Midterm results of mitral valve repair with lifting annuloplasty strip for acute phase infective endocarditis.

BACKGROUND: Mitral valve repair is favored over replacement due to superior outcomes. However, extensive infective endocarditis (IE) often has been considered unreconstructable. We retrospectively analyzed the mid-term outcomes of an individualized repair approach using a lifting annuloplasty strip. METHODS: Between December 2007 and March 2014, 27 consecutive patients with acute single mitral valve IE (age 43 ± 16 years, 11 men) underwent lifting mitral annuloplasty (LMA) with a strip (Mitracon® strip, 28 mm in 4, 32 mm in 10, and 34 mm in 13). Blood culture was positive in 70 % (Streptococcus 10, Staphylococcus 4, HACEK 3, Enterococcus 1, Gram negative bacilli 1). One case (4 %) had a previously repaired mitral valve-the repair was redone. Via right thoracotomy (74 %) or median sternotomy (26 %), repair was performed by removal of vegetation and resection of infected tissue, the defect typically then being repaired using a bovine pericardial patch (81 %). Artificial chordae were formed in 5 patients. Nine (33 %) of them had posterior leaflet augmentation (PLA) to get sufficient coaptation height. Clinical and echocardiographic follow-up were performed. RESULTS: Compared with preoperative ones, postoperative echocardiograms revealed decreases of left ventricular (LV) end-diastolic dimensions (57.2 ± 6.3 versus, 45.4 ± 6.2, or 44.8 ± 4.1 mm, all p < 0.01). The LV ejection fraction decreased immediately, but recovered (64.4 ± 9.6 % vs. 54.5 ± 9.8 %, or 65.2 ± 6.1 %, p = 0.002, p = 1.000, respectively). The latest follow-up echocardiograms (median 28 months) universally showed no or minimal regurgitation, with a preserved mitral valve opening area (2.27 ± 0.48 cm(2)). During the clinical follow-up (median, 54 months), one (3.7 %) death was observed (in-hospital, due to biliary sepsis and pneumonia). There was no reoperation or major cardiovascular event. The 5 year survival rate was 96.3 %. CONCLUSIONS: The repair technique of LMA and/or PLA in patients with IE achieved good structural and functional outcomes as well as an excellent 5 year survival rate. An individualized repair approach should be recommended in patients with acute phase IE.

Lifting posterior mitral annuloplasty for enhancing leaflet coaptation in mitral valve repair: midterm outcomes.

BACKGROUND: We evaluated the midterm outcomes of lifting posterior mitral annuloplasty for enhancing leaflet coaptation in mitral valve repair. METHODS: Between October 2007 and December 2012, 341 consecutive patients with significant mitral regurgitation underwent lifting posterior mitral annuloplasty using a specially designed fabric annuloplasty strip that lifts the middle portion of the posterior annulus. Associated procedures for mitral valve repairs, such as patch valvuloplasty for posterior leaflet prolapse (n=80), new chord placement for anterior leaflet prolapse (n=33), commissurotomy (n=29), and posterior leaflet extension (n=23), were performed in 141 patients (41.3%). RESULTS: Thirty-day mortality was 0.9%. Nine late deaths (2.6%) occurred. Mean overall survival at 5 years was 96.0%±1.1%. During the mean follow-up period of 38±17 months, six patients (1.8%) underwent valve-related reoperation (5-year freedom from valve-related reoperation, 98.1%±0.8%). At 5 years, mean freedom from recurrence of mitral regurgitation grade 3+ to 4+ (moderate to severe) was 95.1%±1.6%. The mean valve pressure gradient (PG) was 3.2±1.5 mmHg across all strip sizes at the time of follow-up. CONCLUSIONS: Lifting posterior mitral annuloplasty using an innovative annuloplasty strip in mitral valve repair has a low rate of recurrent regurgitation or valve-related reoperation with rare relevant complications.

Mid-term results for a patch valvuloplasty technique to correct posterior leaflet prolapse.

