Hemodynamics, anatomy, and outcomes of quadricuspid aortic valves: Multimodality imaging assessment.

BACKGROUND:Quadricuspid aortic valve (QAV) is a rare congenital heart disease with a limited body of literature. This retrospective cohort study investigates QAV morphology, function, and clinical outcomes.METHODS:Echocardiography was used to assess valvular function. Morphological characteristics such as phenotypes, raphe, regurgitant orifice area (ROA), and aortic dilation (diameter >40 ​mm) were assessed by cardiac CT. Patients were followed up for the combined event of all-cause death and aortic valve replacement (AVR).RESULTS:Ninety QAV patients (screened from 322385 CT scans) were included (mean age 55.2 ​± ​13.6 years, 61.1 ​% male). Isolated significant aortic regurgitation (AR) was present in 75.6 ​% of patients. The cohort was dominated by type I (four equal leaflets, 37.8 ​%) and type II (3 larger and 1 smaller leaflets, 42.2 ​%) QAV. Fused raphe was present in 26.7 ​% of patients. ROACT was correlated with AR severity and aortic dilation (41.1 ​%, n ​= ​37). Among patients without AVR at baseline (n ​= ​60), one died and 17 underwent AVR during a median follow-up of 35.0 months (IQR:17.3-62.8). ROACT was associated with an increasing risk of combined event (as a categorical variable with a cut-off of 21.4 ​mm2, HR ​= ​4.25, 95%CI 1.49-12.17, p ​= ​0.007; as a continuous variable (per mm2 increment), HR ​= ​1.04, 95%CI 1.01-1.07, p ​= ​0.003). Additionally, ROACT had incremental prognostic value when added to the AR severity model (area under the receiver-operating characteristic curve increased from 86.8 to 88.4, p ​= ​0.004).CONCLUSION:QAV is characterized by variable anatomy, progressive AR, concomitant cusp fusion and aortic enlargement. ROACT may be a potential ancillary prognostic marker in patients with QAV.

Incremental diagnostic value of radiomics signature of pericoronary adipose tissue for detecting functional myocardial ischemia: a multicenter study.

OBJECTIVES:To determine the incremental diagnostic value of radiomics signature of pericoronary adipose tissue (PCAT) in addition to the coronary artery stenosis and plaque characters for detecting hemodynamic significant coronary artery disease (CAD) based on coronary computed tomography angiography (CCTA).METHODS:In a multicenter trial of 262 patients, CCTA and invasive coronary angiography were performed, with fractional flow reserve (FFR) in 306 vessels. A total of 13 conventional quantitative characteristics including plaque characteristics (N = 10) and epicardial adipose tissue characteristics (N = 3) were obtained. A total of 106 radiomics features depicting the phenotype of the PCAT surrounding the lesion were calculated. All data were randomly split into a training dataset (75%) and a testing dataset (25%). Then three models (including the conventional model, the PCAT radiomics model, and the combined model) were established in the training dataset using multivariate logistic regression algorithm based on the conventional quantitative features and the PCAT radiomics features after dimension reduction.RESULTS:A total of 124/306 vessels showed functional ischemia (FFR ≤ 0.80). The radiomics model performed better in discriminating ischemia from non-ischemia than the conventional model in both training (area under the receiver operating characteristic (ROC) curve (AUC): 0.770 vs 0.732, p < 0.05) and testing datasets (AUC: 0.740 vs 0.696, p < 0.05). The combined model showed significantly better discrimination than the conventional model in both training (AUC: 0.810 vs 0.732, p < 0.05) and testing datasets (AUC: 0.809 vs 0.696, p < 0.05).CONCLUSIONS:The PCAT radiomics model showed good performance in predicting myocardial ischemia. Addition of PCAT radiomics to lesion quantitative characteristics improves the predictive power of functionally relevant CAD.KEY POINTS:• Based on the plaque characteristics and EAT characteristics, the conventional model showed poor performance in predicting myocardial ischemia. • The PCAT radiomics model showed good prospect in predicting myocardial ischemia. • When combining the radiomics signature with the conventional quantitative features (including plaque features and EAT features), it showed significantly better performance in predicting myocardial ischemia.

