Inconsistency in aortic stenosis severity between CT and echocardiography: Prevalence and insights into mechanistic differences using computational fluid dynamics

© 2019 Author(s). Objectives The aims of this study were to evaluate the inconsistency of aortic stenosis (AS) severity between CT aortic valve area (CT-AVA) and echocardiographic Doppler parameters, and to investigate potential underlying mechanisms using computational fluid dynamics (CFD). Methods A total of 450 consecutive eligible patients undergoing transcatheter AV implantation assessment underwent CT cardiac angiography (CTCA) following echocardiography. CT-AVA derived by direct planimetry and echocardiographic parameters were used to assess severity. CFD simulation was performed in 46 CTCA cases to evaluate velocity profiles. Results A CT-AVA>1 cm 2 was present in 23% of patients with echocardiographic peak velocity≥4 m/s (r=-0.33) and in 15% patients with mean Doppler gradient≥40 mm Hg (r=-0.39). Patients with inconsistent severity grading between CT and echocardiography had higher stroke volume index (43 vs 38 mL/m 2, p1 cm 2 in up to a quarter of patients. CFD demonstrates that haemodynamic severity may be exaggerated on Doppler analysis due to high LVOT flow rates, with or without skewed velocity profiles, across the valve orifice. These factors should be considered before making a firm diagnosis of severe AS and evaluation with CT can be helpful

In vivo Bioimaging as a Novel Strategy to Detect Doxorubicin-Induced Damage to Gonadal Blood Vessels

INTRODUCTION: Chemotherapy may induce deleterious effects in normal tissues, leading to organ damage. Direct vascular injury is the least characterized side effect. Our aim was to establish a real-time, in vivo molecular imaging platform for evaluating the potential vascular toxicity of doxorubicin in mice. METHODS: Mice gonads served as reference organs. Mouse ovarian or testicular blood volume and femoral arterial blood flow were measured in real-time during and after doxorubicin (8 mg/kg intravenously) or paclitaxel (1.2 mg/kg) administration. Ovarian blood volume was imaged by ultrasound biomicroscopy (Vevo2100) with microbubbles as a contrast agent whereas testicular blood volume and blood flow as well as femoral arterial blood flow was imaged by pulse wave Doppler ultrasound. Visualization of ovarian and femoral microvasculature was obtained by fluorescence optical imaging system, equipped with a confocal fiber microscope (Cell-viZio). RESULTS: Using microbubbles as a contrast agent revealed a 33% (P<0.01) decrease in ovarian blood volume already 3 minutes after doxorubicin injection. Doppler ultrasound depicted the same phenomenon in testicular blood volume and blood flow. The femoral arterial blood flow was impaired in the same fashion. Cell-viZio imaging depicted a pattern of vessels' injury at around the same time after doxorubicin injection: the wall of the blood vessels became irregular and the fluorescence signal displayed in the small vessels was gradually diminished. Paclitaxel had no vascular effect. CONCLUSION: We have established a platform of innovative high-resolution molecular imaging, suitable for in vivo imaging of vessels' characteristics, arterial blood flow and organs blood volume that enable prolonged real-time detection of chemotherapy-induced effects in the same individuals. The acute reduction in gonadal and femoral blood flow and the impairment of the blood vessels wall may represent an acute universal doxorubicin-related vascular toxicity, an initial event in organ injury

Imaging diagnoses and outcome in patients presenting for primary angioplasty but no obstructive coronary artery disease

OBJECTIVE: A proportion of patients with suspected ST-elevation myocardial infarction (STEMI) presenting for primary percutaneous coronary intervention (PPCI) do not have obstructive coronary disease and other conditions may be responsible for their symptoms and ECG changes. In this study, we set out to determine the prevalence and aetiology of alternative diagnoses in a large PPCI cohort as determined with multimodality imaging and their outcome. METHODS: From 2009 to 2012, 5238 patients with suspected STEMI were referred for consideration of PPCI. Patients who underwent angiography but had no culprit artery for revascularisation and no previous history of coronary artery disease were included in the study. Troponin values, imaging findings and all-cause mortality were obtained from hospital and national databases. RESULTS: A total of 575 (13.0%) patients with a mean age of 58±15 years (69% men) fulfilled the inclusion criteria. A specific diagnosis based on imaging was made in 237 patients (41.2%) including cardiomyopathies (n=104, 18%), myopericarditis (n=48, 8.4%), myocardial infarction/other coronary abnormality (n=27, 4.9%) and severe valve disease (n=23, 4%). Pulmonary embolism and type A aortic dissection were identified in seven (1.2%) and four (0.7%) cases respectively. A total of 40 (7.0%) patients died over a mean follow-up of 42.6 months. CONCLUSIONS: A variety of cardiac and non-cardiac conditions are prevalent in patients presenting with suspected STEMI but culprit-free angiogram, some of which may have adverse outcomes. Further imaging of such patients could thus be useful to help in appropriate management and follow-up

Right ventricular dysfunction but not left ventricular ejection fraction is associated with length of stay in acute heart failure

Abstract Background Acute heart failure (AHF) remains a substantial healthcare burden worldwide. It is therefore important to identify triaging markers which are associated with length of stay (LOS). Attention from an echocardiographic perspective often centres on the left-ventricular ejection fraction (LVEF). The role of right ventricular (RV) function and pulmonary hypertension (PHT) remains less certain. Methods We investigated LOS in 440 consecutive patients presenting in AHF. We also identified those admitted ≥5 days – the cut-off date when reimbursement for AHF-related hospital care is reduced significantly in England. All patients underwent bedside echocardiography within 24 hours of recruitment, prior to intensive diuresis. Patients were followed up for 2 years. We analysed the association between echo parameters with LOS in 414 patients who survived to discharge. We also compared those admitted ≥5 and &amp;lt;5 days. Results The average LOS for survivors was 7.7±5.7 days; 216 (52.2%) stayed ≥5 days, with 198 (47.8%) discharged &amp;lt;5 days. LVEF was not correlated with LOS; Spearman's ρ −0.062 (p=0.207). RV fractional area change (ρ −0.108 [p&amp;lt;0.03]), tricuspid annulus plane systolic plane excursion (ρ −0.166 [p&amp;lt;0.001]) and systolic pulmonary artery pressure (ρ −0.161 [p&amp;lt;0.001]) were all correlated with LOS. In patients with longer LOS, greater BNP, diabetes and chronic kidney disease were more prevalent. 2-year all-cause mortality was 41.0% in those admitted ≥5 days and 27.1% for &amp;lt;5 days (Hazard ratio 1.57; 95% CI 1.13–2.19 [p=0.007]). Discussion RV dysfunction and severe PHT, not LVEF, were correlated with increased LOS in 414 consecutive patients discharged from an admission with AHF. These patients will place a disproportionate cost on health care resources. These hypothesis generating results suggest early echo assessment to quantify RV dysfunction may help to risk stratify patients with AHF and re-design hospital tariffs. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Abbott Laboratories Table and KM curve </jats:sec