BACKGROUND AND AIM OF THE STUDY: Most valve repair techniques require resection and multiple sutures. In the present study, a novel technique without resection for correction of posterior leaflet prolapse due to chordal elongation or rupture was employed, the aim being to evaluate the outcomes of a non-resecting valve repair technique in patients with posterior leaflet prolapse that caused significant mitral regurgitation (MR). METHODS: Between May 2008 and December 2010, a total of 90 consecutive patients with posterior leaflet prolapse (55 males, 35 females; mean age 51.5 ± 14.6 years) underwent patch valvuloplasty. The procedure involved suturing the free margin of the prolapsed leaflet, invagination of the folded leaflet tissue into the left ventricular side, coverage of the dimpled portion with a round bovine pericardial patch using a continuous suture technique, and reshaping of the posterior annulus using a 53- to 61-mm strip. All patients underwent postoperative echocardiography after a mean follow up of 41.9 ± 10.4 months. RESULTS: No early death occurred, but there was one late death due to a non-cardiac cause. At the last echocardiographic follow up, 81 patients (90%) showed none or trace MR, seven (7.8%) had mild MR, and two (2.2%) moderate MR. The mean mitral valve area was 2.4 ± 0.5 cm2 and the mean pressure gradient 2.8 ± 1.2 mmHg. No patient required reoperation due to recurrent or aggravated MR. CONCLUSION: In patients with posterior leaflet prolapse, the applied patch valvuloplasty technique was useful and reliable, showing excellent clinical and echocardiographic outcomes. Additional long-term evaluations with close follow up should be performed.

Fused aortic valve without an elliptical-shaped systolic orifice in patients with severe aortic stenosis: cardiac computed tomography is useful for differentiation between bicuspid aortic valve with raphe and tricuspid aortic valve with commissural fusion.

OBJECTIVE: The objective is to determine cardiac computed tomography (CCT) features capable of differentiating between bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) in severe aortic stenosis (AS) patients with fused cusp and without elliptical-shaped systolic orifices. METHODS: We retrospectively enrolled 53 patients who had severe AS with fused cusps and without an elliptical-shaped systolic orifice on CCT and who had undergone surgery. CCT features were analyzed using: 1) aortic valve findings including cusp size, cusp area, opening shape, midline calcification, fusion length, calcium volume score, and calcium grade; 2) diameters of ascending and descending aorta, and main pulmonary artery; and 3) rheumatic mitral valve findings. The variables were evaluated using univariate and multivariate logistic regression analyses. RESULTS: At surgery, 19 patients had BAV and 34 had TAV. CCT features including uneven cusp size, uneven cusp area, round-shaped systolic orifice, longer cusp fusion, and dilatation of ascending aorta were significantly associated with BAV (P < 0.05). In particular, fusion length (OR, 1.76; P = 0.001), uneven cusp area (OR, 10.46; P = 0.012), and midline calcification (OR, 0.08; P = 0.013) were strongly associated with BAV. CONCLUSION: CCT provides diagnostic clues that helps differentiate between BAV with raphe and TAV with commissural fusion in patients with severe AS. KEY POINTS: • Accurate morphologic assessment of the aortic valve is important for treatment planning. • It is difficult to differentiate BAV from TAV with a fused cusp. • CCT provides diagnostic clues for the differentiation of BAV and TAV.

Quantification of stenotic mitral valve area and diagnostic accuracy of mitral stenosis by dual-source computed tomography in patients with atrial fibrillation: comparison with cardiovascular magnetic resonance and transthoracic echocardiography.

