Assessment of Global Longitudinal and Circumferential Strain Using Computed Tomography Feature Tracking: Intra-Individual Comparison with CMR Feature Tracking and Myocardial Tagging in Patients with Severe Aortic Stenosis

In this study, we used a single commercially available software solution to assess global longitudinal (GLS) and global circumferential strain (GCS) using cardiac computed tomography (CT) and cardiac magnetic resonance (CMR) feature tracking (FT). We compared agreement and reproducibility between these two methods and the reference standard, CMR tagging (TAG). Twenty-seven patients with severe aortic stenosis underwent CMR and cardiac CT examinations. FT analysis was performed using Medis suite version 3.0 (Leiden, The Netherlands) software. Segment (Medviso) software was used for GCS assessment from tagged images. There was a trend towards the underestimation of GLS by CT-FT when compared to CMR-FT (19.4 +/- 5.04 vs. 22.40 +/- 5.69, respectively; p = 0.065). GCS values between TAG, CT-FT, and CMR-FT were similar (p = 0.233). CMR-FT and CT-FT correlated closely for GLS (r = 0.686, p < 0.001) and GCS (r = 0.707, p < 0.001), while both of these methods correlated moderately with TAG for GCS (r = 0.479, p < 0.001 for CMR-FT vs. TAG; r = 0.548 for CT-FT vs. TAG). Intraobserver and interobserver agreement was excellent in all techniques. Our findings show that, in elderly patients with severe aortic stenosis (AS), the FT algorithm performs equally well in CMR and cardiac CT datasets for the assessment of GLS and GCS, both in terms of reproducibility and agreement with the gold standard, TAG

Multischicht-Computertomographie für die Beurteilung von „reverse remodeling“ der Mitralklappe und des linken Ventrikels nach der chirurgischen Rekonstruktion der posterioren linksventrikulären Aneurysmen im Vergleich zu der anterioren Lokalisation

