Protocol to decellularize porcine right ventricular outflow tracts using a 3D printed flow chamber

Surgical treatment of pediatric congenital heart disease with tissue grafts is a lifesaving intervention. Decellularization to reduce immunogenicity of tissue grafts is an increasingly popular alternative to glutaraldehyde fixation. Here, we present a protocol to decellularize porcine right ventricular outflow tracts using a 3D printed flow chamber. We describe steps for 3D printing the flow rig, preparing porcine tissue, and using the flow rig to utilize shear forces for decellularization. We then detail procedures for characterizing the acellular scaffold. For complete details on the use and execution of this protocol, please refer to Vafaee et al.1.

Surgical Patching in Congenital Heart Disease: The Role of Imaging and Modelling

In congenital heart disease, patches are not tailored to patient-specific anatomies, leading to shape mismatch with likely functional implications. The design of patches through imaging and modelling may be beneficial, as it could improve clinical outcomes and reduce the costs associated with redo procedures. Whilst attention has been paid to the material of the patches used in congenital surgery, this review outlines the current knowledge on this subject and isolated experimental work that uses modelling and imaging-derived information (including 3D printing) to inform the design of the surgical patch.

Reporting involvement activities with children and young people in paediatric research: a framework analysis

BACKGROUND

The active involvement of patients and the public in the design and delivery of health research has been increasingly encouraged, if not enforced. Knowledge of how this is realised in practice, especially where children and young people (CYP) are concerned, is limited, partly due to the low level of reporting of patient and public involvement (PPI) in general. The aim of this work was to assess how researchers funded by the National Institute for Health and Care Research (NIHR) report the involvement of CYP in the design and conduct of child health research to better understand the opportunities offered to CYP, and the realities of involvement in practice.

METHODS

A participation matrix, analysis framework and accompanying tools were adapted from existing frameworks, including a child-rights informed framework, the Guidance for Reporting Involvement of Patients and the Public Checklist Short Form (GRIPP2SF), and NIHR reporting expectations. Child-focused research reports were identified from the NIHR Journals Library, including any interventional or observational study involving CYP aged 0-< 24 years. In two co-design workshops with healthcare professionals and CYP, we tested and refined the participation matrix, analysis framework and accompanying tools.

RESULTS

Only thirty-two NIHR reports out of 169 (19%) were identified as relevant and included reporting of PPI with CYP. We identified significant variability in the way PPI with CYP was reported. Only 4/32 (12%) reports fully met NIHR (and GRIPP2SF) reporting criteria. Only 3/32 (9%) reports formally evaluated or self-reflected on PPI activities with CYP, whilst 15/32 (47%) provided minimal information about CYP involvement. The most common approach to involving CYP (23/32, 72%) was through the medium of existing groups or networks.

CONCLUSION

Despite the NIHR's commitment to increase the quality, transparency, and consistency of reporting PPI, the reporting of involvement with CYP remains sub-optimal. Neglecting to report key details of involvement methods and impacts deprives the research community of knowledge to advance the field of delivering 'meaningful' PPI with CYP. Practical guidance on how researchers can report the processes and outputs of CYP involvement more rigorously may help child health researchers to involve them more meaningfully. This research offers practical tools informed by CYP to aid the reporting process.

The Role of Immersive Virtual Reality and Augmented Reality in Medical Communication: A Scoping Review

Communication between clinicians and patients and communication within clinical teams is widely recognized as a tool through which improved patient outcomes can be achieved. As emerging technologies, there is a notable lack of commentary on the role of immersive virtual reality (VR) and augmented reality (AR) in enhancing medical communication. This scoping review aims to map the current landscape of literature on this topic and highlights gaps in the evidence to inform future endeavors. A comprehensive search strategy was conducted across 3 databases (PubMed, Web of Science, and Embase), yielding 1000 articles, of which 623 were individually screened for relevance. Ultimately, 22 articles were selected for inclusion and review. Similarities across the cohort of studies included small sample sizes, observational study design, use of questionnaires, and more VR studies than AR. The majority of studies found these technologies to improve medical communication, although user tolerability limitations were identified. More studies are required, presenting more robust findings, in order to draw more definitive conclusions and stronger recommendations for use of immersive VR/AR in clinical environments.

"Please keep on beating"-Participation in a Creative Workshop Offers Unexpected Benefits to Women With Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TCM) or "broken heart syndrome" is a rare condition that is more common in women than men, particularly those who are postmenopausal. It mimics a myocardial infarction and psychological factors have been implicated in its etiology as well as being consequences of its presentation. As part of a public engagement project we brought together 8 women (of 12 invited) previously diagnosed with TCM to facilitate a discussion, through participation in a creative workshop-based process, about their illness experience, how they made sense of it, and the meaning it had for them in their lives, and to identify areas of unmet need. Through a range of creative activities we identified that participants had high levels of unmet need in terms of information and psychosocial support. All participants enjoyed the creative process and meeting other people with a diagnosis of TCM. The workshop overall was perceived as empowering. Exploring patient narratives during artist-facilitated workshops is one approach for providing the first steps to addressing unmet need, although the importance of ensuring psychological safety cannot be over-stated.

Feasibility of Wave Intensity Analysis from 4D Cardiovascular Magnetic Resonance Imaging Data

Congenital heart defects (CHD) introduce haemodynamic changes; e.g., bicuspid aortic valve (BAV) presents a turbulent helical flow, which activates aortic pathological processes. Flow quantification is crucial for diagnostics and to plan corrective strategies. Multiple imaging modalities exist, with phase contrast magnetic resonance imaging (PC-MRI) being the current gold standard; however, multiple predetermined site measurements may be required, while 4D MRI allows for measurements of area (A) and velocity (U) in all spatial dimensions, acquiring a single volume and enabling a retrospective analysis at multiple locations. We assessed the feasibility of gathering hemodynamic insight into aortic hemodynamics by means of wave intensity analysis (WIA) derived from 4D MRI. Data were collected in n = 12 BAV patients and n = 7 healthy controls. Following data acquisition, WIA was successfully derived at three planes (ascending, thoracic and descending aorta) in all cases. The values of wave speed were physiological and, while the small sample limited any clinical interpretation of the results, the study shows the possibility of studying wave travel and wave reflection based on 4D MRI. Below, we demonstrate for the first time the feasibility of deriving wave intensity analysis from 4D flow data and open the door to research applications in different cardiovascular scenarios.

Perspectives on medical 3D printing at the point-of-care from the new European 3D Printing Special Interest Group

This editorial presents the vision for the newly formed (2022) European 3D Special Interest Group (EU3DSIG) in the landscape of medical 3D printing. There are four areas of work identified by the EU3DSIG in the current landscape, namely: 1) creating and fostering communication channels among researches, clinicians and industry, 2) generating awareness of hospitals point-of-care 3D technologies; 3) knowledge sharing and education; 4) regulation, registry and reimbursement models.

Assessment of post-infarct ventricular septal defects through 3D printing and statistical shape analysis

BACKGROUND

Post-infarct ventricular septal defect (PIVSD) is a serious complication of myocardial infarction. We evaluated 3D-printing models in PIVSD clinical assessment and the feasibility of statistical shape modeling for morphological analysis of the defects.

METHODS

Models (n = 15) reconstructed from computed tomography data were evaluated by clinicians (n = 8). Statistical shape modeling was performed on 3D meshes to calculate the mean morphological configuration of the defects.

RESULTS

Clinicians' evaluation highlighted the models' utility in displaying defects for interventional/surgical planning, education/training and device development. However, models lack dynamic representation. Morphological analysis was feasible and revealed oval-shaped (n = 12) and complex channel-like (n = 3) defects.

CONCLUSION

3D-PIVSD models can complement imaging data for teaching and procedural planning. Statistical shape modeling is feasible in this scenario.

Prospective multiparametric CMR characterization and MicroRNA profiling of anthracycline cardiotoxicity: A pilot translational study

Background

Anthracycline cardiotoxicity is a significant clinical challenge. Biomarkers to improve risk stratification and identify early cardiac injury are required.

