Access path angle in transapical aortic valve replacement: risk factor for paravalvular leakage

Excess of visceral adipose tissue with or without aortic elongation leads to a steeper heart position

BACKGROUND

The heart's position determined as the heart-aorta angle (HAA) has been demonstrated to associate with ascending aortic (AA) dilatation. Visceral adipose tissue (VAT) and aortic elongation may shift the heart to the steeper position.

PURPOSE

To investigate whether VAT and aortic length influence the HAA.

MATERIAL AND METHODS

We examined 346 consecutive patients (58.4% men; mean age = 67.0 ± 14.1 years) who underwent aortic computed tomography angiography (CTA). HAA was measured as the angle between the long axis of the heart and AA midline. The amount of VAT was measured at the level of middle L4 vertebra from a single axial CT slice. Aortic length was measured by combining four anatomical segments in different CTA images. The amount of VAT and aortic length were determined as mild with values in the lowest quartile and as excessive with values in the other three quartiles.

RESULTS

A total of 191 patients (55.2%) had no history of aortic diseases, 134 (38.7%) displayed AA dilatation, 8 (2.3%) had abdominal aortic aneurysm (AAA), and 13 (3.8%) had both AA dilatation and AAA. There was a strong nonlinear regression between smaller HAA and VAT/height, and HAA and aortic length/height. Median HAA was 124.2° (interquartile range 119.0°-130.8°) in patients with a mild amount of VAT versus 120.5° (interquartile range 115.4°-124.7°) in patients with excessive VAT (P < 0.001).

CONCLUSION

An excessive amount of VAT and aortic elongation led to a steeper heart position. These aspects may possess clinical value when evaluating aortic diseases in obese patients.

CT and MR imaging prior to transcatheter aortic valve implantation: standardisation of scanning protocols, measurements and reporting-a consensus document by the European Society of Cardiovascular Radiology (ESCR)

Abstract

Transcatheter aortic valve replacement (TAVR) is a minimally invasive alternative to conventional aortic valve replacement in symptomatic patients with severe aortic stenosis and contraindications to surgery. The procedure has shown to improve patient’s quality of life and prolong short- and mid-term survival in high-risk individuals, becoming a widely accepted therapeutic option which has been integrated into current clinical guidelines for the management of valvular heart disease. Nevertheless, not every patient at high-risk for surgery is a good candidate for TAVR. Besides clinical selection, which is usually established by the Heart Team, certain technical and anatomic criteria must be met as, unlike in surgical valve replacement, annular sizing is not performed under direct surgical evaluation but on the basis of non-invasive imaging findings. Present consensus document was outlined by a working group of researchers from the European Society of Cardiovascular Radiology (ESCR) and aims to provide guidance on the utilisation of CT and MR imaging prior to TAVR. Particular relevance is given to the technical requirements and standardisation of the scanning protocols which have to be tailored to the remarkable variability of the scanners currently utilised in clinical practice; recommendations regarding all required pre-procedural measurements and medical reporting standardisation have been also outlined, in order to ensure quality and consistency of reported data and terminology.

Key Points

• To provide a reference document for CT and MR acquisition techniques, taking into account the significant technological variation of available scanners.

• To review all relevant measurements that are required and define a step-by-step guided approach for the measurements of different structures implicated in the procedure.

• To propose a CT/MR reporting template to assist in consistent communication between various sites and specialists involved in the procedural planning.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06357-8) contains supplementary material, which is available to authorized users.

The association between wedging of the aorta and cardiac structural anatomy as revealed using multidetector-row computed tomography

The aortic root is wedged within the cardiac base. The precise extent of aortic wedging, however, and its influence on the surrounding cardiac structures, has not been systematically investigated. We analysed 100 consecutive patients, who underwent coronary arterial computed tomographic angiography. We assessed the extent of aortic wedging by measuring the vertical distance between the non-adjacent aortic sinus and the inferior epicardium. A shorter distance indicates deeper aortic wedging. We assessed the tilt angle and diameter of the ascending aorta, the relative heights of the left atrial roof and the oval fossa, the shape of the proximal right coronary artery, the angle of the aorta relative to the left ventricular axis, and the lung volume. The mean extent of wedging was 42.7 ± 9.8 mm. Multivariate analysis revealed that ageing, male gender, increased body mass index, patients without cardiomyopathy, the extent of tilting and dilation of the ascending aorta, and lung volume were all independent predictors for deeper aortic wedging (R²  = 0.7400, P < 0.0001). The extent of wedging was additionally correlated with a relatively high left atrial roof (R²  = 0.1394, P < 0.0001) and oval fossa (R²  = 0.1713, P < 0.0001), the shepherd's crook shape of the proximal right coronary artery (R²  = 0.2376, P < 0.0001), and the narrowness of the angulation of the root relative to the left ventricular axis (R²  = 0.2544, P < 0.0001). In conclusion, ageing, male gender, obesity, background cardiac disease, aortic tilting and dilation, and lung volume are all correlated with the extent of wedging of the aortic root within the cardiac base.