Computed tomography anatomical characteristics based on transcatheter aortic valve replacement in aortic regurgitation.

This study analyzed computed tomography (CT) measurement characteristics and anatomical classifications based on transcatheter aortic valve replacement (TAVR) in patients with aortic regurgitation (AR) to establish a preliminary summary of CT anatomical characteristics and to design a novel self-expanding transcatheter heart valve (THV). This single-center retrospective cohort study included 136 patients diagnosed with moderate-to-severe AR at Fuwai Hospital from July 2017 to April 2022. Patients were classified into four anatomical classifications according to dual-anchoring multiplanar measurement of where THV anchoring took place. Types 1-3 were considered candidates for TAVR, whereas type 4 was not. Among 136 patients with AR, there were 117 (86.0%) tricuspid, 14 bicuspid, and five quadricuspid valves. Dual-anchoring multiplanar measurement showed that the annulus was smaller than left ventricular outflow tract (LVOT) at 2, 4, 6, 8, and 10 mm on the annulus. The ascending aorta (AA) 40 mm was wider than AA 30 mm and AA 35 mm, but narrower than AA 45 mm and AA 50 mm. For 10% oversize of the THV, the proportions of the annulus, LVOT, and AA unable to meet the diameter were 22.8%, 37.5%, and 50.0%, respectively, and the proportions of anatomical classification types 1-4 were 32.4%, 5.9%, 30.1%, and 31.6%, respectively. The novel THV could significantly improve the type 1 proportion (88.2%). Existing THVs cannot meet the anatomical characteristics of patients with AR. Conversely, based on anatomical characteristics, the novel THV could theoretically facilitate TAVR.

Cardiovascular Imaging in China: Yesterday, Today, and Tomorrow.

The high prevalence and mortality of cardiovascular diseases in China's large population has increased the use of cardiovascular imaging for the assessment of conditions in recent years. In this study, we review the past 20 years of cardiovascular imaging in China, the increasingly important role played by cardiovascular computed tomography in coronary artery disease and pulmonary embolism assessment, magnetic resonance imaging's use for cardiomyopathy assessment, the development and application of artificial intelligence in cardiovascular imaging, and the future of Chinese cardiovascular imaging.

Artificial Intelligence in Cardiovascular Atherosclerosis Imaging.

At present, artificial intelligence (AI) has already been applied in cardiovascular imaging (e.g., image segmentation, automated measurements, and eventually, automated diagnosis) and it has been propelled to the forefront of cardiovascular medical imaging research. In this review, we presented the current status of artificial intelligence applied to image analysis of coronary atherosclerotic plaques, covering multiple areas from plaque component analysis (e.g., identification of plaque properties, identification of vulnerable plaque, detection of myocardial function, and risk prediction) to risk prediction. Additionally, we discuss the current evidence, strengths, limitations, and future directions for AI in cardiac imaging of atherosclerotic plaques, as well as lessons that can be learned from other areas. The continuous development of computer science and technology may further promote the development of this field.

Feasibility of using deep learning to detect coronary artery disease based on facial photo.

AIMS:Facial features were associated with increased risk of coronary artery disease (CAD). We developed and validated a deep learning algorithm for detecting CAD based on facial photos.METHODS AND RESULTS:We conducted a multicentre cross-sectional study of patients undergoing coronary angiography or computed tomography angiography at nine Chinese sites to train and validate a deep convolutional neural network for the detection of CAD (at least one ≥50% stenosis) from patient facial photos. Between July 2017 and March 2019, 5796 patients from eight sites were consecutively enrolled and randomly divided into training (90%, n = 5216) and validation (10%, n = 580) groups for algorithm development. Between April 2019 and July 2019, 1013 patients from nine sites were enrolled in test group for algorithm test. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were calculated using radiologist diagnosis as the reference standard. Using an operating cut point with high sensitivity, the CAD detection algorithm had sensitivity of 0.80 and specificity of 0.54 in the test group; the AUC was 0.730 (95% confidence interval, 0.699-0.761). The AUC for the algorithm was higher than that for the Diamond-Forrester model (0.730 vs. 0.623, P < 0.001) and the CAD consortium clinical score (0.730 vs. 0.652, P < 0.001).CONCLUSION:Our results suggested that a deep learning algorithm based on facial photos can assist in CAD detection in this Chinese cohort. This technique may hold promise for pre-test CAD probability assessment in outpatient clinics or CAD screening in community. Further studies to develop a clinical available tool are warranted.

