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Burbano-Vera NH, Alfirevic A, Bauer AM, Wakefield BJ, Najm HK, Roselli EE, Tretter JT. Perioperative Assessment of the Hemodynamic Ventriculoarterial Junction of the Aortic Root by Three-Dimensional Echocardiography. J Am Soc Echocardiogr 2024; 37:626-633. [PMID: 38336021 DOI: 10.1016/j.echo.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
Improved strategies in aortic valve-preserving operations appreciate the dynamic, three-dimensional complexity of the aortic root and its valve. This depends not only on detailed four-dimensional imaging of the planar dimensions of the aortic root but also on quantitative assessment of the valvar leaflets and their competency. The zones of apposition and resulting hemodynamic ventriculoarterial junction formed in diastole determine valvar competency. Current understanding and assessment of this junction is limited, often relying on intraoperative direct surgical inspection. However, this direct inspection itself is limited by evaluation in a nonhemodynamic state with limited field of view. In this review, we discuss the anatomy of the aortic root, including its hemodynamic junction. We review current echocardiographic approaches toward interrogating the incompetent aortic valve for presurgical planning. Furthermore, we introduce and standardize a complementary approach to assessing this hemodynamic ventriculoarterial junction by three-dimensional echocardiography to further personalize presurgical planning for aortic valve surgery.
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Affiliation(s)
- Nelson H Burbano-Vera
- Anesthesiology Institute, Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio; Anesthesiology Institute, Department of Pediatric Anesthesiology, Division of Pediatric Cardiac Anesthesiology, Cleveland Clinic, Cleveland, Ohio.
| | - Andrej Alfirevic
- Anesthesiology Institute, Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Andrew M Bauer
- Anesthesiology Institute, Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Brett J Wakefield
- Anesthesiology Institute, Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Hani K Najm
- Congenital Valve Procedural Planning Program, Department of Pediatric Cardiology and Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's, and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Heart, Vascular and Thoracic Institute, Department of Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Heart, Vascular and Thoracic Institute, Department of Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Justin T Tretter
- Congenital Valve Procedural Planning Program, Department of Pediatric Cardiology and Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's, and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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2
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Haq IU, Shabtaie SA, Tan NY, Lachman N, Asirvatham SJ. Anatomy of the Ventricular Outflow Tracts: An Electrophysiology Perspective. Clin Anat 2024; 37:43-53. [PMID: 37337379 DOI: 10.1002/ca.24083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 06/21/2023]
Abstract
Outflow tract ventricular arrhythmias are the most common type of idiopathic ventricular arrhythmia. A systematic understanding of the outflow tract anatomy improves procedural efficacy and enables electrophysiologists to anticipate and prevent complications. This review emphasizes the three-dimensional spatial relationships between the ventricular outflow tracts using seven anatomical principles. In turn, each principle is elaborated on from a clinical perspective relevant for the practicing electrophysiologist. The developmental anatomy of the outflow tracts is also discussed and reinforced with a clinical case.
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Affiliation(s)
- Ikram U Haq
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samuel A Shabtaie
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nirusha Lachman
- Department of Anatomy, Mayo Clinic, Rochester, Minnesota, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
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3
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Sundström E, Laudato M. Machine Learning-Based Segmentation of the Thoracic Aorta with Congenital Valve Disease Using MRI. Bioengineering (Basel) 2023; 10:1216. [PMID: 37892946 PMCID: PMC10604748 DOI: 10.3390/bioengineering10101216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/21/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Subjects with bicuspid aortic valves (BAV) are at risk of developing valve dysfunction and need regular clinical imaging surveillance. Management of BAV involves manual and time-consuming segmentation of the aorta for assessing left ventricular function, jet velocity, gradient, shear stress, and valve area with aortic valve stenosis. This paper aims to employ machine learning-based (ML) segmentation as a potential for improved BAV assessment and reducing manual bias. The focus is on quantifying the relationship between valve morphology and vortical structures, and analyzing how valve morphology influences the aorta's susceptibility to shear stress that may lead to valve incompetence. The ML-based segmentation that is employed is trained on whole-body Computed Tomography (CT). Magnetic Resonance Imaging (MRI) is acquired from six subjects, three with tricuspid aortic valves (TAV) and three functionally BAV, with right-left leaflet fusion. These are used for segmentation of the cardiovascular system and delineation of four-dimensional phase-contrast magnetic resonance imaging (4D-PCMRI) for quantification of vortical structures and wall shear stress. The ML-based segmentation model exhibits a high Dice score (0.86) for the heart organ, indicating a robust segmentation. However, the Dice score for the thoracic aorta is comparatively poor (0.72). It is found that wall shear stress is predominantly symmetric in TAVs. BAVs exhibit highly asymmetric wall shear stress, with the region opposite the fused coronary leaflets experiencing elevated tangential wall shear stress. This is due to the higher tangential velocity explained by helical flow, proximally of the sinutubal junction of the ascending aorta. ML-based segmentation not only reduces the runtime of assessing the hemodynamic effectiveness, but also identifies the significance of the tangential wall shear stress in addition to the axial wall shear stress that may lead to the progression of valve incompetence in BAVs, which could guide potential adjustments in surgical interventions.
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Affiliation(s)
- Elias Sundström
- Department of Engineering Mechanics, FLOW Research Center, KTH Royal Institute of Technology, Teknikringen 8, 10044 Stockholm, Sweden
| | - Marco Laudato
- Department of Engineering Mechanics, FLOW Research Center, KTH Royal Institute of Technology, Teknikringen 8, 10044 Stockholm, Sweden
- Department of Engineering Mechanics, The Marcus Wallenberg Laboratory for Sound and Vibration Research, KTH Royal Institute of Technology, Teknikringen 8, 10044 Stockholm, Sweden
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4
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Sundström E, Tretter JT. Impact of Variation in Commissural Angle between Fused Leaflets in the Functionally Bicuspid Aortic Valve on Hemodynamics and Tissue Biomechanics. Bioengineering (Basel) 2023; 10:1219. [PMID: 37892949 PMCID: PMC10604894 DOI: 10.3390/bioengineering10101219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
In subjects with functionally bicuspid aortic valves (BAVs) with fusion between the coronary leaflets, there is a natural variation of the commissural angle. What is not fully understood is how this variation influences the hemodynamics and tissue biomechanics. These variables may influence valvar durability and function, both in the native valve and following repair, and influence ongoing aortic dilation. A 3D aortic valvar model was reconstructed from a patient with a normal trileaflet aortic valve using cardiac magnetic resonance (CMR) imaging. Fluid-structure interaction (FSI) simulations were used to compare the effects of the varying commissural angles between the non-coronary with its adjacent coronary leaflet. The results showed that the BAV with very asymmetric commissures (120∘ degree commissural angle) reduces the aortic opening area during peak systole and with a jet that impacts on the right posterior wall proximally of the ascending aorta, giving rise to elevated wall shear stress. This manifests in a shear layer with a retrograde flow and strong swirling towards the fused leaflet side. In contrast, a more symmetrical commissural angle (180∘ degree commissural angle) reduces the jet impact on the posterior wall and leads to a linear decrease in stress and strain levels in the non-fused non-coronary leaflet. These findings highlight the importance of considering the commissural angle in the progression of aortic valvar stenosis, the regional distribution of stresses and strain levels experienced by the leaflets which may predispose to valvar deterioration, and progression in thoracic aortic dilation in patients with functionally bicuspid aortic valves. Understanding the hemodynamics and biomechanics of the functionally bicuspid aortic valve and its variation in structure may provide insight into predicting the risk of aortic valve dysfunction and thoracic aortic dilation, which could inform clinical decision making and potentially lead to improved aortic valvar surgical outcomes.
