Investigation and Validation of Imaging Techniques for Mitral Valve Disease Diagnosis and Intervention

Mitral Valve Disease (MVD) describes a variety of pathologies that result in regurgitation of blood during the systolic phase of the cardiac cycle. Decisions in valvular disease management rely heavily on non-invasive imaging. Transesophageal echocardiography (TEE) is widely recognized as the key evaluation technique where backflow of high velocity blood can be visualized under Doppler. In most cases, TEE imaging is adequate for identifying mitral valve pathology, though the modality is often limited from signal dropout, artifacts and a restricted field of view. Quantitative analysis is an integral part of the overall assessment of valve morphology and gives objective evidence for both classification and guiding intervention of regurgitation. In addition, patient-specific models derived from diagnostic TEE images allow clinicians to gain insight into uniquely intricate anatomy prior to surgery. However, the heavy reliance on TEE segmentation for diagnosis and modelling has necessitated an evaluation of the accuracy of the oft-used mitral valve imaging modality. Dynamic cardiac 4D-Computed Tomography (4D-CT) is emerging as a valuable tool for diagnosis, quantification and assessment of cardiac diseases. This modality has the potential to provide a high quality rendering of the mitral valve and subvalvular apparatus, to provide a more complete picture of the underlying morphology. However, application of dynamic CT to mitral valve imaging is especially challenging due to the large and rapid motion of the valve leaflets. It is therefore necessary to investigate the accuracy and level of precision by which dynamic CT captures mitral valve motion throughout the cardiac cycle. To do this, we design and construct a silicone and bovine quasi-static mitral valve phantom which can simulate a range of ECG-gated heart rates and reproduce physiologic valve motion over the cardiac cycle. In this study, we discovered that the dynamic CT accurately captures the underlying valve movement, but with a higher prevalence of image artifacts as leaflet and chordae motion increases due to elevated heart rates. In a subsequent study, we acquire simultaneous CT and TEE images of both a silicone mitral valve phantom and an iodine-stained bovine mitral valve. We propose a pipeline to use CT as the ground truth to study the relationship between TEE intensities and the underlying valve morphology. Preliminary results demonstrate that with an optimized threshold selection based solely on TEE pixel intensities, only 40\% of pixels are correctly classified as part of the valve. In addition, we have shown that emphasizing the centre-line rather than the boundaries of high intensity TEE image regions provides a better representation and segmentation of the valve morphology. This work has the potential to inform and augment the use of TEE for diagnosis and modelling of the mitral valve in the clinical workflow for MVD

How Accurately Does Transesophageal Echocardiography Identify the Mitral Valve?

© 2019, Springer Nature Switzerland AG. Mitral Valve Disease (MVD) describes a variety of pathologies that cause regurgitation of blood during the systolic phase of the cardiac cycle. Decisions in valvular disease management rely heavily on non-invasive imaging. Transesophageal echocardiography (TEE) is widely recognized as the key evaluation technique where backflow of high velocity blood can be visualized under Doppler. However, the heavy reliance on TEE segmentation for diagnosis and modelling necessitates an evaluation of the accuracy of this oft-used mitral valve imaging modality. In this pilot study, we acquire simultaneous CT and TEE images of both a silicone mitral valve phantom and an iodine-stained bovine mitral valve. We propose a pipeline to use CT as ground truth to study the relationship between TEE intensities and the underlying valve morphology. Preliminary results demonstrate that even with an optimized threshold selection based solely on TEE pixel intensities, only 40% of pixels are correctly classified as part of the valve. In addition, we have shown that emphasizing the center line rather than the boundaries of the high intensity regions in TEE provides a better representation and segmentation of the valve morphology. The root mean squared distance between the TEE and CT ground truth is 1.80 mm with intensity-based segmentation and improves to 0.81 mm when comparing the center line extracted from the segmented volumes

