Radioimmunotherapy versus autologous hematopoietic stem cell transplantation in relapsed/refractory follicular lymphoma: a Fondazione Italiana Linfomi multicenter, randomized, phase III trial

BACKGROUND

Optimal consolidation for young patilents with relapsed/refractory (R/R) follicular lymphoma (FL) remains uncertain in the rituximab era, with an unclear benefit of autologous stem cell transplantation (ASCT). The multicenter, randomized, phase III FLAZ12 (NCT01827605) trial compared anti-CD20 radioimmunotherapy (RIT) with ASCT as consolidation after chemoimmunotherapy, both followed by rituximab maintenance.

PATIENTS AND METHODS

Patients (age 18-65 years) with R/R FL and without significant comorbidities were enrolled and treated with three courses of conventional, investigator-chosen chemoimmunotherapies. Those experiencing at least a partial response were randomized 1 : 1 to ASCT or RIT before CD34+ collection, and all received postconsolidation rituximab maintenance. Progression-free survival (PFS) was the primary endpoint. The target sample size was 210 (105/group).

RESULTS

Between August 2012 and September 2019, of 164 screened patients, 159 were enrolled [median age 57 (interquartile range 49-62) years, 55% male, 57% stage IV, 20% bulky disease]. The study was closed prematurely because of low accrual. Data were analyzed on 8 June 2023, on an intention-to-treat basis, with a 77-month median follow-up from enrollment. Of the 141 patients (89%), 70 were randomized to ASCT and 71 to RIT. The estimated 3-year PFS in both groups was 62% (hazard ratio 1.11, 95% confidence interval 0.69-1.80, P = 0.6662). The 3-year overall survival also was similar between the two groups. Rates of grade ≥3 hematological toxicity were 94% with ASCT versus 46% with RIT (P < 0.001), and grade ≥3 neutropenia occurred in 94% versus 41%, respectively (P < 0.001). Second cancers occurred in nine patients after ASCT and three after radioimmunotherapy (P = 0.189).

CONCLUSIONS

Even if prematurely discontinued, our study did not demonstrate the superiority of ASCT versus RIT. ASCT was more toxic and demanding for patients and health services. Both strategies yielded similar, favorable long-term outcomes, suggesting that consolidation programs milder than ASCT require further investigation in R/R FL.

Aortic and vascular involvement in Loeys-Dietz Syndrome. Results from the REPAG registry (Spanish network of genetic aortic diseases)

Background

LDS is a rare disease due to genetic variants in the TGFB pathway. Limited information is available regarding the overall aortic and vascular outcome of these patients

Purpose

To evaluate aortic and vascular complications of patients with mutations in the TGFB pathway.

Methods

Retrospective longitudinal study including patients with (likely) pathogenic (LP/P) variants in the TGFbeta pathway from 10 tertiary centers. Clinical and imaging data were reviewed and data on aortic and vascular outcome included.

Results

A total of 163 patients were included (47.9% women, 38.6% index cases), mean age at first evaluation 32.3±20.4 years, 27.0% with age &lt;16 years. 70 TGFBR1, 43 TGFBR2, 29 SMAD3, 9 TGFB2 and 12 TGFB3 (Table1)

During a mean follow-up of 4.7±3.7 years, 54 (33.1%) patients had at least 1 aortic surgery (max 6). Mean age at first aortic surgery was 37.2±16.8 years (Range 1.2–72.9). First surgery was elective in 42 (77.8%), and included aortic root or ascending aorta in 40 (95.2%) and isolated descending aorta in 2 (4.8%). Emergent surgery included aortic root or ascending aorta in 11 (92.7%). Ascending aorta-root diameter previous to elective surgery was 48.9±4.9mm (range 41–65). 7 patients died during follow-up (2 intracranial bleeding, 1 SD, 2 aortic ruptures, 1post aortic surgery, 1 non-CV). Furthermore, 19 acute aortic syndromes (AAS) were reported (17 dissections, 2 haematomas) in 18 patients, 10 type A (52.6%). Mean age at first AAS was 42.3±11.1 years (min 19.7 years to 62.9 years)

Median survival free of intervention, dissection or death was 57.1 years, being worst for men than women (44.7 yrs vs 69.1 years, p&lt;0.001) (Figure 1), these gender-difference only remained significant in the TGFBR1 and SMAD3 groups (p=0.005 and p=0.008) Regarding aortic branch and intracranial aneurysms, a total of 383 imaging studies of aortic branches and 223 cranial imaging studies were performed during the clinical follow-up. 21 cranial aneurysms and 73 aortic branch aneurisms were reported. 14 (11.5%) patients suffered 19 aneurysms-related events (3 dissections, 3 ruptures, 13 interventions).

Conclusions

In patients with Loeys-Dietz Syndrome, there's a high prevalence of aortic surgeries and acute aortic events, with high numbers of peripheral and intracranial aneurysms. A worst prognosis in men than in women is observed in TGFBR1 and SMAD3 variants. Thus, specialized clinical and imaging follow-up is crucial in the management of these patients

Funding Acknowledgement

Type of funding sources: None.

Aortic flow patterns by 4D flow CMR in Marfan and Loeys-Dietz patients before and after valve sparing aortic root replacement: a comparison with healthy volunteers

Introduction

Abnormal aortic flow patterns in patients with a connective tissue disorder (CTD), such as Marfan or Loeys-Dietz syndrome, may contribute to aortic root dilation [1,2]. Valve sparing aortic root replacement, which is effective in reducing the risk of aortic dissection in case of severe dilation, may also normalize flow patterns beyond the replaced aorta and potentially slow its progressive aortic dilation.

Purpose

To assess aortic flow dynamics in patients with a CTD by 4D flow cardiovascular magnetic resonance (CMR) before and after valve sparing aortic root replacement, and to compare the results with those of healthy volunteers (HV).

Methods

Patients with Marfan or Loeys-Dietz syndrome underwent two non-contrast enhanced 4D flow CMR, one before and another after undergoing valve sparing aortic root replacement. Healthy volunteers matched for age, sex and BSA were also included for comparison. Maximum velocity, in-plane rotational flow (IRF), systolic flow reversal ratio (SFRR) and wall shear stress (WSS) magnitude and its axial and circumferential components were obtained at 24 planes covering the thoracic aorta from the sinotubular junction to the descending aorta at the diaphragmatic level [3–5].

Results

Sixteen patients and 21 healthy volunteers were included. Demographic and clinical data is presented in Table. The mean time between the CMR prior and posterior to surgery was 15 months. Compared to HV, patients with CTD before intervention presented lower maximum velocity at the proximal ascending aorta (Fig. 1A), lower IRF and circumferential WSS at the arch and the proximal descending aorta (Fig. 1B and F), lower magnitude and axial WSS at the proximal ascending and descending aorta (Fig. 1E and D), and increased SFRR at the proximal descending aorta (Fig. 1C). The intervention completely restored maximum velocity and partially-restored physiological helical flow and circumferential WSS, but barely improved axial WSS and SFRR.

Conclusion

Valve sparing aortic root replacement in patients with Marfan or Loeys-Dietz syndrome partially restore to physiological level both in-plane rotational flow and circumferential wall shear stress in the descending aorta. This flow normalization may contribute to prevent progressive dilation after the surgery.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III (Spain) (PI17/00381)Spanish Society of Cardiology (SEC/FEC-INV-CLI 20/015)

Clinical outcomes in patients with bicuspid aortic valves and ascending aorta dilatation equal or above 50mm

Background

Little is known about clinical outcomes in patients with bicuspid aortic valve (BAV) and ascending aortic diameters ≥50 mm where the elective surgical-indication zone begins.

Purpose

To assess incident aortic dissection (AoD), post-surgical survival and guideline implementation.

Methods

Multi-center retrospective study of BAV patients (≥18 years) with maximal root or tubular-ascending aortic diameters ≥50mm detected by transthoracic echocardiography at baseline. Ascertainment of aortic surgery, AoD and death was carried-out at their respective institutions. The primary outcome was AoD: “confirmed” AoD by surgery or death certificate, or “possible” AoD defined as sudden cardiac death of unknown cause by death certificate. Secondary outcomes were aortic surgery, post-surgical survival and guideline implementation.

Results

We included 506 consecutive BAV patients, mean age 61±14 years, 83% men, mean maximal aortic diameter 52±2 mm at baseline, ascending aorta was the most common segment ≥50mm (85%). During a median follow-up of 7.7 years, 356 (71%) underwent elective surgery (89% of class 1 patients). Early-surgery (≤6 months from baseline) occurred in 195 patients and 311 patients remained “under-surveillance”. Surgery under-surveillance (&gt;6 months from baseline) occurred in 161/311 (52%) patients at 2.6 [IQR: 1.5–4.7] years of follow-up. Surgical mortality was 1.4%. Ten-year post-surgical survival was &gt;90% and similar between early-surgery and surgery under-surveillance (p=0.8). Of 8 AoD events, 3 confirmed and 5 possible (all occurring in unoperated patients under-surveillance), 5 events occurred with maximal aortic baseline diameter ≥55 mm and/or &gt;1 year without clinical follow-up; therefore, under guideline non-compliance. Incidence of confirmed plus possible aortic dissection was 0.37% per year with size 50–54mm, 1.13% per year between 55–59mm, and 10.41% per year with size ≥60mm. Aortic stenosis was associated with AoD (p=0.04) and all-cause death in unoperated patients (p=0.001).

Conclusions

Our results suggest that BAV patients can be safely followed as per guidelines after aortic diameters enter the elective surgical zone (≥50mm), with excellent post-surgical survival regardless of whether surgery is early- or under-surveillance. Appropriate guideline implementation for surgical thresholds and interval clinical follow-up could have prevented most AoD events. Valvular disease guideline should also be followed to prevent AoD and improve survival in these patients.

Funding Acknowledgement

Type of funding sources: None.

Mapping of thoracic aorta growth rate on serial self-navigated 3D whole-heart magnetic resonance angiographies by image registration

Introduction

Accurate and reproducible assessment of aortic diameters and their growth rate is of key importance for the management of patients with thoracic aortic aneurysms [1,2]. It has been recently shown that image registration permits the assessment of progressive aortic dilation on ECG-gated contrast-enhanced CT angiography, outperforming manual quantification and allowing for 3D aortic size and growth mapping [3]. However, exposure to radiation makes it convenient to limit the use of CT for serial follow-up, especially in young patients. Self-navigated 3D whole-heart CMR acquisitions provides excellent image quality overcoming these limitations [4].

Purpose

To evaluate the accuracy and reproducibility of registration-based assessment of aortic dilation using self-navigated 3D whole-heart CMR acquisitions.

Methods

Fifteen patients with two self-navigated 3D whole-heart CMR images obtained at least 1 year apart were included. Aortic root and thoracic aorta diameters were measured by 2 independent observers both manually (multiplanar reconstruction) and with the registration-based technique. To perform registration-based assessment, the aorta was semi-automatically segmented and typical anatomical landmarks were placed by each observer at baseline [3]. Geometrical mapping between baseline and follow-up acquisitions was obtained using deformable image registration, and applied to the baseline aortic surface points to obtain their location at follow-up. Finally, aortic diameters and their growth rate were automatically measured and used to calculated 3D aortic dilation maps. Agreement between techniques and their inter-observer reproducibility were calculated.