Objectives

The purpose of this pilot study was to prospectively characterize anthracycline cardiotoxicity using cardiovascular magnetic resonance (CMR), echocardiography and MicroRNAs (MiRNAs), and identify baseline predictors of LVEF recovery.

Methods

Twenty-four patients (age 56 range 18-75 years; 42 % female) with haematological malignancy scheduled to receive anthracycline chemotherapy (median dose 272 mg/m2 doxorubicin equivalent) were recruited and evaluated at three timepoints (baseline, completion of chemotherapy, and 6 months after completion of chemotherapy) with multiparametric 1.5 T CMR, echocardiography and circulating miRNAs sequencing.

Results

Seventeen complete datasets were obtained. CMR left ventricular ejection fraction (LVEF) fell significantly between baseline and completion of chemotherapy (61 ± 3 vs 53 ± 3 %, p < 0.001), before recovering significantly at 6-month follow-up (55 ± 3 %, p = 0.018). Similar results were observed for 3D echocardiography-derived LVEF and CMR-derived longitudinal, circumferential and radial feature-tracking strain. Patients were divided into tertiles according to LVEF recovery (poor recovery, partial recovery, good recovery). CMR-derived mitral annular plane systolic excursion (MAPSE) was significantly different at baseline in patients exhibiting poor LVEF recovery (11.7 ± 1.5 mm) in comparison to partial recovery (13.7 ± 2.7 mm), and good recovery (15.7 ± 3.1 mm; p = 0.028). Furthermore, baseline miRNA-181-5p and miRNA-221-3p expression were significantly higher in this group. T2 mapping increased significantly on completion of chemotherapy compared to baseline (54.0 ± 4.6 to 57.8 ± 4.9 ms, p = 0.001), but was not predictive of LVEF recovery. No changes to LV mass, extracellular volume fraction, T1 mapping or late gadolinium enhancement were observed.

Conclusions

Baseline CMR-derived MAPSE, circulating miRNA-181-5p, and miRNA-221-3p were associated with poor recovery of LVEF 6 months after completion of anthracycline chemotherapy, suggesting their potential predictive role in this context. T2 mapping increased significantly on completion of chemotherapy but was not predictive of LVEF recovery.

A Segmental Approach from Molecular Profiling to Medical Imaging to Study Bicuspid Aortic Valve Aortopathy

Bicuspid aortic valve (BAV) patients develop ascending aortic (AAo) dilation. The pathogenesis of BAV aortopathy (genetic vs. haemodynamic) remains unclear. This study aims to identify regional changes around the AAo wall in BAV patients with aortopathy, integrating molecular data and clinical imaging. BAV patients with aortopathy (n = 15) were prospectively recruited to surgically collect aortic tissue and measure molecular markers across the AAo circumference. Dilated (anterior/right) vs. non-dilated (posterior/left) circumferential segments were profiled for whole-genomic microRNAs (next-generation RNA sequencing, miRCURY LNA PCR), protein content (tandem mass spectrometry), and elastin fragmentation and degeneration (histomorphometric analysis). Integrated bioinformatic analyses of RNA sequencing and proteomic datasets identified five microRNAs (miR-128-3p, miR-210-3p, miR-150-5p, miR-199b-5p, and miR-21-5p) differentially expressed across the AAo circumference. Among them, three miRNAs (miR-128-3p, miR-150-5p, and miR-199b-5p) were predicted to have an effect on eight common target genes, whose expression was dysregulated, according to proteomic analyses, and involved in the vascular-endothelial growth-factor signalling, Hippo signalling, and arachidonic acid pathways. Decreased elastic fibre levels and elastic layer thickness were observed in the dilated segments. Additionally, in a subset of patients n = 6/15, a four-dimensional cardiac magnetic resonance (CMR) scan was performed. Interestingly, an increase in wall shear stress (WSS) was observed at the anterior/right wall segments, concomitantly with the differentially expressed miRNAs and decreased elastic fibres. This study identified new miRNAs involved in the BAV aortic wall and revealed the concomitant expressional dysregulation of miRNAs, proteins, and elastic fibres on the anterior/right wall in dilated BAV patients, corresponding to regions of elevated WSS.

Research priorities in children and adults with congenital heart disease: a James Lind Alliance Priority Setting Partnership

OBJECTIVE

To bring together patients, parents, charities and clinicians in a Priority Setting Partnership to establish national clinical priorities for research in children and adults with congenital heart disease.

METHODS

The established James Lind Alliance methodology was used to identify and prioritise research on the management of congenital heart disease, focusing on diagnosis, treatment and outcomes. An initial open survey was used to gather potential uncertainties which were filtered, categorised, converted into summary questions and checked against current evidence. In a second survey, respondents identified the unanswered questions most important to them. At two final workshops, patients, parents, charities and healthcare professionals agreed the top 10 lists of priorities for child/antenatal and adult congenital heart disease research.

RESULTS

524 respondents submitted 1373 individual questions, from which 313 out of scope or duplicate questions were removed. The remaining 1060 questions were distilled into summary questions and checked against existing literature, with only three questions deemed entirely answered and removed. 250 respondents completed the child/antenatal survey (56 uncertainties) and 252 completed the adult survey (47 uncertainties). The questions ranked the highest by clinicians and non-clinicians were taken forward to consensus workshops, where two sets of top 10 research priorities were agreed.

CONCLUSIONS

Through an established and equitable process, we determined national clinical priorities for congenital heart disease research. These will be taken forward by specific working groups, a national patient and public involvement group, and through the establishment of a UK and Ireland network for collaborative, multicentre clinical trials in congenital heart disease.

Relationship between Pulmonary Regurgitation and Ventriculo-Arterial Interactions in Patients with Post-Early Repair of Tetralogy of Fallot: Insights from Wave-Intensity Analysis

This study aimed to investigate the effect of pulmonary regurgitation (PR) on left ventricular ventriculo-arterial (VA) coupling in patients with repaired tetralogy of Fallot (ToF). It was hypothesised that increasing PR severity results in a smaller forward compression wave (FCW) peak in the aortic wave intensity, because of right-to-left ventricular interactions. The use of cardiovascular magnetic resonance (CMR)-derived wave-intensity analysis provided a non-invasive comparison between patients with varying PR degrees. A total of n = 201 patients were studied and both hemodynamic and wave-intensity data were compared. Wave-intensity peaks and areas of the forward compression and forward expansion waves were calculated as surrogates of ventricular function. Any extent of PR resulted in a significant reduction in the FCW peak. A correlation was found between aortic distensibility and the FCW peak, suggesting unfavourable (VA) coupling in patients that also present stiffer ascending aortas. Data suggest that VA coupling is affected by increased impedance.

Molecular and haemodynamic interplay in bicuspid aortic valve aortopathy: segmental differences across the aortic circumference

Background

Bicuspid aortic valve (BAV) patients develop ascending aortic (AAo) dilation. The pathogenesis of BAV-aortopathy (genetic vs. hemodynamic) remains unclear.

Purpose

To identify regional changes around the AAo wall in BAV patients with aortopathy integrating clinical imaging and molecular data.

Methods

BAV patients with aortopathy (n=20) were recruited prospectively to surgically collect aortic tissue and perform four-dimensional cardiac magnetic resonance (CMR) scans. Molecular markers were measured analysing the tissue biopsies (n=15) and wall shear stress (WSS) across the AAo circumference was calculated from the 4D CMR data (n=11 patients, and n=7 additional healthy volunteers for comparison). Dilated (anterior/right) vs. non-dilated (posterior/left) circumferential segments were profiled for whole genomic microRNAs (Next Generation RNA-Sequencing, miRCURY LNA PCR), proteins content (Tandem Mass Spectrometry) and elastin fragmentation and degeneration (histomorphometric analysis). Picture 1 summarises the study approach (including a map of the AAo divided in the following segments: A=anterior, AR=anterior-right, PR=posterior-right, P=posterior, PL=posterior-left, AL=anterior-left).