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Affiliation(s)
- Elias Sundström
- Department of Engineering Mechanics, Flow Research Center, KTH Royal Institute of Technology, Teknikringen 8, 100 44 Stockholm, Sweden
| | - Justin T. Tretter
- Congenital Valve Procedural Planning Center, Department of Pediatric Cardiology and Division of Pediatric Cardiac Surgery, Cleveland Clinic Children’s, and The Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA;
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5
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Sundström E, Jiang M, Najm HK, Tretter JT. Blood Speckle Imaging: An Emerging Method for Perioperative Evaluation of Subaortic and Aortic Valvar Repair. Bioengineering (Basel) 2023; 10:1183. [PMID: 37892913 PMCID: PMC10604765 DOI: 10.3390/bioengineering10101183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/03/2023] [Accepted: 10/06/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND This article presents the use of blood speckle Imaging (BSI) as an echocardiographic approach for the pre- and post-operative evaluation of subaortic membrane resection and aortic valve repair. METHOD BSI, employing block-matching algorithms, provided detailed visualization of flow patterns and quantification of parameters from ultrasound data. The 9-year-old patient underwent subaortic membrane resection and peeling extensions of the membrane from under the ventricular-facing surface of all three aortic valve leaflets. RESULT Post-operatively, BSI demonstrated improvements in hemodynamic patterns, where quantified changes in flow velocities showed no signs of stenosis and trivial regurgitation. The asymmetric jet with a shear layer and flow reversal on the posterior aspect of the aorta was corrected resulting in reduced wall shear stress on the anterior aspect and reduced oscillatory shear index, which is considered a contributing element in cellular alterations in the structure of the aortic wall. CONCLUSION This proof-of-concept study demonstrates the potential of BSI as an emerging echocardiographic approach for evaluating subaortic and aortic valvar repair. BSI enhances the quantitative evaluation of the left ventricular outflow tract of immediate surgical outcomes beyond traditional echocardiographic parameters and aids in post-operative decision-making. However, larger studies are needed to validate these findings and establish standardized protocols for clinical implementation.
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Affiliation(s)
- Elias Sundström
- Department of Engineering Mechanics, FLOW Research Center, KTH Royal Institute of Technology, Teknikringen 8, 100 44 Stockholm, Sweden
| | - Michael Jiang
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Hani K. Najm
- Congenital Valve Procedural Planning Center, Department of Pediatric Cardiology, Cleveland, OH 44195, USA
- Division of Pediatric Cardiac Surgery, and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Justin T. Tretter
- Congenital Valve Procedural Planning Center, Department of Pediatric Cardiology, Cleveland, OH 44195, USA
- Division of Pediatric Cardiac Surgery, and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Tretter JT, Spicer DE, Franklin RCG, Béland MJ, Aiello VD, Cook AC, Crucean A, Loomba RS, Yoo SJ, Quintessenza JA, Tchervenkov CI, Jacobs JP, Najm HK, Anderson RH. Expert Consensus Statement: Anatomy, Imaging, and Nomenclature of Congenital Aortic Root Malformations. Cardiol Young 2023; 33:1060-1068. [PMID: 37288941 DOI: 10.1017/s1047951123001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Over the past 2 decades, several categorizations have been proposed for the abnormalities of the aortic root. These schemes have mostly been devoid of input from specialists of congenital cardiac disease. The aim of this review is to provide a classification, from the perspective of these specialists, based on an understanding of normal and abnormal morphogenesis and anatomy, with emphasis placed on the features of clinical and surgical relevance. We contend that the description of the congenitally malformed aortic root is simplified when approached in a fashion that recognizes the normal root to be made up of 3 leaflets, supported by their own sinuses, with the sinuses themselves separated by the interleaflet triangles. The malformed root, usually found in the setting of 3 sinuses, can also be found with 2 sinuses, and very rarely with 4 sinuses. This permits description of trisinuate, bisinuate, and quadrisinuate variants, respectively. This feature then provides the basis for classification of the anatomical and functional number of leaflets present. By offering standardized terms and definitions, we submit that our classification will be suitable for those working in all cardiac specialties, whether pediatric or adult. It is of equal value in the settings of acquired or congenital cardiac disease. Our recommendations will serve to amend and/or add to the existing International Paediatric and Congenital Cardiac Code, along with the Eleventh iteration of the International Classification of Diseases provided by the World Health Organization.
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Affiliation(s)
- Justin T Tretter
- Department of Pediatric Cardiology, Cleveland Clinic Children's and The Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, Florida
- Congenital Heart Center, UF Health Shands Hospital, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | - Rodney C G Franklin
- Paediatric Cardiology Department, Royal Brompton & Harefield National Health Service Trust, London, United Kingdom
| | - Marie J Béland
- Division of Pediatric Cardiology, The Montreal Children's Hospital of the McGill University Health Centre, Montréal, Québec, Canada
| | - Vera D Aiello
- Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Andrew C Cook
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Adrian Crucean
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Shi-Joon Yoo
- Division of Cardiology, Department of Pediatrics, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Christo I Tchervenkov
- Division of Cardiovascular Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montréal, Québec, Canada
| | - Jeffrey P Jacobs
- Congenital Heart Center, UF Health Shands Hospital, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert H Anderson
- Cardiovascular Research Centre, Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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7
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Tretter JT, Spicer DE, Franklin RCG, Béland MJ, Aiello VD, Cook AC, Crucean A, Loomba RS, Yoo SJ, Quintessenza JA, Tchervenkov CI, Jacobs JP, Najm HK, Anderson RH. Expert Consensus Statement: Anatomy, Imaging, and Nomenclature of Congenital Aortic Root Malformations. Ann Thorac Surg 2023; 116:6-16. [PMID: 37294261 DOI: 10.1016/j.athoracsur.2023.03.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/03/2023] [Accepted: 03/15/2023] [Indexed: 06/10/2023]
Abstract
Over the past 2 decades, several categorizations have been proposed for the abnormalities of the aortic root. These schemes have mostly been devoid of input from specialists of congenital cardiac disease. The aim of this review is to provide a classification, from the perspective of these specialists, based on an understanding of normal and abnormal morphogenesis and anatomy, with emphasis placed on the features of clinical and surgical relevance. We contend that the description of the congenitally malformed aortic root is simplified when approached in a fashion that recognizes the normal root to be made up of 3 leaflets, supported by their own sinuses, with the sinuses themselves separated by the interleaflet triangles. The malformed root, usually found in the setting of 3 sinuses, can also be found with 2 sinuses, and very rarely with 4 sinuses. This permits description of trisinuate, bisinuate, and quadrisinuate variants, respectively. This feature then provides the basis for classification of the anatomical and functional number of leaflets present. By offering standardized terms and definitions, we submit that our classification will be suitable for those working in all cardiac specialties, whether pediatric or adult. It is of equal value in the settings of acquired or congenital cardiac disease. Our recommendations will serve to amend and/or add to the existing International Paediatric and Congenital Cardiac Code, along with the Eleventh iteration of the International Classification of Diseases provided by the World Health Organization.
