The Feasibility of Velocity Vector Imaging by Transesophageal Echocardiography for Assessment of Elastic Properties of the Descending Aorta in Aortic Valve Disease

Sex differences in aortopathy and valve diseases among patients undergoing cardiac surgery

BACKGROUND

We aimed to study sex differences in aortopathy and valve disease among patients undergoing aortic valve replacement and/or surgery for ascending aortic aneurysm, and assess whether differences are specific for patients with bicuspid (BAV) compared to patients with tricuspid aortic valve (TAV).

METHODS

We used a single-center and observational cohort including 1,045 patients undergoing elective open-heart surgery for aortic valve disease and/or ascending aortic aneurysm at the Karolinska Hospital (Sweden).

RESULTS

Women (33.0%) were older than men (mean [SD]; 67.9 [11] years vs 62.5 [13] years for men; P < 0.001). No significant sex difference in prevalence of ascending aortic aneurysm was found according to absolute measures (P = 0.19), however, women had a greater dilation of the ascending aorta when normalized for body surface area (mean [SD], 21.8 [6.3] mm/m² vs 19.3 [4.4] mm/m² for men; P < 0.001). Among the 560 patients with BAV, women had significantly more AS (adjusted OR, 2.23; 95% CI, 1.19-4.20; P = 0.013) and less AI (adjusted OR 0.42; 95% CI, 0.23-0.78; P < 0.01); whereas no sex difference was found among patients with TAV.

CONCLUSIONS

In this large study of patients undergoing cardiac surgery, we found greater degree of aortic dilation in women compared to men suggesting a need for earlier monitoring of women. Moreover, women with BAV had a significantly higher prevalence of AS compared to men. These results describe the aorta and valvular characteristics of patients by sex and provide guidance regarding which patients might benefit from closer surveillance.

Polypharmacy as a prognostic factor in older patients with advanced non-small-cell lung cancer treated with anti-PD-1/PD-L1 antibody-based immunotherapy

PURPOSE

Polypharmacy is a common problem among older adults. However, its prevalence and impact on the clinical outcomes of anticancer treatment, such as survival and adverse events, in older patients with advanced cancer have not been well investigated.

METHODS

We retrospectively reviewed data from Japanese patients treated with an immune checkpoint inhibitor (ICI) for advanced or recurrent non-small-cell lung cancer (NSCLC) between 2016 and 2019.

RESULTS

Among 157 older (aged ≥ 65 years) patients, the prevalence of polypharmacy, defined as ≥ 5 medications, was 59.9% (94/157). The prevalence of potentially inappropriate medication use, according to the screening tool of older people's prescription (STOPP) criteria version 2, was 38.2% (60/157). The median progression-free survival (PFS) in patients with and without polypharmacy was 3.7 and 5.5 months, respectively (P = 0.0017). The median overall survival (OS) in patients with and without polypharmacy was 9.5 and 28.1 months, respectively (P < 0.001). Multivariate analysis revealed marked associations between polypharmacy and OS, but no significant associations between polypharmacy and PFS. Polypharmacy was not associated with immune-related adverse events but was associated with higher rate of unexpected hospitalizations during ICI treatment (59.6% vs. 31.7%, P < 0.001).

CONCLUSION

Polypharmacy is an independent prognostic factor in older patients with advanced NSCLC treated with ICI. Also, polypharmacy could be utilized as a simple indicator of patients' comorbidities and symptoms or as a predictive marker of unexpected hospitalizations during ICI treatment.

New imaging techniques project the cellular and molecular alterations underlying bicuspid aortic valve development

Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation associated with an increased lifetime risk and a high rate of surgically-relevant valve deterioration and aortic dilatation. Genomic data revealed that different genes are associated with BAV. A dominant genetic factor for the recent past was the basis to the recommendation for a more extensive aortic intervention. However very recent evidence that hemodynamic stressors and alterations of wall shear stress play an important role independent from the genetic trait led to more conservative treatment recommendations. Therefore, there is a current need to improve the ability to risk stratify BAV patients in order to obtain an early detection of valvulopathy and aortopathy while also to predict valve dysfunction and/or aortic disease development. Imaging studies based on new cutting-edge technologies, such us 4-dimensional (4D) flow magnetic resonance imaging (MRI), two-dimensional (2D) or three-dimensional (3D) speckle-tracking imaging (STI) and computation fluid dynamics, combined with studies demonstrating new gene mutations, specific signal pathways alterations, hemodynamic influences, circulating biomarkers modifications, endothelial progenitor cell impairment and immune/inflammatory response, all detected BAV valvulopathy progression and aortic wall abnormality. Overall, the main purpose of this review article is to merge the evidences of imaging and basic science studies in a coherent hypothesis that underlies and thus projects the development of both BAV during embryogenesis and BAV-associated aortopathy and its complications in the adult life, with the final goal to identifying aneurysm formation/rupture susceptibility to improve diagnosis and management of patients with BAV-related aortopathy.