Predictive value of coronary artery calcium score in cardiovascular disease.

We investigated coronary heart disease (CHD) and cardiovascular disease (CVD) event rates in a diverse population with a coronary artery calcium score (CACS) of 0 and the role of CACS in the detection of subclinical noncalcified atherosclerotic plaque. A total of 15,884 participants in five studies were included in this meta-analysis. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were calculated. The results showed that CHD incidence significantly increased with increased CACS (HR=0.05, 95% CI 0.03-0.06, Z=5.82, P=0.002). The CHD rate was low and further increased with CACS of 101-300. With CACS >300, the CHD rate was highest. Similarly, CVD rate was low with CACS of 0, increased with CACS of 1-100 (HR=0.03, 95% CI 0.01-0.06, Z=1.66, P=0.096), and further increased with CACS of 101-300. With CACS >300, the CVD rate was highest. Clinical evidence indicated that the higher the CACS, the higher the CHD and CVD rates, while the CVD rate does not always decreased compared with CHD rate with the same CACS, especially with CACS of 0.

MicroRNA-216a promotes M1 macrophages polarization and atherosclerosis progression by activating telomerase via the Smad3/NF-κB pathway.

Macrophages exhibit heterogeneity and plasticity and imbalance between pro-inflammatory and anti-inflammatory macrophages plays a critical role in atherosclerosis progression. Telomerase reverse transcriptase (TERT) in macrophages can be activated by nuclear factor-kappa B (NF-κB), but the regulation of telomerase activation on macrophages polarization remains unknown. We previously identified microRNA-216a (miR-216a) to promote inflammation through directly targeting the Smad3/NF-κB pathway. The present study aimed to assess whether miR-216a can regulate telomerase activity and promote macrophages polarization during atherosclerosis progression. The results verified that TERT was highly expressed in macrophages of human carotid atherosclerotic plaques. miR-216a was found to promote telomerase activation in macrophages by 4.5-fold (P = 0.002) through the Smad3/NF-κB pathway. miR-216a also induced macrophages senescence characterized by senescence-associated-β-galactosidase activity and p53 and p16 expression. TERT overexpression promoted the transformation of M2 to M1 while this conversion was suppressed once TERT was inhibited, and the related inflammatory factors and lipid uptake ability of M1 cells were also increased by TERT. In the carotid atherosclerotic plaques from miR-216a-treated apolipoprotein E-/- mice, the numbers of M1 macrophages were increased whereas M2 cells reduced, accompanying with inhibited Smad3 expression and upregulated inflammatory markers and TERT activity. Furthermore, plasma miR-216a level was specifically higher in patients with vulnerable mixed plaques (n = 181) than those with calcified plaques (n = 73) and controls (n = 264). In summary, our findings first revealed a new molecular mechanism of macrophage polarization involving telomerase activation induced by miR-216a through the Smad3/NF-κB signaling, which might serve as a potential therapeutic target for atherosclerosis progression.

Optimal pre-TAVR annulus sizing in patients with bicuspid aortic valve: area-derived perimeter by CT is the best-correlated measure with intraoperative sizing.