Results

Integrated bioinformatic analyses of RNA-sequencing and proteomic datasets identified 5 microRNAs (miR-128-3p, miR-210-3p, miR-150-5p, miR-199b-5p, and miR-21-5p) differentially expressed across the AAo circumference. Among them, three miRNAs (miR-128-3p, miR-150-5p, and miR-199b-5p) were predicted to have an effect on eight common target genes, whose expression was dysregulated according to proteomic analyses and involved in vascular endothelial growth factor signalling, hippo signaling and arachidonic acid pathway. Decreased elastic fibre levels and elastic layer thickness were observed in the dilated segments in the histomorphometric analysis. Increased WSS and flow-velocity, helical streamlines and asymmetrical flow were observed at the anterior/right wall in asymmetrically and symmetrically dilated patients (the latter exhibiting higher WSS), compared to healthy volunteers.

Conclusion

This study has newly revealed concomitant expressional dysregulation of miRNAs, proteins, and elastic fibres on the anterior/right wall in dilated BAV patients, corresponding to regions of elevated WSS, contributing to advance the understanding of the interplay of genetic and hemodynamic factors underpinning BAV aortopathy.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation and Above & Beyond

Feasibility of a longitudinal statistical atlas model to study aortic growth in congenital heart disease

Background

Studying anatomical shape progression over time is of utmost importance to refine our understanding of clinically relevant processes. These include vascular remodelling, such as aortic dilation, which is particularly important in some congenital heart defects (CHD).

Purpose

A novel methodological framework for analysing three-dimensional (3D) shape changes over time (“growth”) has been applied for the first time in a CHD scenario, i.e., bicuspid aortic valve (BAV) disease, the most common CHD.

Methods

Three-dimensional aortic shapes (n=94) reconstructed as surface meshes from cardiovascular magnetic resonance imaging (MRI) data represented the input for a longitudinal shape atlas model, using multiple scans over time (n=2–4 scans per patient). This model relies on diffeomorphic transformations in the absence of point-to-point correspondence, and on the correct combination of initialization, estimation, and registration parameters.

Results

We computed the 3D shape trajectory of an average disease progression over time in our cohort (Picture 1, grey to blue shapes), as well as time-dependent parameters, geometric variations and the average shape of the population (Picture 1, red shape). Results cover a spatiotemporal spectrum of visual and numerical information that can be further used to investigate clinical associations and stratify patients, as such capturing aortic remodelling in the presence of BAV aortopathy.

Conclusion

This proof-of-concept study demonstrates the feasibility of applying advanced statistical shape models to track disease progression and stratify patients with CHD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation and NIHR BRC

Left ventricular morphology in patients with aortic coarctation and bicuspid aortic valve: novel insights from a statistical shape modelling framework

Background

The functional implications of left ventricular (LV) morphological characterization in congenital heart disease (CHD) are not widely explored.

Purpose

This study qualitatively and quantitatively assessed LV shape associations with a) LV function and b) thoracic aortic morphology in patients with aortic coarctation (CoA) with/without bicuspid aortic valve (BAV).

Methods

A statistical shape modelling (SSM) framework was employed to analyse three-dimensional (3D) LV shapes from cardiac magnetic resonance (CMR) imaging data in n=110 cases including: isolated CoA (n=25), CoA+BAV (n=30), isolated BAV (n=30), and age-matched healthy controls (n=25). Average 3D templates (Picture 1) and deformations were computed. Correlations between shape data and CMR-derived morphometric parameters (i.e. sphericity, conicity) as well as CMR-derived global and apical strain values were assessed to elucidate possible functional implications. The relationship between LV shape features and arch architecture (i.e. gothicity, tortuosity) was also explored by means of regression analysis.

Results

The LV template was shorter and more spherical in CoA patient (Picture 1), as also confirmed by statistical analysis of the SSM-derived shape modes. LV sphericity, which was higher in CoA, was associated (p≤0.04) with lower global longitudinal, radial and circumferential strain, irrespective of the presence of aortic stenosis and/or regurgitation. Conversely, neither LV morphology nor LV strain was not associated with arch architecture.

Conclusions

Differences in LV morphology were observed between CoA and BAV patients. Increasing LV sphericity was associated with reduced strain, independent of aortic arch architecture and functional aortic valve disease.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation and NIHR BRC

What Arts-and-Health Practices Teach Us About Participation, Re-presentation, and Risk

This article explores the implications of risk in arts-and-health collaborations that represent illness narratives for the purpose of engaging the public. Based on an artist's, bioengineer's, and health psychologist's reflections from pediatric and adult group workshop practice settings, this article canvasses 8 dimensions of risk that deserve ethical attention.

Three-Dimensional Printed Models of the Heart Represent an Opportunity for Inclusive Learning

Three-dimensional (3D) printed models of anatomic structures offer an alternative to studying manufactured, "idealized" models or cadaveric specimens. The utility of 3D printed models of the heart for clinical veterinary students learning echocardiographic anatomy is unreported. This study aimed to assess the feasibility and utility of 3D printed models of the canine heart as a supplementary teaching aid in final-year vet students. We hypothesized that using 3D printed cardiac models would improve test scores and feedback when compared with a control group. Students (n = 31) were randomized to use either a video guide to echocardiographic anatomy alongside 3D printed models (3DMs) or video only (VO). Prior to a self-directed learning session, students answered eight extended matching questions as a baseline knowledge assessment. They then undertook the learning session and provided feedback (Likert scores and free text). Students repeated the test within 1 to 3 days. Changes in test scores and feedback were compared between 3DM and VO groups, and between track and non-track rotation students. The 3DM group had increased test scores in the non-track subgroup. Track students' test scores in the VO group increased, but not in the 3DM group. Students in the 3DM group had a higher completion rate, and more left free-text feedback. Feedback from 3DM was almost universally positive, and students believed more strongly that these should be used for future veterinary anatomy teaching. In conclusion, these pilot data suggest that 3D printed canine cardiac models are feasible to produce and represent an inclusive learning opportunity, promoting student engagement.

The use of 3D-printed models in patient communication: a scoping review

3D models have been used as an asset in many clinical applications and a variety of disciplines, and yet the available literature studying the use of 3D models in communication is limited. This scoping review has been conducted to draw conclusions on the current evidence and learn from previous studies, using this knowledge to inform future work. Our search strategy revealed 269 papers, 19 of which were selected for final inclusion and analysis. When assessing the use of 3D models in doctor-patient communication, there is a need for larger studies and studies including a long-term follow up. Furthermore, there are forms of communication that are yet to be researched and provide a niche that may be beneficial to explore.

Feasibility of a longitudinal statistical atlas model to study aortic growth in congenital heart disease

Studying anatomical shape progression over time is of utmost importance to refine our understanding of clinically relevant processes. These include vascular remodeling, such as aortic dilation, which is particularly important in some congenital heart defects (CHD). A novel methodological framework for three-dimensional shape analysis has been applied for the first time in a CHD scenario, i.e., bicuspid aortic valve (BAV) disease, the most common CHD. Three-dimensional aortic shapes (n = 94) reconstructed from cardiovascular magnetic resonance imaging (MRI) data as surface meshes represented the input for a longitudinal atlas model, using multiple scans over time (n = 2-4 per patient). This model relies on diffeomorphism transformations in the absence of point-to-point correspondence, and on the right combination of initialization, estimation and registration parameters. We computed the shape trajectory of an average disease progression in our cohort, as well as time-dependent parameters, geometric variations and the average shape of the population. Results cover a spatiotemporal spectrum of visual and numerical information that can be further used to run clinical associations. This proof-of-concept study demonstrates the feasibility of applying advanced statistical shape models to track disease progression and stratify patients with CHD.

Isolating the Effect of Arch Architecture on Aortic Hemodynamics Late After Coarctation Repair: A Computational Study

Objectives

Effective management of aortic coarctation (CoA) affects long-term cardiovascular outcomes. Full appreciation of CoA hemodynamics is important. This study aimed to analyze the relationship between aortic shape and hemodynamic parameters by means of computational simulations, purposely isolating the morphological variable.

