Thoracic aorta cardiac-cycle related dynamic changes assessed with a 256-slice CT scanner

Objective: The aim of our study was to demonstrate whether the dynamic changes previously documented at the ascending and abdominal aorta are replicated at the thoracic aorta. Methods and results: A consecutive series of thirty patients referred to our institution to undergo CT angiography of the thoracic aorta (CTA) constituted the study population. Patients with diffuse aortic atherosclerosis were excluded from the analysis. All studies were acquired with a 256-MDCT scanner and ECG-gating was performed in all cases. Two orthogonal imaging planes (maximal and minimal diameters) were obtained at three different levels of the descending thoracic aorta, using the distance from the left subclavian artery as proximal landmark: 10, 40, and 80 mm distance. The mean age was 58.9±15.7 years and 16 (53%) patients were male. Descending aorta measurements at 10, 40, and 80 mm distance from the left subclavian artery were all significantly larger within the systolic window (P<0.01 for all comparisons). Measurements of the maximal diameter were systematically larger than the minimal diameters among all aortic positions including ungated, systolic, and diastolic measurements (P<0.05 for all comparisons). Conclusions: The main finding of our pilot investigation was that the thoracic descending aorta undergoes significant conformational changes during the cardiac cycle, irrespective from the distance from the left subclavian artery.Fil: Carrascosa, Patricia. Diagnóstico Maipú; ArgentinaFil: Capuñay, Carlos. Diagnóstico Maipú; ArgentinaFil: Deviggiano, Alejandro. Diagnóstico Maipú; ArgentinaFil: Rodriguez Granillo, Gaston Alfredo. Diagnóstico Maipú; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Sagarduy, María Inés. Diagnóstico Maipú; ArgentinaFil: Cortines, Patricio. Diagnóstico Maipú; ArgentinaFil: Carrascosa, Jorge. Diagnóstico Maipú; ArgentinaFil: Parodi, Juan C.. Sanatorio Trinidad; Argentin

Early diagnosis of cardiovascular diseases in workers: role of standard and advanced echocardiography

Cardiovascular disease (CVD) still remains the main cause of morbidity and mortality and consequently early diagnosis is of paramount importance. Working conditions can be regarded as an additional risk factor for CVD. Since different aspects of the job may affect vascular health differently, it is important to consider occupation from multiple perspectives to better assess occupational impacts on health. Standard echocardiography has several targets in the cardiac population, as the assessment of myocardial performance, valvular and/or congenital heart disease, and hemodynamics. Three-dimensional echocardiography gained attention recently as a viable clinical tool in assessing left ventricular (LV) and right ventricular (RV), volume, and shape. Two-dimensional (2DSTE) and, more recently, three-dimensional speckle tracking echocardiography (3DSTE) have also emerged as methods for detection of global and regional myocardial dysfunction in various cardiovascular diseases, and applied to the diagnosis of subtle LV and RV dysfunction. Although these novel echocardiographic imaging modalities have advanced our understanding of LV and RV mechanics, overlapping patterns often show challenges that limit their clinical utility. This review will describe the current state of standard and advanced echocardiography in early detection (secondary prevention) of CVD and address future directions for this potentially important diagnostic strategy

Surgical management of aortic root disease in Marfan syndrome and other congenital disorders associated with aortic root aneurysms

Elective root replacement in Marfan syndrome has improved life expectancy in affected patients. Three forms of surgery are now available: total root replacement (TRR) with a valved conduit, valve sparing root replacement (VSRR) and personalised external aortic root support (PEARS) with a macroporous mesh sleeve. TRR can be performed irrespective of aortic dimensions and a mechanical replacement valve is a secure and near certain means of correcting aortic valve regurgitation but has thromboembolic and bleeding risks. VSRR offers freedom from anticoagulation and attendant risks of bleeding but reoperation for aortic regurgitation runs at 1.3% per annum. A prospective multi-institutional study has found this to be an underestimate of the true rate of valve-related adverse events. PEARS conserves the aortic root anatomy and optimises the chance of maintaining valve function but average follow-up is under 5 years and so the long-term results are yet to be determined. Patients are on average in their 30s and so the cumulative lifetime need for reoperation, and of any valve-related complications, are consequently substantial. With lowering surgical risk of prophylactic root replacement, the threshold for intervention has reduced progressively over 30 years to 4.5 cm and so an increasing number of patients who are not destined to have a dissection are now having root replacement. In evaluation of these three forms of surgery, the number needed to treat to prevent dissection and the balance of net benefit and harm in future patients must be considered

Fetal heterotaxy with tricuspid atresia, pulmonary atresia, and isomerism of the right atrial appendages at 22 weeks.

We report the accurate prenatal diagnosis at 22 weeks gestation of right atrial isomerism in association with tricuspid atresia. Several distinctive sonographic features of isomerism of the right atrial appendages were present in this fetus: complex cardiac abnormality, ventriculoarterial discordance, juxtaposition of the aorta and the inferior vena cava to the right side, pulmonary atresia, and anomalous pulmonary venous return to the morphological right atrium. Tricuspid atresia, which is an extremely rare lesion within heterotaxy spectrum disorders, was present. Postnatal investigations confirmed all prenatally diagnosed abnormalities, with additional findings of pulmonary atresia with discontinuous pulmonary arteries and bilateral arterial ducts, asplenia, and bilateral eparterial bronchi. To our knowledge, tricuspid atresia in the setting of isomerism of the right atrial appendages has not previously been diagnosed or reported prenatally. Because of the complexity of cardiac lesions that may be present in cases of atrial isomerism, these disorders should be considered even if sonographic findings are uncommon or atypical