OBJECTIVE:To clarify the optimal measurements for patients with bicuspid aortic valve (BAV) preferred for transcatheter aortic valve replacement (TAVR), our study compared intraoperative sizing with five different approaches by transthoracic echocardiography (TTE), three-dimensional transesophageal echocardiography (3DTEE) and computed tomography (CT).METHODS:We enrolled 104 BAV patients prescreened for TAVR but who underwent surgery with direct intraoperative annulus sizing. All five approaches [2DTTE, 3DTEE, area-derived perimeter (CTarea), perimeter-derived diameter (CTperi) and mean diameter (CTmean)] were compared with intraoperative sizing, respectively. Agreements on theoretical valve selections by five methods with those by intraoperative sizing were analyzed.RESULTS:CTarea showed the highest correlation (r = 0.932) and the best agreement with intraoperative sizing. Agreement for theoretical surgical and TAVR prosthesis selection was found in 84.6% and 74.0% BAVs by CTarea (κ = 0.791, κ = 0.585). CTperi-based prosthesis selection led to overestimation of 26.9% for surgical valves (κ = 0.589) and 36.5% for TAVR valves (κ = 0.425). Good correlations were observed between CT measurements and intraoperative sizing regardless of the predominant site of aortic valve calcification (r = 0.860-0.953).CONCLUSION:The CTarea, which demonstrated the optimal approach to annulus sizing and prosthesis choice of BAVs with high eccentricity, should be included into the BAV-specific annulus sizing recommendation. The insufficiency of CTperi lay in overestimation of surgical or TAVR valve selections. Good agreement of 3DTEE sizing proved its superiority in annulus sizing for BAVs unsuitable for CT, but it should be used with caution for patients with a calcified annulus, where partial acoustic shadowing could lead to image inaccuracy.KEY POINTS:• The area-derived perimeter by CT is the optimal approach to annulus sizing of BAVs. • The perimeter-derived approach is prone to overestimation of BAVs. • 3DTEE showed its superiority in annulus sizing for BAVs unsuitable for CT, but it should be used with caution in patients with a calcified annulus.

Chinese expert consensus on the non-invasive imaging examination pathways of stable coronary artery disease.

Hemodynamics, anatomy, and outcomes of quadricuspid aortic valves: Multimodality imaging assessment.

BACKGROUND:Quadricuspid aortic valve (QAV) is a rare congenital heart disease with a limited body of literature. This retrospective cohort study investigates QAV morphology, function, and clinical outcomes.METHODS:Echocardiography was used to assess valvular function. Morphological characteristics such as phenotypes, raphe, regurgitant orifice area (ROA), and aortic dilation (diameter >40 ​mm) were assessed by cardiac CT. Patients were followed up for the combined event of all-cause death and aortic valve replacement (AVR).RESULTS:Ninety QAV patients (screened from 322385 CT scans) were included (mean age 55.2 ​± ​13.6 years, 61.1 ​% male). Isolated significant aortic regurgitation (AR) was present in 75.6 ​% of patients. The cohort was dominated by type I (four equal leaflets, 37.8 ​%) and type II (3 larger and 1 smaller leaflets, 42.2 ​%) QAV. Fused raphe was present in 26.7 ​% of patients. ROACT was correlated with AR severity and aortic dilation (41.1 ​%, n ​= ​37). Among patients without AVR at baseline (n ​= ​60), one died and 17 underwent AVR during a median follow-up of 35.0 months (IQR:17.3-62.8). ROACT was associated with an increasing risk of combined event (as a categorical variable with a cut-off of 21.4 ​mm2, HR ​= ​4.25, 95%CI 1.49-12.17, p ​= ​0.007; as a continuous variable (per mm2 increment), HR ​= ​1.04, 95%CI 1.01-1.07, p ​= ​0.003). Additionally, ROACT had incremental prognostic value when added to the AR severity model (area under the receiver-operating characteristic curve increased from 86.8 to 88.4, p ​= ​0.004).CONCLUSION:QAV is characterized by variable anatomy, progressive AR, concomitant cusp fusion and aortic enlargement. ROACT may be a potential ancillary prognostic marker in patients with QAV.