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Affiliation(s)
- Justin T Tretter
- Department of Pediatric Cardiology, Cleveland Clinic Children's and The Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St Petersburg, Florida; Congenital Heart Center, UF Health Shands Hospital, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | - Rodney C G Franklin
- Paediatric Cardiology Department, Royal Brompton & Harefield National Health Service Trust, London, United Kingdom
| | - Marie J Béland
- Division of Pediatric Cardiology, The Montreal Children's Hospital of the McGill University Health Centre, Montréal, Québec, Canada
| | - Vera D Aiello
- Heart Institute (InCor), University of São Paulo School of Medicine, São Paulo, Brazil
| | - Andrew C Cook
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Adrian Crucean
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Shi-Joon Yoo
- Division of Cardiology, Department of Pediatrics, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Christo I Tchervenkov
- Division of Cardiovascular Surgery, The Montreal Children's Hospital of the McGill University Health Centre, Montréal, Québec, Canada
| | - Jeffrey P Jacobs
- Congenital Heart Center, UF Health Shands Hospital, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Children's and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert H Anderson
- Cardiovascular Research Centre, Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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Jonnagiri R, Sundström E, Gutmark E, Anderson S, Pednekar AS, Taylor MD, Tretter JT, Gutmark-Little I. Influence of aortic valve morphology on vortical structures and wall shear stress. Med Biol Eng Comput 2023; 61:1489-1506. [PMID: 36763231 DOI: 10.1007/s11517-023-02790-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023]
Abstract
The aim of this paper is to assess the association between valve morphology and vortical structures quantitatively and to highlight the influence of valve morphology/orientation on aorta's susceptibility to shear stress, both proximal and distal. Four-dimensional phase-contrast magnetic resonance imaging (4D PCMRI) data of 6 subjects, 3 with tricuspid aortic valve (TAV) and 3 with functionally bicuspid aortic values (BAV) with right-left coronary leaflet fusion, were processed and analyzed for vorticity and wall shear stress trends. Computational fluid dynamics (CFD) has been used with moving TAV and BAV valve designs in patient-specific aortae to compare with in vivo shear stress data. Vorticity from 4D PCMRI data about the aortic centerline demonstrated that TAVs had a higher number of vortical flow structures than BAVs at peak systole. Coalescing of flow structures was shown to be possible in the arch region of all subjects. Wall shear stress (WSS) distribution from CFD results at the aortic root is predominantly symmetric for TAVs but highly asymmetric for BAVs with the region opposite the raphe (fusion location of underdeveloped leaflets) being subjected to higher WSS. Asymmetry in the size and number of leaflets in BAVs and TAVs significantly influence vortical structures and WSS in the proximal aorta for all valve types and distal aorta for certain valve orientations of BAV. Analysis of vortical structures using 4D PCMRI data (on the left side) and wall shear stress data using CFD (on the right side).
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Affiliation(s)
- Raghuvir Jonnagiri
- Department of Aerospace Engineering and Engineering Mechanics, University of Cincinnati, Cincinnati, OH, 45221, USA.
| | - Elias Sundström
- Department of Engineering Mechanics, Royal Institute of Technology, 10044, Stockholm, Sweden
| | - Ephraim Gutmark
- Department of Aerospace Engineering and Engineering Mechanics, University of Cincinnati, Cincinnati, OH, 45221, USA
| | - Shae Anderson
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Amol S Pednekar
- Division of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Michael D Taylor
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, 45267, USA
| | - Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, 45267, USA
| | - Iris Gutmark-Little
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, 45267, USA.,Division of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
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9
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Sassis L, Kefala-Karli P, Cucchi I, Kouremenos I, Demosthenous M, Diplaris K. Valve Repair in Aortic Insufficiency: A State-of-the-art Review. Curr Cardiol Rev 2023; 19:e270422204131. [PMID: 35490315 PMCID: PMC10201877 DOI: 10.2174/1573403x18666220427120235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/02/2022] [Accepted: 03/09/2022] [Indexed: 02/08/2023] Open
Abstract
Aortic valve insufficiency (AI) describes the pathology of blood leaking through the aortic valve to the left ventricle during diastole and is classified as mild, moderate or severe according to the volume of regurgitating blood. Intervention is required in severe AI when the patient is symptomatic or when the left ventricular function is impaired. Aortic valve replacement has been considered the gold standard for decades for these patients, but several repair techniques have recently emerged that offer exceptional stability and long-term outcomes. The appropriate method of repair is selected based on the mechanism of AI and each patient's anatomic variations. This review aims to describe different pathologies of AI based on its anatomy, along with the different surgical techniques of aortic repair and their reported results.
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Affiliation(s)
| | | | - Irene Cucchi
- University of Nicosia, School of Medicine, Nicosia, Cyprus
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10
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Anderson RH, Spicer DE, Quintessenza JA, Najm HK, Tretter JT. Words and how we use them-Which is to be the master? J Card Surg 2022; 37:2481-2485. [PMID: 35705190 DOI: 10.1111/jocs.16620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Robert H Anderson
- Department of Cardiovascular Research Centre, Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Diane E Spicer
- Department of Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - James A Quintessenza
- Department of Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Hani K Najm
- Department of Pediatric Cardiac Surgery, Cleveland Clinic Children's, and The Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Justin T Tretter
- Department of Pediatric Cardiology, Cleveland Clinic Children's, and The Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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11
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Hancock B, Miller EM, Parrott A, Weaver KN, Tretter JT, Pilipenko V, Shikany AR. Retrospective comparison of parent-reported genetics knowledge, empowerment, and familial uptake of cardiac screening between parents who received genetic counseling by a certified genetic counselor and those who did not: A single US academic medical center study. J Genet Couns 2022; 31:965-975. [PMID: 35261109 DOI: 10.1002/jgc4.1570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 02/23/2022] [Accepted: 02/23/2022] [Indexed: 11/10/2022]
Abstract
Bicuspid aortic valve (BAV) is the most common congenital heart defect, which can cause severe cardiac complications. BAVs cluster in families and demonstrate high heritability. Cardiac screening for first-degree relatives of individuals with a BAV is recommended. This retrospective two-group study evaluated the impact of cardiovascular genetic counseling provided by a board-certified genetic counselor on parent-reported outcomes by comparing parental responses of those who received genetic counseling by a genetic counselor (GC group) for family history of BAV to those who did not (non-GC group). A retrospective chart review from May 2016 to June 2019 identified 133 pediatric patients with an isolated BAV. Parents of eligible probands were invited to complete an online survey assessing genetics knowledge, empowerment (Genomics Outcome Scale), and familial uptake of cardiac screening. Surveys were completed by 38/97 (39%) parents in the non-GC group and 20/36 (56%) parents in the GC group. The median genetics knowledge score was not significantly different between the two groups (GC group: 8, range 3-11 out of a maximum possible of 12; non-GC group: 7, range 2-11; p = .08). The mean empowerment score was not significantly different between the two groups (GC group: mean 24.6, SD 2.2; non-GC group: mean 23.2, SD 3.5; p = .06). The uptake of cardiac screening was significantly higher in the GC group with 39/59 (66%) total first-degree relatives reported as having been screened compared with 36/91 (40%) in the non-GC group (p = .002). Parent-reported outcomes in our study suggest that receiving genetic counseling by a board-certified genetic counselor significantly increased familial uptake of cardiac screening for first-degree relatives of pediatric patients with a BAV. Studies with larger sample sizes are needed to confirm the findings of this study; however, a referral to a genetic counselor should be considered for patients with a BAV.