Methods

Computational simulations were run in three aortic models. MRI-derived aortic geometries were generated using a statistical shape modeling methodology. Starting from n = 108 patients, the mean aortic configuration was derived in patients without CoA (n = 37, "no-CoA"), with surgically repaired CoA (n = 58, "r-CoA") and with unrepaired CoA (n = 13, "CoA"). As such, the aortic models represented average configurations for each scenario. Key hemodynamic parameters (i.e., pressure drop, aortic velocity, vorticity, wall shear stress WSS, and length and number of strong flow separations in the descending aorta) were measured in the three models at three time points (peak systole, end systole, end diastole).

Results

Comparing no-CoA and CoA revealed substantial differences in all hemodynamic parameters. However, simulations revealed significant increases in vorticity at the site of CoA repair, higher WSS in the descending aorta and a 12% increase in power loss, in r-CoA compared to no-CoA, despite no clinically significant narrowing (CoA index >0.8) in the r-CoA model.

Conclusions

Small alterations in aortic morphology impact on key hemodynamic indices. This may contribute to explaining phenomena such as persistent hypertension in the absence of any clinically significant narrowing. Whilst cardiovascular events in these patients may be related to hypertension, the role of arch geometry may be a contributory factor.

Role of 3D printing technology in paediatric teaching and training: a systematic review

BACKGROUND

In the UK, undergraduate paediatric training is brief, resulting in trainees with a lower paediatric knowledge base compared with other aspects of medicine. With congenital conditions being successfully treated at childhood, adult clinicians encounter and will need to understand these complex pathologies. Patient-specific 3D printed (3DP) models have been used in clinical training, especially for rarer, complex conditions. We perform a systematic review to evaluate the evidence base in using 3DP models to train paediatricians, surgeons, medical students and nurses.

METHODS

Online databases PubMed, Web of Science and Embase were searched between January 2010 and April 2020 using search terms relevant to "paediatrics", "education", "training" and "3D printing". Participants were medical students, postgraduate trainees or clinical staff. Comparative studies (patient-specific 3DP models vs traditional teaching methods) and non-comparative studies were included. Outcomes gauged objective and subjective measures: test scores, time taken to complete tasks, self-reported confidence and personal preferences on 3DP models. If reported, the cost of and time taken to produce the models were noted.

RESULTS

From 587 results, 15 studies fit the criteria of the review protocol, with 5/15 being randomised controlled studies and 10/15 focussing on cardiovascular conditions. Participants using 3DP models demonstrated improved test scores and faster times to complete procedures and identify anatomical landmarks compared with traditional teaching methods (2D diagrams, lectures, videos and supervised clinical events). User feedback was positive, reporting greater user self-confidence in understanding concepts with users wishing for integrated use of 3DP in regular teaching. Four studies reported the costs and times of production, which varied depending on model complexity and printer. 3DP models were cheaper than 'off-the-shelf' models available on the market and had the benefit of using real-world pathologies. These mostly non-randomised and single-centred studies did not address bias or report long-term or clinically translatable outcomes.

CONCLUSIONS

3DP models were associated with greater user satisfaction and good short-term educational outcomes, with low-quality evidence. Multicentred, randomised studies with long-term follow-up and clinically assessed outcomes are needed to fully assess their benefits in this setting.

PROSPERO REGISTRATION NUMBER

CRD42020179656.

Educational attainment in patients with congenital heart disease: a comprehensive systematic review and meta-analysis

BACKGROUND

Our aim was to comprehensively review published evidence on the association between having a congenital heart disease (CHD) compared with not, on educational attainment (i.e. not obtaining a university degree, completing secondary education, or completing any vocational training vs. obtaining/completing) in adults.

METHOD

Studies were eligible if they reported the rate, odds, or proportion of level of educational attainment in adults by whether or not they had a CHD.

RESULT

Out of 1537 articles screened, we identified 11 (N = 104,585 participants, 10,487 with CHD), 10 (N = 167,470 participants, 11,820 with CHD), and 8 (N = 150,813 participants, 9817 with CHD) studies reporting information on university education, secondary education, and vocational training, respectively in both CHD and non-CHD participants. Compared to their non-CHD peers, CHD patients were more likely not to obtain a university degree (OR = 1.38, 95% CI [1.16, 1.65]), complete secondary education (OR = 1.33, 95% CI [1.09, 1.61]) or vocational training (OR = 1.11, 95% CI [0.98, 1.26]). For all three outcomes there was evidence of between study heterogeneity, with geographical area contributing to this heterogeneity.

CONCLUSION

This systematic review identified all available published data on educational attainment in CHD patients. Despite broad inclusion criteria we identified relatively few studies that included a comparison group from the same population, and amongst those that did, few adjusted for key confounders. Pooled analyses suggest evidence of lower levels of educational attainment in patients with CHD when compared to non-CHD peers. The extent to which this may be explained by confounding factors, such as parental education, or mediated by treatments is not possible to discern from the current research literature.

Cardiovascular magnetic resonance characterisation of anthracycline cardiotoxicity in adults with normal left ventricular ejection fraction

BACKGROUND

Anthracycline therapy may lead to changes in cardiac structure and function not detectable by solely evaluating left ventricular ejection fraction (LVEF).

OBJECTIVES

We hypothesized that cardiovascular magnetic resonance (CMR) would identify structural and functional myocardial abnormalities in anthracycline-treated cancer survivors with normal LVEF, compared to a matched control population.

METHODS

Forty-five cancer survivors (56 ± 16 yrs., 60% female) with normal LVEF (59.5 ± 4.1%) were studied a median of 11 months (range 3-36) following administration of 237 ± 83 mg/m² anthracycline, and compared with forty-five healthy control subjects of similar age and sex (53 ± 16 yrs., 60% female) with normal LVEF (60.8 ± 2.4%) using 1.5 T CMR.

RESULTS

Significantly smaller indexed left ventricular mass (45.6 ± 8.7 vs 50.3 ± 10.1 g/m², p = 0.02) and indexed myocardial cell volume (30.5 ± 5.7 vs 34.8 ± 7.2 ml/m², p = 0.002) were evident in cancer survivors and the latter was inversely associated with cumulative anthracycline dose (r = -0.31, p = 0.02). Surrogate CMR markers of myocardial fibrosis were significantly increased in cancer survivors (native myocardial T₁: 1021 ± 40 vs 996 ± 35 ms, p = 0.002; extracellular volume: 29.5 ± 4.5 vs 27.4 ± 2.3%, p = 0.006). CMR-derived feature-tracking global longitudinal strain (GLS) was significantly impaired in cancer survivors (2D GLS -18.3 ± 2.6 vs -20.0 ± 2.0%, p < 0.001; 3D GLS -14.5 ± 2.3 vs -16.4 ± 2.6%, p < 0.001). Parameters exhibited good to excellent (ICC = 0.86-0.98) inter- and intra-observer reproducibility.

CONCLUSIONS

Anthracycline-treated cancer survivors with normal LVEF have significant perturbations of LV mass, myocardial cell volume, native myocardial T1, ECV, CMR-derived 2D and 3D GLS, compared to controls, with good to excellent levels of inter- and intra-observer reproducibility.

Diagnostic and prognostic role of peak troponin T in patients with acute coronary syndromes and non-obstructive coronary arteries

Background

Up to 10% of patients who present with an acute coronary syndrome have a myocardial infarction with non-obstructive coronary arteries (MINOCA). Troponin T predicts infarct size and outcomes in patients with ST-elevation myocardial infarction. The value of peak troponin T in patients with a working diagnosis of MINOCA is not well understood.

Purpose

The aim of this study is to investigate the diagnostic and prognostic role of troponin in patients with MINOCA.

Methods

Consecutive patients with a working diagnosis of MINOCA from a single tertiary centre who underwent comprehensive cardiovascular magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) were followed prospectively. Peak troponin T was identified during the index admission and divided into deciles and quartiles for analysis. The primary endpoint was all-cause mortality.