This study aimed to evaluate the utility of dual-source computed tomography (DSCT) for quantification of the mitral valve area (MVA) in patients with atrial fibrillation (AF) and mitral stenosis (MS) and to compare the results of DSCT with those of cardiovascular magnetic resonance (CMR) and transthoracic echocardiography (TTE). One hundred-two patients with AF and MS who had undergone electrocardiography-gated DSCT, TTE and CMR prior to operation were retrospectively enrolled. The MVA was planimetrically determined by DSCT, CMR, and TTE, as well as by Doppler TTE using the pressure half-time method (TTE-PHT). Agreement, relationship between measurements, and the highest accuracy were evaluated using Bland-Altman, Pearson correlation, and receiver operating characteristic analyses. The MVA on DSCT (mean, 1.27 ± 0.27 cm(2)) was significantly larger than that on CMR (1.15 ± 0.28 cm(2), P < 0.05), TTE-planimetry and TTE-PHT (1.16 ± 0.28 and 1.07 ± 0.30 cm(2), respectively; P < 0.05). TTE-planimetry had better correlation with planimetry on DSCT and CMR (r = 0.65 and 0.67, respectively; P < 0.05) than TTE-PHT (r = 0.51 and 0.55, respectively; P < 0.05). Using an MVA of 1.0 cm(2) on TTE-planimetry and TTE-PHT as the reference, the optimal thresholds for detecting severe MS on DSCT was 1.19 cm(2). The planimetry of the MVA measured by DSCT may be a reliable, alternative method for the quantification of MS in patients with AF.

Diagnostic performance of dual-energy CT stress myocardial perfusion imaging: direct comparison with cardiovascular MRI.

OBJECTIVE: The purpose of this study was to assess the diagnostic performance of stress perfusion dual-energy CT (DECT) and its incremental value when used with coronary CT angiography (CTA) for identifying hemodynamically significant coronary artery disease. SUBJECTS AND METHODS: One hundred patients with suspected or known coronary artery disease without chronic myocardial infarction detected with coronary CTA underwent stress perfusion DECT, stress cardiovascular perfusion MRI, and invasive coronary angiography (ICA). Stress perfusion DECT and cardiovascular stress perfusion MR images were used for detecting perfusion defects. Coronary CTA and ICA were evaluated in the detection of ≥50% coronary stenosis. The diagnostic performance of coronary CTA for detecting hemo-dynamically significant stenosis was assessed before and after stress perfusion DECT on a per-vessel basis with ICA and cardiovascular stress perfusion MRI as the reference standard. RESULTS: The performance of stress perfusion DECT compared with cardiovascular stress perfusion MRI on a per-vessel basis in the detection of perfusion defects was sensitivity, 89%; specificity, 74%; positive predictive value, 73%; negative predictive value, 90%. Per segment, these values were sensitivity, 76%; specificity, 80%; positive predictive value, 63%; and negative predictive value, 88%. Compared with ICA and cardiovascular stress perfusion MRI per vessel territory the sensitivity, specificity, positive predictive value, and negative predictive value of coronary CTA were 95%, 61%, 61%, and 95%. The values for stress perfusion DECT were 92%, 72%, 68%, and 94%. The values for coronary CTA and stress perfusion DECT were 88%, 79%, 73%, and 91%. The ROC AUC increased from 0.78 to 0.84 (p=0.02) with the use of coronary CTA and stress perfusion DECT compared with coronary CTA alone. CONCLUSION: Stress perfusion DECT plays a complementary role in enhancing the accuracy of coronary CTA for identifying hemodynamically significant coronary stenosis.

Direct comparison of stress- and rest-dual-energy computed tomography for detection of myocardial perfusion defect.

We assessed the diagnostic performance of stress- and rest-dual-energy computed tomography (DECT) and their incremental value when used with coronary CT angiography (CCTA) compared with combined invasive coronary angiography (ICA)/cardiovascular magnetic resonance (CMR) for detecting hemodynamically significant stenosis causing a myocardial perfusion defect. Forty patients (30 men; mean age, 63.4 ± 8.8 years) with known or suspected coronary artery disease detected by CCTA underwent stress- and rest-DECT, CMR, and ICA. DECT iodine maps were compared with CMR on a per-segment and per-vessel basis. Diagnostic value of CCTA was assessed on a per-vessel basis before and after stress- and rest-DECT and compared to that of ICA/CMR. Compared to CMR, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of rest-DECT for detecting segment (vessel)-based perfusion defects were 29% (46%), 88% (79%), 56% (61%), and 70% (67%), respectively. Corresponding values using stress-DECT were 73% (94%), 83% (74%), 70% (72%), and 85% (95%), respectively. There was fair (κ = 0.39) agreement between rest- and stress-DECT iodine maps in identifying segments with perfusion defects. Compared with the ICA/CMR for identifying hemodynamically significant stenoses, per-vessel territory sensitivity, specificity, PPV, and NPV of CCTA were 91, 56, 55, and 91%, respectively; those using CCTA/rest-DECT were 42, 83, 59, and 70%, respectively; and those using CCTA/stress-DECT were 87, 79, 71, and 91%, respectively. The area under the receiver operating characteristic curve decreased from 0.74 to 0.62 (P = 0.06) using CCTA/rest-DECT but increased to 0.83 (P = 0.02) using CCTA/stress-DECT. Stress-DECT has incremental value when used with CCTA for detecting hemodynamically significant stenoses.