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Affiliation(s)
- Bailey Hancock
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Erin M Miller
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ashley Parrott
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Genome Medical, San Francisco, California, USA
| | - Kathryn Nicole Weaver
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Justin T Tretter
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Valentina Pilipenko
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Amy R Shikany
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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13
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Abstract
Unicuspid aortic valve (UAV) is a rare congenital aortic valve anomaly. It has two subtypes and often is associated with aortic valve dysfunction and corresponding clinical presentations. Echocardiography is the first choice of diagnostic method for UAV. Three-dimensional echocardiography has played an increasingly important role in diagnosis, intraprocedural guidance, and post-procedural assessment in recent years. There remain challenges in distinguishing UAV from bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV). Misdiagnosis is most resulted from raphes or leaflet calcifications. Multi-modality imaging has obvious advantages over single-modality imaging and is crucial for UAV diagnosis. Accurate identification of aortic valve morphology is important to choose the best treatment. Aortic balloon valvoplasty, surgical valvotomy, commissurotomy, Ross procedure, surgical valve repair and surgical replacement are most common treatment modalities of UAV. In this review, we aim to discuss UAV including epidemiology, definition, classification, diagnostic importance and necessity, valvular function, clinical presentation, associated disorders, non-invasive diagnostic modalities and therapeutic approaches.
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Affiliation(s)
- Jianhong Pan
- Department of Internal Medicine, Tianjin NanKai Hospital, Tianjin, China
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14
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Tretter JT, Izawa Y, Spicer DE, Okada K, Anderson RH, Quintessenza JA, Mori S. Understanding the Aortic Root Using Computed Tomographic Assessment: A Potential Pathway to Improved Customized Surgical Repair. Circ Cardiovasc Imaging 2021; 14:e013134. [PMID: 34743527 DOI: 10.1161/circimaging.121.013134] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There is continued interest in surgical repair of both the congenitally malformed aortic valve, and the valve with acquired dysfunction. Aortic valvar repair based on a geometric approach has demonstrated improved durability and outcomes. Such an approach requires a thorough comprehension of the complex 3-dimensional anatomy of both the normal and congenitally malformed aortic root. In this review, we provide an understanding of this anatomy based on the features that can accurately be revealed by contrast-enhanced computed tomographic imaging. We highlight the complimentary role that such imaging, with multiplanar reformatting and 3-dimensional reconstructions, can play in selection of patients, and subsequent presurgical planning for valvar repair. The technique compliments other established techniques for perioperative imaging, with echocardiography maintaining its central role in assessment, and enhances direct surgical evaluation. This additive morphological and functional information holds the potential for improving selection of patients, surgical planning, subsequent surgical repair, and hopefully the subsequent outcomes.
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Affiliation(s)
- Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, OH (J.T.T.)
| | - Yu Izawa
- Division of Cardiovascular Medicine, Department of Internal Medicine (Y.I.), Kobe University Graduate School of Medicine, Japan
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.E.S., J.A.Q.)
| | - Kenji Okada
- Department of Cardiovascular Surgery (K.O.), Kobe University Graduate School of Medicine, Japan
| | - Robert H Anderson
- Cardiovascular Research Centre, Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom (R.H.A.)
| | - James A Quintessenza
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (D.E.S., J.A.Q.)
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA (S.M.)
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15
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Manuel AM, Ladeiras-Lopes R, Ribeiro J, Ferreira ND, Faria R, Carvalho M, Ferreira W, Ferraz R, Gonçalves F, Batista A, Gonçalves C, Pires-Morais G, Rodrigues A, Sampaio F, Teixeira M, Braga P, Fontes-Carvalho R. Prevalence, multimodality imaging characterization, and mid-term prognosis of quadricuspid aortic valves: an analysis of eight cases, based on 160 004 exams performed during 12 years in a tertiary care hospital. Eur Heart J Cardiovasc Imaging 2021; 22:765-776. [PMID: 33400773 DOI: 10.1093/ehjci/jeaa355] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/15/2020] [Indexed: 12/12/2022] Open
Abstract
AIMS Quadricuspid aortic valve (QAV) is a rare abnormality, which may cause aortic regurgitation (AR) requiring surgical intervention in some patients. The characteristics associated with aortic valve functional degeneration in patients with QAV are still unknown. The aim of this study is to describe QAV prevalence, characterize the disease by multimodality imaging, evaluate predictors of severe AR, and assess mid-term prognosis. METHODS AND RESULTS Retrospective search in imaging exams database of one tertiary centre, for patients diagnosed with QAV between January 2007 and September 2019. QAV was characterized by cardiac computed tomography, transthoracic/transoesophageal echocardiography, and cardiac magnetic resonance. A total of 160 004 exams were reviewed and eight patients with QAV were identified (50% men, mean age 53.5 ± 10.7 years). The prevalence of QAV was 0.005%. During a median follow-up of 52 months (interquartile range 16-88), there were no deaths. Seven patients (88%) had pure AR (three severe, one moderate, and three mild) and one patient (12%) had moderate AR and moderate aortic stenosis. Three patients (38%) with severe AR underwent valve surgery (two replacements and one repair). Analysis of predictors of severe AR was not statistically significant. CONCLUSION QAV is a rare congenital cardiac defect, with a prevalence of 0.005% in our study. Its predominant functional abnormality was regurgitation and about one-third of the patients required aortic valve surgery. Multimodality imaging may play a pivotal role in assessing patients with QAV with significant valve dysfunction or associated congenital heart disease and improve their treatment strategy.