Noninvasive Imaging of Flow and Vascular Function in Disease of the Aorta

With advancements in technology and a better understanding of human cardiovascular physiology, research as well as clinical care can go beyond dimensional anatomy offered by traditional imaging and investigate aortic functional properties and the impact disease has on this function. Linking the knowledge of the histopathological changes with the alterations in aortic function observed on noninvasive imaging results in a better understanding of disease pathophysiology. Translating this to clinical medicine, these noninvasive imaging assessments of aortic function are proving to be able to diagnose disease, better predict risk, and assess response to therapies. This review is designed to summarize the various hemodynamic measures that can characterize the aorta, the various noninvasive techniques, and applications for various disease states.

The application of ultrasonic velocity vector imaging technique of carotid plaque in predicting large-artery atherosclerotic stroke

BACKGROUND

Large-artery atherosclerotic stroke (LAAs) is related to carotid plaque, but the mechanical mechanism is unclear. We aimed to use ultrasonic velocity vector imaging (VVI) technique to study the mechanical difference of carotid plaque in patients with LAAs and controls.

METHODS

We enrolled 43 LAAs patients and 38 controls but all showing plaque on carotid ultrasonography. Ultrasonic VVI technique was used to analyze radial systolic and diastolic peak velocity (R-vs, R-vd), radial and circumferential peak strain (R-s, C-s) and radial displacement (R-dis) of carotid plaque.

RESULTS

Compared with controls, LAAs patients showed higher pulse pressure (P = .001), pulse pressure index (PPI, P = .006), and greater stress at carotid plaque as manifested by higher absolute value of radial diastolic peak velocity (R-vd, P = .021), radial systolic peak velocity (R-vs, P = .007), radial peak strain (R-s, P = .015), and radial displacement (R-dis, P = .022). PPI was significantly correlated with R-vs (r = -.274, P = .013), R-vd (r = .304, P = .006), and R-dis (r = -.28, P = .011). But there was no correlation between R-s and blood pressure. R-s was screened to be the most predictable parameters for LAAs (odds ratio, 1.118; 95% confidence interval, 1.012∼1.236; P = .029). The area under the curve of R-s was .627.

CONCLUSIONS

Radial peak strain (R-s) is a predictable parameter for the occurrence of LAAs. We predict using ultrasonic VVI technique to analyze whether the mechanics of carotid plaque is helpful to screen patients with high risks of LAAs.

Quantitative Assessment of Aortic Elasticity With Aging Using Velocity-Vector Imaging and Its Histologic Correlation

Objective—

Velocity-vector imaging (VVI) represents a valuable new method for noninvasive quantification of vascular properties associated with aging. The purpose of this study was to assess the correlations between VVI parameters and histological changes with aging.

Approach and Results—

Fourteen mongrel dogs were classified as either young (n=7; age, 1–2 years; female; weighing 22–29 kg) or senescent (n=7; age, 8–12 years; female; weighing 36–45 kg). The short-axis image of the descending thoracic aorta was obtained for VVI analysis with transesophageal echocardiography. The location of the image was identified using fluoroscopic guidance, and the aortic tissue was extracted. After dividing the aortic wall into 6 segments, both regional and segmental tissue collagen and elastin contents were quantified and correlated with the aortic elastic properties. In the regional analysis, the M-mode–derived aortic dimensions and elastic moduli except for intima-media thickness were not significantly different between the groups, whereas the VVI-derived aortic area and fractional area changes showed more dilated and stiffer aorta in senescent dogs. Also, fractional area change was significantly correlated with the tissue collagen content unlike the M-mode–derived elastic moduli. In the segmental analysis, the radial velocity, circumferential strain, and strain rates of VVI were more reduced in senescent dogs than young dogs, and the radial velocity and circumferential strain showed independent associations with the collagen content of the corresponding aortic wall.

Conclusions—

VVI was a feasible method for direct quantification of aortic elastic properties with a significant histological correlation.

Proximal aortic compliance and diastolic function assessed by speckle tracking imaging

PURPOSE

Speckle tracking imaging (STI) is a recent technique that evaluates an echocardiographic image throughout the cardiac cycle and provides dynamic variables such as tissue velocities and strain rates. The objective of our study was to determine 1) if STI can be used to quantify proximal aortic compliance and 2) if decreased aortic compliance determined by STI will reproduce the previously reported correlation with diastolic function.

METHODS

This was a retrospective observational case series using previously obtained intraoperative transesophageal images. Diastolic performance was quantified by STI-based longitudinal velocities of the basal-septal and basal-lateral walls of the left ventricle in early diastole (LV E'). Change in proximal aortic volume was calculated using STI to measure peak longitudinal and radial velocities in early diastole. After normalizing for mean arterial pressure, compliance was calculated and then compared with basal-septal and basal-lateral LV E' using single regression analysis.