Objectives: Involvement of the mitral valve (MV) apparatus represents a challenge in surgical ventricular repair (SVR), especially of posterior left ventricular (LV) aneurysms. Here we investigate the capability of MSCT for assessment of the MV/LV complex to optimize the surgical procedure for LV aneurysms, the surgically relevant differences between posterior and anterior localization, and the mid-term results of both groups. Methods: Thirty consecutive patients (m:w = 24:6, median age 66.0 years; mean New York Heart Association (NYHA) class 2.98) with posterior LV aneurysm (group 1) and 41 consecutive patients (m:w = 31:10, median age 57.7 years; mean NYHA class 3.01) with anterior LV aneurysm (group 2) were operated upon. End-diastolic and end-systolic volumes of LV were indexed to body surface area (LVEDVI/LVESVI). The MV apparatus was characterized by coaptation distance, tenting area, MV closure angle, MV annulus area, intercommissural/anteroposterior MV annulus diameter and interpapillary muscle distance (CD/TA/MVCA/MVAA/ICD/APD/IMD). Results: Groups 1 and 2 showed 30-day mortality of 10% and 0% and 5-year survival of 83.1% and 82.7% respectively. Reduction of LVESVI from 110.6 ± 88.8 to 50.2 ± 22.9 ml/m2 (p = 0.001) in group 1 and from 118.6 ± 49.2 to 63.6 ± 32.1 ml/m2 (p < 0.001) in group 2 was achieved after surgery. LV ejection fraction (LVEF) increased from 29.5 ± 15.1% to 43.4 ± 9.9% (p < 0.001) in group 1 and from 29.6 ± 9.1% to 40.9 ± 10.3% (p < 0.001) in group 2. Both groups showed significantly higher initial values of MVAA, CD and TA in patients who needed MV repair or replacement, while group 2 showed additionally a higher prevalence of concomitant posterior scars. Postoperative reduction of mitral regurgitation (MR) after SVR without additional MV surgery corresponded in group 1 with significant reduction in ICD, APD, MVAA, TA, CD, MVCA and IMD and in group 2 with a slight reduction of MVAA and significant reduction of TA, CD and IMD. Conclusions: MSCT-guided SVR of LV aneurysms of both localizations allows excellent mid-term results to be achieved due to adequate volume reduction and functional improvement. The patients of both groups who needed additional mitral surgery demonstrated advanced changes in MV geometry associated with lesions of the posterior LV wall and posterior papillary muscle. Postoperative reduction of moderate MR without additional MV surgery corresponded with significant improvement of MV geometry in both groups. Based on the MSCT assessment we propose an algorithm for surgical planning in posterior LV aneurysms.Einleitung: Die Beteiligung der Mitralklappe (MK) stellt eine Herausforderung in der chirurgischen Therapie von Aneurysmen des linken Ventrikels (LV) dar, insbesondere der posterioren LV-Wand. Diese Arbeit analysiert die Möglichkeiten der Multischicht-Computertomographie (MSCT) für die Beurteilung des Mitralapparates und des LV als funktionalen Komplex für die Optimierung der chirurgischen Vorgehensweise bei LV-Aneurysmen, die Unterschiede zwischen der posterioren und der anterioren Lokalisation und die mittelfristigen Ergebnisse in beiden Gruppen. Methodik: Eine chirurgische LV-Rekonstruktion (LVR) wurde bei 30 konsekutiven Patienten (m:w = 24:6, Alter median 66.0 Jahre; mean New York-Heart-Association (NYHA)-Klasse 2.98) mit posterioren (Gruppe 1) und 41 konsekutiven Patienten (m:w = 31:10, Alter median 57.7 Jahre; mean NYHA-Klasse 3.01) mit anterioren (Gruppe 2) LV-Aneurysmen durchgeführt. Enddiastolische und endsystolische Volumina des LV wurden zu Körperoberfläche indexiert (LVEDVI/LVESVI). Der MK-Apparat wurde durch Kooaptationsdistanz, Koaptationsfläche, MK-Schlusswinkel, MK-Annulusfläche, interkommissuralen/anteroposterioren MK-Annulusdiameter und Interpapillarmuskelabstand (KD, KF, MKSW, MKAF, IKD, APD, IMA) charakterisiert. Ergebnisse: In Gruppe 1 und 2 betrugen die 30-Tage-Mortalität 10% und 0%, die 5-Jahre-Überlebensrate - 83.1% und 82.7%. In Gruppe 1 wurde nach chirurgischer LVR eine Reduktion des LVESVI von 110.6 ± 88.8 auf 50.2 ± 22.9 ml/m2 (p = 0.001), in Gruppe 2 - von 118.6 ± 49.2 auf 63.6 ± 32.1 ml/m2 (p < 0.001) erzielt. Die LV-Ejektionsfraktion (LVEF) stieg von 31.5 ± 15.1% auf 43.4 ± 9.9% (p < 0.001) in der Gruppe 1 und von 29.6 ± 9.1% auf 40.9 ± 10.3% (p < 0.001) in der Gruppe 2 an. Beide Gruppen demonstrierten signifikant höhere Ausgangswerte der MKAF, KD und KF bei Patienten, die eine zusätzliche MK-Rekonstruktion oder Ersatz brauchten, Gruppe 2 zeigte zusätzlich eine höhere Prävalenz von begleitenden posterioren Myokardnarben. Die postoperative Reduktion der Mitralregurgitation (MR) nach LVR ohne MK-Chirurgie korrespondierte in der Gruppe 1 mit signifikanter Reduktion der IKD, APD, MKAF, KD, KF, MKSW und IMA; in der Gruppe 2 - mit leichter Reduktion der MVAA und signifikanter Reduktion der KD, KF und IMA. Schlussfolgerung: Eine chirurgische LVR, unterstützt durch MSCT, führt bei LV-Aneurysmen beider Lokalisationen zu exzellenten mittelfristigen Ergebnissen durch adäquate Volumenreduktion und funktionale Verbesserung. Die Patienten beider Gruppen, die eine zusätzliche MK-Chirurgie benötigten, zeigten fortgeschrittene Veränderungen der MK-Geometrie, assoziiert mit Dysfunktion der posterioren LV- Wand und des posterioren Papillarmuskels. Die postoperative Reduktion der moderaten begleitenden MR bei Patienten beider Gruppen ohne zusätzliche MK- Chirurgie korrespondierte mit einer Verbesserung der MK-Geometrie. Auf Basis der MSCT-Analyse schlagen wir einen Algorithmus für die chirurgische Planung bei posterioren LV-Aneurysmen vor

