Association of aortic diameters and mortality in the general population-an MRI-based study.

BACKGROUND: Increased diameters of the aorta are associated with increased mortality risk. In the present analyses, we assessed whether aortic diameters are associated with cardiovascular and all-cause mortality in community-dwelling individuals free of known cardiovascular disease (CVD). METHODS: MRI-derived vascular parameters of the thoracic and abdominal aorta from 2668 participants (median age = 53 years; 51.1% women) of the population-based SHIP-START-2 and SHIP-TREND-0 cohorts without CVD were analyzed. Age- and sex-adjusted, as well as multivariable-adjusted Cox-proportional hazard models, were used to estimate associations of diameters of six different aortic segments to mortality. RESULTS: Over a median follow-up time of 10.6 years (IQR: 8.7; 12.4), a total of 188 participants (126 men and 62 women) died, of which 38 deaths were due to CVD. In unadjusted models, mortality rates were higher in participants with aortic diameters above the median compared to below the median for all investigated aortic sections (all log-rank p < 0.001). In multivariable-adjusted models, the diameters of the ascending thoracic aorta (HR = 1.34 95% CI: 1.04; 1.72, p = 0.022) and of the infrarenal aorta (HR = 3.75 95% CI: 1.06; 13.3, p = 0.040), modeled continuously, were associated with greater cardiovascular mortality. The diameter of the subphrenic aorta was associated with higher cardiovascular mortality only in the age and sex-adjusted model (HR = 3.65 95% CI: 1.01; 13.3, p = 0.049). None of the investigated aortic segments were associated with all-cause mortality. CONCLUSION: Non-indexed diameters of the ascending thoracic and infrarenal aorta were associated with higher cardiovascular mortality but not with all-cause mortality in a population sample free of clinically overt CVD at baseline. CLINICAL RELEVANCE STATEMENT: Increased aortic diameter is associated with cardiovascular mortality and can help to identify high-risk patients. KEY POINTS: Increased aortic diameter is associated with mortality. Non-indexed diameters of the ascending and infrarenal aorta are associated with cardiovascular mortality but not all-cause mortality. Aortic diameter measurements support the estimate of cardiovascular mortality.

Patient selection for LIVE therapy: From clinical indications to multimodality imaging individual case planning.

BACKGROUND: Less Invasive Ventricular Enhancement (LIVE) with Revivent TC is an innovative therapy for symptomatic ischemic heart failure (HF). It is designed to reconstruct a negatively remodeled left ventricle (LV) after an anterior myocardial infarction (MI) by plication of the scar tissue. Its indications are specific, and as with any other structural heart intervention, the success of the procedure starts with appropriate patient selection. We aim to present the indications of the technique, crucial aspects in patient selection, and individual case planning approach. METHODS AND RESULTS: After clinical evaluation, transthoracic echocardiography is the first imaging modality to be performed in a potential candidate for the therapy. However, definitive indication and detailed case planning rely on late gadolinium-enhanced cardiac magnetic resonance imaging or multiphasic contrast-enhanced cardiac computed tomography. These imaging modalities also assist with relative or absolute contra-indications for the procedure. Individual assessment is done to tailor the procedure to the specifics of the LV anatomy and location of the myocardial scar. CONCLUSION: LIVE procedure is a unique intervention to treat symptomatic HF and ischemic cardiomyopathy after anterior MI. It is a highly customizable intervention that allows a patient-tailored approach, based on multimodality imaging assessment and planification.

The relevance of low-fidelity virtual reality simulators compared with other learning methods in basic endovascular skills training.