Results

Patients age was 27.2±14.5 years and 40% were male. Mean follow-up duration was 2.7±1.6 years. Compared to manual assessment, the registration-based technique presented low bias and excellent agreement for aortic diameters (Table 1), and low bias and moderate agreement for growth rates both in the aortic root and the thoracic aorta (Table, Fig. 1A). The techniques presented similar inter-observer reproducibility in the assessment of aortic diameters (Table 1), while the registration-based method demonstrated much higher inter-observer reproducibility in the assessment of growth rates in the aortic root and the thoracic aorta (Table 1, Fig. 1A and B). Three-dimensional mapping of thoracic aortic diameters and growth was highly reproducible (mean regional ICC=0.90 for diameters; 0.82 for growth rate).

Conclusion

The assessment of the dilation rate of the thoracic aorta via registration of serial self-navigated 3D whole-heart CMR acquisitions is accurate and reproducible in the aortic root and the thoracic aorta. Thus, it allows to assess local aortic growth without the drawbacks of CT.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III and Ministerio de Ciencia e Innovaciόn (Spain)

The impact of first wave of COVID-19 on the nursing-sensitive and rehabilitation outcomes of patients undergoing hip fracture surgery: a single centre retrospective cohort study

BACKGROUND

During the COVID-19 pandemic, the care of hip fracture patients remains a clinical priority. To date, there is limited empirical knowledge about the impact of pandemic on the care of patients surgically treated for hip fracture, affected or not by COVID-19.

OBJECTIVE

To investigate the effects of the COVID-19 pandemic on the nursing-sensitive and rehabilitation outcomes of frail patients undergoing hip fracture surgery.

METHODS

A retrospective cohort study was conducted in an Italian Orthopaedic Research Institute. All patients aged ≥ 65 years admitted with fragility hip fractures between 1st March and 30th June in 2019 (group PP: pre-pandemic) and in the same period in 2020 (group P: pandemic), were compared. In the P group, COVID-19 positive patients were excluded due to the presence of a specific treatment pathway. Data on patient demographics and baseline characteristics, and peri-operative care factors were obtained from the Institute's computer-based patient-record system. The primary outcome was the incidence of any stage hospital-acquired pressure ulcers (PUs). The secondary outcome was time to first static verticalization and to first ambulation.

RESULTS

Three-hundred and sixty patients were included in the study, which comprised 108 patients in PP group and 252 patients in P group. Overall PUs incidence was significantly higher in the P-group (21.8%) than in the PP-group (10.2%) (p = 0.009). Specifically, the incidence of sacral PUs was significantly lower in P-group (38.1%) vs PP-group (91%) (p = 0.004); on the contrary, the incidence of PUs localized to the heels or other body sites were significantly higher in P-group (30.9% and 30.9%, respectively) vs PP-group (0% and 9%, respectively) (p = 0.004). No significant between groups differences were found for all the secondary outcomes.

CONCLUSION

In the pandemic period, nursing and rehabilitation care provided to patients with fragility hip fracture maintained high standards comparable to the pre-pandemic period. The increase in PUs incidence in the pandemic period was probably due to the older age of the patients admitted to hospital. The qualitative evaluation of the care administered and the emotional impact of the pandemic on the patients are very interesting topic which would deserve further investigation.

Mitral valve prolapse but no mitral annular disjunction is related to mitral regurgitation progression in patients with Marfan syndrome

Funding Acknowledgements

Type of funding sources: None.

Background

Mitral annular disjunction (MAD) is a structural abnormality of the mitral annular fibrosus characterized by a separation between the atrial wall-mitral valve junction, and the left ventricular attachment (1,2). It has been associated with mitral valve prolapse (MVP). Limited data is available regarding the impact of the presence of MVP on the evolution of mitral regurgitation in these syndromic entities.

Purpose

To evaluate the prevalence of MAD, PMV, and the combination of both in patients with syndromic hereditary thoracic aortic disease (HTAD) including Marfan (MFS), Loeys-Dietz (LDS), and vascular Ehlers-Danlos syndromes (vEDS), and its relationship with mitral regurgitation (MR) severity and the need for mitral surgery at the follow-up.

Methods

Adult patients with syndromic HTAD seen at our specialized unit were retrospectively included. The presence of MAD, MVP, and significant MR at the first echocardiogram were evaluated. Electronic medical records were reviewed to register the need for mitral surgery. The last echocardiogram available was also assessed to evaluate MR progression. 

Results

A total of 295 patients were included (235 MFS, 42 LDS, and 18 vEDS). The mean age at baseline was 39.0+-14.4 and 52.9% were female. MAD was present in 87 (37.0%) of MFS, 6 (14.3 %) of LDS and was not present in vEDS (p&lt; 0.001). MVP was found in 105 (44.7%) of MFS, 6 (14.3%) of LDS and 0 in vEDS (p&lt; 0.001).

In MFS, MAD was significantly associated with MVP (p= &lt;0.001) (Table 1). Concretely, 73 (31.1%) of the MFS patients had the concurrence of MAD and MVP and 14 (6.0%) of patients had isolated MAD (Table 2). At baseline, significant MR was observed in 30 (12.8%) of the MFS and in 18 (24.7%) of patients with concurrent MAD and MVP. Interestingly, significant MR was absent in patients with isolated MAD (Figure 1). MVP (OR 16.85 CI 4.43 – 64.07) but not MAD (p = 0.607), was associated with significant MR in the multivariate analysis.

A second echocardiogram was available in 220 patients at &gt; = 1 year (mean 4.1 +- 1.4 years). Overall, 25 (11.4%) presented significant progression of MR, 0 in the isolated MAD group, 13 (19.4%) in the MAD/MVP group and 6 (20.0%) of the isolated MVP (p = 0.007).

After a mean clinical follow-up of 7.5 +- 3.2yrs, 10 patients required mitral surgery (6 prostheses, 4 valvuloplasties).

After adjustment for the presence of MVP and time of follow-up, MAD was not associated with progression of MR (p= 0.529) but MVP was (OR 5.2 IC 1.70 - 15.93). Similarly, MVP (OR 5.6 CI 1.23 - 25.86)  but not MAD  (P= 0.096) was associated with the  need for mitral surgery ., 

Conclusions

The prevalence of MAD in syndromic HTAD is high, especially in Marfan syndrome, and absent in vEDS. In this retrospective observational study, the presence of MVP but not MAD was associated with mitral regurgitation evolution and the need for mitral surgery. Abstract Table 1  Abstract Figure 1

Circumferential wall shear stress predicts co-localized progressive dilation in bicuspid aortic valve patients

Background

Bicuspid aortic valve (BAV), a congenital heart defect, is associated with ascending aorta (AAo) dilation. Whether the high prevalence of dilation in BAV patients is related to alteration of aortic blood flow and thus in wall shear stress (WSS) [1,2], which have been associated with aortic wall degeneration [3], or intrinsic abnormalities of the aortic wall, such as altered aortic stiffness [4], has not been established. Recently, a technique for the semi-automatic quantification of progressive aortic dilation maps via image registration has been introduced [5].

Purpose

To test whether ascending aorta WSS predicts co-localized progressive dilation in BAV patients.

Methods

Forty BAV patients free from moderate and severe aortic valve regurgitation (regurgitant fraction &lt;16%) and stenosis (maximum velocity at the aortic valve &lt;3m/s), with no previous aortic or aortic valve surgery or replacement and included in a double-blind clinical trial (BICATOR, NCT02679261) were enrolled. All patients underwent a baseline 4D flow CMR study to assess aortic hemodynamics, followed by two contrast-enhanced computed tomography angiographies to quantify progressive dilation. WSS was computed at 64 pre-specified standardized ascending aortic regions, automatically obtained dividing the ascending aorta into 8 equidistant longitudinal sections which were further divided along the circumference into 8 equal regions (I = inner, L = left, O = outer and R = right) [2]. WSS was also projected into axial and circumferential directions, as previously described [1,2]. Progressive dilation was assessed in terms of growth rate (GR), i.e. increase in diameter divided by follow-up duration [mm/year], following a previously described methodology [5], at the same 64 pre-specified ascending aortic locations. A two-tailed p-value &lt;0.05 was considered statistically significant.

Results

Demographic and clinical characteristics of the patients are shown in Table 1. WSS and growth rate maps are shown in Figure 1. Follow-up duration was 44.8±2.6 months. Growth rate (Figure 1A) was heterogeneously distributed, being highest (up to 0.26 mm/year) in the outer region of the mid AAo and in the inner region of the proximal-mid AAo. Circumferential WSS showed highest values in the outer region of the mid AAo (Figure 1C) while WSS (magnitude) and its axial component (Figure 1B and D) presented maximum values in the right region of the mid AAo. Maps of statistically significant association between GR and WSS values showed circumferential WSS to be correlated with GR in regions where progressive dilation was fastest, while WSS magnitude and its axial component resulted in limited associations with GR maps.

Conclusions

Circumferential wall shear stress predicts location-matched progressive dilation in bicuspid aortic valve patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study has received funding from the Instituto de Salud Carlos III (PI17/00381). Guala A. has received funding from Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I). Table 1. DemographicsFigure 1. GR and WSS maps and correlations

Clinical impact on treatment and prognosis of advanced cardiac imaging with echocardiography in the acute setting of a COVID-19 infection

Background and objectives

Despite myocardial injury being related to excess mortality in acute COVID-19 infection, its impact on imaging findings remains unclear. This study aimed to characterize transthoracic echocardiographic (TTE) findings in patients admitted with COVID-19 infections and its impact on management and prognosis.

Methods

A prospective observational cohort study was performed among 66 COVID-19 patients who were admitted to a tertiary center between March 1 and May 25, 2020 and underwent TTE. High-sensitivity troponin I (hs-cTnI) data, echocardiographic assessment of right and left ventricular (LV) functional parameters, strain, and myocardial work analysis were obtained.

Results

2025 patients were admitted with COVID-19 and in 200 a complete TTE study was performed. Due to poor image quality, only 66 studies were included in the final analysis. The median age was 62 years (IQR, 55–70) and 59.1% of patients were males. The most common comorbidity was hypertension (47%), followed by smoking history (30.3%), atrial fibrillation (9.1%), and chronic obstructive pulmonary disease (7.9%). More than half of the patients (39, 59%) were admitted to the ICU, and half of them (33, 50%) required invasive mechanical ventilation. TTE was mainly indicated because of concerns for systemic conditions (50%) and evaluation of hemodynamic assessment (30%). Thirty-six patients (54.5%) had an abnormal TTE result and 57% had elevated hs-cTnI levels. The most common cardiac abnormality was LV diastolic dysfunction in 33% of the patients, followed by right ventricular dysfunction (12%) and LV dysfunction (6%) (Figure 1). LV GLS was reduced in 48.5% of the cases. Myocardial work performance indices were all reduced in patients with an abnormal TTE (GWI 30%, GCW 30%, GWW 40%, and GWE 40%), although differences were not significant (P&gt;0.2 for all parameters). Patients with an abnormal TTE were older and presented a higher cardiovascular risk profile. There were no significant differences in the levels of D-dimer, NTproBNP, and hs-cTnI between patients with and without diastolic dysfunction, RV, or LV dysfunction (P&gt;0.3 for all parameters). Using Spearman rank correlation, there was an inverse relationship between hs-cTnI and LV strain and myocardial work analysis. TTE results impacted clinical management in 60 patients, mainly de-escalation of medical treatment (Figure 2). Abnormal TTE results did not impact in-hospital outcomes.

Conclusions

Severe echocardiographic abnormalities are uncommon in hospitalized patients with COVID-19 infections, presenting mostly with subclinical myocardial changes, such as diastolic dysfunction, reduced LV GLS, and myocardial work indices, both associated with high-sensitivity troponin I elevation. An echocardiographic study should be limited to rule out long-term ICU complications or to evaluate hemodynamic instability. Although TTE was a valuable tool for guiding management, it had no significant impact on prognosis.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Findings on TTE studies.Figure 2. Changes in management.

