1
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Handa K, Kawamura M, Yoshioka D, Saito S, Kawamura T, Kawamura A, Misumi Y, Taira M, Shimamura K, Komukai S, Kitamura T, Miyagawa S. Impact of the Aortomitral Positional Anatomy on Atrioventricular Conduction Disorder Following Mitral Valve Surgery. J Am Heart Assoc 2024; 13:e035826. [PMID: 39158546 DOI: 10.1161/jaha.124.035826] [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: 03/31/2024] [Accepted: 07/26/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Variations in the aortomitral positional anatomy, including aortic root rotation appear to be related to variations in the location of the conduction system, including the bundle of His. However, little is known about their clinical significance. METHODS AND RESULTS This study included 147 patients with normal ECGs who underwent mitral valve surgery. The aortomitral anatomy was classified using preoperative 3-dimensional transesophageal echocardiography, and postoperative conduction disorders, including atrioventricular block and bundle branch block, were analyzed. Variations classified as aortomitral appearance were designated as having a center appearance (85.7%, n=126/147) or lateral appearance (14.3%, n=21/147) on the basis of whether the aortic root was located at the center or was shifted to the left fibrous trigone side. Subsequently, those with a center appearance, aortic root rotation was classified as having a center rotation (83.3% [n=105/126]), in which the commissure of the left and noncoronary aortic leaflet was located at the center, lateral rotation (14.3% [n=18/126]), rotated to the left trigone side, or medial rotation (2.4% [n=3/126]), rotated to the right. The incidence of 3-month persistent new-onset conduction disorder was higher in the lateral appearance than the center appearance group (21.1% versus 5.0%; P=0.031) and higher in the lateral rotation than in the center or medial rotation groups (29.4% versus 1.0% versus 0.0%, respectively; P<0.001). CONCLUSIONS Aortomitral variations can be classified using 3-dimensional transesophageal echocardiography. Lateral appearance and lateral rotation are risk factors for conduction disorders in mitral valve surgery.
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Affiliation(s)
- Kazuma Handa
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Masashi Kawamura
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Shunsuke Saito
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Takuji Kawamura
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Ai Kawamura
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Yusuke Misumi
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Masaki Taira
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Osaka Japan
| | - Sho Komukai
- Department of Integrated Medicine, Institute of Biomedical Statistics, Osaka University Graduate School of Medicine Osaka Japan
| | - Tetsuhisa Kitamura
- Department of Social and Environmental Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Osaka Japan
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2
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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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3
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Nakayama T, Yamamoto J, Ozeki T, Tokoroyama S, Mori Y, Hori M, Tsujita M, Shirasawa Y, Takeda A, Kondo C, Murata M, Suzuki S, Kinoshita Y, Fukuda M, Ueki T, Ikehara N, Sugiura M, Goto T, Hashimoto H, Yajima K, Maruyama S, Koyama H, Morozumi K, Seo Y. Impact of an angulated aorto-septal relationship on cardio-cerebrovascular outcomes in patients undergoing hemodialysis. PLoS One 2024; 19:e0298637. [PMID: 38394305 PMCID: PMC10890729 DOI: 10.1371/journal.pone.0298637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
Aortic and valvular calcification are well-known risk factors for cardio-cerebrovascular events in patients undergoing hemodialysis. We investigated the clinical impact of an angulated aorto-septal angle as a result of aortic elongation due to aortic calcification on cardio-cerebrovascular outcomes in patients undergoing hemodialysis. We investigated 306 patients (mean age 65.4 years, 68% male) who underwent pre-scheduled routine echocardiography between April and September 2018. The angle between the anterior wall of the aorta and the ventricular septal surface (ASA) was quantified. We determined aortic and mitral valve calcification scores based on calcified cardiac changes; the aortic and mitral valve scores ranged between 0-9 and 0-6, respectively. The primary endpoint was a composite including cardio-cerebrovascular events and cardio-cerebrovascular death. The mean duration of dialysis among the patients in this analysis was 9.6 years. The primary endpoint was observed in 54 patients during the observational period (median 1095 days). Multivariable Cox proportional hazards analyses identified left ventricular ejection fraction (per 10% increase: hazard ratio [HR] 0.67; 95% confidential interval [CI] 0.53-0.84, P = 0.001), left ventricular mass index (per 10 g/m2 increase: HR 1.14; 95% CI 1.05-1.24, P = 0.001), ASA (per 10 degree increase: HR 0.69; 95% CI 0.54-0.88; P = 0.003), and aortic valve calcification score (HR 1.15; 95% CI 1.04-1.26, P = 0.005) as independent determinants of the primary endpoint. Kaplan-Meier analysis showed a higher incidence of the primary endpoint in patients with ASA <119.4 degrees than those with ASA ≥119.4 degrees (Log-rank P < 0.001). An angulated aorto-septal angle is an independent risk factor for cardio-cerebrovascular events and cardio-cerebrovascular death in patients undergoing hemodialysis.