Surgical management of recurrent leiomyosarcoma in heart.

Leiomyosarcoma may occur anywhere in the body but rarely occurs in the heart or great vessels. Leiomyosarcoma may be managed by surgical resection with or without chemotherapy or radiotherapy. Owing to the high rate of metastasis and poor prognosis, a definitive treatment modality for leiomyosarcoma has not yet been suggested. This case study reports the surgical management of the recurrent leiomyosarcoma of the heart and the great vessels in a 63-year-old woman.

Mid-term results in patients having tricuspidization of the quadricuspid aortic valve.

BACKGROUND: Quadricuspid aortic valve (QAV) is a rare congenital anomaly. We investigate the mid-term results of aortic valve reconstruction by tricuspidization in patients with QAV. METHODS: We analyzed the outcome of eight consecutive patients who underwent aortic valve reconstruction surgery (AVRS) with pericardial leaflets with symptomatic quadricuspid aortic valve (QAV) disease between December 2007 and May 2012. AVRS consists of leaflet reconstruction and fixation of the sino-tubular junction in order to maintain coaptation of the new valve. RESULTS: Six males and two females were included; ages ranged from 19 to 63 years (mean age, 51 years). According to Hurwitz and Roberts's classification, three patients had type A, three patients had type B, one patient had type C, and one patient had type E. All patients had significant aortic regurgitation (AR): moderate in three patients, moderate to severe in one patient, and severe in four patients. Concomitant ascending aorta wrapping with an artificial vascular graft was performed in one case. There was no occurrence of mortality during the follow-up period (42.4 ± 18.0 months). No redo-operation was required. The NYHA functional class showed improvement from 2.1 ± 0.2 to 1.1 ± 0.2 (p= 0.008). The latest echocardiograms showed AR absent or trivial in seven patients, and mild in one patient. The aortic valve orifice area index (AVAI) was 1.03 ± 0.49 cm2/m2. Compared with preoperative echocardiograms, the left ventricular (LV) ejection fraction showed improvement from 57.6 ± 17.0 to 63.7 ± 13.2% (p=0.036); the end-diastolic and end-systolic LV dimensions showed a significant decrease, from 63.5 ± 9.6 to 49.5 ± 3.1 mm (p=0.012) and 43.6 ± 11.8 to 32.1 ± 5.4 mm (p=0.012), respectively. CONCLUSION: In patients with QAV, AVRS with tricuspidization showed satisfactory early and mid-term results. Long-term follow-up will be necessary in order to study the durability of AVRS; however, it can be considered as a potential standard procedure.

Aortic valve reconstruction with leaflet replacement and sinotubular junction fixation: early and midterm results.

BACKGROUND: Aortic valve reconstruction surgery (AVRS), consisting of aortic leaflet reconstruction with tailored pericardial patches and fixation of the sinotubular junction with properly sized fabric rings, is performed for the treatment of aortic valve diseases. The early and midterm outcomes of AVRS were analyzed. METHODS: Between December 2007 and December 2012, 262 patients with isolated aortic valve disease underwent AVRS in one center. Clinical outcomes, effective orifice area, mean gradients, and left ventricular mass index were evaluated yearly. RESULTS: Mean follow-up duration was 36.0±17.1 months and was complete in 100% of surviving patients. There was no hospital mortality, but there were 3 late deaths (1.1% late mortality). Seven patients (2.7%) required reoperation: 5 because of endocarditis and 2 because of suture disruption of the leaflets. Ten patients (3.8%) experienced neurologic events. Aortic valve regurgitation was absent or trivial in 226 patients (87.3%) and mild in 29 (11.2%), mild to moderate in 3 (1.2%), and moderate to severe in 1 (0.4%). The mean valve gradient and valve orifice index were 10.6±5.3 mm Hg and 1.3±0.4 cm2/m2, respectively. CONCLUSIONS: The data from the first 5 years after AVRS reveal good clinical and hemodynamic outcomes, suggesting that AVRS is a new alternative technique to the practice of replacement with stented bioprostheses and mechanical prostheses. However, whether the reconstructed aortic valve represents a truly long-term valve remains to be demonstrated.