Arrhythmia and cardiomyopathy in Heritable Thoracic Aortic Disease: an international retrospective cohort study

Background

Marfan syndrome (MFS), Loeys-Dietz syndrome (LDS) and related heritable thoracic aortic diseases (HTAD) are well-known for their aortic complications. Myocardial dysfunction and arrhythmia are less known in this setting but have been increasingly reported as additional causes of morbidity and mortality. Related to the rarity of the disorders, data on the prevalence of these features and clinical characteristics of the patients are difficult to obtain, calling for a multicentre initiative.

Purpose

To study the prevalence of myocardial dysfunction and arrhythmia in patients with HTAD and describe their clinical and genetic profile.

Methods

Nine centres from seven countries participated in this multicentre retrospective study. Medical records of patients 12 years or older carrying a (likely) pathogenic variant in the FBN1 gene, LDS genes (TGFBR1, TGFBR2, TGFB2, TGFB3 and SMAD3) or ACTA2 gene were screened. Patients presenting myocardial dysfunction and/or arrhythmia were identified, and clinical and genetic data were collected. Myocardial dysfunction included (a)symptomatic reduced ejection fraction (EF &lt;50% – HFrEF) or symptomatic preserved EF (HFpEF), as documented in the patient charts. Arrhythmias included atrial fibrillation or flutter (AF/AFL), ventricular tachycardia (VT), ventricular fibrillation (VF) and (aborted) sudden cardiac death (SCD) (presumed arrhythmogenic).

Results

In total, 3219 patients with HTAD were screened: 2761 with a variant in FBN1, 385 with a variant in one of the LDS genes (TGFBR1, TGFBR2, TGFB2, TGFB3 and SMAD3) and 73 carrying a variant in ACTA2. Myocardial dysfunction and arrhythmia were not reported in patients carrying an ACTA2 variant. Myocardial dysfunction was observed in patients with a variant in FBN1 and the LDS genes, without significant differences in prevalence (2.3% vs. 1.8%, p=0.563). Patients with a variant in the LDS genes presenting myocardial dysfunction were younger than patients carrying a variant in FBN1 (25±11 years vs. 39±17 years, p=0.034). The prevalence of VT/VF/SCD was similar in patients with a variant in one of the LDS genes compared to those with a variant in FBN1 (1.6% vs. 0.8%, p=0.132) and there was no difference in age at time of event (26±13 years vs. 33±14 years, p=0.289). Among patients with a variant in the LDS genes, the prevalence of VT/VF/SCD was highest in patients carrying a variant in the TGFBR2 gene and was significantly higher compared to patients with a variant in FBN1 (3.4% vs. 0.8%, p=0.017). In contrast, AF/AFL was significantly more often reported in patients with a variant in FBN1 compared to those with a variant in one of the LDS genes (1.7% vs. 0.3%, p=0.033).

Conclusions

Myocardial dysfunction and arrhythmia are rare features in patients with HTAD. They occur predominantly in patients with a variant in FBN1 and LDS genes, but were not reported in patients carrying a variant in the ACTA2 gene. Further analysis to identify other contributing factors is necessary.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Mitral annular disjunction in patients with syndromic hereditary aorthopaties

Background

Mitral annular disjunction (MAD) is a structural abnormality of the mitral annular fibrosus characterized by a separation between the atrial wall-mitral valve junction, and the left ventricular attachment (1). It has been associated with mitral valve prolapse (MVP) (2) but also, with arrhythmias and sudden cardiac death (SCD) (3). There is no evidence of its prevalence and clinical significance in patients with syndromic hereditary aortopathies.

Purpose

To evaluate the prevalence of MAD, PMV, and the combination of both in patients with syndromic hereditary thoracic aortic disease (HTAD) including Marfan (MFS), Loeys-Dietz (LDS) and vascular Ehlers-Danlos syndromes (vEDS), and its relationship with arrhythmias, SCD, mitral regurgitation (MR) severity and the need for mitral surgery at the follow-up.

Methods

Adult patients with syndromic HTAD seen at our specialized unit were retrospectively included. The presence of MAD, MVP, and significant MR at first echocardiogram were evaluated. Electronic medical records were reviewed to register the occurrence of arrhythmic events and the need of mitral surgery. Last echocardiogram available was also assessed to evaluate MR progression.

Results

A total of 295 patients were included (235 MFS, 42 LDS and 18 vEDS). Mean age at baseline was 39.0±14.4 and 52.9% were female. MAD was present in 87 (37.0%) of MFS, 6 (14.3%) of LDS and was not present in vEDS (p&lt;0.001). MVP was found in 105 (44.7%) of MFS, 6 (14.3%) of LDS and 0 in vEDS (p&lt;0.001).

In MFS, the presence of MAD was significantly associated with MVP (p≤0.001) (Table 1). However, 14 (6.0%) of patients had isolated MAD (Table 2). At baseline, significant MR was observed in 18 (24.7%) of patients with concurrent MAD and MVP and was not present in patients with isolated MAD (Table 2). MVP (OR 16.85 IC 4.43 – 64.07) but not MAD (p=0.607), was associated with significant MR in the multivariate analysis.

A second echocardiogram was available in 220 patients at ≥1 year (mean 4.1±1.4 years). Overall, 25 (11.4%) presented significant progression of MR, 0 in the isolated MAD group, 13 (19.4%) in the MAD/MVP group and 6 (20.0%) of the isolated MVP (p=0.007).

After a mean clinical follow-up of 7.5±3.2 years, 10 patients required mitral surgery (6 prosthesis, 4 valvuloplasty), 22 (9.4%) presented atrial fibrillation, flutter or supraventricular tachycardia (SVT), and 2 (0.9%) SCD.

After adjustment for the presence of MVP and time of follow-up, MAD was not associated with progression of MR (p=0.529) need for mitral surgery (p=0.096), atrial fibrillation-flutter or SVT (p=0.510) nor SCD. (p=0.997).

Conclusions

The prevalence of MAD in syndromic HTAD is high, especially in Marfan syndrome, and absent in vEDS. In this retrospective observational study, the presence of MAD in Marfan was not associated with mitral regurgitation evolution or arrhythmic events.

Funding Acknowledgement

Type of funding sources: None. Characteristics of MFS patientsPresence of significant MR by groups.

Prognosis of left ventricular noncompaction with preserved ejection fraction

Introduction

Left ventricular noncompaction (LVNC) is a poorly defined entity with heterogeneous prognosis. LV ejection fraction (LVEF) is one of the main predictors of major adverse cardiovascular events (MACE). However, outcomes of LVNC patients with preserved LVEF (pEF) remain uncertain.

Purpose

The aim of our study was to determine the incidence and predictors of MACE in LVNC patients with pEF as well as to assess the evolution of LVEF throughout follow-up.

Methods

We conducted a retrospective, longitudinal, multicentre cohort study. Consecutive patients with transthoracic echocardiography (TTE) and/or cardiac magnetic resonance (CMR) diagnostic criteria for LVNC and initially pEF (LVEF≥50%) were recruited. MACE were defined as a composite of heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and/or all-cause mortality. Progressive systolic dysfunction was defined as an LVEF&lt;50% at last TTE and/or an absolute ≥10-point decrease in LVEF from first to last TTE. Lower limit of LVEF values were considered 50–53% for TTE and 50–57% for CMR, according to current recommendations.

Results

A total of 305 patients from 12 centres were included from 2000 to 2018. Age was 38±19 years, 165 (54%) were men and 185 (61%) were probands. LVEF was 62±8% and 8% had late gadolinium enhancement (LGE). During a median follow-up of 4.7 (IQR 2.1–7.4) years, MACE occurred in 40 (13%) patients with an incidence rate of 2.96 (95% CI 2.17–4.04) events per 100 person-years: 8 HF, 27 VA, 3 SE and 5 deaths. LVEF by TTE (HR 0.95, 95% CI 0.90–0.99, p=0.035) and age (HR 1.02, 95% CI 1.01–1-04, p=0.04) were the only variables independently associated with the endpoint. Patients with lower limit LVEF values showed an increased risk of MACE (Figure 1). Among probands, those with family aggregation presented a higher incidence of MACE compared to nonfamilial cases (HR 2.74, p=0.043). A positive genotype was not associated.

Sixty-one (21%) patients experienced progressive systolic dysfunction: 31 (11%) had an LVEF&lt;50% and 48 (17%) an absolute ≥10-point decrease in LVEF at last follow-up. On multivariate analysis, LVEF by CMR was the only independent predictor (HR 0.96, 95% CI 0.92–0.99, p=0.031). Patients with lower limit LVEF values had an increased risk (Figure 2). In this subgroup, LGE was also associated with the endpoint (HR 3.52, p=0.011). Family aggregation was not associated, while a positive genotype correlated with lower risk (HR 0.52, p=0.029).

Conclusions

Patients with left ventricular noncompaction and preserved ejection fraction carry a moderate risk of major adverse cardiovascular events and progressive systolic dysfunction. LVEF remains the main predictor of outcomes in this subgroup. Patients with lower limit LVEF values are at increased risk, probably suggesting subclinical systolic dysfunction. Therefore, they should be carefully monitored.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Do morphological, haemodynamic and biomechanical parameters relate to aortic growth rate in chronic type B aortic dissection? A 4D flow CMR study

Background

Aortic dissection (AD) is the most devastating complication of thoracic aortic disease (1). In the chronic phase, yearly clinical and imaging follow-up of the maximum aortic diameter is recommended, since indication for thoracic endovascular aortic repair or surgery is suggested by guidelines in case of thoracic aortic enlargement or false lumen (FL) aneurysms (2). Most of the reported parameters related adverse events in chronic AD are focused on morphological variables (3) and not on the haemodynamics and biomechanics of the FL.

Purpose

To evaluate the relationship between aortic growth rate and anatomical variables, flow patterns and aortic stiffness in patients with chronic type B AD.

Methods

Forty-one patients with chronic type B aortic dissection, no connective tissue disorders and with an imaging follow-up including two computed tomography angiograms (CTA) acquired at least 3 years apart underwent contrast-enhanced 4D-flow CMR and MR angiography (MRA). The FL volume was segmented from MRA, and velocity data inside the 3D volume of the FL was extracted from 4D-flow CMR and used for parameter quantification. Retrograde systolic and diastolic flow, wall shear stress (WSS) and in-plane rotational flow (IRF) were calculated at 8 equidistant planes in the distal descending aorta (DAo), from the pulmonary bifurcation to the diaphragmatic level, and averaged values were used [4]. Aortic stiffness in the FL was assessed in terms of pulse wave velocity (PWV), which was calculated from the third supraortic trunk to the diaphragmatic level on 4D-flow CMR [5]. The percentage of thrombus in the FL was calculated as the ratio of thrombus and FL volumes on MRA. Dominant entry tear area was quantified on the baseline CTA (Figure 1). Aortic growth rate (GR) was defined as the difference between final and baseline aortic diameters as measured on CTA divided by follow-up duration.

Results

Anatomical, haemodynamic and biomechanical parameters are shown in Table. Twenty-five patients have repaired type A AD with residual entry tear and 16 have type B AD. Mean follow-up duration was of 4.9±2.7 years. In bivariate analysis, WSS, IRF and PWV were positively related to GR, whereas dominant entry tear area and percentage of thrombus in the FL showed a positive tendency with GR (Table) (Figure). In multivariate analysis IRF, PWV, dominant entry tear area and thrombus in the FL were positively and independently associated with GR (Table). Retrograde systolic and diastolic flow were not related to GR while WSS tended to statistical significance.