Incremental diagnostic value of radiomics signature of pericoronary adipose tissue for detecting functional myocardial ischemia: a multicenter study.

OBJECTIVES:To determine the incremental diagnostic value of radiomics signature of pericoronary adipose tissue (PCAT) in addition to the coronary artery stenosis and plaque characters for detecting hemodynamic significant coronary artery disease (CAD) based on coronary computed tomography angiography (CCTA).METHODS:In a multicenter trial of 262 patients, CCTA and invasive coronary angiography were performed, with fractional flow reserve (FFR) in 306 vessels. A total of 13 conventional quantitative characteristics including plaque characteristics (N = 10) and epicardial adipose tissue characteristics (N = 3) were obtained. A total of 106 radiomics features depicting the phenotype of the PCAT surrounding the lesion were calculated. All data were randomly split into a training dataset (75%) and a testing dataset (25%). Then three models (including the conventional model, the PCAT radiomics model, and the combined model) were established in the training dataset using multivariate logistic regression algorithm based on the conventional quantitative features and the PCAT radiomics features after dimension reduction.RESULTS:A total of 124/306 vessels showed functional ischemia (FFR ≤ 0.80). The radiomics model performed better in discriminating ischemia from non-ischemia than the conventional model in both training (area under the receiver operating characteristic (ROC) curve (AUC): 0.770 vs 0.732, p < 0.05) and testing datasets (AUC: 0.740 vs 0.696, p < 0.05). The combined model showed significantly better discrimination than the conventional model in both training (AUC: 0.810 vs 0.732, p < 0.05) and testing datasets (AUC: 0.809 vs 0.696, p < 0.05).CONCLUSIONS:The PCAT radiomics model showed good performance in predicting myocardial ischemia. Addition of PCAT radiomics to lesion quantitative characteristics improves the predictive power of functionally relevant CAD.KEY POINTS:• Based on the plaque characteristics and EAT characteristics, the conventional model showed poor performance in predicting myocardial ischemia. • The PCAT radiomics model showed good prospect in predicting myocardial ischemia. • When combining the radiomics signature with the conventional quantitative features (including plaque features and EAT features), it showed significantly better performance in predicting myocardial ischemia.

Computed tomography anatomical characteristics based on transcatheter aortic valve replacement in aortic regurgitation.

This study analyzed computed tomography (CT) measurement characteristics and anatomical classifications based on transcatheter aortic valve replacement (TAVR) in patients with aortic regurgitation (AR) to establish a preliminary summary of CT anatomical characteristics and to design a novel self-expanding transcatheter heart valve (THV). This single-center retrospective cohort study included 136 patients diagnosed with moderate-to-severe AR at Fuwai Hospital from July 2017 to April 2022. Patients were classified into four anatomical classifications according to dual-anchoring multiplanar measurement of where THV anchoring took place. Types 1-3 were considered candidates for TAVR, whereas type 4 was not. Among 136 patients with AR, there were 117 (86.0%) tricuspid, 14 bicuspid, and five quadricuspid valves. Dual-anchoring multiplanar measurement showed that the annulus was smaller than left ventricular outflow tract (LVOT) at 2, 4, 6, 8, and 10 mm on the annulus. The ascending aorta (AA) 40 mm was wider than AA 30 mm and AA 35 mm, but narrower than AA 45 mm and AA 50 mm. For 10% oversize of the THV, the proportions of the annulus, LVOT, and AA unable to meet the diameter were 22.8%, 37.5%, and 50.0%, respectively, and the proportions of anatomical classification types 1-4 were 32.4%, 5.9%, 30.1%, and 31.6%, respectively. The novel THV could significantly improve the type 1 proportion (88.2%). Existing THVs cannot meet the anatomical characteristics of patients with AR. Conversely, based on anatomical characteristics, the novel THV could theoretically facilitate TAVR.

Cardiovascular Imaging in China: Yesterday, Today, and Tomorrow.