Systolic ejection murmurs and the left ventricular outflow tract in boxer dogs

Turbulence of various genesis in the left ventricular outflow tract (LVOT) causes systolic ejection murmurs. The prevalence of murmurs in adult boxer dogs is 50-80%, the majority of which are of low intensity. Some of the murmurs are caused by aortic stenosis (AS), while the origin of the others is unclear. The aim of this thesis was to study the physiology and clinical evaluation of systolic ejection murmurs and their relation to the development of the LVOT in boxers with and without AS. Growing and adult boxer dogs were examined by the standard methods cardiac auscultation, ECG, phonocardiography and echocardiography. Additionally, the complementary methods time-frequency and complexity analyses of heart murmurs and contrast echocardiography were evaluated. Studies on inter-observer variation in cardiac auscultation proved the importance of experience in detection and grading of low intensity ejection murmurs. Excitement of the dogs by exercise or noise stimulation (barking dog and squeaky toy) caused higher murmur grades, longer murmur duration and increased aortic flow velocities. No differences were found between diameters measured at different levels of the LVOT in growing boxers. Contrast echocardiography enhanced Doppler signals, but did not allow evaluation of myocardial blood flow. Using time-frequency analysis, duration of murmur frequency >200 Hz proved useful for differentiation between dogs with mild AS and dogs without. Combining assessment of murmur duration >200 Hz and complexity analysis using the correlation dimension (T2), a sensitivity of 94% and a specificity of 82% for differentiation between dogs with and without AS was achieved. The variability in presence and intensity of low intensity murmurs during growth was high. None of the young dogs developed AS, whereas 3 out of 16 individuals developed mild-moderate aortic insufficiency. Aortic or pulmonic flow velocities did not differ significantly between growing dogs with or without low intensity murmurs. In conclusion, the variability in presence and intensity of low intensity ejection murmurs in boxers is high during growth with no obvious progression. Both in young and adult boxers the murmur grade increased during excitement, which may be due to rapid flow in a comparatively small LVOT that has been suggested for the boxer breed. Experience is important in cardiac auscultation of low intensity murmurs. Therefore, assessment of murmur duration > 200 Hz combined with T2 analysis may be a useful complementary method for diagnosis of cardiovascular function in dogs

Cardiac papillary fibroelastomas: A 10-year single-center surgical experience and long-term echocardiographic follow-up study

Aims. Limited contemporary data are available on the clinical and echocardiographic outcomes after surgery for cardiac papillary fibroelastoma (CPF). The aim of this study was to review the clinical manifestations, pathological characteristics, surgical management, and prognoses of patients with histologically verified CPF, who underwent surgery at our cardiac surgery center from 2008 to 2018. Methods and Results. Twelve patients of median age 62 years (28 to 77 years) were treated. Embolic stroke or transient ischemic attack (five patients, 42%) were the only CPF clinical manifestations. Eleven (92%) tumors were localized on the valves, with the aortic valve being the most common tumor site (seven patients; 58%). Multiple factor analysis revealed no independent predictor of CPF-related embolization. Simple shave tumor excision was sufficient in most patients (10 patients, 83%). No operative or tumor-related late mortality during the median follow-up period of 4.7 years (1.1 to 10.2 years) was recorded. Asymptomatic metachronous valve tumor recurrence (in a location different from that of the original tumor) was revealed in two patients (17%) by transesophageal echocardiography (TEE), not detected by transthoracic echocardiography (TTE). One of these two patients underwent repeated surgery for CPF but later suffered a recurrent embolic stroke, due to another tumor recurrence. Conclusion. CPF can be safely and effectively treated surgically. TEE is superior to the TTE option in CPF post-operative recurrence detection. There is a clear need for a prospective study to determine criteria for embolization risk stratification and optimum management in patients with CPF.Web of Science1641918

Modelling mitral valvular dynamics–current trend and future directions

Dysfunction of mitral valve causes morbidity and premature mortality and remains a leading medical problem worldwide. Computational modelling aims to understand the biomechanics of human mitral valve and could lead to the development of new treatment, prevention and diagnosis of mitral valve diseases. Compared with the aortic valve, the mitral valve has been much less studied owing to its highly complex structure and strong interaction with the blood flow and the ventricles. However, the interest in mitral valve modelling is growing, and the sophistication level is increasing with the advanced development of computational technology and imaging tools. This review summarises the state-of-the-art modelling of the mitral valve, including static and dynamics models, models with fluid-structure interaction, and models with the left ventricle interaction. Challenges and future directions are also discussed

Including Aortic Valve Morphology in Computational Fluid Dynamics Simulations: Initial Findings and Application to Aortic Coarctation

Computational fluid dynamics (CFD) simulations quantifying thoracic aortic flow patterns have not included disturbances from the aortic valve (AoV). 80% of patients with aortic coarctation (CoA) have a bicuspid aortic valve (BAV) which may cause adverse flow patterns contributing to morbidity. Our objectives were to develop a method to account for the AoV in CFD simulations, and quantify its impact on local hemodynamics. The method developed facilitates segmentation of the AoV, spatiotemporal interpolation of segments, and anatomic positioning of segments at the CFD model inlet. The AoV was included in CFD model examples of a normal (tricuspid AoV) and a post-surgical CoA patient (BAV). Velocity, turbulent kinetic energy (TKE), time-averaged wall shear stress (TAWSS), and oscillatory shear index (OSI) results were compared to equivalent simulations using a plug inlet profile. The plug inlet greatly underestimated TKE for both examples. TAWSS differences extended throughout the thoracic aorta for the CoA BAV, but were limited to the arch for the normal example. OSI differences existed mainly in the ascending aorta for both cases. The impact of AoV can now be included with CFD simulations to identify regions of deleterious hemodynamics thereby advancing simulations of the thoracic aorta one step closer to reality