Conclusions

In-plane rotational flow, regional aortic stiffness, dominant entry tear area and percentage of thrombus in the false lumen are positively and independently related to aortic growth rate in patients with chronic type B aortic dissection. Further prospective studies are needed to confirm if the assessment of these parameters may help to identify patients at higher risk of adverse clinical events.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Accurate and reproducible aortic growth rate mapping via registration of serial contrast-enhanced computed tomography angiograms

Introduction

Accurate assessment of aortic diameters and growth rates is key for clinical management of patients with aortic aneurysms [1]. Manual assessment on multiplanar reformatted views of computed tomography angiograms (CTA) is recommended [1], although its reproducibility in the assessment of growth rates has not been reported [2]. Image registration has been proposed to provide 3D maps of aortic diameters and growth [3], but its accuracy and reproducibility have not been established.

Purpose

To quantify accuracy and inter-observer reproducibility of aortic root and thoracic aorta diameters and growth rate by registration of serial CTAs compared to current standard.

Methods

Forty non-operated patients with ≥2 contrast-enhanced ECG-gated CTA acquired at least 6 months apart were included. Aortic diameters and growth rates were measured in the aortic root and thoracic aorta by two independent observers, both with the current standard and with the registration-based technique. To perform registration-based assessment, each observer semi-automatically segmented the aorta at baseline and located typical anatomical landmarks (Fig. 1A). Then, deformable image registration was used to map baseline and follow-up CT scans and deformation was applied to the baseline aortic surface points to obtain their location at follow-up (Fig. 1B). Finally, aortic root diameters and growth rate and 3D maps of thoracic aortic diameters and growth rate were automatically obtained (Fig. 1C). Agreement between techniques and their inter-observer reproducibility were calculated.

Results

Follow-up duration was 3.3±1.5 years (range 0.52–6.2). Compared with manual assessment, registration-based aortic diameters presented low bias and excellent agreement in the aortic root (0.42 mm, ICC=0.99) and the thoracic aorta (0.55 mm, ICC=0.99), and similar inter-observer reproducibility (ICC=0.99 for both). Compared with manual assessment, registration-based growth rates presented low bias and good agreement in the aortic root (0.12 mm/y, ICC=0.84) and the thoracic aorta (0.03 mm/y, ICC=0.77) (Fig. 2A), and much higher inter-observer reproducibility (ICC=0.96 vs 0.68 in the aortic root, ICC=0.96 vs 0.80 in the thoracic aorta) (Fig. 2B and C). Registration-based aortic growth rates reproducibility at 6 months follow-up was comparable to that obtained by manual assessment at 2.7 years (LoA = [−0.01, 0.33] and LoA = [−0.13, 0.21], respectively). Aortic diameters and growth rate 3D maps were highly reproducible (ICC&gt;0.9) in the whole thoracic aorta.

Conclusions

Progressive aortic dilation assessment via registration of CTAs is accurate and more reproducible than the current standard even over follow-ups as short as 6 months, and further provides robust 3D mapping of aortic diameters and growth rates. Its application may provide new insights in aneurysms pathophysiology and improve the clinical management of these patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study has received funding from the Instituto de Salud Carlos III (PI17/00381). Guala A. has received funding from Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I). Figure 1. Methodology.Figure 2. Growth rate comparison.

Bicuspid aortic valve fusion length correlates with maximum aortic diameter and heamodynamic abnormalities: a 4D flow CMR study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Guala A. received funding from the Spanish Ministry of Science, Innovation and Universities.

Background

Bicuspid aortic valve (BAV), a congenital heart defect, is associated with ascending aorta dilation, possibly via alteration of aortic blood flow [1]. In BAV abnormal flow condition have been associated with aortic extracellular matrix dysregulation and elastic fiber degeneration [2]. Current morphological classification of BAV patients with aortic valve with a single fusion between two adjacent leaflets does not allow for risk stratification.

Purpose

This research work tested whether the extent of fusion between leaflets is related to AAo diameter and flow alterations.

Methods

Ninety BAV patients free from moderate and severe aortic valve disease and with no previous aortic or aortic valve surgery or replacement were prospectively enrolled. A comprehensive magnetic resonance protocol comprised a stack of double-oblique 2D balanced steady-state free-precession (bSSFP) cine CMR of the aortic valve, which was used to measure the length of the fusion between leaflets, a cine CMR at the level of the pulmonary bifurcation to assess aortic diameter and 4D flow MRI sequence to assess flow characteristics and regional stiffness [3]. Jet angle and flow radial displacement, quantifying the extent of flow eccentricity, and systolic flow reversal ratio (SFRR), assessing the relative amount of backward flow during systole, were computed at 8 equidistant planes in the ascending aorta and 4 equidistant planes in the aortic arch [4]. A two-tailed p-value &lt; 0.05 was considered statistically significant.

Results

The length of leaflet fusion varied widely (median 7.7 mm, inter-quartile range [5.5; 10.2]), Table 1). In bivariate analysis, fusion length was also associated to ascending aortic diameter (R = 0.391, p &lt; 0.001), age (R = 0.313, p = 0.005) and body surface area (R = 0.396, p &lt; 0.001). It was also positively related to flow abnormalities: like displacement in the proximal and distal ascending aorta, jet angle in the mid ascending aorta, and SFRR in the ascending aorta and the aortic arch (see Figure 1). The association between fusion length and ascending aorta diameter persisted in multivariate analysis after correction for age (p = 0.006).

Conclusions

Bicuspid aortic valve fusion extent varies greatly and it is associated with aortic diameter, possibly through flow alterations. Prospective longitudinal studies are needed to establish whether fusion length may allow for risk stratification in bicuspid aortic valve patients.

Aortic rotational flow patterns and stiffness by 4D flow CMR in patients with Loeys-Dietz syndrome compared to healthy volunteers and patients with Marfan syndrome

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): La Marató de TV3, Instituto de Salud Carlos III through the project and Spanish Ministry of Science, Innovation and Universities.

BACKGROUND

Loeys-Dietz (LDS) and Marfan (MFS) syndromes are rare genetic connective tissue disorders associated with progressive aortic dilation, however, aortic dissections have been observed at lower aortic root diameters in LDS than in MFS. Recent CMR studies in MFS patients reported increased aortic stiffness (1–3) and altered rotational flow (4), but research on aortic flow dynamics and biomechanics in LDS is lacking.

PURPOSE

The aim of this study was to assess rotational aortic flow and aortic stiffness in LDS compared to healthy volunteers (HV) and MFS patients, using 4Dflow CMR.

METHODS

Twenty-one LDS and 44 MFS patients, without previous aortic dissection or surgery, and 43 HV underwent a non-contrast-enhanced 4D flow CMR. Aortic stiffness was quantified at the AAo and DAo using pulse wave velocity (PWV). In-plane rotational flow (IRF), systolic flow reversal ratio (SFRR) (5) and local aortic diameters were obtained at 20 equidistant planes from the ascending (AAo) to the proximal descending aorta (DAo).

RESULTS

LDS patients had lower IRF at the distal AAo and proximal DAo compared to HV (p = 0.053 and 0.004, respectively), once adjusted for age, stroke volume and local aortic diameter; but no differences were found with respect to MFS (Figure). Although SFRR at the proximal DAo was increased in LDS patients compared to both HV (p = 0.037) and MFS populations (p = 0.015), once adjusted for age and aortic diameter, the difference in magnitude was small (Figure). On the other hand, AAo and DAo PWV revealed stiffer aortas in LDS patients compared to HV but no differences versus MFS patients (Table).

CONCLUSIONS

Patients with Loeys-Dietz syndrome showed decreased in-plane rotational flow and abnormally-high regional aortic stiffness compared to healthy controls, and similar hemodynamics and aortic stiffness with respect to patients with Marfan syndrome.

Prognostic role of cardiac magnetic resonance in left ventricular noncompaction

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular noncompaction (LVNC) is a heterogeneous entity with a wide phenotypic expression. Risk factors have not been well established and prognostic stratification remains challenging.

Purpose

Describe prognostic role of CMR on long term outcomes of LVNC patients. 

Methods

 

Retrospective multicentric longitudinal cohort study of consecutive patients fulfilling imaging diagnostic criteria for LVNC (Jenni echo criteria and Petersen and Jacquier CMR criteria). Demographic, ECG, genetic, family and treatment variables were recorded. Baseline CMR was used for the analysis. LV ejection fraction (LVEF) was categorized according to heart failure (HF) guidelines and late gadolinium enhancement (LGE) was visually assessed in a binary way. End points were HF, ventricular arrhythmias (VA), systemic embolisms (SE) and all-cause death. Major adverse cardiovascular events (MACE) were the combination of the four previous end points. In patients with initially preserved LVEF (≥ 50%), LV adverse remodelling (LVAR) was defined as an LVEF &lt; 50% and/or absolute decrease of ≥10% in LVEF at last follow-up.

Results

585 patients from 12 referral centres were included from 2000 to 2018. Age at diagnosis was 45 ± 20 years, 334 (57%) were male, baseline LVEF was 48 ± 17% and 18% presented LGE. During a median follow-up of 5.1 years (IQR 2.3-8.1), 110 (19%) patients presented HF, 87 (15%) VA, 18 (3%) SE and 34 (6%) died. MACE occurred in 223 (38%) patients.

LVEF was independently associated with HF, VA, SE and MACE: HR were 1.08, 1.02, 1.04 and 1.02 respectively (all p &lt; 0.05). LGE was more frequent in patients with reduced LVEF (39 Vs 53%, p &lt; 0.001) and was associated with higher HF and VA risk in patients with an LVEF &gt; 35% (HR 2.69 and 2.48 respectively, p &lt; 0.05) (Figure 1). No MACE (0%) occurred during long-term follow-up in patients with preserved LVEF, no LGE as well as no ECG abnormalities and no family aggregation.

305 (52%) patients presented with initially preserved LVEF, and 230 (75%) of those had LVEF available at last follow-up. LVAR occurred in 50 (22%) patients: 22 (10%) had an LVEF &lt; 50% and 41 (18%) an absolute ≥ 10% decrease in LVEF. LGE was independently associated with LVAR (HR 3.51, p = 0.045) (Figure 2). 

Conclusions

Cardiac magnetic resonance has an important prognostic role in LVNC. LVEF is the most powerful predictor of events. Myocardial fibrosis is associated with worse outcomes in patients without severe systolic dysfunction, as well as with left ventricular adverse remodelling in those with initially preserved LVEF. Besides, CMR may identify a low-risk subgroup of LVNC patients. Therefore, CMR should be used in risk stratification in LVNC.

Aortic root longitudinal strain by speckle-tracking echocardiography predicts progressive aortic root dilation in Marfan syndrome patients

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation and Universities; Instituto de Salud Carlos III

Introduction

In Marfan syndrome (MFS) patients reduced longitudinal strain of the ascending aorta (AAo) as measured by applying feature-tracking on cine cardiac magnetic resonance (CMR) images predicts aortic root dilation and aortic events during the follow-up. Speckle-tracking is well established for cardiac deformation assessment but proximal aorta applications are challenging due to limited wall thickness and substantial cardiac motion. Moreover, echocardiography is widely used in the clinical assessment aortic diseases.