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Affiliation(s)
- Ana Mosalina Manuel
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | | | - José Ribeiro
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | - Nuno Dias Ferreira
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | - Rita Faria
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | - Mónica Carvalho
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | - Wilson Ferreira
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | - Ricardo Ferraz
- Cardiothoracic Surgery Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | - Fernando Gonçalves
- Cardiology Department, Trás-os-Montes e Alto Douro Hospital Centre, Vila Real, Portugal
| | - Ana Batista
- Cardiology Department, Trás-os-Montes e Alto Douro Hospital Centre, Vila Real, Portugal
| | - Carlos Gonçalves
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | - Gustavo Pires-Morais
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | - Alberto Rodrigues
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | - Francisco Sampaio
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal.,Cardiovascular Research & Development Unit, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Madalena Teixeira
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | - Pedro Braga
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal
| | - Ricardo Fontes-Carvalho
- Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Porto, Portugal.,Cardiovascular Research & Development Unit, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Porto, Portugal
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16
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Tretter JT, Mori S, Spicer DE, Anderson RH. The aortic valve with four leaflets: how should we best describe this blue moon? Eur Heart J Cardiovasc Imaging 2021; 22:777-780. [PMID: 33421050 DOI: 10.1093/ehjci/jeaa420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 12/23/2020] [Indexed: 01/09/2023] Open
Affiliation(s)
- Justin T Tretter
- Department of Pediatrics, Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, 100 UCLA, Medical Plaza Driveway Suite 690, Los Angeles, CA, 90095 USA
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, 501 6th Ave S St. Petersburg, FL, 33701 USA
| | - Robert H Anderson
- Cardiovascular Research Centre, Biosciences Institute, Newcastle University, Newcastle upon Tyne, NE17RU UK
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17
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Izawa Y, Mori S, Tretter JT, Quintessenza JA, Toh H, Toba T, Watanabe Y, Kono AK, Okada K, Hirata KI. Normative Aortic Valvar Measurements in Adults Using Cardiac Computed Tomography - A Potential Guide to Further Sophisticate Aortic Valve-Sparing Surgery. Circ J 2021; 85:1059-1067. [PMID: 33408304 DOI: 10.1253/circj.cj-20-0938] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND A thorough understanding of the anatomy of the aortic valve is necessary for aortic valve-sparing surgery. Normal valvar dimensions and their relationships in the living heart, however, have yet to be fully investigated in a 3-dimensional fashion.Methods and Results:In total, 123 consecutive patients (66±12 years, Men 63%) who underwent coronary computed tomographic angiography were enrolled. Mid-diastolic morphology of the aortic roots, including height of the interleaflet triangles, geometric height, free margin length of each leaflet, effective height, and coaptation length were measured using multiplanar reconstruction images. Average height of the interleaflet triangle, geometric height, free margin length, effective height, and the coaptation length were 17.3±1.8, 14.7±1.3, 32.6±3.6, 8.6±1.4, and 3.2±0.8 mm, respectively. The right coronary aortic leaflet displayed the longest free margin length and shortest geometric height. Geometric height, free margin length, and effective height showed positive correlations with aortic root dimensions. Coaptation length, however, remained constant regardless of aortic root dimensions. CONCLUSIONS Diversities, as well as characteristic relationships among each value involving the aortic root, were identified using living-heart datasets. The aortic leaflets demonstrated compensatory elongation along with aortic root dilatation to maintain constant coaptation length. These measurements will serve as the standard value for revealing the underlying mechanism of aortic regurgitation to plan optimal aortic valve-sparing surgery.
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Affiliation(s)
- Yu Izawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Justin T Tretter
- The Heart Institute, Cincinnati Children's Hospital Medical Center.,Department of Pediatrics, University of Cincinnati College of Medicine
| | - James A Quintessenza
- The Heart Institute, Cincinnati Children's Hospital Medical Center.,Kentucky Children's Hospital, University of Kentucky, UK Healthcare
| | - Hiroyuki Toh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Takayoshi Toba
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Yoshiaki Watanabe
- Department of Radiology, Kobe University Graduate School of Medicine
| | - Atsushi K Kono
- Department of Radiology, Kobe University Graduate School of Medicine
| | - Kenji Okada
- Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
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18
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Sundström E, Jonnagiri R, Gutmark-Little I, Gutmark E, Critser P, Taylor MD, Tretter JT. Hemodynamics and tissue biomechanics of the thoracic aorta with a trileaflet aortic valve at different phases of valve opening. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2020; 36:e3345. [PMID: 32359198 DOI: 10.1002/cnm.3345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 02/17/2020] [Accepted: 04/19/2020] [Indexed: 06/11/2023]
Abstract
In a normal cardiac cycle, the trileaflet aortic valve opening is progressive, which correlates with the phasic blood flow. Therefore, we aimed to determine the impact of including an anatomically accurate reconstructed trileaflet aortic valve within a fluid-structure interaction (FSI) simulation model and determine the cyclical hemodynamic forces imposed on the thoracic aortic walls from aortic valve opening to closure. A pediatric patient with a normal trileaflet valve was recruited. Using the Cardiac Magnetic Resonance Data (CMR), a 3D model of the aortic valve and thoracic aorta was reconstructed. FSI simulations were employed to assess the tissue stress during a cardiac cycle as the result of changes in the valve opening. The blood flow was simulated as a mixture of blood plasma and red blood cells to account for non-Newtonian effects. The computation was validated with phase-contrast CMR. Windkessel boundary conditions were employed to ensure physiological pressures during the cardiac cycle. The leaflets' dynamic motion during the cardiac cycle was defined with an analytic grid velocity function. At the beginning of the valve opening a thin jet is developing. From mid-open towards full opening the stress level increases where the jet impinges the convex wall. At peak systole two counter-rotating Dean-like vortex cores manifest in the ascending aorta, which correlates with increased integrated mean stress levels. An accurate trileaflet aortic valve is needed for capturing of both primary and secondary flow features that impact the forces on the thoracic aorta wall. Omitting the aortic valve underestimates the biomechanical response.
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Affiliation(s)
- Elias Sundström
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Raghuvir Jonnagiri
- Department of Aerospace Engineering and Engineering Mechanics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Iris Gutmark-Little
- Division of Endocrine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ephraim Gutmark
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Aerospace Engineering and Engineering Mechanics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Paul Critser
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael D Taylor
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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19
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Suzuki M, Mori S, Izawa Y, Shimoyama S, Takahashi Y, Toh H, Tsuda D, Toba T, Fujiwara S, Tanaka H, Hirata KI, Anderson RH, Tretter JT. Three-dimensional volumetric measurement of the aortic root compared to standard two-dimensional measurements using cardiac computed tomography. Clin Anat 2020; 34:333-341. [PMID: 32249462 DOI: 10.1002/ca.23597] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Two-dimensional measurements are self-evidently limited when seeking accurately to represent the three-dimensional complexity of the aortic root. Volumetric measurement, therefore, seems an ideal alternative for a more accurate assessment. MATERIALS AND METHODS We retrospectively analyzed 123 individuals undergoing cardiac computed tomography. We measured the dimensions of the sinuses of Valsalva using routine multiplanar short axis imaging. Three conventional two-dimensional methods were applied to measure the dimensions of the sinuses. These involved bisecting center of sinus-to-center of interleaflet triangle measures, along with center of sinus-to-center of sinus, and largest sinus-to-sinus measurements. We then quantified the volumes of the root using the volume-rendering method. RESULTS The mean dimensions of the sinuses were significantly greater when measured using the largest sinus-to-sinus method as opposed to center of sinus-to-center of interleaflet triangle and center of sinus-to-center of sinus methods (33.6 ± 3.6 mm vs. 31.1 ± 3.1 mm and 30.9 ± 3.3 mm, p < .0001). The mean root volume of 13.6 ± 4.2 ml showed the strongest correlation with the mean dimensions of the sinuses of Valsalva measured using the bisecting method (R2 = .8401, p < .0001). CONCLUSIONS By using two- and three-dimensional measurements, we have provided average data for the structurally normal aortic root. The differences and correlations encountered should be noted when evaluating and following changes in the diseased root.