Relationship between bicuspid aortic valve phenotype, valvular function, and ascending aortic dimensions.

BACKGROUND AND AIM OF THE STUDY: Bicuspid aortic valve (BAV) is known to be associated with aortic valve dysfunction and ascending aorta (AA) dilatation. However, the relationship between BAV morphology and AA dimensions remains unclear. Thus, the study aim was to characterize the aortic valve function and AA dimensions according to the presence of raphe and BAV phenotype. METHODS: A total of 164 patients with BAV who underwent aortic valve surgery between October 2007 and November 2012 was investigated. BAV was classified as either type I (anterior-posterior orientation) or type II (right-left orientation), and subdivided as raphe+ (presence of raphe) and raphe-(no raphe). RESULTS: Type I BAV was present in 103 patients (62.8%), and raphe+ in 100 (61.0%). Patients with raphe+ were typically younger than those with raphe-, and male gender was more predominant (88.0% and 53.1%, respectively, p < 0.05). Aortic regurgitation was more common in patients with type I and raphe+ BAV, and aortic stenosis in patients with type II and raphe- BAV. In patients with raphe+, the diameters of aortic annulus related to the body surface area (BSA) were larger, and the diameters of the tubular portion of AA indexed to BSA were smaller than in patients with raphe- (p < 0.05). CONCLUSION: BAV morphology is helpful for predicting the type of aortic valve dysfunction and the location of AA dilatation.

Aortic valve reconstruction with use of pericardial leaflets in adults with bicuspid aortic valve disease: early and midterm outcomes.

In this study, we retrospectively analyzed the outcomes of adults with bicuspid aortic valve (BAV) disease who underwent aortic valve reconstructive surgery (AVRS), consisting of replacement of the diseased BAV with 2 or 3 pericardial leaflets plus fixation of the sinotubular junction for accurate and constant leaflet coaptation. From December 2007 through April 2013, 135 consecutive patients (mean age, 49.2 ± 13.1 yr; 73.3% men) with symptomatic BAV disease underwent AVRS. Raphe was observed in 84 patients (62.2%), and the remaining 51 patients had pure BAV without raphe. A total of 122 patients (90.4%) underwent 3-leaflet reconstruction, and 13 (9.6%) underwent 2-leaflet reconstruction. Concomitant aortic wrapping with an artificial graft was performed in 63 patients (46.7%). There were no in-hospital deaths and 2 late deaths (1.5%); 6 patients (4.4%) needed valve-related reoperation. The 5-year cumulative survival rate was 98% ± 1.5%, and freedom from valve-related reoperation at 5 years was 92.7% ± 3.6%. In the last available echocardiograms, aortic regurgitation was absent or trivial in 116 patients (85.9%), mild in 16 (11.9%), moderate in 2 (1.5%), and severe in one (0.7%). The mean aortic valve gradient was 10.2 ± 4.5 mmHg, and the mean aortic valve orifice area index was 1.3 ± 0.3 cm(2)/m(2). The 3-leaflet technique resulted in lower valve gradients and greater valve areas than did the 2-leaflet technique. Thus, in patients with BAV, AVRS yielded satisfactory early and midterm results with low mortality rates and low reoperation risk after the initial procedure.

Detection of left atrial thrombus in patients with mitral stenosis and atrial fibrillation: retrospective comparison of two-phase computed tomography, transoesophageal echocardiography and surgical findings.