Purpose

We aimed to test a speckle-tracking tool for root longitudinal strain analysis in terms of comparison with CMR-derived AAo longitudinal strain and reproducibility and as predictor of dilation in MFS patients.

Methods

Thirty-five MFS patients diagnosed by original GHENT criteria, with maximum aortic root diameter of 45 mm and free from previous aortic dissection or cardiac/aortic surgery and non-severe aortic regurgitation were consecutive enrolled and followed-up. CMR and echocardiography were performed less than 2 months apart. Baseline and final aortic root diameter were measured on CMR images. To quantify aortic root cyclic elongation by echocardiography, two regions of interests were manually created covering both walls in a parasternal long-axis view and tracked along the cardiac cycle (Figure 1). Longitudinal strain was computed as the average of maximum increase in relative distance of several sub-regions covering both walls. CMR-derived AAo longitudinal strain was available in 29 patients. Intra-observer reproducibility was tested in 15 patients via intraclass correlation coefficient (ICC) for single-rater absolute agreement.

Results

Aortic root longitudinal strain by echocardiography was mildly related to CMR-derived AAo longitudinal strain (R = 0.27) and was larger compared to CMR-derived values (16.2 ± 6.0 vs 11.3 ± 4.3). Reproducibility was high, with ICC of 0.811, R = 0.802, p &lt; 0.001. After a mean follow up of 76 ± 13 months, aortic root diameter grew in 20 patients with a rate of 0.29± 0.24 mm/year. Overall mean growth-rate was 0.87 ± 0.33 mm/year. In multivariable analysis corrected for age and baseline aortic root diameter, baseline longitudinal strain by echocardiography was independently and inversely related to progressive dilation (p = 0.033).

Conclusions

The measurement of aortic root longitudinal strain by speckle-tracking echocardiography is feasible. Aortic root longitudinal strain is an independent predictor of progressive dilation in MFS patients. This may permit the improvement of risk-stratification in aortic diseases in large scale studies.

Abstract Figure 1

Leaflets fusion length in bicuspid aortic valve is related to ascending and aortic root dilation and ascending aorta wall shear stress

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Spanish Ministry of Science, Innovation and Universities, Instituto de Salud Carlos III

Background

Bicuspid aortic valve (BAV) is the most common congenital heart defect, consisting in the fusion of two aortic valve leaflets. Altered flow patterns have been related to aortic wall degeneration in BAV patients and may be responsible for the high prevalence of aortic disease in these patients. A number of studies on excised BAV or using advanced imaging modalities reported a wide variability of fusion extent between leaflet, but no previous study assessed whether leaflet fusion length may be used to stratify BAV patients.

Purpose

We aimed to test whether leaflet fusion extent can be quantified by cardiac magnetic resonance imaging (CMR) and whether it is related to aortic dilation and flow abnormalities in non-dysfunctional BAV.

Methods

One hundred and twenty BAV adults with no previous aortic or aortic valve surgery or significant valvular disease were consecutively enrolled. Patients with two sinuses of Valsalva (true BAV) or fusion of the left and non-coronary cusps, both being rare forms of BAV, were excluded. Twenty-eight healthy volunteers were also included for comparison. A 4D flow CMR sequence was acquired and circumferential wall shear stress and pulse wave velocity were assessed in the ascending aorta. A stack of double-oblique cine images of the aortic valve were used to quantify the length of the fusion between leaflets.

Results

The length of the fusion between leaflets was effectively measured in 112/120 patients (93%). Reproducibility was good (ICC = 0.826). Fusion length varied greatly (range 2.3 – 15.4 mm, 7.8 ± 3.2 mm, tertiles cut-off points were 6 and 9.3 mm). After correction for age, BSA, stroke volume and BAV fusion morphotype, fusion length was independently associated with diameter at the sinus of Valsalva (p = 0.002). Moreover, once corrected for age, stroke volume and ascending aorta pulse wave velocity, fusion length was positively related to ascending aorta diameter (p = 0.028). The comparison of maps of circumferential peak-systolic WSS in healthy volunteers (left) and BAV patients pertaining to the three leaflet fusion length tertiles is shown in Figure 1. Circumferential WSS progressively increase with larger fusion length. This trend was statistically significant (p &lt; 0.05) in the right and outer regions of the proximal and mid ascending aorta.

Conclusions

Bicuspid aortic leaflet fusion length varies considerably and it is independently associated with ascending aorta and aortic root dilation, possibly through flow alterations.

Abstract Figure 1

Regional curvature in thoracic aortic aneurysms of different aetiologies and its relationship with established risk factors

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation and Universities ; Instituto de Salud Carlos III

Introduction

The aorta is a 3D hollow, curvilinear elastic structure whose diseases have life-threatening consequences. Despite much effort has been paid to study aortic diameter, diameter is a poor predictor of events. Conversely, much less is known about aortic curvature, its distribution in the thoracic aorta and the potential impact of risk factors in aneurysms associated with different conditions. Currently, 4D flow magnetic resonance imaging (4D flow CMR) allows to obtain 3D geometry, 4D flow data and regional aortic stiffness.

Purpose

We aim to study regional aortic curvature in thoracic aorta aneurysms of different aetiologies and define its relationship with established risk factors.

Methods

One-hundred twenty patients (40 for each group, selected out of prospective cohorts of 156 bicuspid aortic valve – BAV-, 77 Marfan –MFS- and 67 patients with a degenerative aneurysm – TAVdeg-) were matched for age, sex and BSA via propensity score with 40 healthy volunteers (HV). The thoracic aorta was semi-automatically segmented from angiograms and the centreline was computed. Local curvature was assessed at 20 planes covering the thoracic aorta from the sinotubular junction to the proximal descending aorta (DAo) at the level of the pulmonary artery bifurcation. Local curvature was normalized by subject mean thoracic aorta curvature. Length was measured as centreline length. Aortic stiffness was measured in the DAo by pulse wave velocity (PWV). Aneurysm was defined by z-score ≥ 2 using diameters measured by double-oblique cine CMR.

Results

Matching was successful in all groups with the exception of a residual age difference between HV and TAVdeg. Curvature in HV showed a fairly smooth transition between the straighter ascending aorta (AAo) and DAo to a more curved aortic arch, with a peak in the mid aortic arch (Figure 1A).  Conversely, all patients’ groups presented a peak in curvature in the proximal DAo and a decreased local curvature in the aortic arch and mid DAo close to the level of the pulmonary artery. BAV and TAVdeg patients showed also increased curvature in the mid AAo, were dilation is prevalent. Conversely, in the same area MFS showed a reduced curvature and limited prevalence of aneurysm. In the overall population, age, AAo and root diameters, mean blood pressure, DAo PWV and aortic length, all established risk factors for aortic events, were inversely related to curvature in the distal AAo and aortic arch (Figure 1B).

Conclusions

Aneurysms related to different aetiologies show similar abnormalities in aortic curvature, with limited curvature in the aortic arch and a peak soon after the third supra-aortic vessel. Age, aortic diameter, length, stiffness and blood pressure, all known risk factors, are all related to reduced curvature in the distal ascending aorta and aortic arch.

Abstract Figure.

Reinforcement machine learning-based aortic anatomical landmarks detection from phase-contrast enhanced magnetic resonance angiography

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation and Universities; La Marató de TV3

Introduction

Automatic analysis of medical imaging data may improve their clinical impact by reducing analysis time and improving reproducibility. Many medical imaging data, like 4D-flow magnetic resonance imaging (MRI), are often quantified regionally, implying the need for anatomical landmark identification to locate correspondences in the extracted data and compare among patients. Machine learning (ML) techniques hold potential for automatic analysis of medical imaging. Phase-contrast enhanced magnetic resonance angiography (PC-MRA) is a class of angiograms not requiring the administration of contrast agents.

Purpose

We aimed to test whether a machine learning algorithm can be trained to identify key anatomical cardiovascular landmarks on PC-MRA images and compare its performance with humans.

Methods

Three-hundred twenty-three aortic PC-MRA were manually annotated with the location of 4 landmarks: sinotubular junction, pulmonary artery bifurcation and first and third supra-aortic vessels (Figure 1), often used to separate the aorta in sub-regions. Patients included in the training dataset comprised healthy volunteers (40), bicuspid aortic valve patients (141), patients with degenerative aortic disease (60) and patients with genetically-triggered aortic disease (82), all without previous aortic surgery and with native aortic valve. PC-MRA images and manual annotations were used to train a DQN, a reinforcement learning algorithm that combines Q-learning with deep neural networks. The agents can navigate the images and optimally find the landmarks by following the policies learned during training. Data from thirty patients, distributed in terms of aortic condition as the training set, unseen by the algorithm in the training phase, were used to quantify intra-observer reproducibility and to assess ML algorithm performance. Distance between points was used as metric for comparisons, original human annotation was used as ground-truth and repeated-measures ANOVA was used for statistical testing.

Results

Human and machine learning performed similarly in the identification of the sinotubular junction (distance between points of 11.0 ± 8.1 vs. 11.1 ± 8.6 mm, respectively, p = 0.949) and first (6.6 ± 3.9 vs. 6.8 ± 5.6 mm, p = 0.886) and third (6.8 ± 4.0 vs. 8.4 ± 7.4 mm, p = 0.161) supra-aortic vessels branches but human annotation outperformed ML landmark detection in the identification of the pulmonary artery bifurcation (10.2 ± 7.0 vs. 15.2 ± 13.1 mm, p = 0.008). Computation time for landmark detection by ML was between 0.8 and 1.6 seconds on a standard computer while human annotation took approximatively two minutes.

Conclusions

ML-based aortic landmarks detection from phase-contrast enhanced magnetic resonance angiography is feasible and fast and performs similarly to human. Reinforced learning anatomical landmark identification unlock automatic extraction of a variety of regional aortic data, including complex 4D flow parameters.

Abstract Figure

Semi-automatic quantification of aortic root progressive dilation by automatic co-registration of computed tomography angiograms: a preliminary comparison with manual assessment in Marfan patients

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Spanish Ministry of Science, Innovation and Universities Instituto de Salud Carlos III

Background. Dilation of the aortic root is a key feature of Marfan syndrome and it is related to the occurrence of aortic events and death. On top of maximum diameter, rapid annual growth rate is suggested by guidelines for indication of aortic root replacement. Current gold-standard for aortic root diameter assessment is manual quantification on multiplanar reformatted 3D computed tomography (CT) or magnetic resonance angiogram. However, inter- and intra-observer reproducibility are limited and different measurement methods, i.e. cusp-to-cusp and cusp-to-commissure, may be used in different clinical centres, leading to difficulties in the clinical assessment of progressive dilation.

Purpose. We aimed to test whether aortic root growth rate during follow-up can be reliably quantified by semi-automatic co-registration of two CT angiograms.

Methods. Seven Marfan syndrome patients, free from previous aortic surgery, with a total of 11 pairs of CT were identified. Manual assessment of six aortic root diameters (right-non coronary -RN- , right-left -RL- and left-non coronary -LN- cusp-to-cusp and R, L and N cusp-to-commissure) was obtained from all CTs by an experienced researcher blind to semi-automatic results. The thoracic aorta and the outflow tract were semi-automatically segmented in the baseline CT and commissure and cusps were manually located. A 10 mm-thick region of interest containing the aortic wall was automatically generated from segmentation boundary. Co-registration was obtained with three, fully-automatic steps. Firstly, baseline and follow-up CT scans were aligned by means of a rigid registration. Then, scans were co-registered with multi-resolution affine followed by b-spline non-rigid registrations based on mutual information metric. The transformation pertaining to the location of baseline commissure and cusps points was used to locate the same points in the follow-up scan (Fig. 1 top).

