion: The proposed CCT-based analysis of hemodynamics combining CFD with SSM seems promising to facilitate the analysis of intracardiac flow, thus increasing the value of CCT for diagnostic and treatment decisions. With further enhancement of the computational approach, the methodology has the potential to be embedded in clinical routine workflows and support clinicians., Competing Interests: HL and ASz were employed by 1000shapes GmbH, which received funds from Charité-Universitätsmedizin Berlin to create the statistical shape model and perform the presented research in relation to the statistical shape model. The remaining 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 © 2022 Goubergrits, Vellguth, Obermeier, Schlief, Tautz, Bruening, Lamecker, Szengel, Nemchyna, Knosalla, Kuehne and Solowjowa.)

In patients with ischemic cardiomyopathy and left ventricular aneurysm formation who are symptomatic despite optimal medical therapy, it is challenging to determine whether surgical ventricular reconstruction, heart transplantation, or left ventricular assist device (LVAD) implantation is the treatment of choice. This report describes the concept of surgical ventricular reconstruction with a specially prepared LVAD fixation ring to facilitate subsequent LVAD implantation if required. In the patient reported in this case, endoventricular circular LVAD ring plasty sufficiently reduced the ventricular volume, normalized the left ventricular geometry, and subsequently led to an improvement of left ventricular ejection fraction., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aims: Assessing frailty and sarcopenia is considered a valuable cornerstone of perioperative risk stratification in advanced heart failure patients. The lack of an international consensus on a diagnostic standard impedes its implementation in the clinical routine. This study aimed to compare the feasibility and prognostic impact of different assessment tools in patients undergoing continuous-flow left ventricular assist device (cf-LVAD) implantation., Methods and Results: We prospectively compared feasibility and prognostic values of six frailty/sarcopenia assessment methods in 94 patients prior to cf-LVAD implantation: bioelectrical impedance analysis (BIA), computed tomography (CT)-based measurement of two muscle areas/body surface area [erector spinae muscle (TMESA/BSA) and iliopsoas muscle (TPA/BSA)], physical performance tests [grip strength, 6 min walk test (6MWT)] and Rockwood Clinical Frailty Scale (RCFS). Six-month mortality and/or prolonged ventilation time >95 h was defined as the primary endpoint. BIA and CT showed full feasibility (100%); physical performance and RCFS was limited due to patients' clinical status (feasibility: 87% grip strength, 62% 6MWT, 88% RCFS). Phase angle derived by BIA showed the best results regarding the prognostic value for 6 month mortality and/or prolonged ventilation time >95 h (odds ratio (OR) 0.66 [95% confidence interval (CI): 0.46-0.92], P = 0.019; area under the curve (AUC) 0.65). It provided incremental value to the clinical risk assessment of EuroSCORE II: C-index of the combined model was 0.75 [95% CI; 0.651-0.848] compared with C-index of EuroSCORE II alone, which was 0.73 (95% CI: 0.633-0.835). Six-month survival was decreased in patients with reduced body cell mass derived by BIA or reduced muscle area in the CT scan compared with patients with normal values: body cell mass 65% (95% CI: 51.8-81.6%) vs. 83% (95% CI: 74.0-93.9%); P = 0.03, TMESA/BSA 65% (95% CI: 51.2-82.2%) vs. 82% (95% CI: 73.2-93.0%); P = 0.032 and TPA/BSA 66% (95% CI: 53.7-81.0%) vs. 85% (95% CI: 75.0-95.8%); P = 0.035., Conclusions: Bioelectrical impedance analysis parameters and CT measurements were shown to be suitable to predict 6-month mortality and/or prolonged ventilation time >95 h in patients with advanced heart failure prior to cf-LVAD implantation. Phase angle had the best predictive capacity and sarcopenia diagnosed by reduced body cell mass in BIA or muscle area in CT was associated with a decreased 6 month survival., (© 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Surgical ventricular restoration (SVR) leads to functional improvement by volume reduction and restoration of left ventricular (LV) geometry. Our purpose was to refine the planning for SVR using cardiac computed tomography (CCT)., Methods: The possibility to anticipate the postoperative residual LV volume was assessed using CCT in 205 patients undergoing SVR combined with coronary artery bypass grafting (77%), mitral valve repair/replacement (19%) and LV thrombectomy (19%). The potential of CCT to guide the procedure was evaluated. Additionally, the predictive value of CCT characteristics on survival was addressed., Results: 30-day, 1- and 5-year survival was 92.6, 82.7, and 72.1%, respectively, with a marked reduction of NYHA class III-IV quota after surgery (95.1% vs. 20.5% in the follow-up). Both pre- and postoperative LV end-systolic volume index (LVESVI) were predictive of all defined endpoints according to the following tertiles: preoperative: <74 ml/m 2 , 74-114 ml/m 2 and >114 ml/m 2 ; postoperative: <58 ml/m 2 , 58-82 ml/m 2 and >82 ml/m 2 . On average, a 50 ml/m 2 increase of preoperative LVESVI was associated with a 35% higher hazard of death ( p = 0.043). Aneurysms limited to seven antero-apical segments (1-7) were associated with a lower death risk ( n = 60, HR 0.52, CI 0.28-0.96, p = 0.038). LVESVI predicted by CCT was found to correlate significantly with effectively achieved LVESVI ( r = 0.87 and r = 0.88, respectively, p < 0.0001)., Conclusions: CCT-guided SVR can be performed with good mid-term survival and significant improvement in HF severity. CCT-based assessment of achievable postoperative LV volume helps estimate the probability of therapeutic success in individual patients., Competing Interests: VF disclosed financial relationships with the following entities: Medtronic GmbH, Biotronik SE & Co, Abbott GmbH & Co KG, Boston Scientific, Edwards Lifesciences, Berlin Heart, Novartis Pharma GmbH, JOTEC GmbH, and Zurich Heart. The remaining 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 © 2022 Solowjowa, Nemchyna, Hrytsyna, Meyer, Hennig, Falk and Knosalla.)