OBJECTIVE: This retrospective study aims to assess the accuracy of two-phase computed tomography (CT) and transoesophageal echocardiography (TEE) for the detection of left atrial (LA) thrombus in patients with mitral stenosis (MS) and atrial fibrillation (AF), by using intraoperative findings as the reference standard. METHODS: Preoperative two-phase CT and intraoperative TEE were performed in 106 patients with MS and AF. The ratio (LAA/AAL) of Hounsfield units (HU) in the LA appendage (LAA) to the ascending aorta (AA) was calculated on the late-phase CT image. RESULTS: LA echodense masses on TEE and LA filling defects on two-phase CT were observed in 29 and 39 patients, respectively. Thirty-five LA thrombi were identified at surgery in 27 patients. Compared with the intraoperative findings, per-patient sensitivity, specificity, positive and negative predictive values of two-phase CT were 100 %, 85 %, 69 % and 100 %, and those by using TEE were 93 %, 95 %, 86 % and 97 % in detecting LAA thrombus. After adopting the cut-off value of 0.5 for the LAA/AAL HU ratio, the specificity and positive predictive value of two-phase CT were increased to 96 % and 90 %, respectively. CONCLUSION: Two-phase CT with a cut-off value of LAA/AAL HU ratio of 0.5 provides high performance for the detection of LAA thrombus. KEY POINTS: • Accurate detection of left atrial appendage (LAA) thrombus is extremely important. • However artefacts from flow effects influence both CT and ultrasound findings. • Two-phase ECG-gated CT offers new insight into thrombus detection. • Analysis of aortic/atrial opacification helps differentiate LAA thrombus from artefact at CT.

Evaluation of the aortic and mitral valves with cardiac computed tomography and cardiac magnetic resonance imaging.

Cardiac computed tomography (CT) produces high-quality anatomical images of the cardiac valves and associated structures. Cardiac magnetic resonance imaging (MRI) provides images of valve morphology, and allows quantitative evaluation of valvular dysfunction and determination of the impact of valvular lesions on cardiovascular structures. Recent studies have demonstrated that cardiac CT and MRI are important adjuncts to echocardiography for the evaluation of aortic and mitral valvular heart diseases (VHDs). Radiologists should be aware of the technical aspects of cardiac CT and MRI that allow comprehensive assessment of aortic and mitral VHDs, as well as the typical imaging features of common and important aortic and mitral VHDs on cardiac CT and MRI.

Comparative analysis of thoracotomy and sternotomy approaches in cardiac reoperation.

BACKGROUND: Reoperation of cardiac surgery via median sternotomy can be associated with significant complications. Thoracotomy is expected to reduce the risk of reoperation and to enhance the surgical outcomes. We retrospectively analyzed two operative approaches (thoracotomy vs. sternotomy) in cardiac reoperation. MATERIALS AND METHODS: From September 2007 to December 2010, 35 patients who required reoperation of the mitral valvular disease following previous median sternotomy were included. Average age of patients was 45.8±15.4 years (range, 14 to 76 years) and male-to-female was 23:12. Interval period between primary operation and reoperation was 135.8±105.6 months (range, 3.3 to 384.9 months). RESULTS: Comparative analysis was done dividing the patient group into two groups that are thoracotomy group (22 patients) and sternotomy group (13 patients). Thoracotomy group was significantly lower in operative time (415.2±90.3 vs. 497.5±148.0, p<0.05), bleeding control time (108.0±29.5 vs. 146.4±66.8, p<0.05) and chest tube drainage (287.5±211.5 mL vs. 557.3±365.5 mL, p<0.05) compared to sternotomy group. CONCLUSION: The thoracotomy approach is superior to sternotomy in some variables, and it is considered as a valid alternative to repeat median sternotomy in patients who underwent a previous median sternotomy.

Short-term Outcomes of Aortic Wrapping for Mild to Moderate Ascending Aorta Dilatation in Patients Undergoing Cardiac Surgery.