RESULTS

Twenty patients were included in our analysis. Linear regression of basal-septal LV E' and basal-lateral LV E' vs proximal aortic compliance during diastole each resulted in an R(2) value of 0.26 (P < 0.05).

CONCLUSION

Speckle tracking can be used to describe the physical motion of the aortic wall and to calculate its compliance. We confirm that variation in diastolic function can be attributed, in part, to aortic compliance. Our novel approach of measuring compliance throughout the cardiac cycle, isolating radial and longitudinal contributions, and evaluating previously obtained images retrospectively provides advantages over previously reported measures of aortic compliance. Speckle tracking promises new insights into ventricular function, aortic mechanics, and the interaction between these structures.

[Evaluation of vascular function by modern non-invasive methods]

Vascular functional alterations frequently precede morphological changes and, therefore, their recognition may theoretically improve early detection of vascular injury. The aim of this review is to demonstrate recently available non-invasive clinical methods including vascular stiffness examinations, flow-mediated vasodilatation, coronary flow reserve and myocardial flow reserve measurements.

Comparison of cardiac MRI tissue tracking and myocardial tagging for assessment of regional ventricular strain

This study sought to compare regional measures of ventricular strain by tissue tracking (TT) to those derived from myocardial tagging (MT) within cardiac MR (CMR), in normal subjects and patients with hypertrophic cardiomyopathy. CMR images from 13 normal subjects and 11 subjects with hypertrophic cardiomyopathy were retrospectively analyzed. For each subject, equivalent mid-papillary level short-axis cine steady-state free precession and MT slices from the same examination were evaluated. The time to peak circumferential strain and magnitude of the peak strain were calculated for 6 matched left ventricular segments. Data from 24 slices (n = 144 segments) were compared. The mean difference between techniques in magnitude of peak strain and time to peak strain was 1 ± 9% and 1 ± 58 ms, respectively. The mean difference in the standard deviation of time to peak strain within a slice was 0 ± 19 ms (mean cardiac cycle duration 1,013 ± 204 ms). Bland-Altman analysis showed closer agreement in time to peak strain than peak strain magnitude. Measurements of segmental time to peak strain by TT and MT were in close agreement; agreement for the magnitude of peak segmental strain was more modest. The TT approach does not add to CMR examination time and may be a useful tool for the assessment of ventricular synchrony.

[Functional vascular alterations associated with aortic valve stenosis]

Degenerative changes, atherosclerotic process and calcification of valvular leaflets are mostly responsible for valvular aortic valve stenosis, but congenital bicuspid aortic valve and rheumatic fever in history are also known predisposing factors. Aortic valve stenosis is frequently associated with different functional vascular alterations. The aim of this review is to demonstrate these vascular alterations evaluated by non-invasive methods and underlying physiologic and pathophysiologic processes.

Bicuspid aortic valve leaflet morphology in relation to aortic root morphology: a study of 300 patients undergoing open-heart surgery

OBJECTIVE

There is an ongoing discussion regarding the mechanism of aortic dilatation in bicuspid aortic valve (BAV) disease, that is, is this a hemodynamic effect or related to an inborn weakness of the aortic wall? This study evaluated the possibility of BAV morphology being related to ascending aorta morphology as such a correlation would strengthen the idea that hemodynamic alterations cause the dilatation of the aorta.

METHODS

The morphology of the ascending aorta of 300 patients admitted for aortic valve and/or ascending aorta disease was evaluated by echocardiography and related to the surgeon's inspection of the aortic valve.

RESULTS

A tricuspid aortic valve (TAV), BAV, or unicuspid aortic valve (UAV) was present in 130, 160, and 10 patients, respectively. Ascending aortic aneurysm was more common in patients with BAV compared with TAV (36% and 12%, respectively; p < 0.001), while ectasia of the aorta was similarly common (8% in both groups). Aortic stenosis or regurgitation was equally distributed in TAV and BAV patients with normal aortas (p=0.82). When the aorta was dilated, aortic stenosis was predominantly associated with BAV (BAV 56%, TAV 4%; p < 0.001), while aortic regurgitation was more common in TAV (TAV 81%, BAV 29%; p<0.001). In BAV patients, fusion of the right- and left coronary cusp was predominant (74%) followed by right- and non-coronary cusp fusion (14%) and true BAV (fusion of the right- and left coronary cusp without remnant raphe; 11%) (p < 0.001). The relative distribution of ascending aortic aneurysm or ectasia was similar in all morphologically different BAV (p = 0.95).

CONCLUSIONS

In our study population, >50% of the patients admitted for surgery had a bicuspid valve. Aortic aneurysm was more common in BAV than in TAV patients. Aortic stenosis and aortic regurgitation were equally common in TAV and BAV with normal aortic dimensions, while aortic regurgitation was predominant in TAV with dilated aortas and aortic stenosis in BAV with dilated aortas. Dilatation of the aorta was similarly distributed regardless of BAV leaflet morphology. These findings support the idea of an intrinsic mechanisms underlying dilatation of the aorta in BAV patients.