Angiography ; Aortic Valve Stenosis ; Heart Valve Prosthesis ; Humans ; Tomography

Heart Valve Prosthesis ; Heart Valve Prosthesis Implantation ; Humans ; Printing, Three-Dimensional ; Transcatheter Aortic Valve Replacement

3D printing technology has been used in the diagnosis and treatment of cardiovascular diseases worldwide,i.e.,preoperative assessment of complex congenital heart disease,comprehensive assessment of novel clinical techniques,management of postoperative complications,and clinical teaching and training.Chinese hospitals introduced cardiovascular 3D printing technology from 2014.Preliminary clinical application showed that 3D printing had a positive significance,howeverit was expensive and caused inevitableloss of image information.Scholars should have an open but critical mind,actively try this technology and improve it.It can be reasonably believed as a good supplement of existing imaging tools in future.

Objective To investigate the feasibility, image quality, and safety of low?tube?voltage, low iodine load iso?osmolar contrast comprehensive cardiac and aortoiliac CT angiography (CTA) for transcatheter aortic valve replacement (TAVR) planning. Methods Ninety?eight consecutive TAVR candidates prospectively underwent combined contrast?enhanced CTA of the aortic root complex and vascular access route. Patients were assigned to group A (2nd generation dual?source CT, 100 kV, contrast 270 mgI/ml iodixanol) or group B (2nd generation dual?source CT, 120 kV, contrast 370 mgI/ml). Mean vascular attenuation, noise, signal?to?noise ratio (SNR), and contrast?to?noise ratio (CNR) of aorta including aortic root, aortic arch, descending aorta at level of diaphragm, abdominal aorta at level of renal artery and femoral artery were compared. Patient creatinine levels before the examination of CTA and during follow?up (24—48 h) were measured. Results The image quality score of aortic root and whole aorta was (4.2±0.7) and (4.3±0.4) respectively in experimental group, (4.3±0.6) and (4.3±0.3) in control group. No significant difference in subjective image quality score between two groups including aortic root image and whole aorta image (t=-0.130,-0.155,P=0.694, 0.822). The image noise of aortic root and femoral artery were higher in experimental group than that in control group (P<0.05). Radiation dose in experimental group was higher than that in control group [(6.1 ± 0.4) vs. (8.0 ± 0.4) mSv, t=-9.253, P=0.001]. There were no significant changes in creatinine levels among groups during the follow?up. Conclusion TAVR candidates can be safely and effectively evaluated by a comprehensive CTA protocol with low iodine load iso?osmolar contrast using low?tube?voltage acquisition.

Objective: To compare the characteristics of aortic valve dysfunction and ascending aorta dimension in patients with different bicuspid aortic valve (BAV) morphology. Methods: A total of 197 patients who underwent aortic valve replacement between April 2014 and March 2015 and were diagnosed with BAV by pathology were included, and their clinical data were retrospectively analyzed. Patients were divided into raphe⁺ group(109 cases) and raphe^- group(88 cases) according to the presence or absence of raphe, and L-R group(fusion of left and right cusp, 125 cases) and L/R-N group(fusion of left or right and noncoronary cusp, 72 cases) according to fusion type of the cusps. The characteristics of aortic valve dysfunction and ascending aorta dimension in patients with different BAV morphology were compared. Results: (1) Aortic stenosis incidence was lower in raphe⁺ group than in raphe^- group(22.9%(25/109) vs. 69.3%(61/88), P<0.001). Aortic regurgitation incidence was higher in raphe⁺ group than in raphe^- group (61.5%(67/109) vs. 22.7%(20/88), P<0.001). Incidence of type 1 of aortic root dilation was higher in raphe⁺ group than in raphe^- group (23.9%(26/109)vs.10.2%(9/88), P=0.024). (2) Aortic stenosis incidence was lower in L-R group than in L/R-N group(29.6%(37/125) vs. 68.1%(49/72), P<0.001). Aortic regurgitation incidence was higher in L-R group than in L/R-N group (59.2%(74/125) vs. 18.1%(13/72), P<0.001). Incidence of type 3 of aortic root dilation was lower in L-R group than in L/R-N group(10.4%(13/125) vs. 37.5%(27/72), P=0.006). (3) Aortic stenosis incidence was lower in L-R patients than in L/R-N patients(15.1%(13/86)vs. 52.2%(12/23), P=0.001), and aortic regurgitation incidence was higher in L-R patients than in L/R-N patients in raphe⁺ group(73.3%(63/86)vs. 17.4%(4/23), P<0.001). Conclusion There is significant difference in the type of valvular dysfunction and ascending aorta dilatation in patients with different morphological characteristics of BAV.