Results

Among 796 patients undergoing CMR, 719 met the study criteria and had underwent a diagnostic quality scan. The peak Troponin T threshold for optimal diagnostic sensitivity and specificity was 211 ng/L. Peak troponin T ≥211 ng/L and time to CMR of ≤14 days has a sensitivity of 94%, specificity of 35%, PPV 57% and NPV 94% for the CMR making a diagnosis. Each increase in troponin decile increases the mean diagnostic yield of the CMR by 3.65% (p&lt;0.001, 95% CI 3.38 – 3.91; R2 0.84; Figure 1).

If the troponin is in the lowest decile and the CMR is performed at ≤14 days, the diagnostic yield is still 72%. There is no overall difference in median troponin in patients who died and those who survived (229 ng/l v. 424 ng/l; p=0.157), however mortality is significantly lower in the highest two troponin quartiles (6.9% versus 11.9%; p=0.009; Figure 2).

Conclusion

Peak troponin T is readily available during the index admission in patients presenting with MINOCA and provides useful diagnostic and prognostic information for the attending cardiologist.

Funding Acknowledgement

Type of funding sources: None. Figure 1. CMR diagnosis by troponin decileFigure 2. Mortality by troponin quartile

Sex and age differences in patients with acute coronary syndrome and non-obstructive coronary arteries: presentation and outcome

Aims

A substantial number of patients present with acute coronary syndrome (ACS) and non-obstructive coronary arteries. Sex and age differences in these patients are not well understood. This study aims to evaluate the impact of sex and age on clinical presentation and outcome in patients with ACS and non-obstructive coronary arteries, with either an ischaemic or non-ischaemic cause.

Methods and results

Consecutive patients with an ACS and non-obstructive coronary arteries (n=719) from a single tertiary centre underwent comprehensive cardiovascular magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE). The primary endpoint was all-cause mortality. CMR was performed at a median time of 30 days after presentation and identified a diagnosis in 74% of patients. Patients with an ischaemic or non-ischaemic aetiology (n=529) on CMR were followed prospectively. All-cause mortality was 11% over a median follow up of 4.9 years, with no significant difference between sexes (11% versus 11% p=0.732). Women were more likely to have an ischaemic aetiology on CMR (40% v 31%, p=0.037). Age group (HR 1.48, p=0.002), log peak troponin (HR 0.78, p=0.033) and LVEF (HR 0.98, p=0.032) were independent predictors of mortality. Men aged &gt;60 years with a non-ischaemic aetiology on their CMR were at higher risk of death than women &gt;60 years (p=0.003).

Conclusions

There is no difference in all-cause mortality between sexes in patients presenting with ACS and non-obstructive coronary arteries but increasing age is an important predictor of mortality in both sexes.

Funding Acknowledgement

Type of funding sources: None. Sex differences in CMR diagnosisSex, age and mortality

Long-term outcome of myocardial scarring and deformation with cardiovascular magnetic resonance in out of hospital cardiac arrest survivors

AIMS

Cardiovascular magnetic resonance (CMR) is increasingly recognized as a diagnostic and prognostic tool in out of hospital cardiac arrest (OHCA) survivors. After assessing CMR findings early after ventricular fibrillation (VF) OHCA, we sought to explore the long-term outcome of myocardial scarring and deformation.

METHODS AND RESULTS

We included 121 consecutive VF OHCA survivors (82% male, median 62 years) undergoing CMR within 2 weeks from cardiac arrest. Late gadolinium-enhancement (LGE) was quantified using the full width at half maximum method and tissue tracking analysis software was used to assess myocardial deformation. LGE was found in 71% of patients (median LGE mass 6.2% of the left ventricle, LV), mainly with an ischaemic pattern. Myocardial deformation was overall impaired and showed a significant correlation with LGE presence and extent (P < 0.001). A composite end-point of all-cause mortality and appropriate ICD discharge/anti-tachycardia pacing was met in 24% of patients. Patients meeting the end-point had significantly greater LGE extent (8.6% of LV myocardium vs. 4.1%, P = 0.02), while there was no difference with regards to myocardial deformation. Survival rate was significantly lower in patients with LGE (P = 0.05) and LGE mass >4.4% of the LV identified a group of patients at higher risk of adverse events (P = 0.005).

CONCLUSIONS

We found a high prevalence of LGE, early after OHCA, and an overall impaired myocardial deformation. On long-term follow-up both LGE presence and extent showed a significant association with recurrent adverse events, while LV ejection fraction and myocardial deformation did not identify patients with an unfavourable outcome.

The role of peak troponin in patients with a working diagnosis of myocardial infarction with non-obstructive coronary arteries (MINOCA)

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Rosetrees Trust James Tudor Foundation

Background

6-10% of patients who present with an acute coronary syndrome have a myocardial infarction with non-obstructive coronary arteries (MINOCA). Troponin T predicts infarct size and outcomes in patients with ST-elevation myocardial infarction. The value of peak troponin T in patients with a working diagnosis of MINOCA is not well understood.

Purpose

The aim of this study is to investigate the diagnostic and prognostic role of troponin in patients with MINOCA. 

Methods

Consecutive patients with a working diagnosis of MINOCA (n = 719) from a single tertiary centre who underwent comprehensive cardiovascular magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) were followed prospectively. The primary endpoint was all-cause mortality.

Results

Peak troponin T ≥211 ng/L and time to CMR of ≤17 days have a positive predictive value of 94% for being able to make a diagnosis on CMR. If the scan was performed in ≤17 days the diagnostic yield was still 75% even in the lowest troponin decile, but this was 59% if performed after 17 days. Each increase in troponin decile increases the mean diagnostic yield of the CMR by 3.7% (p &lt; 0.001, 95% CI 3.4 – 3.9; R2 0.84; Figure 1). There is no overall difference in median troponin in patients who died and those who survived (229 ng/l v. 424 ng/l; p = 0.157), however mortality is significantly lower in the highest two troponin quartiles (11.9% versus 6.9%; p = 0.009, figure 2). 

Conclusions

Peak troponin T and time to CMR can be used by cardiologists to determine the likelihood of making a diagnosis using CMR. A higher troponin quartile is associated with lower mortality.

Sex and age differences in patients with a working diagnosis of myocardial infarction with non-obstructive coronary arteries (MINOCA): presentation and outcome

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Rosetrees Trust James Tudor Foundation

Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) is an increasingly recognised working diagnosis. Sex and age differences in MINOCA are not well understood.

Purpose  This study aims to evaluate the impact of sex and age in patients with MINOCA due to ischaemic and non-ischaemic causes on clinical presentation and outcome.

Methods and Results Consecutive patients with a working diagnosis of MINOCA (n = 719) from a single tertiary centre who underwent comprehensive cardiovascular magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) were followed prospectively. The primary endpoint was all-cause mortality.  CMR was performed at a median time of 30 days after presentation and identified a diagnosis in 74% of patients. Men were more likely to have a non-ischaemic cause on CMR (55% v. 41%, p &lt; 0.001) and less likely to have a normal/non-specific scan (21% v. 32%, p = 0.001, figure 1).  All-cause mortality was 9.5% over a median follow up of 4.9 years, with no significant difference between sexes (8.7% versus 10.1% p = 0.456).  Age group (HR 1.61, p &lt; 0.001) and LVEF (HR 0.98, p = 0.020) were independent predictors of mortality. Men aged &gt;60 years with a non-ischaemic aetiology on their CMR were at higher risk of death than women with non-ischaemic causes &gt;60 years (p = 0.003, figure 2).

Conclusions There is no difference in all-cause mortality between sexes in MINOCA but increasing age is the most important predictor of mortality in both sexes.

Pregnancy in the FONTAN palliation: physiology, management and new insights from bioengineering

Fontan palliation for the single ventricle results in a challenging and delicate physiological state. At rest, the body adapts to a low cardiac output and high systemic venous pressure. However, when physiological demands increase, such as in the case of exercise or pregnancy, this delicate physiology struggles to adapt due to the inability of the heart to pump blood into the lungs and the consequent lack of augmentation of the cardiac output.