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Affiliation(s)
- Takafumi Nakayama
- Department of Cardiology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
- Department of Cardiology, Nagoya City University West Medical Center, Nagoya, Aichi, Japan
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Junki Yamamoto
- Department of Cardiology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Toshikazu Ozeki
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | | | - Yoshiko Mori
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Mayuko Hori
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Makoto Tsujita
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Yuichi Shirasawa
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Asami Takeda
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Chika Kondo
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Minako Murata
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Shigeru Suzuki
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Yuko Kinoshita
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Michio Fukuda
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Tsuneo Ueki
- Department of Urology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Noriyuki Ikehara
- Department of Cardiology, Nagoya City University West Medical Center, Nagoya, Aichi, Japan
| | - Masato Sugiura
- Department of Cardiology, Nagoya City University West Medical Center, Nagoya, Aichi, Japan
| | - Toshihiko Goto
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Hiroya Hashimoto
- Clinical Research Management Center, Nagoya City University Hospital, Nagoya, Aichi, Japan
| | - Kazuhiro Yajima
- Department of Cardiology, Nagoya City University West Medical Center, Nagoya, Aichi, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Hiroichi Koyama
- Department of General Medicine, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Kunio Morozumi
- Department of Nephrology, Masuko Memorial Hospital, Nagoya, Aichi, Japan
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
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4
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Tretter JT, Spicer DE, Macías Y, Talbott C, Kasten JL, Sánchez-Quintana D, Kapadia SR, Anderson RH. Vulnerability of the ventricular conduction axis during transcatheter aortic valvar implantation: A translational pathologic study. Clin Anat 2023. [PMID: 36864653 DOI: 10.1002/ca.24032] [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: 01/23/2023] [Accepted: 03/01/2023] [Indexed: 03/04/2023]
Abstract
The ventricular components of the conduction axis remain vulnerable following transcatheter aortic valvar replacement. We aimed to describe features which may be used accurately by interventionalists to predict the precise location of the conduction axis, hoping better to avoid conduction disturbances. We scanned eight normal adult heart specimens by 3T magnetic resonance, using the images to simulate histological sections in order accurately to place the conduction axis back within the heart. We then used histology, tested in two pediatric hearts, to prepare sections, validated by the magnetic resonance images, to reveal the key relationships between the conduction axis and the aortic root. The axis was shown to have a close relationship to the nadir of the right coronary leaflet, in particular when the aortic root was rotated in counterclockwise fashion. The axis was more vulnerable in the setting of a narrow inferoseptal recess, when the inferior margin of the membranous septum was above the plane of the virtual basal ring, and when minimal myocardium was supporting the right coronary sinus. The features identified in our study are in keeping with the original description provided by Tawara, but at variance with more recent accounts. They suggest that the vulnerability of the axis during transcatheter valvar replacement can potentially be inferred on the basis of knowledge of the position of the aortic root within the ventricular base. If validated by clinical studies, our findings may better permit avoidance of new-onset left bundle branch block following transcatheter aortic valvar replacement.