Objective To investigate the possibility of showing coronary bio-degradable stent(BDS) and luminal stenosis by using coronary computed tomography angiography(CCTA). Methods A total of 27 consecutive patients who had undergone CCTA follow-up for BDS implantation were enrolled from January to June of 2015. The duration between CCTA and coronary BDS implantation was 1 year. The patients' age were(54 ± 7)years in average. There were 18 male and 9 female patients. Of those patients, 18 BDS were implanted in left anterior descending coronary artery, and 9 in right coronary artery. Quantitative measurement of luminal stenosis, average areas of noncalcified and calcified plaque in proximal segment of stent (5 mm proximal to the stent), intra-stent, and distal segment of stent (5 mm distal to the stent) were performed and compared, using Kruskal Wallis as well as Mann-Whitney U tests. Results The mean length of BDS was (16.1 ± 4.4)mm. Coronary diameter stenosis (%) of the proximal segment, intra-stent and distal segment to BDS were 14.4%(11.5%, 23.1%), 23.4%(17.4%, 27.4%), and 16.4%(12.7%, 24.1%), respectively(H=10.17,P<0.05). The mean areas of noncalcified plaques were 6.6 (4.8, 8.4), 7.0 (5.4, 9.3) and 5.5 (4.1, 7.6) mm2, respectively in the segments of proximal, intra and distal to the BDS. The mean areas of calcified plaques were 0.5 (0, 1.5), 0.1 (0, 0.8) and 0.1 (0, 0.2) mm2, respectively, whereas no significant differences were found (P>0.05). Conclusion CCTA could be used to assess coronary bio-degradable stent and luminal stenosis without affection of mental artifact. Intra-stent restenosis was more frequently observed than proximal and distal segments of the BDS.calcified plaques were 0.5 (0, 1.5), 0.1 (0, 0.8) and 0.1 (0, 0.2) mm2, respectively, whereas no significant differences were found (P>0.05). Conclusion CCTA could be used to assess coronary bio-degradable stent and luminal stenosis without affection of mental artifact. Intra-stent restenosis was more frequently observed than proximal and distal segments of the BDS.

Objective:To investigate the classification and prevalence of simple congenital coronary artery anomalies (CCAA) in Chinese in a large samples of coronary CT angiography (CCTA), and briefly summarize the CT characteristics of "malignant" anomalies.Methods:The data of patients who had undergone CCTA from July 2009 to January 2017 and were diagnosed as simple CCAA were analyzed retrospectively. CCAA were classified according to the origination, number of orifices and termination, and the prevalence of various CCAA was statistically analyzed. Anomalous origin of coronary artery included the origin of coronary artery from the opposite coronary sinus, the non-coronary sinus, the aorta or around the primary sinus, the pulmonary artery, and left circumflex artery originated from the diagonal branch. Abnormal number of orifices included single coronary artery (SCA), right coronary artery and conus branch arising separately, and left anterior descending branch and circumflex branch arising separately. Abnormal termination was coronary artery fistula (CAF). Anomalous origin of coronary artery from the opposite sinus, anomalous origin of the coronary artery from the pulmonary artery, SCA, and multiple or large CAFs were defined as"malignant"anomalies.Results:Among 165 133 patients, 2 148(1.301%) had coronary anomalies, including 1 302 (0.789%) of origin anomalies, 298 (0.181%) of abnormal number of orifices and 548 (0.332%) of abnormal termination. There were 700 cases (0.424%) with coronary artery rising from the opposite sinus, 179 of which had opening or proximal lumen stenosis due to compression, 7 of which had subendocardial myocardial ischemia or infarction on CCTA without coronary artery disease (CAD). The coronary arteries originated from posterior sinus, the aorta or around the primary sinus were found in 48 cases (0.029%), 531 cases(0.322%), respectively. Coronary artery originating from pulmonary artery was detected in 20 cases (0.012%), all of which were left main trunk originating from pulmonary artery, showed tortuous dilation of coronary arteries. Five cases showed obvious subendocardial myocardial ischemia or infarction without CAD. SCA, right coronary artery and conus branch arising separately, left anterior descending branch and circumflex artery arising separately were detected in 102 (0.062%), 53 (0.032%) and 143 (0.087%) cases respectively. Only 1 of 102 cases with SCA showed myocardial ischemia without CAD. A total of 548 cases (0.332%) were diagnosed as CAF, of which the coronary-pulmonary fistula was most common with a highest prevalence of 0.277% (458 cases). Coronary artery-atrial fistula and coronary artery-ventricular fistula were detected in 22 (0.013%) and 60 (0.036%) cases. There were 6 cases (0.004%) of coronary artery-coronary venous fistula and 2 cases (0.001%) of coronary artery-superior vena cava fistula.Conclusions:The occurrence of CCAA is not uncommon, among which anomalous origin of coronary artery is the most common, and special attention should be paid to "malignant"anomalies.

