The Imaging Application Study Of Transcatheter Aortic Valve Replacement Related To Valve Leaflet Classification And The Predictive Value Of Leaflet Coaptation Calcification For New Postoperative Block

Characteristics of aorto-iliofemoral arterial tree according to aortic valve morphology in Chinese patients considered for TAVRObjective To characterize the anatomy of aorto-iliofemoral arterial tree according to aortic valve phenotype by computed tomography(CT)in patients referred for transcatheter aortic valve replacement(TAVR).Methods We retrospectively enrolled 215 patients with severe symptomatic(AS)screened for TAVR who underwent CT.Dimensions,calcification,vascular tortuosity index score and other putative risk features of thirteen different regions(the iliac artery,external iliac artery,femoral artery and following sections of entire aorta:aortic annulus,sinus of Valsalva,sinotubular junction,maximal ascending aorta,proximal arch,distal arch,aortic isthmus,descending aorta,suprarenal aorta and infra-renal aorta)were evaluated for bicuspid aortic valve(BAV)and tricuspid aortic valve(TAV)morphology,Results The study consisted of 44%(n=94)BAVs with younger age than TAVs(74.4 ±7.3 years vs 76.6 ± 6.7 years,p=0.02).The dimensions of the annulus,sinus of Valsalva,ascending aorta and aortic arch were consistently larger in BAVs.There is a significantly higher prevalence of ascending aortic dilation in the BAV group compared with the TAV group(p=0.03).Univariate analysis indicated that the prevalence of calcification of aortic arch was significantly higher in TAV cohort(45%vs 27%,p=0.01;23%vs 9%?p=0.01).Rates of both over grade ? and grade ? aortic arch calcification remained significantly higher in TAV group(p=0.047,p=0.04,respectively)even after adjustment.BAVs was associated with two-fold higher odds of having over I degree AA calcification(odds ratio,2.02;95%CI 1.60-5.31;p<0.001).The prevalence of slight iliac tortuosity(tortuosity index=1)is only 15%for BAVs,but for persons with TAV,the prevalence increases to 29%(p=0.01).BAVs had a trend to more atheroma,intramural hematoma and penetrating ulcers than TAVs in 5 segments of aorta.Conclusions BAV anatomy is common in Chinese AS patients screened for TAVR.Aorto-iliofemoral pathology varies according to aortic valve phenotype,which may contribute to technical challenges in BAV vs TAV anatomy and support the need for specific anatomical TAVR risk scores for each valve phenotype.Study on the optimal annulus sizing approach for patients assigned for transcatheter aortic valve replacement with bicuspid aortic valveObjective To clarify the optimal measurements for patients with bicuspid aortic valve(BAV)preferred to transcatheter aortic valve replacement(TAVR),our study eompared intraoperative sizing with five different approaches by transthoracic echocardiography(TTE),3-dimensional transesophageal echocardiography(3DTEE)and computed tomography(CT).Methods We enrolled 104 BAVs suffering from severe aortic stenosis who were prescreened for TAVR but underwent surgery.All patients had at least intermediate surgical risk and underwent preoperative 2DTTE,3DTEE,CT and intraoperative measurement of the aortic annulus with metric sizers.All five approaches(2DTTE,3DTEE,area-derived perimeter(CTarea),perimeter-derived diameter(CTperi)and mean diameter(CTmean))were compared with intraoperative sizing respectively.All patients were divided into three subgroups according to the predominant localization of aortic valve calcifications.Agreements of theoretical valve selections by five methods with those by intraoperative sizing were analyzed.The surgical valve and TAVR valve were theoretically selected according to 3DTEE measurements,CTmean measurements,CTperi measurements,CTarea measurements,and intraoperative measurements,respectively.Patients were stratified according to the suggested surgical valve size by CTperi relative to the implanted surgical valve size.Results One hundred and four patients with BAV(mean age,69.1 ± 6.2 years;55.7%male)constituted the study population,and the STS score was 6.8 ± 3.2%.The eccentricity index of 0.21±0.07 indicated a pronounced oval shape of the annulus in BAVs.Significant differences in the mean values and those indexed to BSA,were both observed in all five calculations,while area-derived diameter and indexed area-derived diameter were only slightly higher than those obtained by intraoperative measurements(25.6±2.1 mm vs 25.3± 2.0 mm,p<0.001;15.5 ± 0.6 mm/m2 vs 15.3 ± 0.6 mm/m2,p<0.001).The perimeter-derived diameter was markedly larger than that assessed in surgery by approximately one millimeter(26.2 ± 2.2 mm vs 25.3±2.0 mm,p<0.001).CTarea showed the highest correlation(r=0.932,p<0.001)and the best agreement with intraoperative sizing.CTarea and CTperi were found to be more reproducible than other measurements(ICC 0.90,95%CI 0.81 to 0.95;ICC 0.89,95%CI 0.79 to 0.95).The diameters measured by 3DTEE were systematically smaller than those by intraoperative sizing(mean difference,0.53 mm;limits of agreement,-0.72 mm to 1.78 mm),Agreement for theoretical surgical and TAVR prosthesis selection was found in 84.6%and 74.0%BAVs by CTarea(??0.791,p<0.001;?