Background: Cardiac CT (CCT) is well suited for a detailed analysis of heart structures due to its high spatial resolution, but in contrast to MRI and echocardiography, CCT does not allow an assessment of intracardiac flow. Computational fluid dynamics (CFD) can complement this shortcoming. It enables the computation of hemodynamics at a high spatio-temporal resolution based on medical images. The aim of this proposed study is to establish a CCT-based CFD methodology for the analysis of left ventricle (LV) hemodynamics and to assess the usability of the computational framework for clinical practice., Materials and Methods: The methodology is demonstrated by means of four cases selected from a cohort of 125 multiphase CCT examinations of heart failure patients. These cases represent subcohorts of patients with and without LV aneurysm and with severe and no mitral regurgitation (MR). All selected LVs are dilated and characterized by a reduced ejection fraction (EF). End-diastolic and end-systolic image data was used to reconstruct LV geometries with 2D valves as well as the ventricular movement. The intraventricular hemodynamics were computed with a prescribed-motion CFD approach and evaluated in terms of large-scale flow patterns, energetic behavior, and intraventricular washout., Results: In the MR patients, a disrupted E-wave jet, a fragmentary diastolic vortex formation and an increased specific energy dissipation in systole are observed. In all cases, regions with an impaired washout are visible. The results furthermore indicate that considering several cycles might provide a more detailed view of the washout process. The pre-processing times and computational expenses are in reach of clinical feasibility., Conclusion: The proposed CCT-based CFD method allows to compute patient-specific intraventricular hemodynamics and thus complements the informative value of CCT. The method can be applied to any CCT data of common quality and represents a fair balance between model accuracy and overall expenses. With further model enhancements, the computational framework has the potential to be embedded in clinical routine workflows, to support clinical decision making and treatment planning., 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 © 2022 Obermeier, Vellguth, Schlief, Tautz, Bruening, Knosalla, Kuehne, Solowjowa and Goubergrits.)

Objectives: Parameters of left ventricular (LV) mechanics, obtained from speckle-tracking echocardiography (STE), were found to be of prognostic value in patients with heart failure and those who underwent cardiac surgery. This study aimed to assess the value of STE in patients scheduled to undergo surgical ventricular restoration (SVR)., Methods: A total of 158 consecutive patients with baseline STE who underwent SVR due to an LV anteroapical aneurysm were included in the analysis. Preoperative longitudinal STE parameters were evaluated for their association with an outcome, defined as all-cause mortality, LV assist device implantation, or heart transplantation. The echocardiographic follow-up to assess the change in the regional function of the segments remote from the aneurysm was performed in 43 patients at a median of 10 months [interquartile range (IQR): 6-12.7 months] after SVR., Results: During a median follow-up of 5.1 years (IQR: 1.6-8.7 years), events occurred in 68 patients (48%). Less impaired mean basal end-systolic longitudinal strain (BLS) with a cutoff value ≤ -10.1 % demonstrated a strong association with event-free survival, also in patients with an LV shape corresponding to an intermediate shape between aneurysmal and globally akinetic. Initially hypo- or akinetic basal segments with preoperative end-systolic strain ≤ -7.8% showed a greater improvement in wall motion at the short-term follow up., Conclusion: Patients with less impaired preoperative BLS exhibited a better event-free survival after SVR, also those with severe LV remodeling. The preserved preoperative segmental longitudinal strain was associated with a greater improvement in regional wall motion after SVR. BLS assessment may play a predictive role in patients with an LV anteroapical aneurysm who are scheduled to undergo SVR., 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 © 2022 Nemchyna, Solowjowa, Dandel, Hrytsyna, Stein, Knierim, Schoenrath, Hennig, Falk and Knosalla.)