Objective:To investigate the reproducibility of left ventricular strain assessed by CT feature tracking(CT-FT) and its correlation and agreement with speckle tracking echocardiography (STE).Methods:Thirty outpatients with suspected coronary heart disease who underwent whole cardiac cycle coronary CTA and transthoracic echocardiography within one week were prospectively enrolled in November 2019. Left ventricular volume and strain parameters were measured by CT-FT and STE, including left ventricular end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), global longitudinal strain(GLS), global radial strain (GRS),and global circumferential strain(GCS). GLS included endocardial global longitudinal strain (EndoGLS) and myocardial global longitudinal strain (MyoGLS), GCS included endocardial global circumferential strain (EndoGCS) and myocardial global circumferential strain (MyoGCS). ICC was used to evaluate intra-and inter-observer differences in strain measured by CT-FT. The differences of measurements between CT-FT and STE were compared by paired-samples t test. Pearson correlation coefficient was used to analyze the correlation between CT-FT and STE measurements. Agreement between measurements of two modalities was assessed by Bland-Altman analysis. Results:There was a good consistency in EDV, ESV, EF, EndoGLS, MyoGLS, GRS, EndoGCS and MyoGCS measured by CT-FT between intra-and inter-observer (ICC was 0.775-0.964, P<0.001). There was no significant difference in EF measured by CT-FT and STE [(60.27±8.70) % and (61.22±5.64) %, P=0.443]. EndoGLS, MyoGLS, GRS and MyoGCS measured by CT-FT were (-20.47±4.01)%, (-18.06±3.75)%, (73.90±20.58) % and (-18.48±3.65)%, respectively, while the strain measured by STE were (-18.97±3.33)%, (-16.49±2.60)%, (18.56±3.06)% and (-20.26±4.45)%, respectively. The differences were statistically significant between CT-FT and STE ( t=-2.367, -2.945, 12.161, 2.459, P<0.05). The EndoGCS measured by CT-FT and STE were (-27.78±6.66)% and (-29.18±7.24)%, respectively, with no statistical significance ( P=0.223).The correlation coefficients of EndoGLS, MyoGLS, GRS, EndoGCS and MyoGCS measured by CT-FT and STE were 0.566, 0.629, 0.509, 0.606 and 0.539, respectively ( P<0.05). The average difference of EndoGLS, MyoGLS, GRS, EndoGCS and MyoGCS measured by CT-FT and STE was -1.5%, -1.6%, 55.3%, 1.4% and 1.8%, respectively, with 95% limits of agreement was -8.3%-5.3%, -7.3%-4.2%, 18.1%-92.5%, -10.7%-13.6% and -6.0%-9.5%, respectively. Conclusions:The left ventricular global strain evaluated by CT-FT was feasible, and the agreement of global strain between CT-FT and STE was good but not interchangeable. CT can be an alternative method for "one-stop" evaluation of cardiac anatomy and function in patients with poor echogenic windows and contraindications for MRI.