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Affiliation(s)
- Masataka Suzuki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yu Izawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shinsuke Shimoyama
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yu Takahashi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Toh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Daisuke Tsuda
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takayoshi Toba
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Sei Fujiwara
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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20
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Almoosawy SA, Lucka P, Cummine R, Buchan K. The aortic root hexagon as an aide memoire to the important surgical landmarks. Clin Anat 2020; 33:1228-1234. [PMID: 31983068 DOI: 10.1002/ca.23571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 01/06/2020] [Accepted: 01/18/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND The anatomy of the aortic root and its relationship to cardiac landmarks is important for valve-sparing surgery and understanding the pathology of lesions arising in this structure. Rapid understanding of the key anatomical details can be achieved by a geometrical concept based on the shape of a hexagon. METHODS Definitions, structure, and key anatomical concepts of the aortic root according to the current literature were reviewed. Thirty pig hearts were dissected to explore the relationships of the six points on the aortic root. Six double 2/0 ethibond needles were placed into the six points at 90°. The passage of the needles through the specific cardiac landmarks at each point was noted. The aortic root hexagon is a geometrical structure formed by two triangles superimposed on each other. The six points in the hexagon relate to important adjacent cardiac landmarks. RESULTS The two best-known anatomical relationships are of the left-non coronary aortic commissure to the longitudinal axis of symmetry of the aortic leaflet of the mitral valve and the relationship of the nadir of the noncoronary aortic valve leaflet to the medial commissure of the mitral valve. The other four points are related to equally significant and well defined anatomical landmarks. CONCLUSION The aortic root hexagon is made by two triangles superimposed on each other, these are the commissural and nadir triangles respectively. We have found this concept to be a quick way to learn and remember the key anatomical relationships of the aortic root.
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Affiliation(s)
- Sayed A Almoosawy
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, UK
| | - Petra Lucka
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
| | - Rhona Cummine
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
| | - Keith Buchan
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
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21
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Toh H, Mori S, Tretter JT, Izawa Y, Shimoyama S, Suzuki M, Takahashi Y, Tsuda D, Toba T, Fujiwara S, Hirata KI, Anderson RH. Living Anatomy of the Ventricular Myocardial Crescents Supporting the Coronary Aortic Sinuses. Semin Thorac Cardiovasc Surg 2020; 32:230-241. [DOI: 10.1053/j.semtcvs.2020.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 01/09/2020] [Indexed: 02/01/2023]
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22
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Bax JJ, Delgado V, Hahn RT, Leipsic J, Min JK, Grayburn P, Sondergaard L, Yoon SH, Windecker S. Transcatheter Aortic Valve Replacement. JACC Cardiovasc Imaging 2020; 13:124-139. [DOI: 10.1016/j.jcmg.2018.10.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 10/15/2018] [Accepted: 10/18/2018] [Indexed: 01/14/2023]
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23
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Mori S, Izawa Y, Shimoyama S, Tretter JT. Three-Dimensional Understanding of Complexity of the Aortic Root Anatomy as the Basis of Routine Two-Dimensional Echocardiographic Measurements. Circ J 2019; 83:2320-2323. [DOI: 10.1253/circj.cj-19-0652] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Yu Izawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | | | - Justin T. Tretter
- Heart Institute, Cincinnati Children’s Hospital Medical Center
- Department of Pediatrics, University of Cincinnati College of Medicine
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24
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Amofa D, Mori S, Toh H, Ta HT, Du Plessis M, Davis N, Izawa Y, Spicer DE, Anderson RH, Tretter JT. The rotational position of the aortic root related to its underlying ventricular support. Clin Anat 2019; 32:1107-1117. [PMID: 31444826 DOI: 10.1002/ca.23462] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/17/2019] [Accepted: 07/22/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Dorothy Amofa
- Department of Anatomical SciencesSt. George's University School of Medicine St. George's Grenada West Indies
| | - Shumpei Mori
- Division of Cardiovascular MedicineKobe University Graduate School of Medicine Kobe Japan
| | - Hiroyuki Toh
- Division of Cardiovascular MedicineKobe University Graduate School of Medicine Kobe Japan
| | - Hieu T. Ta
- The Heart InstituteCincinnati Children's Hospital Medical Center Cincinnati Ohio
| | - Maira Du Plessis
- Department of Anatomical SciencesSt. George's University School of Medicine St. George's Grenada West Indies
| | - Nelson Davis
- Department of Anatomical SciencesSt. George's University School of Medicine St. George's Grenada West Indies
| | - Yu Izawa
- Division of Cardiovascular MedicineKobe University Graduate School of Medicine Kobe Japan
| | - Diane E. Spicer
- Department of Pediatric CardiologyUniversity of Florida Gainesville Florida
| | - Robert H. Anderson
- Institute of Genetic MedicineNewcastle University Newcastle upon Tyne UK
| | - Justin T. Tretter
- The Heart InstituteCincinnati Children's Hospital Medical Center Cincinnati Ohio
- Department of PediatricsUniversity of Cincinnati College of Medicine Cincinnati Ohio
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25
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Gomez-Stallons MV, Tretter JT, Hassel K, Gonzalez-Ramos O, Amofa D, Ollberding NJ, Mazur W, Choo JK, Smith JM, Kereiakes DJ, Yutzey KE. Calcification and extracellular matrix dysregulation in human postmortem and surgical aortic valves. Heart 2019; 105:1616-1621. [PMID: 31171628 DOI: 10.1136/heartjnl-2019-314879] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Calcific aortic valve disease (CAVD) is a progressive disease ranging from aortic valve (AoV) sclerosis to AoV stenosis (AS), characterised by severe calcification with impaired leaflet function. Due to the lack of early symptoms, the pathological progression towards valve dysfunction is poorly understood. The early patterns of AoV calcification and altered extracellular matrix (ECM) organisation were analysed in individuals postmortem without clinical AS compared with clinical AS. METHODS Histological patterns of calcification and ECM organisation in postmortem AoV leaflets without clinical AS obtained from a tissue repository and surgical specimens obtained from individuals with clinical AS were compared with in vivo imaging prior to transcatheter AoV implantation. RESULTS AoV calcification was detected in all samples from individuals >50 years old, with severity increasing with age, independent of known CAVD risk factors. Two distinct types of calcification were identified: 'Intrinsic', primarily found at the leaflet hinge of postmortem leaflets, accompanied by abnormal collagen and proteoglycan deposition; and 'Nodular', extending from the middle to the tip regions in more severely affected postmortem leaflets and surgical specimens, associated with increased elastin fragmentation and loss of elastin integrity. Even in the absence of increased thickening, abnormalities in ECM composition were observed in postmortem leaflets without clinical AS and worsen in clinical AS. CONCLUSIONS Two distinct phenotypes of AoV calcification are apparent. While the 'nodular' form is recognised on in vivo imaging and is present with CAVD and valve dysfunction, it is unclear if the 'intrinsic' form is pathological or detected on in vivo imaging.