Results. Follow-up duration was 35 ± 22 (range 12-70.3) months. Automatic quantification of diameter growth during the follow-up was obtained in 62 out of 66 (94%) diameter comparisons. High Pearson correlation coefficients (R) and ICC were found between manual and semi-automatic assessment of growth rate, both for cusp-to-cusp and cusp-to-commissure diameters: R = 0.727 and ICC = 0.678 for RN; R = 0.822 and ICC = 0.602 for RL; R = 0.648 and ICC = 0.668 for LN; R = 0.726 and ICC = 0.711 for R; R = 0.911 and ICC = 0.895 for L and R = 0.553 and ICC = 0.482 for N. Scatter and Bland-Altman plots for all growth rates (Fig. 1) confirmed very good correlation (R = 0.810) but a slight tendency (R=-0.270) for underestimation at high growth rate.  No correlation was found between follow-up duration and difference between techniques (R = 0.06).

Conclusions. Semi-automatic quantification of aortic root growth rate by co-registration of pairs of CT angiograms is feasible for follow-up as short as one year. Larger studies are needed to confirm these preliminary data.

Abstract Figure. CT measurements. Automatic vs manual.

Are aortic root and ascending aorta echocardiographic diameters by adult vs paediatric guidelines recommendations interchangeable?

Background

Both aortic root size and ascending aorta are clinical parameters with significant therapeutic implications which can be easily assessed by transthoracic echocardiography (TTE). However, measurement values may vary according to cardiac cycle and the edge convention used.

Purpose

This study aimed to compare the aortic diameter values measured using the lastest recommendations of two different guidelines, adults and children, to determine the influence of these methods on echocardiographic measurements.

Methods

Two hundred and fifty adult patients (56% male, 63±15 years of age) and 67 children (65% male, 10.04±4.5 years of age) in whom TTE was clinically indicated were included. Aortic diameters were measured twice at 2 levels (sinuses of Valsalva and ascending aorta): leading edge to leading edge during diastole, (L-L in D) following the 2015 American Society of Echocardiography (ASE) adults guidelines and inner edge to inner edge during systole (I-I in S) following the 2010 ASE paediatric guidelines.

Results

Mean aortic diameters obtained by L-L in D and I-I in S are shown in Table 1. Correlation coefficient was 0.990 (CI95% 0.988–0.992) for sinuses of Valsalva measurements and 0.991 (CI95% 0.989–0.993) for ascending aorta in adult patients and 0.983 (CI95% 0.975–0.973) and 0.970 (CI95% 0.956–0.952) in childrens respectively. When both populations were analysed together, concordance correlation coefficients were 0.991 (CI95% 0.989–0.993) and 0.970 (CI95% 0.991–0.994), respectively. Bland- Altman analysis for each level measured (A: aortic root; B: ascending aorta) in the total cohort of 317 patients is shown in Figure 1. Mean aortic diameters and differences in the whole group are shown in Table 1.

Conclusions

Measurement of aortic root and ascending aorta showed a significantly larger diameters by L-L in D than by I-I in S. However, these differences had subclinical significance and management implications. These similar diameter values may be used indifferently but systematically during follow-up. Systolic diameter expansion has a similar value to that of anterior aortic wall thickness; however, it is more vulnerable to changes in haemodynamic conditions.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Vall d'Hebron Research Institute

Relationship between aortic distensibility and aortic regurgitation depending on aortic valve anatomy. A CMR study

Background

Aortic regurgitation (AR) can be evaluated by cardiac magnetic resonance (CMR).The most commonly used method to quantify AR is direct measurement using phase contrast (PC) imaging, at the aortic root (as close as possible to the aortic valve), for the calculation of regurgitant fraction (RF). Aortic distensibility (AD) may affect aortic valve dynamics and, as a result, aortic regurgitation grade. However, the impact of aortic distensibility in this evaluation remains unknown.

Purpose

The aim of the study was to evaluate the relationship between AD and AR in patients with different aortic valve anatomy.

Methods

213 patients with different AR severity grades and aortic valve anatomy (tricuspid (TAV) and bicuspid valve (BAV) patients) were enrolled (32.2% female, 74% BAV, 55.5±15.4 years), excluding connective tissue disease. All patients underwent a CMR study with PC sequences for the evaluation of regurgitant fraction at the aortic valve level. AR was considered as mild (&lt;15%), moderate (15–30%) or severe (&gt;30%) depending on RF value. Furthermore we used cine-sequences to estimate aortic diameters and distensibilities, using Art Fun software. Distensibility was calculated as (change in aortic area between systole and diastole/diastolic area)/brachial pulse pressure.

Results

159 (73.7%) AR were mild, 30 (14.1%) moderate and 24 (11.3%) severe. RF significantly correlated with aortic root diameter (r=0.337, p&lt;0.001) and did not correlate with AD at the level of proximal descending aorta (r=0.121 and p=0.107). Furthermore descendig aorta distensibility correlated with age (r=−0.631, p&lt;0.001) and aortic root diameter (r=−0.224, p=0.002). Dividing population in two different groups, depending on aortic valve anatomy, in TAV patients RF continued to not correlate with AD (r=0.159, p=0.369). In contrast, RF in BAV patients was positively correlated with AD (r=0.223, p=0.007) even after adjustment for aortic diameter and age in a multiple regression model (p&lt;0.001, R2=0.478).

Conclusions

In our study, aortic regurgitation is positively related to descending aorta distensibility in BAV patients, regardless of age and aortic root diameter. Thus, AD may play a role in the evaluation of AR in case of bicuspid valves. In contrast, in TAV patients, distensibility does not seem to influence the assessment of AR severity.

Descending aorta distensibility

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Research grant provided by the Cardiopath PhD program

Aortic stiffness and hemodynamics in Loeys-Dietz syndrome by 4Dflow CMR: a comparison with healthy volunteers and patients with Marfan syndrome

Background

Connective tissue disorders, such as Loeys-Dietz (LDS) and Marfan (MFS) syndromes, are rare genetic diseases associated with progressive aortic dilation. Aortic dissections have been observed at lower aortic root diameters in LDS than in MFS, and research on aortic flow dynamics and biomechanics in LDS is lacking.

Purpose

To evaluate rotational aortic flow and aortic stiffness in LDS compared to healthy volunteers (HV) and MFS patients, using 4Dflow CMR.

Methods

Twenty-one LDS and 44 MFS patients, without previous aortic dissection or surgery, and 44 HV underwent a non-contrast-enhanced 4D flow CMR. In-plane rotational flow (IRF), systolic flow reversal ratio (SFRR) and local aortic diameters were obtained at 20 equidistant planes from the ascending (AAo) to the proximal descending aorta (DAo). Aortic stiffness was quantified at the AAo and DAo using pulse wave velocity (PWV).

Results

LDS patients had lower IRF at the distal AAo and proximal DAo compared to HV (p=0.053 and 0.004, respectively), once adjusted for age, stroke volume and local aortic diameter; but no differences were found with respect to MFS (Figure). Although SFRR at the proximal DAo was increased in LDS patients compared to both HV (p=0.037) and MFS populations (p=0.015), once adjusted for age and aortic diameter, the difference in magnitude was small (Figure). On the other hand, AAo and DAo PWV revealed stiffer aortas in LDS patients compared to HV but no differences versus MFS patients (Table).

Conclusions

LDS patients showed decreased in-plane rotational flow and abnormally-high regional aortic stiffness compared to healthy controls, and similar hemodynamics and aortic stiffness with respect to MFS patients

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Instituto de Salud Carlos III, La Maratό TV3

Patients with blunt traumatic thoracic aortic injury treated with TEVAR present increased flow dynamics alterations and pulse wave velocity: a 4D flow CMR study

Background

Thoracic endovascular aortic repair (TEVAR) is widely used for the treatment of blunt traumatic thoracic aortic injuries. Aortic flow dynamics and mechanical implications of this intervention are poorly investigated and may be of particular interest in the long-term follow-up of these mostly young patients.

Purpose

To assess whether the presence of TEVAR in a cohort of otherwise healthy subjects was related to dilation of the proximal aorta or increase in aortic stiffness and flow alterations.

Methods

Nineteen patients who underwent TEVAR implantation after a traumatic injury of the thoracic descending aorta (DAo) (10.0±6.1 years from intervention) and 44 healthy volunteers (HV) underwent 4D flow CMR to compute ascending aorta (AAo) pulse wave velocity (PWV), a marker of aortic stiffness, systolic flow reversal ratio (SFRR), quantifying backward flow during systole and in-plane rotational flow (IRF), measuring in-plane strength of helical flow. IRF and SFRR were assessed at 20 planes between the sinotubular junction and the mid thoracic DAo. Aortic diameters were measured using double-oblique cine CMR.

Results

Patients with TEVAR and HV did not differ in age, sex, body surface area, blood pressure and DAo diameter distal to TEVAR (Table). However, TEVAR patients presented larger diameters at the sinus of Valsalva and AAo, increased AAo PWV and strong flow alterations: IRF was reduced from the distal AAo to the proximal DAo, while SFRR was increased in the whole thoracic aorta (Figure).

Conclusions

In patients with blunt traumatic thoracic aortic injury treated with TEVAR the aorta proximal to TEVAR is dilated, stiffer and present potentially pathogenic flow conditions. Longitudinal studies are needed to assess whether these alterations have prognostic value and may improve clinical prevention and management of these patients.

Figure 1. IRF and SFRR in healthy vs TEVAR

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study has been funded by Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation (PI19/01480). Guala A. received funding from the Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I).

The length of the fusion between leaflets in bicuspid aortic valve is independently related to ascending aorta dilation and flow dynamics alterations assessed by 4D-flow CMR

Background

Aortic dilation in bicuspid aortic valve (BAV) patients has been related to altered flow patterns, which contribute to aortic wall degeneration. However, preventive aortic replacement is currently based on a diameter threshold. Several studies on excised BAV reported wide variability of fusion extent.

Purpose

To unveil whether leaflet fusion extent can be quantified by CMR and is related to aortic dilation and flow abnormalities in non-dysfunctional BAV.

Methods

One hundred and twenty adults with non-dysfunctional BAV and no previous aortic or aortic valve surgery and 28 healthy volunteers underwent double-oblique cine and 4D flow CMR. BAV patients with two sinuses of Valsalva or left and non-coronary cusps fusion were excluded. Peak systolic circumferential wall shear stress (WSSc) and pulse wave velocity (PWV) in the ascending aorta (AAo) were assessed by 4D flow CMR. Fusion length between leaflets was measured using a stack of double-oblique cine CMR images of the aortic valve.

Results

The length of the fusion was effectively measured in 112/120 (93%) patients with good reproducibility (ICC = 0.826) and showed great variability (range 2.3–15.4 mm, 7.8±3.2 mm and tertiles cut-off points 6 and 9.3 mm). In multivariate analysis adjusted for clinical and demographic characteristics and PWV, fusion length was independently associated with the diameter at the sinus of Valsalva (p=0.002) and the AAo (p=0.02) (Table). WSSc progressively increased with larger fusion length (Figure), with statistical significance (p&lt;0.05) in the right and outer regions of the proximal and mid AAo.

Conclusions

Bicuspid aortic leaflet fusion length varies considerably, and it is independently associated with AAo and aortic root dilation, possibly through flow alterations.

Figure 1. Maps of circumferential WSS

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study has been partially funded by Instituto Carlos III, Spanish Ministry of Science and Innovation (PI17/00381). Guala A. has received funding from the Spanish Ministry of Science, Innovation and Universities (IJC2018-037349-I).