Due to the advances in paediatric cardiology, surgery and intensive care, today most patients born with congenital heart disease reach adulthood. Consequently, many women with a Fontan circulation are becoming pregnant and so far data suggest that, although maternal risk is not high, the outcomes are poor for the foetus. Little is known about the reasons for this disparity and how the Fontan circulation adapts to the physiological demands of pregnancy.

Here we review current knowledge about pregnancy in Fontan patients and explore the potential role of computational modelling as a means of better understanding this complex physiology in order to potentially improve outcomes, particularly for the foetus.

Routine surveillance of patients post Fontan palliation: lessons learnt from cardiac catheterisation

Background

There is no consensus on the clinical utility of ‘routine’ diagnostic cardiac catheterisation in patients with Fontan palliation in the absence of symptoms or haemodynamic lesions.

Objective

We sought to evaluate whether diagnostic cardiac catheterisation for a variety of indications led to a change in the clinical management of patients with a Fontan circulation.

Methods

All adult patients (≥16 years) with Fontan palliation undergoing diagnostic cardiac catheterisation at our institution from 2016 to 2019 were included retrospectively. Patients undergoing electrophysiological studies were excluded as haemodynamic measurements were not taken. Routine cardiac catheterisation at our institution is considered in adult patients who have not had a diagnostic cardiac catheter for more than 5 years.

Results

Thirty-eight patients, mean age 27 ± 7 years, 60% NYHA I, 31% NYHA II, 8% NYHA III, at mean duration post Fontan of 20 ± 6 years, lateral tunnel (LT) n = 20, extracardiac (EC) n = 14 and atriopulmonary (AP) n = 4, underwent 41 diagnostic cardiac catheterisation procedures. Indication for cardiac catheterisation was as follows: haemodynamic lesion identified on cross-sectional imaging in 12; routine catheterisation in 9; cyanosis in 8; dyspnoea in 8; significant liver stiffness on ultrasound hepatic elastography in 2; and arrhythmia in 2. Of the 9 patients undergoing routine diagnostic catheterisation, 3 had not had any diagnostic catheterisation since their Fontan completion and, in the remaining six, the mean time lapsed since the last diagnostic catheter was 8 ± 3 years. The diagnostic catheterisation led to a recommended change in clinical management on 24 occasions (59%): catheter intervention in 17 (40%); surgery in 4 (10%); medication change in 3 (17%); and transplant referral in 2 (5%). The clinical indications that led to changes in clinical management were: cyanosis (8/8), dyspnoea (7/8), haemodynamic lesions on cross-sectional imaging (8/11) and arrhythmia (1/2). None of the 9 patients listed for routine diagnostic catheterisation or as a result of findings on ultrasound hepatic elastography had a recommended change in clinical management.

Conclusion

Diagnostic cardiac catheterisation frequently leads to changes in the clinical management of patients with Fontan palliation presenting with dyspnoea, cyanosis, and for further evaluation of potential haemodynamic lesions identified on cross-sectional imaging. Routine cardiac catheterisation in the absence of the above indications had limited impact on clinical management in our cohort.

Case of placental insufficiency and premature delivery in a Fontan pregnancy: physiological insights and considerations on risk stratification

OBJECTIVES

The coexistence of two complex physiologies such as Fontan and pregnancy is still not fully understood. We aim to add a unique and essential knowledge to help our colleagues in the management of Fontan patients that undergo pregnancy as well as the fetus and the placenta perfusion.

METHODS AND RESULTS

We analyse the coexistence of Fontan and pregnancy physiology on a complex case of a woman with hypoplastic left heart syndrome palliated with a univentricular repair who became pregnant, delivered very prematurely and had atypical placental findings.

CONCLUSION

Histopathological analysis of the placenta could help us to refine the understanding of Fontan physiology adaptation during pregnancy, predict women and fetal outcomes as well as to plan a better pre-pregnancy status. However, further evidence is needed in order to reach a more solid and unified conclusion.

Wave Reflection and Ventriculo-Arterial Coupling in Bicuspid Aortic Valve Patients With Repaired Aortic Coarctation

BACKGROUND

Ventriculo-arterial (VA) coupling in bicuspid aortic valve (BAV) patients can be affected by the global aortopathy characterizing BAV disease and the presence of concomitant congenital lesions such as aortic coarctation (COA). This study aimed to isolate the COA variable and use cardiovascular magnetic resonance (CMR) imaging to perform wave intensity analysis non-invasively to shed light on VA coupling changes in BAV. The primary hypothesis was that BAV patients with COA exhibit unfavorable VA coupling, and the secondary hypothesis was that BAV patients with COA exhibit increased wave speed as a marker of reduced aortic distensibility despite successful surgical correction.

METHODS

Patients were retrospectively identified from a CMR database and divided into two groups: isolated BAV and BAV associated with repaired COA. Aortic and ventricular dimensions, global longitudinal strain (GLS), and ascending aortic flow data and area were collected and used to derive wave intensity from CMR data. The main variables for the analysis included all wave magnitudes (forward compression/expansion waves, FCW and FEW, respectively, and reflected backward compression wave, BCW) and wave speed.

RESULTS

In the comparison of patients with isolated BAV and those with BAV associated with repaired COA (n = 25 in each group), no differences were observed in left ventricular ejection fraction, GLS, or ventricular volumes, whilst significant increases in FCW and FEW magnitude were noted in the BAV and repaired COA group. The FCW inversely correlated with age and aortic size. Whilst the BCW was not significantly different compared with that in patients with/without COA, its magnitude tends to increase with a lower COA index. Patients with repaired COA exhibited higher wave speed velocity. Aortic wave speed (inversely related to distensibility) was not significantly different between the two groups.

CONCLUSION

In the absence of a significant restenosis, VA coupling in patients with BAV and COA is not negatively affected compared to patients with isolated BAV. A reduction in the magnitude of the early systolic FCW was observed in patients who were older and with larger aortic diameters.

Rapid Prototyping Flexible Aortic Models Aids Sizing of Valve Leaflets and Planning the Ozaki Repair

Two patients with bicuspid aortic valve were selected for aortic valve repair using the Ozaki procedure. Patient-specific models of their aortic roots were generated based on computed tomography data and were 3-dimensional printed using a flexible resin. The models allowed sizing of the valve leaflets and practicing of leaflet suturing. (Level of Difficulty: Advanced.).

Magnetic Resonance Imaging to Detect Cardiovascular Effects of Cancer Therapy: JACC CardioOncology State-of-the-Art Review

This paper aims to empower and inform cardio-oncologists by providing a practical guide to the clinical application of cardiac magnetic resonance (CMR) in the rapidly evolving field of cardio-oncology. Specifically, we describe how CMR can be used to assess the cardiovascular effects of cancer therapy. The CMR literature, relevant societal guidelines, indication-specific imaging protocols, and methods to overcome some of the challenges encountered in performing and accessing CMR are reviewed.

Analysis of Neat Biofluids Obtained During Cardiac Surgery Using Nanoparticle Tracking Analysis: Methodological Considerations

Small extracellular vesicles (sEVs) are those nanovesicles 30-150 nm in size with a role in cell signalling and potential as biomarkers of disease. Nanoparticle tracking analysis (NTA) techniques are commonly used to measure sEV concentration in biofluids. However, this quantification technique can be susceptible to sample handing and machine settings. Moreover, some classes of lipoproteins are of similar sizes and could therefore confound sEV quantification, particularly in blood-derived preparations, such serum and plasma. Here we have provided methodological information on NTA measurements and systematically investigated potential factors that could interfere with the reliability and repeatability of results obtained when looking at neat biofluids (i.e., human serum and pericardial fluid) obtained from patients undergoing cardiac surgery and from healthy controls. Data suggest that variables that can affect vesicle quantification include the level of contamination from lipoproteins, number of sample freeze/thaw cycles, sample filtration, using saline-based diluents, video length and keeping the number of particles per frame within defined limits. Those parameters that are of less concern include focus, the "Maximum Jump" setting and the number of videos recorded. However, if these settings are clearly inappropriate the results obtained will be spurious. Similarly, good experimental practice suggests that multiple videos should be recorded. In conclusion, NTA is a perfectible, but still commonly used system for sEVs analyses. Provided users handle their samples with a highly robust and consistent protocol, and accurately report these aspects, they can obtain data that could potentially translate into new clinical biomarkers for diagnosis and monitoring of cardiovascular disease.