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Affiliation(s)
- Justin T Tretter
- Department of Pediatric Cardiology, Cleveland Clinic Children's, and Cardiovascular Medicine Department, The Heart, Vascular, & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Congenital Heart Center, UF Health Shands Hospital, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Yolanda Macías
- Department of Medical and Surgical Therapeutics, Faculty of Veterinary, University of Extremadura, Cáceres, Spain
| | - Cheryl Talbott
- Department of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer L Kasten
- Department of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Damián Sánchez-Quintana
- Department of Human Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - Samir R Kapadia
- Cardiovascular Medicine Department, Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
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5
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Kong LY, Liu F, Chen LL, Zhang R, Wang XJ, Zhang P. Longitudinal change, gender difference and hemodynamic implications of aortoseptal angle in adults without structural heart diseases. Int J Cardiol 2022; 359:105-107. [DOI: 10.1016/j.ijcard.2022.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/30/2022] [Accepted: 04/13/2022] [Indexed: 11/05/2022]
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6
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Tsuda D, Mori S, Izawa Y, Toh H, Suzuki M, Takahashi Y, Toba T, Fujiwara S, Tanaka H, Watanabe Y, Kono AK, Hirata KI. Diversity and determinants of the sigmoid septum and its impact on morphology of the outflow tract as revealed using cardiac computed tomography. Echocardiography 2022; 39:248-259. [PMID: 35038184 DOI: 10.1111/echo.15298] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 12/27/2021] [Accepted: 01/01/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The sigmoid septum has been generally evaluated subjectively and qualitatively, without detailed examination of its diversity, impact on the morphology of the left ventricular outflow tract (LVOT), and anatomical background. METHODS We enrolled 100 patients without any background cardiac diseases (67.5 ± 12.8 years old; 43% women) who underwent cardiac computed tomography. Basal septal morphology was evaluated using antero-superior and medial bulging angles (bidirectional angulation of the basal septum relative to the LVOT). The eccentricity index of the LVOT, area narrowing ratio (LVOT/virtual basal ring area), aortic-to-left ventricular axial angle (angulation of the aortic root relative to the left ventricle), and wedged height (non-coronary aortic sinus to inferior epicardium distance) were also quantified. RESULTS The antero-superior bulging, medial bulging, aortic-to-left ventricular axial angles, LVOT eccentricity index, area narrowing ratio, and wedged height were 76° ± 17°, 166° ± 27°, 127° ± 9°, 1.8 ± 0.5, 1.0 ± 0.2, and 41.2 ± 9.1 mm, respectively. Both bulging angles were correlated with each other and contributed to the narrowing and deformation of the LVOT. Angulated aortic root was not correlated with either bidirectional septal bulge or LVOT narrowing. Clockwise rotation of the aortic root rotation was an independent predictor of prominent antero-superior septal bulge. Deeper aortic wedging was a common independent predictor of bidirectional septal bulge. CONCLUSIONS The extent of septal bulge varies in normal hearts. Along with deep aortic wedging, the bidirectional bulge of the basal septum deforms and narrows the LVOT without affecting the virtual basal ring morphology.
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Affiliation(s)
- Daisuke Tsuda
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Yu Izawa
- 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
| | - Masataka Suzuki
- Division of Cardiovascular Medicine, Department of Internal Medicine, 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
| | - 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
| | - Yoshiaki Watanabe
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsushi K Kono
- Department of Radiology, 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
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7
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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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8
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Macías Y, Tretter JT, Sánchez-Quintana D, Cabrera JA, Spicer DE, de Almeida MC, Anderson RH. The atrioventricular conduction axis and the aortic root-Inferences for transcatheter replacement of the aortic valve. Clin Anat 2021; 35:143-154. [PMID: 34580916 DOI: 10.1002/ca.23793] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/19/2021] [Accepted: 09/22/2021] [Indexed: 02/05/2023]
Abstract
Conduction problems still occur following transcatheter aortic valvar replacement. With this in mind, we have assessed the relationship of the conduction axis to the aortic root. We used serial histological sections, made perpendicular to the base of the triangle of Koch in nine hearts, and perpendicular to the aortic root in 11 hearts. We first defined the extent of the fibrous tissues forming the boundaries of an infero-septal recess of the subaortic outflow tract, found in all datasets but one. When the recess was present, the axis penetrated through its rightward wall, giving rise to the left bundle branch prior to entering the outflow tract. The axis itself was usually on the crest of the ventricular septum, but could be deviated leftward or rightward. Its proximity to the virtual basal plane reflected the angulation of the muscular septum. On average, the superior edge of the left bundle was within 3.3 mm of the hinge of the right coronary leaflet, with a range from 0.4 to 10.2 mm. The arrangement was markedly different in the case lacking an infero-septal recess. Our findings necessitated a redefinition of the right fibrous trigone and the central fibrous body. The atrioventricular conduction axis, having entered the aortic root, is usually closest at the hinge of the right coronary leaflet. Knowledge of the depth of the infero-septal recess, and the angulation of the muscular ventricular septal, may help to avoid conduction problems following transcatheter implantation of the aortic valve.