Objective:To explore current status of scanning protocol and radiation dose of coronary CT angiography (CCTA) in China from 2017 to 2018.Methods:Cluster sampling was conducted according to the number and distribution of tertiary and secondary hospitals in provinces across the country, and 75 hospitals (30 secondary hospitals and 45 tertiary hospitals) were finally included. The patients who underwent CCTA from October 2017 to May 2018 were systematically sampled, and 1 312 patients were finally included. Patients were divided into two groups according to the level of hospital. Basic clinical characteristics were collected, including age, sex, height, weight, CT scanning equipment, scanning parameters, scanning model, post-processing scheme and radiation dose. Wilcoxon rank sum test, χ 2 tes were used in statistical analysis. Radiation dose was compared between different tube voltage, scanning model and post-processing solutions groups. Results:The ratio of employing low tube voltage (≤100 kV) was 35.4% (464/1 312). The rate of using low tube voltage in different weight groups (<60, 60-90,>90 kg) were 45.0%(126/280), 39.6%(256/647), 33.3%(8/24) in tertiary hospitals respectively, and 27.8%(25/90), 18.5%(49/265), 0(0/6) in secondary hospitals respectively. The rate of using low tube voltage in different weight groups (<60, 60-90,>90 kg) was significantly higher in tertiary hospitals than in secondary hospitals (χ2=34.25, 51.05, 207.05, P<0.001). Prospective electrocardiogram triggering model was used in 38.5% (505/1 312) of the patients. Application rate of iterative reconstruction was 82.5% (1 082/1 312). Among the patients who applied iterative reconstruction, tube voltage of 120 kV and above was used in 58.8% (636/1 082) of the patients. The effective radiation dose (ED) of CCTA was 11.84 (6.33, 16.66) mSv. The ED of CCTA examination in tertiary hospitals was slightly lower than that of secondary hospitals ( Z=-5.73, P<0.001). The ED of CCTA examination using prospective electrocardiogram triggering model was lower than that of retrospective electrocardiogram triggering model ( Z=-15.76, P<0.001). The ED of CCTA examination with iterative reconstruction [11.76 (6.94, 17.58) mSv] was slightly lower than those without iterative reconstruction ( Z=-3.45, P=0.004). Conclusions:The problems were focused on tube voltage fixation, low application proportion of low tube voltage and prospective electrocardiogram triggered protocol, and nonstandard application of iterative reconstruction technology during CCTA examination in the investigated hospitals. The nonstandard scanning protocol was an important causation of high ED in CCTA examination. Although the scanning standardization degree of tertiary hospitals was higher than that of secondary hospitals, but it still did not meet the guidelines.

Background::The study aimed to describe the aortic valve morphology in Chinese patients underwent transcatheter aortic valve replacement (TAVR) for symptomatic severe aortic stenosis (AS), and the impact of sizing strategies and related procedural outcomes.Methods::Patients with severe AS who underwent TAVR were consecutively enrolled from 2012 to 2019. The anatomy and morphology of the aortic root were assessed. "Downsize" strategy was preformed when patients had complex morphology. The clinical outcomes of patients who performed downsize strategy were compared with those received annular sizing strategy. The primary outcome was device success rate, and secondary outcomes included Valve Academic Research Consortium-3 clinical outcomes variables based on 1-year follow-up.Results::A total of 293 patients were enrolled. Among them, 95 patients (32.4%) had bicuspid aortic valve. The calcium volume (Hounsfield Unit-850) of aortic root was 449.90 (243.15-782.15) mm 3. Calcium is distributed mostly on the leaflet level. Downsize strategy was performed in 204 patients (69.6%). Compared with the patients who performed annular sizing strategy, those received downsize strategy achieved a similar device success rate (82.0% [73] vs. 83.3% [170], P= 0.79). Aortic valve gradients (downsize strategy group vs. annular sizing group, 11.28 mmHg vs. 11.88 mmHg, P = 0.64) and percentages of patients with moderate or severe paravalvular regurgitation 2.0% (4/204) vs. 4.5% (4/89), P = 0.21) were similar in the two groups at 30 days after TAVR. These echocardiographic results were sustainable for one year. Conclusions::Chinese TAVR patients have more prevalent bicuspid morphology and large calcium volume of aortic root. Calcium is distributed mostly on the leaflet level. Compare with annular sizing strategy, downsize strategy provided a non-inferior device success rate and transcatheter heart valve hemodynamic performance in self-expanding TAVR procedure.