Endovascular treatment of an anastomotic outflow graft pseudoaneurysm of the descending aorta after implantation of a left ventricular assist device

Introduction: Outflow graft (OG) obstruction is a dangerous complication that may occur for various reasons after the implantation of the left ventricular assist device (LVAD). Case Report: In this study, we describe the case of a 67‐year‐old patient on LVAD support who developed a late pseudoaneurysm of the OG anastomosis (to the descending aorta) causing OG stenosis at the level of the anastomosis. The patient was treated with a customized fenestrated endovascular stent graft placed into the descending aorta and stent implantation into the OG.ISSN:0886-0440ISSN:1540-819

CT-Based Simulation of Left Ventricular Hemodynamics: A Pilot Study in Mitral Regurgitation and Left Ventricle Aneurysm Patients

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

Surgical Restoration of Antero-Apical Left Ventricular Aneurysms: Cardiac Computed Tomography for Therapy Planning

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: 114 ml/m2; postoperative: 82 ml/m2. On average, a 50 ml/m2 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.ISSN:2297-055

Surgical treatment of outflow graft kinking complicated by external obstruction with a fibrin mass in a patient with LVAD

Background Outflow graft (OG) obstruction is a dangerous complication that may occur for various reasons after left ventricular assist device (LVAD) implantation. Case Summary We describe the case of a 51‐year‐old patient on LVAD support who developed significant OG kinking and external OG obstruction due to a fibrin mass causing severe stenosis. Both the OG kinking and external obstruction were eliminated via a left lateral thoracotomy.ISSN:0886-0440ISSN:1540-819

Percutaneous mitral valve repair assisted by a catheter-based circulatory support device in a heart transplant patient

Background: Systemic infections and chronic graft rejection represent common causes of mortality and morbidity in heart transplant patients. In severe cases, cardiogenic shock (CS) may occur and require hemodynamic stabilization with temporary mechanical circulatory support (tempMCS). Under these devastating circumstances, treatment of sequelae of left ventricular dysfunction, such as secondary mitral regurgitation (MR) is challenging, especially when surgical repair is deemed futile. In nontransplant patients, interventional mitral valve repair strategies such as the MitraClip system (Abbott Cardiovascular) have been used to successfully treat secondary MR and allow for weaning from tempMCS. Case summary: We report about the first patient in whom profound CS after heart transplantation was stabilized with tempMCS followed by interventional elimination of secondary MR.ISSN:0886-0440ISSN:1540-819

Predictive Value of Two-Dimensional Speckle-Tracking Echocardiography in Patients Undergoing Surgical Ventricular Restoration

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.ISSN:2297-055

Validity of visual assessment of aortic valve morphology in patients with aortic stenosis using two-dimensional echocardiography

The diagnostic value of a visual assessment of aortic valve (AV) morphology for grading aortic stenosis (AS) remains unclear. A visual score (VS) for assessing the AV was developed and its reliability with respect to Doppler measurements and the calcium score (ctCS) derived by multislice computed tomography was evaluated. 99 Patients with AS of various severity and 38 patients without AS were included in the analysis. Echocardiographic studies were evaluated using the new VS which includes echogenicity, thickening, localization of lesions and leaflet mobility, with a total score ranging from 0 to 11. The association of VS with ctCS and the severity of AS was analyzed. There was a significant correlation of VS with AV hemodynamic parameters and with ctCS. The cut-off value for the detection of AS of any grade was a VS of 6 (sensitivity 95%, specificity 85% for women; sensitivity 85%, specificity 88% for men). A VS of 9 for women and of 10 for men was able to predict severe AS with a high specificity (96% in women and 94% in men, AUC 0.8 and 0.86, respectively). The same cut-off values were identified for the detection of ctCS of ≥ 1600 AU and ≥ 3000 AU with a specificity of 77% and 82% (AUC 0.69 and 0.81, respectively). Assessment of aortic valve morphology can serve as an additional diagnostic tool for the detection of AS and an estimation of its severity