The role of descending aorta diastolic reverse flow in the quantification of aortic regurgitation by CMR

Background

EACVI recommends the use of an “integrative approach”, using several parameters, in aortic regurgitation (AR) quantification. This approach is easily achieved by echocardiography although cardiovascular magnetic resonance (CMR) remains the gold standard for the quantification of regurgitant fraction (RF).

Purpose

The aim of the study was to analyze the accuracy of descending aorta (DA) diastolic reverse flow in the assessment of chronic AR severity by CMR to identify an additional parameter.

Methods

188 patients (34% female, 54.6±15.6 years) with different severity grades of chronic AR were enrolled. All patients underwent a CMR study. Aortic regurgitation was considered as absent (≤1%), mild (≤15%), moderate (≤15%) or severe (≥30%) depending on RF value at valve level. Furthermore, cine-sequences were used to estimate aortic diameters and distensibilities using Art Fun software. Velocity-time integral (VTI) of reverse flow in DA was calculated from maximum velocity curves by an in-house MatLab code.

Results

AR was absent in 21 (12%) patients, mild in 114 (62.9%), moderate in 23 (12.7%) and severe in 21 (11.6%).DA VTI reverse flow was significantly higher as was the RF at valve level (r=0.805, p&lt;0.001) (IMG, Table). It also positively correlated withaortic root diameter (r=0.347, p&lt;0.001) and DA distensibility (r=0.279, p&lt;0.001). It did not correlate with age (r=−0.91, p=0.22). In a statistically significant multiple regression model (p&lt;0.001, R2 = 0.697), although VTI reverse flow in DA correlated strongly with RF at valve level (p&lt;0.001; beta = 0.733), it was also influenced by DA distensibility (p&lt;0.001; beta = 0.197) and aortic root diameter (p&lt;0.001; beta= 0.140).

Conclusions

VTI reverse flow in DA correlates strongly with the degree of AR and may be useful in the assessment of its severity. Neverthless, owing to the influence of other factors (aortic distensibility and aortic root diameter), it cannot be used as a single parameter in the quantification of AR severity by CMR.

Scatter Plot graphs

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): research grant provided by the Cardiopath PhD program

Hospitalization costs related to long-term management of patients undergoing CABG (PRIORITY project)

Background

Identifying potential tools that could help improving the standard of care and lead to a better allocation of economic resources represents a main objective of research in public health. Using data from the PRIORITY cohort, this study aims to describe inpatients costs after a discharge for isolated coronary artery bypass surgery (CABG).

Methods

The PRIORITY project was designed to evaluate the long-term outcomes of 2 large multicenter cohort studies on CABG conducted between 2002-04 and 2007-08. For each patient discharged alive after a CABG intervention, costs of hospitalizations were estimated as the sum of costs of all the admissions occurred during 3 years of follow-up. NHS reimbursement rates were used as standard costs (in Euros). Inpatients costs were analysed according to their baseline risk factors.

Results

Among the 7363 patients included in this analysis, the median 3-year hospitalization costs were 4341€ (IQR: 1865-11699). Median costs were around 4.000€ for subjects alive at the end of follow up but higher for patients dying within 1 (about 8.600€) and 2-3 years of follow up (about 20.000€). The presence of comorbidities (such as diabetes and cancer) lead to higher median hospitalization costs while the on-pump approach was associated to lower median cost. Sixteen per cent of patients were at zero cost having no re-hospitalizations during the 3 years of follow-up (97% alive). Subjects at zero cost received more frequently on-pump approach, had a lower frequency of cancer, arteriopathy and ictus, but a higher frequency of angina and infarction.

Conclusions

Inpatient costs after isolated CABG are affected by preoperative comorbidities and by operative variables that could be removed or managed. Identifying independent risk factors for re-hospitalization will lead to the definition of a preoperative clinical and decision-making path that will bring both a clinical advantage for the patient and an optimization of costs for the NHS.

Key messages

Inpatient costs after isolated CABG are affected by preoperative comorbidities and operative characteristics like the on-pump approach. Appropriate management of operative approaches mainly based on operator preferences can have important implications in terms of healthcare costs.

Fluid-structure interaction simulations outperform computational fluid dynamics in the description of thoracic aorta haemodynamics and in the differentiation of progressive dilation in Marfan syndrome patients

Abnormal fluid dynamics at the ascending aorta may be at the origin of aortic aneurysms. This study was aimed at comparing the performance of computational fluid dynamics (CFD) and fluid-structure interaction (FSI) simulations against four-dimensional (4D) flow magnetic resonance imaging (MRI) data; and to assess the capacity of advanced fluid dynamics markers to stratify aneurysm progression risk. Eight Marfan syndrome (MFS) patients, four with stable and four with dilating aneurysms of the proximal aorta, and four healthy controls were studied. FSI and CFD simulations were performed with MRI-derived geometry, inlet velocity field and Young's modulus. Flow displacement, jet angle and maximum velocity evaluated from FSI and CFD simulations were compared to 4D flow MRI data. A dimensionless parameter, the shear stress ratio (SSR), was evaluated from FSI and CFD simulations and assessed as potential correlate of aneurysm progression. FSI simulations successfully matched MRI data regarding descending to ascending aorta flow rates (R 2 = 0.92) and pulse wave velocity (R 2 = 0.99). Compared to CFD, FSI simulations showed significantly lower percentage errors in ascending and descending aorta in flow displacement (-46% ascending, -41% descending), jet angle (-28% ascending, -50% descending) and maximum velocity (-37% ascending, -34% descending) with respect to 4D flow MRI. FSI- but not CFD-derived SSR differentiated between stable and dilating MFS patients. Fluid dynamic simulations of the thoracic aorta require fluid-solid interaction to properly reproduce complex haemodynamics. FSI- but not CFD-derived SSR could help stratifying MFS patients.

P754 Severe aortic stenosis with preserved ejection prognostic differences according to flow status and gradient fraction: a Spanish multicentre study

Background and objectives

Low-flow low-gradient (LFLG) aortic stenosis portends bad prognosis in different series. The objective of this study was to evaluate the evolution of this entity in our country.

Methods

We included 1394 consecutive patients evaluated between 2008-2016 with severe AS (AVA &lt;1 cm²) and ejection fraction&gt; 50% from 14 Spanish centres. The results (aortic valve intervention and mortality) were compared using the Kaplan-Meier survival analysis.

Results

Three groups based on gradient and flow status were established (high gradient: HG, normal flow under gradient: NFLG, low gradient low flow: LFLG). No significant demographic or clinical differences between groups were observed. After a follow-up of 61.52 months (IQR 43.5-86.5), 551 (73.8%) HG, 268 (35.4%) with NFLG and 81 (57.9%) LFLG received intervention, with a later surgery/TAVI indication in the LFLG group compared with HG group (p = 0.001) (Figure 1). The analysis of the Kaplan-Meier mortality curves showed no significant differences.

Conclusions

Patients with LFLG aortic stenosis with normal ejection fraction received less and later aortic valve intervention than the HG group with no significant differences in mortality.

Abstract P754 Figure. Time to surgery

P1441 Predictors of systemic embolisms in a large cohort of left ventricular noncompaction patients

BACKGROUND

Left ventricular noncompaction (LVNC) is associated with an increased risk of systemic embolisms (SE). However, incidence and risk factors are not well established.

PURPOSE

To evaluate the rate of SE in LVNC and describe risk factors.

METHODS

LNVC patients were included in a multicentric registry. Those with SE were considered for the analysis.

RESULTS

514 patients with LVNC from 10 Spanish centres were recruited from 2000 to 2018. During a median follow-up of 4.2 years (IQR 1.9-7.1), 23 patients (4.5%) had a SE. Patients with SE (Table 1) were older at diagnosis, with no differences in gender and had similar cardiovascular risk factors. They were more frequently under oral anticoagulation (OAC). Besides, they had a more reduced LVEF, and more dilated LV and left atrium (LA). Late gadolinium enhancement (LGE) was more frequent, altogether suggesting a more severe phenotype.

Patients with SE had non-significantly higher rates of hospitalization for heart failure (33% Vs 24%, p = 0.31) and atrial fibrillation (35% Vs 19%, p = 0.10). In multivariate analysis, only LA diameter was an independent predictor of SE (OR 1.04, p = 0.04). A LA diameter &gt; 45 mm had an independent 3 fold increased risk of SE (OR 3.04, p = 0.02) (Image 1).

CONCLUSIONS

LVNC carries a moderate mid-term risk of SE, which appears to be irrespective of atrial fibrillation and associated with age, LV dilatation and systolic dysfunction and mainly LA dilatation. This subgroup of patients should be considered for oral anticoagulation in primary prevention.

Table 1 Systemic embolisms (n = 23) No systemic embolisms (n = 491) p Men, n (%) 15 (65) 289 (56) 0.52 Median age at diagnosis (IQR) - yr 60 (48-76) 48 (30-64) 0.02 Median follow up (IQR) - yr 5.9 (3.1-7.8) 4.2 (1.8-7.1) 0.18 OAC, n (%) 19 (83) 118 (24) 0.01 LVEF (SD) - % 37 (15) 48 (17) 0.01 LVEDD (SD) - mm 58 (11) 54 (10) 0.04 LA diameter (SD) - mm 46 (9) 39 (9) 0.01 Characteristics of patients with and without systemic embolisms

Abstract P1441 Figure. Image 1

P372 Aortic stiffness in Loeys-Dietz syndrome: a comparison with Marfan syndrome patients and healthy volunteers

Funding Acknowledgements

ISCIII PI14/0106 and PI17/00381, La Marató de TV3 (20151330), Eur FP7/People 267128 and CIBERCV

BACKGROUND

Genetic syndromic aortic diseases are rare, with Marfan syndrome (MFS) being the most common. However, less is known of Loeys-Dietz syndrome (LDS) which has much lower prevalence and presumed worse prognosis. Increased aortic stiffness in MFS has been previously described but no studies have evaluated aortic biomechanics in LDS. Pulse wave velocity (PWV) is the gold standard measure for arterial stiffness and can be quantified by 4D flow MRI. We aim to evaluate regional aortic PWV by 4D flow MRI in LDS compared to MFS and healthy volunteers.

METHODS

Sixteen LDS patients with a pathogenic mutation, 76 MFS and 49 healthy volunteers were prospectively and consecutively included. No patient had previous aortic dissection or surgery. All underwent a 4D flow MRI study in a 1.5 T clinical scanner. Ascending (AAo) and descending (DAo) aorta PWV were computed using wavelet analysis of the systolic upslope for transit time calculation (Figure). Statistical comparison was made with non-parametric analysis to account for the non-normality of data and multivariate analysis was evaluated separately for AAo and DAo PWV.

RESULTS

Ascending and descending aortic PWV revealed stiffer aortas in LDS patients than in healthy volunteers, even after adjustment for diameter of sinus of Valsalva (SoV) and sex. Conversely, no differences in aortic stiffness were found between LDS and MFS patients (Table).

CONCLUSIONS

Abnormally high regional aortic stiffness was observed in LDS patients when compared with controls. The severity of increased regional aortic stiffness was found similar to the one affecting MFS patients.