=0.585,p<0.001).CTperi-based prosthesis selection led to overestimation of 26.9%for surgical valves(??0.589,p<0.001)and 36.5%for TAVR valves(?=0.425,p<0.001).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 for annulus sizing and prosthesis choice of BAVs with high eccentricity,should be included into the BAV-specific annulus sizing recommendation.The insufficiency of CTperi lied 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 with caution for patients with calcified annulus.Commissural-based calcification assessment by CT to aid post-TAVR NOCD predictionsObjective The predictive value of the quantification,distribution and asymmetry of the calcification on new onset conduction disturbance(NOCD),particularly regarding its anatomic proximity to the conduction pathway is poorly characterized.We aim to identify the predictors of NOCD following transcatheter aortic valve replacement(TAVR),with a particular emphasis on sector calcification quantified by a new dividing method.Methods A total of 136 patients who underwent TAVR and computed tomography(CT)were analyzed and divided into two groups according to the appearance of NOCD.Calcification was quantitatively measured by using the 850-Hounsfield unit threshold in the aortic valve complex(AVC)region and the left ventricular outflow tract(LVOT)region.Calciul load was then quantified precisely by coronary cusps(left coronary cusp[LCC],right coronary cusp[RCC],non-coronary cusp[NCC])and sectors according to its positional relationship with the conduction pathway(the adjacent sector[AVCadj/LVOTadj]and the remote sector[AVCrem/LVOTrem]).The asymmetry was assessed by the maximum absolute difference of calcium volume.Implantation depth of the prosthesis and oversizing rate were also measured.Mann-Whitney U test was used to analyze the calcification data in different regions or sectors.Receiver-operating characteristic(ROC)cun es were generated using the new onset conduction disturbance and the area under the curve(AUC)was calculated.The best discriminatory thresholds of calcium volume were calculated by determining the Youden index separately for each area of interest.Preoperative and perioperative variables with a p-value of<0.05 at univariate analysis were included into the multivariate analysis to test for independence.Results Of the 136 patients(mean age,76.9 ± 6.2 years;81.6%male),24.2%(n=33)presented with pre-existing conduction disturbance.Patients with NOCD exhibited higher 1edian calcium volumes of total calcium volume(578.4 mm3 vs.474.7 mm3,p=0.038),calcium volume of LCC(247.8 mm3 vs.149.2 mm3,p=0.001),remote sector(AVCrem)(403.1 mm3 vs.259.5 mm3,p<0.001)and higher asymmetry(aAVC)(AAVC 238.4 mm3 vs.31.4 mm3,p<0.001).For the LVOT region,calcium volumes in the LVOTNCC(2.7 mm3 vs 2.3 mm3,p=0.021),LVOTadj(3.3 mm3 vs 2.8 mm3,p=0.028)and LVOTtotal(4.9 mm3 vs 3.9 mm3,p=0.004)was associated with NOCD.The greatest discriminatory value for NOCD was numerically highest in ?AVC,followed by AVCrem.Multivariate analysis revealed AVCrem calcium volume>374.1 mm3(OR:5.55;95%CI:1.03 to 29.87;p=0.046):?AVC calcium volume>103.3 mm3(OR:9.57;95%CI:9.44 to 26.65;p<0.001)and prosthesis implantation depth>6.0 mm(OR:3.34;95%CI:1.22 to 8.63;p=0.013)as independent predictors of NOCD.The elevated NOCD rate,driven largely by the presence of aAVC calcium volume>103.3 mm3,was observed predominantly in patients with all 3 risk factors when compared with patients of co-existing implantation depth>6.0 mm and AVCrem>374.1 mm3(94.4%vs 50.0%).Conclusion Calcification asymmetry in the AVC region,elevated AVCrem calcification and deeper prosthesis implantation were identified as independent predictors ofpost-TAVR NOCD,with an emphasis on the calcium asymmetry of AVC.Our proposed division methodology could help the pre-TAVR calcification assessment by CT that may effectively help identity NOCD risk-groups,especially for Chinese TAVR patients with frequent calcification in the borderline area.