Multimodality Evaluation of Aortic Insufficiency and Aortitis in Rheumatologic Diseases

Use of complementary electrocardiogram-gated cardiac computed tomography in the assessment of aortic valve repairability: a pilot study†

OBJECTIVES

In young patients with type I/II aortic regurgitation, the feasibility of aortic valve (AV) repair has been traditionally evaluated with echocardiography. We evaluate electrocardiogram (ECG)-gated cardiac computed tomography as a complement to transoesophageal echocardiography in the preoperative assessment of aortic repairability.

METHODS

Patients undergoing non-urgent AV repair with or without aortic root replacement from October 2016 to May 2023 who had both imaging tests for the evaluation of AV repairability were included. The measurements obtained with echocardiography and ECG-gated scan of geometric height, aortic annulus and commissural orientation were compared using the intraclass correlation coefficient for inter-rater reliability.

RESULTS

All 24 patients were males, with a median age of 47.5 years (41.9-59.3). Of these, 87.5% presented severe aortic regurgitation; 62.5% had associated aortopathy. 58.3% were in New York Heart Association class I and the remnant 41.7% in class II. The AV was bicuspid in 62.5% of the patients. The intraclass correlation coefficient indicated excellent reliability of ECG-gated scan for commissural orientation (ICC = 0.98, 95% CI: 0.96-0.99) and conjoined cusp geometric height (ICC = 0.91, 95% CI: 0.74-0.97) in bicuspid AVs, while in tricuspid valves it showed good reliability for left cusp geometric height (ICC = 0.76, 95% CI: 0.19-0.93) and annular diameter (ICC = 0.8, 95% CI: 0.33-0.95).

CONCLUSIONS

ECG-gated cardiac scan complements echocardiography in aortic repair, showing excellent agreement for morphologic evaluation and commissural orientation. It is particularly reliable for geometric height in bicuspid valves and annular diameter and left cusp geometric height in tricuspid valves.

[Secondary vasculitides]

Vasculitides that occur in association with underlying primary diseases are called secondary vasculitides. In the diverse differential diagnostics of vasculitides, a large variety of secondary vasculitides have to be considered. Secondary vasculitides cover the full spectrum of vasculitides, presenting in manifold clinical manifestations. This article provides an overview of systemic diseases and etiological factors, such as infections, drugs, and malignancies, which can be associated with vasculitides. The possible associations with infectious agents are too numerous to be comprehensively covered and are discussed in an exemplary fashion and with a western European focus. Especially in atypical and refractory disease courses, a secondary vasculitis should be considered. In light of the diversity of differential diagnoses and the particular challenges posed by secondary vasculitides, interdisciplinary collaboration is the key for an accurate and early diagnosis as well as for successful treatment management. Treatment of the primary disease should always be prioritized and, if a drug-induced vasculitis is suspected, immediate cessation of the culprit drug is mandatory.

Novel Imaging Approaches to Cardiac Manifestations of Systemic Inflammatory Diseases: JACC Scientific Statement

Derangements in the innate and adaptive immune responses observed in systemic inflammatory syndromes contributes to unique elevated atherosclerotic risk and incident cardiovascular disease. Novel multimodality imaging techniques may improve diagnostic precision for the screening and monitoring of disease activity. The integrated application of these technologies lead to earlier diagnosis and noninvasive monitoring of cardiac involvement in systemic inflammatory diseases that will aid in preclinical studies, enhance patient selection, and provide surrogate endpoints in clinical trials, thereby improving clinical outcomes. We review the common cardiovascular manifestations of immune-mediated systemic inflammatory diseases and address the clinical and investigational role of advanced multimodality cardiac imaging.

Retinal Vascular Density Change in Patients With Aortic Valve Regurgitation

BACKGROUND

The aim of this study was to assess retinal vessel density in the superficial capillary plexus layer, deep capillary plexus layer and choriocapillaris plexus layer in patients with aortic valve regurgitation (AR) using optical coherence tomography angiography (OCTA).

METHODS

Thirty-eight healthy participants (group 1) and 38 patients with AR (group 2) were assessed for this study. Diagnosis of AR is made by transthoracic echocardiography (TTE). Severity of AR was assessed according to values in the 2014 American Heart Association/American College of Cardiology (AHA/ACC) valve guideline. Superficial capillary plexus density (SCPD), deep capillary plexus density (DCPD) and choriocapillaris plexus density (CCPD) were analyzed between groups using OCTA.

RESULTS

SCPD measurements were found to be decreased in the nasal, inferior and central regions of patients with AR (P ≤ 0.05). DCPD measurements were found to be decreased in the nasal and inferior regions of patients with AR (P ≤ 0.05). CCPD measurements were found to be decreased in the inferior and central regions of patients with AR (P ≤ 0.05). In patients with AR, CCPD measurements were significantly decreased in the inferior region compared to the control group. Central macular thickness was found to be significantly decreased in the patients with AR.

CONCLUSIONS

Patients with AR showed decreased flow density compared with healthy controls. Retinal perfusion measured using OCTA in patients with AR may give an idea about microperfusion.

Case report: Mitral valve replacement for Libman-Sacks endocarditis and cerebral embolism of primary antiphospholipid syndrome

Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by recurrent arteriovenous thrombosis and/or morbid pregnancy. Valve involvement is the most common cardiac manifestation of APS, with lesions characterized by valve thickening and vegetations known as Libman-Sacks endocarditis (LSE). This report discussed a rare case of a 26-year-old young woman diagnosed with primary APS with multiple cerebral infarctions and right middle cerebral artery occlusion that occured 3 years ago. During the investigation, transthoracic echocardiography (TTE) revealed vegetations on both leaflets of the mitral valve with mild to moderate mitral regurgitation. One year following corticosteroid and anticoagulant treatment, mitral valve fibrosis and moderate to severe regurgitation were noted, after which mitral mechanical valve replacement was finally performed. Accordingly, this report suggests that LSE occurrence should be alerted during the examination of APS patients especially in those with cerebrovascular disease. Furthermore, establishing an early diagnosis and conducting close follow-ups are necessary for its timely intervention and treatment.