MicroRNAs as potential biomarkers in congenital heart surgery

OBJECTIVE

Pediatric congenital heart surgery (CHS) involves intracardiac, valvular, and vascular repairs. Accurate tools to aid short-term outcome prediction in pediatric CHS are lacking. Clinical scores, such as the vasoactive-inotrope score and ventilation index, are used to define outcome in clinical studies. MicroRNA-1-3p (miR-1) is expressed by both cardiomyocytes and vascular cells and is regulated by hypoxia. In adult patients, miR-1 increases in the circulation after open-heart cardiac surgery, suggesting its potential as a clinical biomarker. Thus, we investigated whether perioperative circulating miR-1 measurements can help predict post-CHS short-term outcomes in pediatric patients.

METHODS

Plasma miR-1 was retrospectively measured in a cohort of 199 consecutive pediatric CHS patients (median age 1.2 years). Samples were taken before surgery and at the end of the operation. Plasma miR-1 concentration was measured by reverse transcription-quantitative polymerase chain reaction and expressed as miR-1 copies/μL and as relative expression to spiked-in exogenous cel-miR-39.

RESULTS

Baseline plasma miR-1 did not vary across different diagnoses, increased during surgery (204-fold median relative increase, P < .001), and was associated with aortic crossclamp duration postoperatively (P < .001). Importantly, miR-1 levels at the end of the operation positively correlated with intensive care stay (P < .001), early severe cardiovascular events (P = .01), and with high vasoactive-inotrope score (P = .001) and ventilation index (P < .001), suggesting that miR-1 could accelerate the identification of patients with cardiopulmonary bypass-related ischemic complications, requiring more intensive support.

CONCLUSIONS

Our study suggests miR-1 as a novel potential circulating biomarker to predict early postoperative outcome and inform clinical management in pediatric heart surgery.

Feasibility of Wave Intensity Analysis in Patients With Conotruncal Anomalies Before and After Pregnancy: New Physiological Insights?

Background: Conotruncal anomalies (CTA) are associated with ongoing dilation of the aortic root, as well as increased aortic stiffness, which may relate to intrinsic properties of the aorta. Pregnancy hormones lead to hemodynamic changes and remodeling of the tunica media, resulting in the opposite effect, i.e., increasing distensibility. These changes normalize post-pregnancy in healthy women but have not been fully investigated in CTA patients. Methods: We examined aortic distensibility and ventriculo-arterial coupling before and after pregnancy using cardiovascular magnetic resonance (CMR)-derived wave intensity analysis (WIA). Pre- and post-pregnancy CMR data were retrospectively analyzed. Aortic diameters were measured before, during, and after pregnancy by cardiac ultrasound and before and after pregnancy by CMR. Phase contrast MR flow sequences were used for calculating wave speed (c) and intensity (WI). A matched analysis was performed comparing results before and after pregnancy. Results: Thirteen women (n = 5, transposition of the great arteries; n = 6, tetralogy of Fallot; n = 1, double outlet right ventricle, n = 1, truncus arteriosus) had 19 pregnancies. Median time between delivery and second CMR was 2.3 years (range: 1-6 years). The aortic diameter increased significantly after pregnancy in nine (n = 9) patients by a median of 4 ± 2.3 mm (range: 2-7.0 mm, p = 0.01). There was no difference in c pre-/post-pregnancy (p = 0.73), suggesting that increased compliance, typically observed during pregnancy, does not persist long term. A significant inverse relationship was observed between c and heart rate (HR) after pregnancy (p = 0.01, r = 0.73). There was no significant difference in cardiac output, aortic/pulmonary regurgitation, or WI peaks pre-/post-pregnancy. Conclusions: WIA is feasible in this population and could provide physiological insights in larger cohorts. Aortic distensibility and wave intensity did not change before and after pregnancy in CTA patients, despite an increase in diameter, suggesting that pregnancy did not adversely affect coupling in the long-term.

Long-Term Comparison Between Pulmonary Homograft Versus Bioprosthesis for Pulmonary Valve Replacement in Tetralogy of Fallot

Background

Tetralogy of Fallot repair results in late occurrence of pulmonary regurgitation, which requires pulmonary valve replacement in a large proportion of patients. Both homografts and bioprostheses are used for pulmonary valve replacement as uncertainty remains on which prosthesis should be considered superior. We performed a long‐term imaging and clinical comparison between these 2 strategies.

Methods and Results

We compared echocardiographic and clinical follow‐up data of 209 patients with previous tetralogy of Fallot repair who underwent pulmonary valve replacement with homograft (n=75) or bioprosthesis (n=134) between 1995 and 2018 at a tertiary hospital. The primary end point was the composite of pulmonary valve replacement reintervention and structural valve deterioration, defined as a transpulmonary pressure decrease ≥50 mm Hg or pulmonary regurgitation degree of ≥2. Mixed linear model and Cox regression model were used for comparisons. Echocardiographic follow‐up duration was longer in the homograft group (8 [interquartile range, 4–12] versus 4 [interquartile range, 3–6] years; P<0.001). At the latest echocardiographic follow‐up, homografts showed a significantly lower transpulmonary systolic pressure decrease (16 [interquartile range, 12–25] mm Hg) when compared with bioprostheses (28 [interquartile range, 18–41] mm Hg; mixed model P<0.001) and a similar degree of pulmonary regurgitation (degree 0‐4) (1 [interquartile range, 0–2] versus 2 [interquartile range, 0–2]; mixed model P=0.19). At 9 years, freedom from structural valve deterioration and reintervention was 81.6% (95% CI, 71.5%–91.6%) versus 43.4% (95% CI, 23.6%–63.2%) in the homograft and bioprosthesis groups, respectively (adjusted hazard ratio, 0.27; 95% CI, 0.13–0.55; P<0.001).

Conclusions

When compared with bioprostheses, pulmonary homografts were associated lower transvalvular gradient during follow‐up and were associated with a significantly lower risk of reintervention or structural valve degeneration.

'Making the Invisible Visible': an audience response to an art installation representing the complexity of congenital heart disease and heart transplantation

The arts can aid the exploration of individual and collective illness narratives, with empowering effects on both patients and caregivers. The artist, partly acting as conduit, can translate and re-present illness experiences into artwork. But how are these translated experiences received by the viewer-and specifically, how does an audience respond to an art installation themed around paediatric heart transplantation and congenital heart disease? The installation, created by British artist Sofie Layton and titled Making the Invisible Visible, was presented at an arts-and-health event. The piece comprised three-dimensional printed medical models of hearts with different congenital defects displayed under bell jars on a stainless steel table reminiscent of the surgical theatre, surrounded by hospital screens. The installation included a soundscape, where the voice of a mother recounting the journey of her son going through heart transplantation was interwoven with the voice of the artist reading medical terminology. A two-part survey was administered to capture viewers' expectations and their response to the piece. Participants (n=125) expected to acquire new knowledge around heart disease, get a glimpse of patients' experiences and be surprised by the work, while after viewing the piece they mostly felt empathy, surprise, emotion and, for some, a degree of anxiety. Viewers found the installation more effective in communicating the experience of heart transplantation than in depicting the complexity of cardiovascular anatomy (p<0.001, z=7.56). Finally, analysis of open-ended feedback highlighted the intimacy of the installation and the privilege viewers felt in sharing a story, particularly in relation to the soundscape, where the connection to the narrative in the piece was reportedly strengthened by the use of sound. In conclusion, an immersive installation including accurate medical details and real stories narrated by patients can lead to an empathic response and an appreciation of the value of illness narratives.