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Affiliation(s)
- Yolanda Macías
- Department of Medical and Surgical Therapeutics, Faculty of Veterinary, University of Extremadura, Cáceres, Spain
| | - Justin T Tretter
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Damián Sánchez-Quintana
- Department of Human Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - José-Angel Cabrera
- Division of Cardiology, Hospital Universitario Quirón Salud, European University of Madrid, Madrid, Spain
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Marcos C de Almeida
- Department of Genetics and Morphology, Brasilia's University, Campus Asa Norte, Brasilia, Brazil
| | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
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9
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Chung BS, Chung MS. Real color volume model of cadaver for learning cardiac computed tomographs and echocardiographs. Surg Radiol Anat 2021; 43:569-576. [PMID: 33646359 DOI: 10.1007/s00276-021-02713-w] [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: 11/18/2020] [Accepted: 02/09/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE It is difficult for medical students and novice clinicians to interpret cardiac computed tomographs and echocardiographs. This study was intended to help familiarize them with the clinical images of the heart by providing software to browse the various planes of a heart's volume model with real color and high resolution. METHODS On the sectioned images of a male cadaver, the heart and adjacent structures were segmented to obtain color-filled images. Volume models of the sectioned images and color-filled images were reconstructed and sectioned to obtain three orthogonal planes and five standard oblique planes. The planes were inputted into lab-made browsing software, which was then distributed free of charge. RESULTS Users of the software would hopefully progress as follows. After experiencing the real color and high resolution, they would become familiar with the grayscale and low resolution. After experiencing the automatic annotation of the basic heart structures, they would become familiar with the detailed structures. After experiencing the designated planes, they would become familiar with the arbitrary planes. After experiencing the still heart, they would become familiar with the moving heart during echocardiography. CONCLUSION The software, with a user-friendly interface and realistic features, is expected to properly orient medical novices to cardiac computed tomography and echocardiography images.
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Affiliation(s)
- Beom Sun Chung
- Department of Anatomy, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Min Suk Chung
- Department of Anatomy, Ajou University School of Medicine, Suwon, Republic of Korea.
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10
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Yamamoto K, Mori S, Fukuzawa K, Miyamoto K, Toba T, Izawa Y, Tanaka H, Kono AK, Hirata KI. Revisiting the prevalence and diversity of localized thinning of the left ventricular apex. J Cardiovasc Electrophysiol 2020; 31:915-920. [PMID: 32090387 DOI: 10.1111/jce.14386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND The left ventricular apex commonly has a paper-thin structure. However, available data about its structure are limited to variable samples, methodologies, and results. OBJECTIVE To investigate the structural anatomy of the left ventricular apex using living heart datasets with the latest computed tomography scanner. METHODS One hundred thirty-one consecutive patients (median age, 73 years; 58% men) who underwent cardiac computed tomography were retrospectively analyzed. Patients with severe aortic stenosis were analyzed separately. Thickness and diameters of the thinnest part of the left ventricular apex during mid-diastole were measured using orthogonal multiplanar reconstruction images. The area of thinning was estimated using the formula for the ellipse. RESULTS In 88 patients without severe aortic stenosis, the median thickness of the thinnest area of the left ventricular apex was only 0.9 mm. Among them, 74%, 99%, and 100% of cases displayed a left ventricular apex thinner than 1.0, 3.0, and 5.0 mm, respectively. The median area of the thinnest region was 5.6 mm2 . In 43 patients with severe aortic stenosis, the median thickness of the thinnest area of the left ventricular apex was 1.2 mm. Among them, 51%, 93%, and 100% of cases displayed a left ventricular apex thinner than 1.0, 3.0, and 5.0 mm, respectively. The median area of the thinnest region was 3.9 mm2 . CONCLUSIONS Localized thinning of the left ventricular apex is unexceptional, regardless of aortic stenosis with concentric left ventricular hypertrophy, thus highlighting the need for a reappreciation of this feature to avoid inadvertent catastrophic complications.