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Affiliation(s)
- M Victoria Gomez-Stallons
- Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Justin T Tretter
- Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Keira Hassel
- Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Osniel Gonzalez-Ramos
- Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Dorothy Amofa
- Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicholas J Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Wojciech Mazur
- The Ohio Heart and Vascular Center, The Christ Hospital, Cincinnati, Ohio, USA
| | - Joseph K Choo
- The Ohio Heart and Vascular Center, The Christ Hospital, Cincinnati, Ohio, USA
| | | | - Dean J Kereiakes
- The Ohio Heart and Vascular Center, The Christ Hospital, Cincinnati, Ohio, USA
| | - Katherine E Yutzey
- Molecular Cardiovascular Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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26
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Tretter JT, Mori S. Two-Dimensional Imaging of a Complex Three-Dimensional Structure: Measurements of Aortic Root Dimensions. J Am Soc Echocardiogr 2019; 32:792-794. [DOI: 10.1016/j.echo.2019.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Indexed: 10/27/2022]
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27
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Anderson RH, Mori S. Nomenclature of the components of the aortic root. Eur J Cardiothorac Surg 2019; 55:1020. [PMID: 30428026 DOI: 10.1093/ejcts/ezy358] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/27/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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Tretter JT, Mori S, Anderson RH, Taylor MD, Ollberding N, Truong V, Choo J, Kereiakes D, Mazur W. Anatomical predictors of conduction damage after transcatheter implantation of the aortic valve. Open Heart 2019; 6:e000972. [PMID: 31168378 PMCID: PMC6519402 DOI: 10.1136/openhrt-2018-000972] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/20/2019] [Accepted: 03/04/2019] [Indexed: 01/09/2023] Open
Abstract
Objective Conduction damage following transcatheter aortic valve implantation (TAVI) remains common. Anatomical risk factors remain elusive. We assessed the impact of variability in the dimensions of the membranous septum and position of the aortic root on the occurrence of conduction damage following TAVI. Methods The dimensions of the membranous septum, the rotational position of the aortic root correlating to variability in the central fibrous body width, and wedging of the aortic root were assessed on pre-TAVI CT datasets. The depth of implantation was measured from the final aortic angiogram. The variables were compared with the occurrence of both permanent pacemaker insertion (PPI) and left bundle branch block (LBBB) following TAVI. Results Of 200 patients who met inclusion criteria (mean age = 81 years ± 7.7, 49% men), 20.5 % underwent PPI after TAVI. New LBBB occurred in 23.5%, 21.3 % of whom required PPI. Preprocedural right bundle branch block (OR = 7.00; CI 3.13 to 15.64), valve type (OR=2.35; CI 1.13 to 4.87), depth of implantation (OR=1.62; CI 1.01 to 2.61) and the difference between depth of implantation and the distance from the virtual basal ring to the inferior margin of the membranous septum (OR=0.61; CI 0.38 to 0.99) were all associated with PPI, with similar associations with LBBB. No gross anatomical variable alone was associated with conduction damage. Conclusions Gross anatomical variation of the aortic root and its underlying support, including the membranous septum, were not associated with the occurrence of either PPI or new LBBB. Procedural characteristics associated with these adverse outcomes suggest that the depth of implantation and radial force of the bioprosthesis, regardless of gross anatomical variability, increase the risk for conduction damage.
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Affiliation(s)
- Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Michael D Taylor
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Nicholas Ollberding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Vien Truong
- Department of Ohio Heart and Vascular, The Christ Hospital and Lindner Center for Research and Education, Cincinnati, Ohio, USA
| | - Joseph Choo
- Department of Ohio Heart and Vascular, The Christ Hospital and Lindner Center for Research and Education, Cincinnati, Ohio, USA
| | - Dean Kereiakes
- Department of Ohio Heart and Vascular, The Christ Hospital and Lindner Center for Research and Education, Cincinnati, Ohio, USA
| | - Wojciech Mazur
- Department of Ohio Heart and Vascular, The Christ Hospital and Lindner Center for Research and Education, Cincinnati, Ohio, USA
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Mori S, Tretter JT, Spicer DE, Bolender DL, Anderson RH. What is the real cardiac anatomy? Clin Anat 2019; 32:288-309. [PMID: 30675928 PMCID: PMC6849845 DOI: 10.1002/ca.23340] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/21/2019] [Indexed: 12/24/2022]
Abstract
The heart is a remarkably complex organ. Teaching its details to medical students and clinical trainees can be very difficult. Despite the complexity, accurate recognition of these details is a pre‐requisite for the subsequent understanding of clinical cardiologists and cardiac surgeons. A recent publication promoted the benefits of virtual reconstructions in facilitating the initial understanding achieved by medical students. If such teaching is to achieve its greatest value, the datasets used to provide the virtual images should themselves be anatomically accurate. They should also take note of a basic rule of human anatomy, namely that components of all organs should be described as they are normally situated within the body. It is almost universal at present for textbooks of anatomy to illustrate the heart as if removed from the body and positioned on its apex, the so‐called Valentine situation. In the years prior to the emergence of interventional techniques to treat cardiac diseases, this approach was of limited significance. Nowadays, therapeutic interventions are commonplace worldwide. Advances in three‐dimensional imaging technology, furthermore, now mean that the separate components of the heart can readily be segmented, and then shown in attitudinally appropriate fashion. In this review, we demonstrate how such virtual dissection of computed tomographic datasets in attitudinally appropriate fashion reveals the true details of cardiac anatomy. The virtual approach to teaching the arrangement of the cardiac components has much to commend it. If it is to be used, nonetheless, the anatomical details on which the reconstructions are based must be accurate. Clin. Anat. 32:288–309, 2019. © 2019 The Authors. Clinical Anatomy published by Wiley Periodicals, Inc. on behalf of American Association of Clinical Anatomists.
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Affiliation(s)
- Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Diane E Spicer
- Department of Pediatric Cardiology, University of Florida, Gainesville, Florida
| | - David L Bolender
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle, United Kingdom
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How Do We Reconcile Echocardiography, Computed Tomography, and Hybrid Imaging in Assessing Discordant Grading of Aortic Stenosis Severity? JACC Cardiovasc Imaging 2019; 12:267-282. [DOI: 10.1016/j.jcmg.2018.11.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 12/18/2022]
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Yang E, Schiminger M, Madrazo JA. Unicuspid Aortic Valve Presenting with Decompensated Critical Aortic Stenosis. CASE (PHILADELPHIA, PA.) 2018; 2:129-134. [PMID: 30128410 PMCID: PMC6098169 DOI: 10.1016/j.case.2018.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
•UAV is a rare congenital anomaly that leads to severe symptomatic stenosis.•Echocardiography plays a critical role in the evaluation of aortic stenosis.•Correctly distinguishing between UAV and BAV is relevant in determining intervention.