Determinants of aortic growth rate in patients with bicuspid aortic valve by cardiovascular magnetic resonance

Objectives

This study aimed to identify determinants of aortic growth rate in bicuspid aortic valve (BAV) patients. We hypothesised that (1) BAV patients with repaired coarctation (CoA) exhibit decreased aortic growth rate, (2) moderate/severe re-coarctation (reCoA) results in increased growth rate, (3) patients with right non-coronary (RN) valve cusps fusion pattern exhibit increased aortic growth rate compared with right-left cusps fusion and type 0 valves.

Methods

Starting from n=521 BAV patients with cardiovascular magnetic resonance data, we identified n=145 patients with at least two scans for aortic growth analysis. Indexed areas of the sinuses of Valsalva and ascending aorta (AAo) were calculated from cine images in end-systole and end-diastole. Patients were classified based on dilation phenotype, presence of CoA, aortic valve function and BAV morphotype. Comparisons between groups were performed. Linear regression was carried out to identify associations between risk factors and aortic growth rate.

Results

Patients (39±16 years of age, 68% male) had scans 3.7±1.8 years apart; 32 presented with AAo dilation, 18 with aortic root dilation and 32 were overall dilated. Patients with repaired CoA (n=61) showed decreased aortic root growth rate compared with patients without CoA (p≤0.03) regardless of sex or age. ReCoA, aortic stenosis, regurgitation and history of hypertension were not associated with growth rate. RN fusion pattern showed the highest aortic root growth rate and type 0 the smallest (0.30 vs 0.08 cm²/m*year, end-systole, p=0.03).

Conclusions

Presence of CoA and cusp fusion morphotype were associated with changes in rate of root dilation in our BAV population.

P4163Long term comparison between homograft vs stented bio-prostheses for pulmonary valve replacement in tetralogy of Fallot patients

Background

Tetralogy of Fallot (TOF) repair results in long term chronic pulmonary regurgitation requiring pulmonary valve replacement (PVR). Homograft and stented bio-prosthesis are currently used for PVR but whether one should be considered superior to another remains unknown.

Aim

To compare echocardiographic and clinical outcomes after PVR with Homograft vs stented bioprosthesis in patients with previous TOF repair.

Methods

137 patients who underwent PVR with stented bioproshesis were compared with 80 patients who received an homograft using Mixed linear model and multivariate Cox regression.

Results

Homograft were associated with a significantly lower transpulmonary gradient postoperatively (P=0.04) and after a mean follow-up 6 years (table). Homograft were associated with a significantly lower risk of reintervention (HR 0.24; 95% CI 0.07–0.85, p=0.026) while long term mortality was comparable between the two groups (P=0.1).

Echocardiographic findings BIO HOMOGRAFT P N 137 80 Preoperatively   TV regurgitation (mean, sd) 1.80 (0.63) 1.94 (0.81) 0.353   TV regurgitation pressure drop (mean,sd) 35.15 (15.49) 45.34 (25.24) 0.009   PV regurgitation (mean,sd) 3.63 (0.52) 3.34 (0.64) 0.004   PV systolic peak gradient (mean, sd) 25.07 (17.05) 30.68 (21.70) 0.138 Early postoperatively   TV regurgitation (mean,sd) 1.52 (0.54) 1.54 (0.55) 0.858   TV regurgitation pressure drop (mean,sd) 30.10 (13.82) 29.13 (13.98) 0.733   PV regurgitation (mean,sd) 1.50 (0.54) 1.64 (0.53) 0.224   PV systolic peak gradient (mean,sd) 24.05 (11.10) 20.16 (14.19) 0.045 Latest follow_up   TV regurgitation (mean,sd) 1.63 (0.61) 1.83 (0.80) 0.195   TV regurgitation pressure drop (mean,sd) 37.46 (18.84) 32.58 (13.47) 0.233   PV regurgitation (mean,sd) 2.06 (0.77) 2.07 (0.94) 0.982   PV systolic peak gradient (mean,sd) 32.22 (18.17) 21.25 (13.47) 0.001 TAPSE: Tricuspid annular plane systolic excursion; TV: tricuspid valve; PV: pulmonary valve.

PV re-intervention

Conclusions

When compared to stented bio-prostheses, homografts were associated better early and late hemodynamic profile and a significantly lower risk of re-intervention. Homograft should be considered the first choice in patients undergoing PVR after TOF repair.

BDNF (Brain-Derived Neurotrophic Factor) Promotes Embryonic Stem Cells Differentiation to Endothelial Cells Via a Molecular Pathway, Including MicroRNA-214, EZH2 (Enhancer of Zeste Homolog 2), and eNOS (Endothelial Nitric Oxide Synthase)

Objective- The NTs (neurotrophins), BDNF (brain-derived neurotrophic factor) and NT-3 promote vascular development and angiogenesis. This study investigated the contribution of endogenous NTs in embryonic stem cell (ESC) vascular differentiation and the potential of exogenous BDNF to improve the process of ESC differentiation to endothelial cells (ECs). Approach and Results- Mouse ESCs were differentiated into vascular cells using a 2-dimensional embryoid body (EB) model. Supplementation of either BDNF or NT-3 increased EC progenitors' abundance at day 7 and enlarged the peripheral vascular plexus with ECs and SM22α⁺ (smooth muscle 22 alpha-positive) smooth muscle cells by day 13. Conversely, inhibition of either BDNF or NT-3 receptor signaling reduced ECs, without affecting smooth muscle cells spread. This suggests that during vascular development, endogenous NTs are especially relevant for endothelial differentiation. At mechanistic level, we have identified that BDNF-driven ESC-endothelial differentiation is mediated by a pathway encompassing the transcriptional repressor EZH2 (enhancer of zeste homolog 2), microRNA-214 (miR-214), and eNOS (endothelial nitric oxide synthase). It was known that eNOS, which is needed for endothelial differentiation, can be transcriptionally repressed by EZH2. In turn, miR-214 targets EZH2 for inhibition. We newly found that in ESC-ECs, BDNF increases miR-214 expression, reduces EZH2 occupancy of the eNOS promoter, and increases eNOS expression. Moreover, we found that NRP-1 (neuropilin 1), KDR (kinase insert domain receptor), and pCas¹³⁰ (p130 Crk-associated substrate kinase), which reportedly induce definitive endothelial differentiation of pluripotent cells, were increased in BDNF-conditioned ESC-EC. Mechanistically, miR-214 mediated the BDNF-induced expressional changes, contributing to BDNF-driven endothelial differentiation. Finally, BDNF-conditioned ESC-ECs promoted angiogenesis in vitro and in vivo. Conclusions- BDNF promotes ESC-endothelial differentiation acting via miR-214.

Beyond apical ballooning: computational modelling reveals morphological features of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TCM) is characterized by transient myocardial dysfunction, typically at the left ventricular (LV) apex. Its pathophysiology and recovery mechanisms remain unknown. We investigated LV morphology and deformation in n = 28 TCM patients. Patients with MRI within 5 days from admission ("early TCM") showed reduced LVEF and higher ventricular volumes, but no differences in ECG, global strains or myocardial oedema. Statistical shape modelling described LV size (Mode 1), apical sphericity (Mode 2) and height (Mode 3). Significant differences in Mode 1 suggest that "early TCM" LV remodeling is mainly influenced by a change in ventricular size rather than apical sphericity.

Imaging the carotid atherosclerotic plaque

This mini review provides a concise overview of imaging techniques that are currently used to image the atheroscletoric plaque in the carotid artery in vivo. The main techniques include ultrasound imaging, X-ray imaging, magnetic resonance imaging and positron emission tomography imaging. Each technique has advantages and limitations and may be chosen depending on the availability, cost and clinical justification for its use. Common to all the imaging techniques presented here is the need for a skilled imaging professional to allow for high reliability and repeatability. While ultrasound-based imaging currently is regarded as a first line technique in clinical practice, the use of other techniques such as computed tomography angiography or magnetic resonance angiography need to be considered in the presence of significant stenosis with or without symptoms. Advancements in these two modalities, as well as in positron emission tomography imaging, are increasingly moving toward a better understanding of the risk-stratification and pre-interventional monitoring of patients at risk of plaque rupture as well as early identification of plaque development and better understanding of plaque composition (e.g. metabolic imaging).