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Affiliation(s)
- Kyoko Yamamoto
- 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
| | - Koji Fukuzawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.,Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Koji Miyamoto
- Division of Arrhythmia and Electrophysiology, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - 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
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsushi K Kono
- Department of Radiology, 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.,Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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11
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Toba T, Mori S, Izawa Y, Toh H, Tsuda D, Shimoyama S, Kawamori H, Otake H, Tanaka H, Fujiwara S, Hirata KI. Ascending aortic elongation and correlative change in overall configuration of the proximal aorta in elderly patients with severe aortic stenosis. Clin Anat 2020; 33:1240-1248. [PMID: 32012343 DOI: 10.1002/ca.23575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/11/2020] [Accepted: 01/22/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Configurational changes in the proximal aorta are relevant to the procedural difficulty of transcatheter aortic valve implantation (TAVI). Among several morphological changes involving the ascending aorta, elongation is characteristics of elderly patients with aortic stenosis and can compromise the success and safety of TAVI. However, the effect of ascending aortic elongation on the overall morphology of the proximal aorta has not been established. AIMS Our primary purpose was to investigate the effect of ascending aortic elongation on structural changes in the proximal aorta in TAVI candidates. MATERIALS & METHODS In total, 121 consecutive patients with severe aortic stenosis (mean age, 84.5 ± 5.3 years; 69% women) who had undergone preprocedural computed tomography before TAVI were enrolled. We examined the structural anatomy of the proximal aorta in detail, focusing on its elongation, dilatation, tilting, rotation, and wedging. RESULTS The mean length of the ascending aorta was 68.0 ± 9.2 mm, and the length was significantly correlated with dilatation (R = .278, p = .002), rightward tilting (R = .437, p < .001), clockwise rotation (R = .228, p = .018), and deep wedging (R = -.366, p < .001) of the proximal aorta. Elongation of the ascending aorta was correlated with dilatation, rightward tilting, clockwise rotation, and deep wedging of the proximal aorta in an elderly population with severe aortic stenosis. DISCUSSION Appreciation of the clinical anatomy around the proximal aorta is required for clinicians involved in TAVI to estimate the procedural difficulty. CONCLUSION Elongation of the ascending aorta was associated with dilatation, rightward tilting, clockwise rotation, and deep wedging of the proximal aorta.
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Affiliation(s)
- Takayoshi Toba
- 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
| | - 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
| | - Shinsuke Shimoyama
- Department of Radiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Kawamori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiromasa Otake
- 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
| | - Sei Fujiwara
- 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
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12
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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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13
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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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14
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Anderson RH, Mohun TJ, Sánchez-Quintana D, Mori S, Spicer DE, Cheung JW, Lerman BB. The anatomic substrates for outflow tract arrhythmias. Heart Rhythm 2019; 16:290-297. [DOI: 10.1016/j.hrthm.2018.08.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Indexed: 12/13/2022]
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15
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Mori S, Nishii T, Tretter JT, Spicer DE, Hirata KI, Anderson RH. Demonstration of living anatomy clarifies the morphology of interatrial communications. Heart 2018; 104:2003-2009. [DOI: 10.1136/heartjnl-2018-313758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/19/2018] [Accepted: 08/07/2018] [Indexed: 11/04/2022] Open
Abstract
Inferences made regarding the postnatal anatomy of the atrial septum still tend to be based on developmental evidence. Although atrial septation is a well-defined process, it is remarkably complex and remains poorly understood. It is now established, however, that the process involves the conjugation of several myocardial structures and mesenchymal tissues of both intracardiac and extracardiac origin. The resultant postnatal morphology is equally complex, evidenced by the fact that, in the normal heart, only the floor of the oval fossa, along with its anteroinferior muscular buttress, are true anatomical septums. In this regard, septums can be defined as partitions that can be removed without creating communications with the extracavitary space. The true septal components are surrounded by grooves, which themselves largely represent infolding of the atrial walls. These anatomical features can now accurately be revealed using virtual dissection of CT data sets. These images, when carefully reconstructed, demonstrated the anatomy with as much accuracy as when hearts are dissected in the autopsy room. Such virtual dissection, furthermore, shows the components as they are seen within the chest, thus facilitating understanding for those intending to undertake interventional therapeutic procedures. By preparing such images, we show the complexity of the normal atrial septum and its surrounds. We show that it is only defects within the oval fossa, or the much rarer vestibular defects, which can appropriately be illustrated in the context of a normally constructed heart.
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16
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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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