BACKGROUND: The adequate management of mild to moderate dilatation of the ascending aorta during cardiac operations remains controversial. In this study, we present the short-term outcomes of 90 patients undergoing ascending aortic wrapping with a Dacron graft during other cardiac operations. MATERIALS AND METHODS: From March 2008 to January 2011, 90 consecutive patients underwent treatment for ascending aortic aneurysm using the external wrapping technique during the concomitant procedure. The study group consisted of 49 male and 41 female patients with a mean age of 58.7±13 years. The primary cardiac surgical procedures were coronary artery bypass grafting (CABG) in 3, aortic valve replacement in 2, and aortic valvuloplasty in 85 patients (isolated in 62 and combined with CABG or mitral valvuloplasty in 23). The ascending aorta diameter was measured using a computed tomography scan within 4 weeks after surgery, and was compared with the preoperative value. RESULTS: The diameters of the ascending aorta wrapped with the Dacron graft were significantly reduced within a month after surgery from 46.4±4.3 mm to 33.0±3.5 mm (p<0.05). There was no early mortality or major surgical complication. During the mean follow-up period of 15.4±5.2 months, there was only one late death caused by septic multiorgan failure. CONCLUSION: Dacron wrapping of the ascending aorta offers excellent results with very low mortality and morbidity, and it can be regarded as a safe and effective method for the treatment of moderately dilated ascending aorta in selected patients.

Morphological assessment of the aortic valve using coronary computed tomography angiography, cardiovascular magnetic resonance, and transthoracic echocardiography: comparison with intraoperative findings.

To compare the diagnostic accuracies of coronary computed tomography angiography (CCTA), cardiovascular magnetic resonance (CMR), and transthoracic echocardiography (TTE) in aortic valve (AV) morphological assessments with operative findings. We retrospectively enrolled 262 patients who underwent CCTA, CMR, and TTE before AV surgery. Two independent blinded observers assessed AV morphology as being tricuspid, bicuspid, or quadricuspid using three imaging modalities. Interobserver and intermodality agreements were obtained with kappa statistics. The diagnostic accuracies of CCTA, CMR, and TTE for identifying AV morphology (tricuspid vs. non-tricuspid) were compared with intraoperative findings as the reference standard. At surgery, tricuspid AV, bicuspid AV, and quadricuspid AV were present in 179, 80, and 3 patients, respectively. The CCTA and CMR image qualities were all diagnostic. Thirteen cases of TTE were not evaluable due to severe AV calcification. An excellent correlation between CMR and CCTA was seen for the identification of AV morphology (κ = 0.97). Good correlations existed between CCTA and TTE (κ = 0.72) and between CMR and TTE (κ = 0.74). CCTA, CMR, and TTE had an excellent or good interobserver agreement (κ = 0.90, 0.95, and 0.72, respectively). Sensitivity, specificity, and positive and negative predictive values for AV morphology assessment (tricuspid vs. non-tricuspid) were: 97, 95, 98, and 94 % with CCTA (n = 262); 98, 96, 98, and 95 % with CMR (n = 262); and 98, 88, 95, and 96 % with TTE (n = 249). CCTA and CMR are highly accurate for identifying AV morphology.

Diagnostic performance of combined noninvasive anatomic and functional assessment with dual-source CT and adenosine-induced stress dual-energy CT for detection of significant coronary stenosis.