The high prevalence and mortality of cardiovascular diseases in China's large population has increased the use of cardiovascular imaging for the assessment of conditions in recent years. In this study, we review the past 20 years of cardiovascular imaging in China, the increasingly important role played by cardiovascular computed tomography in coronary artery disease and pulmonary embolism assessment, magnetic resonance imaging's use for cardiomyopathy assessment, the development and application of artificial intelligence in cardiovascular imaging, and the future of Chinese cardiovascular imaging.

Artificial Intelligence in Cardiovascular Atherosclerosis Imaging.

At present, artificial intelligence (AI) has already been applied in cardiovascular imaging (e.g., image segmentation, automated measurements, and eventually, automated diagnosis) and it has been propelled to the forefront of cardiovascular medical imaging research. In this review, we presented the current status of artificial intelligence applied to image analysis of coronary atherosclerotic plaques, covering multiple areas from plaque component analysis (e.g., identification of plaque properties, identification of vulnerable plaque, detection of myocardial function, and risk prediction) to risk prediction. Additionally, we discuss the current evidence, strengths, limitations, and future directions for AI in cardiac imaging of atherosclerotic plaques, as well as lessons that can be learned from other areas. The continuous development of computer science and technology may further promote the development of this field.

Feasibility of using deep learning to detect coronary artery disease based on facial photo.

AIMS:Facial features were associated with increased risk of coronary artery disease (CAD). We developed and validated a deep learning algorithm for detecting CAD based on facial photos.METHODS AND RESULTS:We conducted a multicentre cross-sectional study of patients undergoing coronary angiography or computed tomography angiography at nine Chinese sites to train and validate a deep convolutional neural network for the detection of CAD (at least one ≥50% stenosis) from patient facial photos. Between July 2017 and March 2019, 5796 patients from eight sites were consecutively enrolled and randomly divided into training (90%, n = 5216) and validation (10%, n = 580) groups for algorithm development. Between April 2019 and July 2019, 1013 patients from nine sites were enrolled in test group for algorithm test. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) were calculated using radiologist diagnosis as the reference standard. Using an operating cut point with high sensitivity, the CAD detection algorithm had sensitivity of 0.80 and specificity of 0.54 in the test group; the AUC was 0.730 (95% confidence interval, 0.699-0.761). The AUC for the algorithm was higher than that for the Diamond-Forrester model (0.730 vs. 0.623, P < 0.001) and the CAD consortium clinical score (0.730 vs. 0.652, P < 0.001).CONCLUSION:Our results suggested that a deep learning algorithm based on facial photos can assist in CAD detection in this Chinese cohort. This technique may hold promise for pre-test CAD probability assessment in outpatient clinics or CAD screening in community. Further studies to develop a clinical available tool are warranted.

Predictive value of coronary artery calcium score in cardiovascular disease.

We investigated coronary heart disease (CHD) and cardiovascular disease (CVD) event rates in a diverse population with a coronary artery calcium score (CACS) of 0 and the role of CACS in the detection of subclinical noncalcified atherosclerotic plaque. A total of 15,884 participants in five studies were included in this meta-analysis. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were calculated. The results showed that CHD incidence significantly increased with increased CACS (HR=0.05, 95% CI 0.03-0.06, Z=5.82, P=0.002). The CHD rate was low and further increased with CACS of 101-300. With CACS >300, the CHD rate was highest. Similarly, CVD rate was low with CACS of 0, increased with CACS of 1-100 (HR=0.03, 95% CI 0.01-0.06, Z=1.66, P=0.096), and further increased with CACS of 101-300. With CACS >300, the CVD rate was highest. Clinical evidence indicated that the higher the CACS, the higher the CHD and CVD rates, while the CVD rate does not always decreased compared with CHD rate with the same CACS, especially with CACS of 0.

MicroRNA-216a promotes M1 macrophages polarization and atherosclerosis progression by activating telomerase via the Smad3/NF-κB pathway.