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Affiliation(s)
- Eunice Yang
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Jose A Madrazo
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
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Hahn RT, Nicoara A, Kapadia S, Svensson L, Martin R. Echocardiographic Imaging for Transcatheter Aortic Valve Replacement. J Am Soc Echocardiogr 2018; 31:405-433. [DOI: 10.1016/j.echo.2017.10.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Indexed: 02/06/2023]
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33
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Mori S, Tretter JT, Toba T, Izawa Y, Tahara N, Nishii T, Shimoyama S, Tanaka H, Shinke T, Hirata KI, Spicer DE, Saremi F, Anderson RH. Relationship between the membranous septum and the virtual basal ring of the aortic root in candidates for transcatheter implantation of the aortic valve. Clin Anat 2018. [DOI: 10.1002/ca.23071] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Justin T. Tretter
- The Heart Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Takayoshi Toba
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Yu Izawa
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Natsuko Tahara
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Tatsuya Nishii
- Department of Radiology; Kobe University Graduate School of Medicine; Kobe Japan
| | - Shinsuke Shimoyama
- Department of Radiology; Kobe University Graduate School of Medicine; Kobe Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Toshiro Shinke
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine; Kobe University Graduate School of Medicine; Kobe Japan
| | - Diane E. Spicer
- Division of Pediatric Cardiology; University of Florida; Gainesville Florida
| | - Farhood Saremi
- University of Southern California; Los Angeles California
| | - Robert H. Anderson
- Institute of Genetic Medicine, Newcastle University; Newcastle-upon-Tyne United Kingdom
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Tretter JT, Mori S, Saremi F, Chikkabyrappa S, Thomas K, Bu F, Loomba RS, Alsaied T, Spicer DE, Anderson RH. Variations in rotation of the aortic root and membranous septum with implications for transcatheter valve implantation. Heart 2017; 104:999-1005. [DOI: 10.1136/heartjnl-2017-312390] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 10/27/2017] [Accepted: 10/30/2017] [Indexed: 12/31/2022] Open
Abstract
ObjectiveIt is intuitive to suggest that knowledge of the variation in the anatomy of the aortic root may influence the outcomes of transcatheter implantation of the aortic valve (TAVI). We have now assessed such variation.MethodsWe used 26 specimens of normal hearts and 78 CT data sets of adults with a mean age of 64±15 years to measure the dimensions of the membranous septum and to assess any influence played by rotation of the aortic root, inferring the relationship to the atrioventricular conduction axis.ResultsThe aortic root was positioned centrally in the majority of both cohorts, although with significant variability. For the cadaveric hearts, 14 roots were central (54%), 4 clockwise-rotated (15%) and 8 counterclockwise-rotated (31%). In the adult CT cohort, 44 were central (56%), 21 clockwise-rotated (27%) and 13 counterclockwise-rotated (17%). A mean angle of 15.5° was measured relative to the right fibrous trigone in the adult CT cohort, with a range of −32° to 44.7°. The dimensions of the membranous septum were independent of rotation. Fibrous continuity between the membranous septum and the right fibrous trigone increased with counterclockwise to clockwise rotation, implying variation in the relationship to the atrioventricular conduction axis.ConclusionsThe central fibrous body is wider, providing greater fibrous support, in the setting of clockwise rotation of the aortic root. Individuals with this pattern may be more vulnerable to conduction damage following TAVI. Knowledge of such variation may prove invaluable for risk stratification.
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Richardson R, Eley L, Donald-Wilson C, Davis J, Curley N, Alqahtani A, Murphy L, Anderson RH, Henderson DJ, Chaudhry B. Development and maturation of the fibrous components of the arterial roots in the mouse heart. J Anat 2017; 232:554-567. [PMID: 29034473 PMCID: PMC5835783 DOI: 10.1111/joa.12713] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2017] [Indexed: 12/22/2022] Open
Abstract
The arterial roots are important transitional regions of the heart, connecting the intrapericardial components of the aortic and pulmonary trunks with their ventricular outlets. They house the arterial (semilunar) valves and, in the case of the aorta, are the points of coronary arterial attachment. Moreover, because of the semilunar attachments of the valve leaflets, the arterial roots span the anatomic ventriculo-arterial junction. By virtue of this arrangement, the interleaflet triangles, despite being fibrous, are found on the ventricular aspect of the root and located within the left ventricular cavity. Malformations and diseases of the aortic root are common and serious. Despite the mouse being the animal model of choice for studying cardiac development, few studies have examined the structure of their arterial roots. As a consequence, our understanding of their formation and maturation is incomplete. We set out to clarify the anatomical and histological features of the mouse arterial roots, particularly focusing on their walls and the points of attachment of the valve leaflets. We then sought to determine the embryonic lineage relationships between these tissues, as a forerunner to understanding how they form and mature over time. Using histological stains and immunohistochemistry, we show that the walls of the mouse arterial roots show a gradual transition, with smooth muscle cells (SMC) forming the bulk of wall at the most distal points of attachments of the valve leaflets, while being entirely fibrous at their base. Although the interleaflet triangles lie within the ventricular chambers, we show that they are histologically indistinguishable from the arterial sinus walls until the end of gestation. Differences become apparent after birth, and are only completed by postnatal day 21. Using Cre-lox-based lineage tracing technology to label progenitor populations, we show that the SMC and fibrous tissue within the walls of the mature arterial roots share a common origin from the second heart field (SHF) and exclude trans-differentiation of myocardium as a source for the interleaflet triangle fibrous tissues. Moreover, we show that the attachment points of the leaflets to the walls, like the leaflets themselves, are derived from the outflow cushions, having contributions from both SHF-derived endothelial cells and neural crest cells. Our data thus show that the arterial roots in the mouse heart are similar to the features described in the human heart. They provide a framework for understanding complex lesions and diseases affecting the aortic root.
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Affiliation(s)
- Rachel Richardson
- Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Lorraine Eley
- Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Charlotte Donald-Wilson
- Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Jonathon Davis
- Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Natasha Curley
- Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Ahlam Alqahtani
- Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Lindsay Murphy
- Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Robert H Anderson
- Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah J Henderson
- Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Bill Chaudhry
- Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
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Khoche S, Ramsingh D, Maus T. The Year in Perioperative Echocardiography: Selected Highlights From 2016. J Cardiothorac Vasc Anesth 2017; 31:1554-1561. [DOI: 10.1053/j.jvca.2017.04.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Indexed: 01/15/2023]
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Hahn RT, Pibarot P. Accurate Measurement of Left Ventricular Outflow Tract Diameter: Comment on the Updated Recommendations for the Echocardiographic Assessment of Aortic Valve Stenosis. J Am Soc Echocardiogr 2017; 30:1038-1041. [DOI: 10.1016/j.echo.2017.06.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Indexed: 11/26/2022]
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Variations in structure of the outflow tract of the human embryonic heart: A new hypothesis for generating bicuspid aortic semilunar valves. Ann Anat 2017; 211:88-103. [PMID: 28179104 DOI: 10.1016/j.aanat.2016.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 12/23/2016] [Accepted: 12/26/2016] [Indexed: 12/25/2022]
Abstract
Outflow tract development of the heart is complex. The presence, differential growth and interactions of the various tissues through space and time contribute to the final development of the tract. This paper presents a novel interpretation of observations of outflow tract development, in particular of the aortic and pulmonary semilunar valves in embryos from the Shaner Collection at the University of Alberta. Three-dimensional reconstructions assist in the visualization of the spatial relationships of the developing valve tissues. In some embryos the aortic intercalated valve swelling is displaced proximally, giving rise to a bicuspid aortic semilunar valve more distally. In addition, the developing valve tissue first appears external to the myocardial cuff. The pulmonary semilunar valve regions appear to be more normal. This paper thus proposes a novel mechanism for generating a bicuspid aortic valve and also supports the idea that there is some independence of the aortic and pulmonary regions from each other during development.
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