OBJECTIVE: The purpose of our study was to prospectively evaluate the incremental diagnostic value of combined dual-source coronary CT angiography (CTA) and CT myocardial perfusion imaging (MPI) for the detection of significant coronary stenoses. SUBJECTS AND METHODS: Forty-five patients with known coronary artery disease detected by dual-source coronary CTA were investigated by adenosine-induced stress dual-source CTA and conventional coronary angiography. Analysis was performed in three steps: classification of coronary stenosis severity using dual-source coronary CTA, identification of myocardial perfusion defects using rest and stress CT MPI, and reclassification of coronary stenosis severity according to combined dual-source coronary CTA and CT MPI. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of dual-source coronary CTA before and after CT MPI were calculated on a per-vessel basis compared with conventional coronary angiography as the standard of reference. RESULTS: Dual-source coronary CTA revealed 87 significantly stenotic vessels in 45 patients. Conventional coronary angiography revealed significant stenoses in 73 vessels in 42 patients. CT MPI showed myocardial perfusion defects in 81 vessel territories in 43 patients. After the CT MPI analysis, dual-source coronary CTA identified significant stenoses in 77 coronary vessels in 42 patients. Sensitivity, specificity, PPV, and NPV of the dual-source coronary CTA on a per-vessel basis before CT MPI were 91.8%, 67.7%, 73.6%, and 87.5%, respectively, and after CT MPI were 93.2%, 85.5%, 88.3%, and 91.4%, respectively. The area under the receiver operating characteristic curve increased significantly from 0.798 to 0.893 (p = 0.004). CONCLUSION: Combined dual-source coronary CTA and CT MPI provides incremental diagnostic value compared with dual-source coronary CTA alone for the detection of significant coronary stenoses.

Assessment of global left ventricular function with dual-source computed tomography in patients with valvular heart disease.

BACKGROUND: Left ventricular (LV) function is a vital parameter for prognosis, therapy guidance, and follow-up of cardiovascular disease. Dual-source computed tomography (DSCT) provides an accurate analysis of global LV function. PURPOSE: To assess the performance of DSCT in the determination of global LV functional parameters in comparison with cardiovascular magnetic resonance (CMR) and two-dimensional transthoracic echocardiography (2D-TTE) in patients with valvular heart disease (VHD). MATERIAL AND METHODS: A total of 111 patients (58 men, mean age 49.9 years) with known VHD and who underwent DSCT, 2D-TTE, and CMR a period of 2 weeks before undergoing valve surgery were included in this study. LV end-systolic volume (ESV), end-diastolic volume (EDV), stroke volume (SV), and ejection fraction (EF) were calculated by DSCT using the threshold-based technique, by 2D-TTE using a modified Simpson's method, and by CMR using Simpson's method. Agreement for parameters of LV global function was determined with the Pearson's correlation coefficient (r) and Bland-Altman analysis. All the DSCT and CMR data-sets were assessed independently by two readers. RESULTS: Fifty of the total 111 patients had aortic VHD, 29 patients had mitral VHD, and 32 patients had mixed aortic and mitral VHD. An excellent inter-observer agreement was seen for the assessment of global LV function using DSCT (r = 0.910-0.983) and CMR (r = 0.854-0.965). An excellent or good correlation (r = 0.93, 0.95, 0.87, and 0.71, respectively, P < 0.001) was noted between the DSCT and 2D-TTE values for EDV, ESV, SV, and EF. EDV (33.7 mL, P < 0.001), ESV (12.1 mL, P < 0.001), SV (21.2 mL, P < 0.001), and EF (1.6%, P = 0.019) were significantly overestimated by DSCT when compared with 2D-TTE. An excellent correlation (r = 0.96, 0.97, 0.91, and 0.94, respectively, P < 0.001) between DSCT and CMR was seen in the evaluation of EDV, ESV, SV, and EF. EDV (15.9 mL, P < 0.001), ESV (7.3 mL, P < 0.001), and SV (8.5 mL, P < 0.001) were significantly underestimated, but EF (1.1%, P = 0.002) was significantly overestimated by DSCT when compared with CMR. CONCLUSION: Our study showed that DSCT measurements of global LV function using the threshold-based technique were highly reproducible and compared more favorably with CMR measurements using Simpson's method than those of 2D-TTE using the modified Simpson's method. DSCT enables accurate quantification of global LV function in patients with VHD.

Bicuspid aortic valve: spectrum of imaging findings at cardiac MDCT and cardiovascular MRI.

OBJECTIVE: Cardiac MDCT and cardiovascular MRI have become widely used for the evaluation of cardiovascular disease, including aortic valve disease. The purpose of this article is to present the cardiac MDCT and cardiovascular MRI findings of bicuspid aortic valve, its various complications, and other congenital cardiovascular malformations. CONCLUSION: Radiologists should be aware of the clinical significance and the varied appearance of bicuspid aortic valve at cardiac MDCT and cardiovascular MRI.