OBJECTIVE: The use of simulators has shown a profound impact on the development of both training and assessment of endovascular skills. Furthermore, there is evidence that simulator training is of great benefit for novice trainees. However, there are only a few simulators available geared specifically toward novice learners. Whereas research suggests that low-fidelity simulators could fill this gap, there are insufficient data available to determine the role of low-fidelity simulators in the training of endovascular skills. METHODS: Medical students in their fifth year (N = 50) with no previous endovascular experience were randomized into three groups: conventional learning through a video podcast (group V; n = 12), low-fidelity simulation training with tablet-paired touch-gesture navigation (group A; n = 12), and low-fidelity simulation training with tablet-paired physical endovascular tool navigation (group S; n = 26). Within their respective groups, all students attended a 1-day class on basic endovascular skills. Questionnaire items for self-assessment before and after the class and assessment after the class of the participant's practical skills on a high-fidelity simulator were analyzed across all three groups as well as for each group separately using nonparametric tests. RESULTS: All 50 participants completed the training. Participants in group S showed a significantly increased interest in working in interventional cardiology (P = .02) and vascular surgery (P = .03) after the class. Evaluation of the questionnaire items after the class showed that participants in group S rated their practical skills significantly higher after the class compared with those in group V and group A (P < .001 for pairwise comparison of all three groups, respectively), creating a significant trend across the three groups. However, analysis of the practical skills assessment for all three groups showed a significant difference between the groups only for choosing a guidewire (P = .045) and a significant trend in performance across the groups for choosing a guidewire and for positioning the guidewire in the vessel (P = .02 and P = .05, respectively). All other steps of the skills assessment showed no significant differences or a trend across the groups. CONCLUSIONS: Low-fidelity simulation training, particularly with physical endovascular tool navigation, led to increased motivation in novice trainees. Whereas simulator training was associated with increased confidence of trainees in their skills, assessment of their practical skills showed no actual improvement in this study. Overall, low-fidelity simulation has the potential to benefit novice trainees, but possible risks of simulation training should be further evaluated.

Staged treatment of mega aortic syndrome using the frozen elephant trunk and hybrid thoracoabdominal repair.

OBJECTIVE: We report our experience with a staged hybrid approach for the treatment of extended aortic disease, also known as "mega aortic syndrome." METHODS: A total of 15 patients (10 male, 5 female) underwent staged repair of the thoracoabdominal aorta, consisting of 3 separate stages (repair of ascending aorta and aortic arch using the frozen elephant trunk technique and hybrid thoracoabdominal repair with debranching of the renovisceral branches and stent graft implantation). RESULTS: The procedure was completed in 14 patients. After the first stage (repair of ascending aorta and aortic arch), no mortality or spinal cord ischemia occurred. One patient required temporary dialysis. After the thoracoabdominal repair, permanent paraplegia developed in 1 patient. One patient died intraoperatively after aneurysm rupture. The in-hospital mortality for the complete repair reached 6.7%. None of the surviving patients required permanent dialysis. Interval aortic events consisted of 1 contained rupture. CONCLUSIONS: The concept of a staged hybrid repair of the mega aortic syndrome is technically feasible. The frozen elephant trunk technique represents an attractive treatment option, offering an adequate landing zone for later thoracoabdominal repair in patients with extended aortic disease. For completion of the repair, a staged hybrid approach with renovisceral debranching and aneurysm exclusion using off-the-shelf stent grafts shows promising results with low surgical morbidity and mortality.

Does Simulation-Based Training Improve Procedural Skills of Beginners in Interventional Cardiology?--A Stratified Randomized Study.

OBJECTIVE: To assess whether mentored simulation-based-training can improve the procedural skills of beginners in coronary interventional procedures. BACKGROUND: Simulation based-catheter training is a valuable tool to practice interventional procedures. Whether this type of training enhances the procedural skills of fellows learning percutaneous coronary interventions has never been studied. METHODS: Eighteen cardiology fellows were randomized either into the simulation-based training (n = 9) or the control group (n = 9). The simulation group received 7.5 hours of virtual reality (VR) simulation training, whereas the control group attended 4.5 hours of lectures. Each participant had to perform a simple (pre-evaluation) and a more complex (post-evaluation) catheter intervention on a pulsatile coronary flow model in a catheterization laboratory. All procedures were videotaped, analyzed, and rated by 3 expert interventionalists, who were blinded to the randomization. To assess the individual performance level, a "skills score" was determined, comprising 14 performance characteristics (5-level Likert scale, maximum score of 70 points). RESULTS: The "skills score" increased by 5.8 ± 6.1 points in the VR simulation group and decreased by 6.7 ± 8.4 in the control group (P = 0.003) from the simple stenosis at pre- to the more complex lesion at post-evaluation demonstrating the effectiveness of simulation-based training. CONCLUSION: This pilot study suggests that curriculum-based mentored VR simulation training improves the performance level of cardiology fellows in coronary interventions. Further investigation to evaluate the effect on clinical outcomes is warranted.

Successful percutaneous management of partial avulsion of the native aortic valve complex complicating transcatheter aortic valve replacement.

This is the first reported case of partial aortic valve and annulus rupture during transcatheter aortic valve replacement, and its successful management through percutaneous means. It stresses the fact that even severe procedural complications can often be treated by a heart team endovascularly, without requiring sternotomy.