Dynamic heart phantom with functional mitral and aortic valves

© 2015 SPIE. Cardiac valvular stenosis, prolapse and regurgitation are increasingly common conditions, particularly in an elderly population with limited potential for on-pump cardiac surgery. NeoChord©, MitraClip © and numerous stent-based transcatheter aortic valve implantation (TAVI) devices provide an alternative to intrusive cardiac operations; performed while the heart is beating, these procedures require surgeons and cardiologists to learn new imageguidance based techniques. Developing these visual aids and protocols is a challenging task that benefits from sophisticated simulators. Existing models lack features needed to simulate off-pump valvular procedures: functional, dynamic valves, apical and vascular access, and user flexibility for different activation patterns such as variable heart rates and rapid pacing. We present a left ventricle phantom with these characteristics. The phantom can be used to simulate valvular repair and replacement procedures with magnetic tracking, augmented reality, fluoroscopy and ultrasound guidance. This tool serves as a platform to develop image-guidance and image processing techniques required for a range of minimally invasive cardiac interventions. The phantom mimics in vivo mitral and aortic valve motion, permitting realistic ultrasound images of these components to be acquired. It also has a physiological realistic left ventricular ejection fraction of 50%. Given its realistic imaging properties and non-biodegradable composition-silicone for tissue, water for blood-the system promises to reduce the number of animal trials required to develop image guidance applications for valvular repair and replacement. The phantom has been used in validation studies for both TAVI image-guidance techniques1, and image-based mitral valve tracking algorithms2

Chloromethane Utilization Gene Cluster from Hyphomicrobium chloromethanicum Strain CM2(T) and Development of Functional Gene Probes To Detect Halomethane-Degrading Bacteria

Hyphomicrobium chloromethanicum CM2(T), an aerobic methylotrophic member of the α subclass of the class proteobacteria, can grow with chloromethane as the sole carbon and energy source. H. chloromethanicum possesses an inducible enzyme system for utilization of chloromethane, in which two polypeptides (67-kDa CmuA and 35-kDa CmuB) are expressed. Previously, four genes, cmuA, cmuB, cmuC, and purU, were shown to be essential for growth of Methylobacterium chloromethanicum on chloromethane. The cmuA and cmuB genes were used as probes to identify homologs in H. chloromethanicum. A cmu gene cluster (9.5 kb) in H. chloromethanicum contained 10 open reading frames: folD (partial), pduX, orf153, orf207, orf225, cmuB, cmuC, cmuA, fmdB, and paaE (partial). CmuA from H. chloromethanicum (67 kDa) showed high identity to CmuA from M. chloromethanicum and contains an N-terminal methyltransferase domain and a C-terminal corrinoid-binding domain. CmuB from H. chloromethanicum is related to a family of methyl transfer proteins and to the CmuB methyltransferase from M. chloromethanicum. CmuC from H. chloromethanicum shows identity to CmuC from M. chloromethanicum and is a putative methyltransferase. folD codes for a methylene-tetrahydrofolate cyclohydrolase, which may be involved in the C(1) transfer pathway for carbon assimilation and CO(2) production, and paaE codes for a putative redox active protein. Molecular analyses and some preliminary biochemical data indicated that the chloromethane utilization pathway in H. chloromethanicum is similar to the corrinoid-dependent methyl transfer system in M. chloromethanicum. PCR primers were developed for successful amplification of cmuA genes from newly isolated chloromethane utilizers and enrichment cultures

Delayed colorectal cancer care during covid-19 pandemic (decor-19). Global perspective from an international survey

Background The widespread nature of coronavirus disease 2019 (COVID-19) has been unprecedented. We sought to analyze its global impact with a survey on colorectal cancer (CRC) care during the pandemic. Methods The impact of COVID-19 on preoperative assessment, elective surgery, and postoperative management of CRC patients was explored by a 35-item survey, which was distributed worldwide to members of surgical societies with an interest in CRC care. Respondents were divided into two comparator groups: 1) ‘delay’ group: CRC care affected by the pandemic; 2) ‘no delay’ group: unaltered CRC practice. Results A total of 1,051 respondents from 84 countries completed the survey. No substantial differences in demographics were found between the ‘delay’ (745, 70.9%) and ‘no delay’ (306, 29.1%) groups. Suspension of multidisciplinary team meetings, staff members quarantined or relocated to COVID-19 units, units fully dedicated to COVID-19 care, personal protective equipment not readily available were factors significantly associated to delays in endoscopy, radiology, surgery, histopathology and prolonged chemoradiation therapy-to-surgery intervals. In the ‘delay’ group, 48.9% of respondents reported a change in the initial surgical plan and 26.3% reported a shift from elective to urgent operations. Recovery of CRC care was associated with the status of the outbreak. Practicing in COVID-free units, no change in operative slots and staff members not relocated to COVID-19 units were statistically associated with unaltered CRC care in the ‘no delay’ group, while the geographical distribution was not. Conclusions Global changes in diagnostic and therapeutic CRC practices were evident. Changes were associated with differences in health-care delivery systems, hospital’s preparedness, resources availability, and local COVID-19 prevalence rather than geographical factors. Strategic planning is required to optimize CRC care