Macrophages exhibit heterogeneity and plasticity and imbalance between pro-inflammatory and anti-inflammatory macrophages plays a critical role in atherosclerosis progression. Telomerase reverse transcriptase (TERT) in macrophages can be activated by nuclear factor-kappa B (NF-κB), but the regulation of telomerase activation on macrophages polarization remains unknown. We previously identified microRNA-216a (miR-216a) to promote inflammation through directly targeting the Smad3/NF-κB pathway. The present study aimed to assess whether miR-216a can regulate telomerase activity and promote macrophages polarization during atherosclerosis progression. The results verified that TERT was highly expressed in macrophages of human carotid atherosclerotic plaques. miR-216a was found to promote telomerase activation in macrophages by 4.5-fold (P = 0.002) through the Smad3/NF-κB pathway. miR-216a also induced macrophages senescence characterized by senescence-associated-β-galactosidase activity and p53 and p16 expression. TERT overexpression promoted the transformation of M2 to M1 while this conversion was suppressed once TERT was inhibited, and the related inflammatory factors and lipid uptake ability of M1 cells were also increased by TERT. In the carotid atherosclerotic plaques from miR-216a-treated apolipoprotein E-/- mice, the numbers of M1 macrophages were increased whereas M2 cells reduced, accompanying with inhibited Smad3 expression and upregulated inflammatory markers and TERT activity. Furthermore, plasma miR-216a level was specifically higher in patients with vulnerable mixed plaques (n = 181) than those with calcified plaques (n = 73) and controls (n = 264). In summary, our findings first revealed a new molecular mechanism of macrophage polarization involving telomerase activation induced by miR-216a through the Smad3/NF-κB signaling, which might serve as a potential therapeutic target for atherosclerosis progression.

Optimal pre-TAVR annulus sizing in patients with bicuspid aortic valve: area-derived perimeter by CT is the best-correlated measure with intraoperative sizing.

OBJECTIVE:To clarify the optimal measurements for patients with bicuspid aortic valve (BAV) preferred for transcatheter aortic valve replacement (TAVR), our study compared intraoperative sizing with five different approaches by transthoracic echocardiography (TTE), three-dimensional transesophageal echocardiography (3DTEE) and computed tomography (CT).METHODS:We enrolled 104 BAV patients prescreened for TAVR but who underwent surgery with direct intraoperative annulus sizing. All five approaches [2DTTE, 3DTEE, area-derived perimeter (CTarea), perimeter-derived diameter (CTperi) and mean diameter (CTmean)] were compared with intraoperative sizing, respectively. Agreements on theoretical valve selections by five methods with those by intraoperative sizing were analyzed.RESULTS:CTarea showed the highest correlation (r = 0.932) and the best agreement with intraoperative sizing. Agreement for theoretical surgical and TAVR prosthesis selection was found in 84.6% and 74.0% BAVs by CTarea (κ = 0.791, κ = 0.585). CTperi-based prosthesis selection led to overestimation of 26.9% for surgical valves (κ = 0.589) and 36.5% for TAVR valves (κ = 0.425). Good correlations were observed between CT measurements and intraoperative sizing regardless of the predominant site of aortic valve calcification (r = 0.860-0.953).CONCLUSION:The CTarea, which demonstrated the optimal approach to annulus sizing and prosthesis choice of BAVs with high eccentricity, should be included into the BAV-specific annulus sizing recommendation. The insufficiency of CTperi lay in overestimation of surgical or TAVR valve selections. Good agreement of 3DTEE sizing proved its superiority in annulus sizing for BAVs unsuitable for CT, but it should be used with caution for patients with a calcified annulus, where partial acoustic shadowing could lead to image inaccuracy.KEY POINTS:• The area-derived perimeter by CT is the optimal approach to annulus sizing of BAVs. • The perimeter-derived approach is prone to overestimation of BAVs. • 3DTEE showed its superiority in annulus sizing for BAVs unsuitable for CT, but it should be used with caution in patients with a calcified annulus.

Chinese expert consensus on the non-invasive imaging examination pathways of stable coronary artery disease.