Table Controls (N = 49) LDS (N = 16) MFS (N = 76) LDS vs. HV LDS vs. MFN Parameter Unadjusted p-value Adjusted p-value Unadjusted p-value Adjusted p-value Age [years] 39 ± 12 39 ± 16 36 ± 12 0.903 0.599 Men 32 (65%) 6 (37%) 34 (45%) 0.079 0.782 Weight [kg] 72 ± 11 69 ± 13 74 ± 16 0.288 0.194 Height [cm] 172 ± 8 172 ±12 181 ± 11 0.834 0.008 Systolic BP [mmHg] 126 ± 18 125 ± 14 127 ± 17 0.957 0.523 Diastolic BP [mmHg] 70 ± 11 77 ± 6 75 ± 12 0.011 0.318 SoV diameter [mm] 30.6 ± 3.9 35.4 ± 4.6 38.1 ± 5.9 0.001 0.060 AAo diameter [mm] 27.7 ± 3.8 29,0 ± 5.0 29.7 ± 5.4 0.458 0.579 DAo diameter [mm] 20.0 ± 2.0 21.3 ± 3.6 22.9 ± 3.8 0.546 0.124 AAo PWV [m/s] 5.2 ± 1.9 7.6 ± 2.4 7.3 ± 2.8 0.001 0.050* 0.534 NS DAo PWV [m/s] 7.1 ± 2.2 9.4 ± 2.6 10.7 ± 4.6 0.003 0.025** 0.493 NS

Abstract P372 Figure

P1600 Aortic dilatation in patients with chronic descending aorta dissection is related to maximum false-lumen systolic flow deceleration rate as evaluated by 4D-flow MRI

Background

Due to improved surgical strategies a growing number of patients survive acute aortic dissection. Patent false lumen (FL) is common in chronic dissection and it has been associated with poor prognosis, which is mainly driven by FL expansion. Several variables indirectly related to flow characteristics have been associated with progressive aortic dilation. We aimed to evaluate whether the maximum systolic flow deceleration rate (MSDR) in the FL, quantified by 4D-flow MR, is related to FL dilation in chronic type B aortic dissection.

Methods

Twenty-nine patients with a patent FL after aortic dissection and a prior follow-up of at least 3 years underwent contrast-enhanced 4D-flow MR. Marfan patients were excluded. Time-resolved FL flow acceleration was calculated in a 5 cm-long volume of the descending aorta around the level of the pulmonary bifurcation. MSDR was determined as the maximum minus the minimum acceleration in systole over the corresponding time interval (Figure 1a). Aortic growth rate (GR) was measured as the difference between final and initial maximum FL diameters obtained by angio-CT divided by follow-up duration. Population was divided into tertiles based on GR.

Results

Demographic and clinical variables were similar among GR tertiles (Table). MSDR was lower in patients with a GR &lt;1mm/year (group 1) compared to both the other two patient groups (p = 0.009 and 0.003 for groups 2 and 3, respectively) (Figure 1c). MSDR showed a marked positive linear correlation with GR (R = 0.481, p = 0.008) (Figure 1b).

Conclusions

The MSDR in the FL of chronic type B aortic dissection is linearly related to FL growth rate and discriminated between tertiles of aortic dilation. Prospective longitudinal studies are need to unveil possible prognostic value of this parameter.

Table Group 1 (n = 9) Group 2 (n = 10) Group 3 (n = 10) p-value Age (years) 63.44 ±13.54 62.50 ± 13.60 64.56 ± 6.67 0.902 BSA (m2) 2.00 ± 0.18 1.77 ± 0.20 1.94 ± 0.12 0.213 Men 6 (86%) 4 (57%) 4 (100%) 0.210 Hypertension 4 (66%) 5 (71%) 4 (100%) 0.438 Atheroclerosis 1 (17%) 1 (14%) 0 (0%) 0.699 Initial Diameter (mm) 45.00 ± 7.69 36.00 ± 4.20 37.00 ± 6.48 0.078 Final Diameter (mm) 49.50 ± 6.74 44.86 ± 5.70 59.25 ± 9.84 0.049 Follow-up (year) 11.83 ± 8.79 7.82 ± 3.34 8.08 ± 4.05 0.921 GR (mm/year) 0.27 ± 0.29 1.18 ± 0.26 2.64 ± 0.97 &lt;0.001 MSDR (cm/s3) 1212.18 ± 467.61 2410.54 ± 1034.30 2558.16 ± 1098.06 0.005

Abstract P1600 Figure 1

P1442 Outcomes of patients with left ventricular noncompaction and preserved ejection fraction

CONCLUSIONS

Patients with LVNC and pEF have an overall excellent prognosis, which is markedly better than those with rEF. However, there is progressive decrease in LVEF, associated with heart failure, and moderate risk of life threatening arrhythmias. Therefore, periodic follow-up should be promoted.

Table 1 LVNC pEF (n = 239) LVNC rEF (n = 252) p Men, n (%) 131 (55) 146 (58) 0.65 Median age at diagnosis (IQR) - yr 38 (23-54) 58 (42-72) 0.01 Median follow up (IQR) - yr 4.9 (2.1-7.3) 3.9 (1.4-7.9) 0.04 QRS (SD) - ms 93 (18) 117 (32) 0.01 LGE, n (%) 18 (9) 52 (30) 0.01

Abstract P1442 Figure. Image 1

P917 Additional value of atrial parameters evaluated by echocardiography on the scales of cardioembolic risk in atrial fibrillation

Background

Atrial morphological parameters may influence the presence of atrial thrombus, a factor strongly associated with cardiac thromboembolism, independently of those included in the CHA2DS2-VASc risk estimation scale in patients with a history of atrial fibrillation (AF). The aim of our study was to evaluate this possible association by transthoracic echocardiography (TTE).

Methods

Prospective multicenter study including 401 patients with a history of AF, in which a TTE and a transesophageal echocardiogram (TEE) were performed for evaluation of atrial thrombus between 2016-2019. The parameters included in the CHA2DS2-VASc scale, the heart rhythm at the time of the study and the anticoagulant treatment performed, as well as the atrial morphological parameters were collected.

Results

Twenty-three patients (6%) presented with atrial thrombus in TEE. The left atrial area (28 ± 6cm2 vs 33 ± 6cm2; p &lt; 0.001), the presence of AF during the study (83% vs 17%; p = 0.002) and CHA2DS2-VASc (1.7 ± 1.5cm2 vs 3.0 ± 1.3cm2; p &lt; 0.001) were associated with the presence of atrial thrombus. The left atrial area was a diagnostic predictor of atrial thrombus (area under the curve = 73%; p = 0.001): a value &gt;30cm2 presented a sensitivity of 79% and a specificity of 70% to detect its presence. Logistic regression analysis, including heart rhythm during the study and anticoagulant treatment, showed that CHA2DS2-VASc (OR = 1.5; CI95%=1.1-1.9; p = 0.003) and left atrial area &gt;30cm2 (OR = 5.2;CI 95% =1.7-16.0; p = 0.004) were independent predictors of atrial thrombus presence.

Conclusions

The left atrial area is associated with the presence of atrial thrombus in patients with a history of AF independently of the CHA2DS2-VASc scale, heart rhythm during the study, and anticoagulant treatment. This parameter should be evaluated to be included in the cardioembolic risk scales.

P1601 Relationship between aortic distensibility and aortic regurgitation assessed by CMR in bicuspid valve patients

Funding Acknowledgements

Spanish Ministry of Economy and Competitiveness RTC-2016-5152-1, ISCIII PI17/00381, La Marató de TV3 (20151330), Eur FP7/People 267128 and CIBERCV

BACKGROUND

The severity of aortic regurgitation can be evaluated with cardiac magnetic resonance (CMR) through calculation of regurgitant fraction (RF) in phase contrast sequences acquired at the aortic root (as close as possible to the aortic valve). However, the impact of aortic distensibility in this evaluation remains unkown.

PURPOSE

The aim of the study was to evaluate the relation between aortic distensibility and RF valve in bicuspid aortic valve patients.

METHODS

We enrolled bicuspid aortic valve patients without significant aortic stenosis (maximum velocity &lt;2.5 m/s) and connective tissue disease. All patients underwent a CMR study with phase contrast sequences for evaluation of regurgitant fraction at the level of the aortic valve. Aortic regurgitation was considered as mild, moderate or severe depending on RF value (mild &lt;15%; moderate 15-30%; severe &gt;30%). Furthermore we used cine-sequences of aortic root, ascending and proximal descending aorta to estimate aortic diameters and distensibilities, using Art Fun software. Distensibility was calculated as (change in aortic area between systole and diastole/diastolic area)/brachial pulse pressure.

RESULTS

A total of 98 bicuspid aortic valve patients were included (30% female, 49.7 ± 14.5 years). 75 (76,5%) AR was mild, 17 (17,4%) moderate and 6 (6,1%) severe. RF valvewas significantly correlated with aortic root diameter (r= 0.430 y p &lt; 0.001 )and aortic distensibility at the level of the ascending (r = 0.273 p =0.016) and descending aorta (r = 0.502 and p&lt; 0.001). Aortic distensibility was positively correlated with RFvalve even after adjustment for aortic diameter ( p = 0.002 and p &lt;0.001 respectively) . (Table) (IMG)

CONCLUSIONS

In our study, aortic regurgitation in bicuspid valve patients, evaluated by CMR using RF valve, is related to aortic distensibility. Thus, aortic distensibility should be included in the evaluation of aortic regurgitation by CMR as additional parameter. However, longitudinal studies are needed to evaluate the impact of including aortic distensibility in the evaluation of AR severity by CMR.

AR SEVERITY MILD MODERATE SEVERE Descending aorta distensibility(mean ± std. deviation) 2693,68 ± 997,5 3285,8 ±1952,7 5042,99 ±2873,44 Correlation between AR severity (by RFvalve) and descending aorta distensibility

Abstract P1601 Figure.

P1447 Ascending aorta longitudinal strain in bicuspid aortic valve patients: a comparison with healthy volunteers and patients with degenerative aortic aneurysm

Funding Acknowledgements

Spanish Ministry of Economy and Competitiveness RTC-2016-5152-1, ISCIII PI17/00381, La Marató de TV3 (20151330), Eur FP7/People 267128 and CIBERCV

Background

Histological findings of fibrillin-1 deficiency in bicuspid aortic valve (BAV) ascending aorta (AAo), as observed in Marfan (MFS), supported the existence of intrinsic aortic wall abnormalities, but recent studies reported the absence of an intrinsic impairment in stiffness. A recent study in MFS showed that AAo longitudinal strain was reduced in MFS and predicted dilation and aortic events. This parameter has not been studied in BAV.

Purpose

We investigated whether ascending aorta longitudinal strain is intrinsically altered in BAV with respect to tricuspid aortic valve (TAV) individuals.

Methods

80 BAV, 31 healthy volunteers (HV) and 29 TAV with AAo aneurysm, all without moderate valvular disease, were consecutively included. AAo dilation was defined as a z-score &gt; 2. The 1.5T CMR protocol included a set of 2D cine CMR stacks covering the proximal aorta in saggital, coronal and axial views. AAo longitudinal strain was computed by an in-house Matlab code performing a feature tracking of the aortic valve in each of the cine images.

Results

Twenty (25%) of BAV had AAo dilation. AAo longitudinal strain was lower in non-dilated BAV compared to HV, but the difference was not significant in multivariate analysis adjusted for AAo diameter and systolic blood pressure. Similarly, the difference between dilated BAV and dilated TAV found in univariate analysis was not confirmed by multivariate analysis. On the other hand, both dilated BAV and TAV showed decreased AAo longitudinal strain compared to HV, which were confirmed in multivariate analyses.

Conclusions

AAo longitudinal strain, a marker of aortic stiffness with predictive value in MFS, is not altered in BAV patients compared to TAV matched for dilation prevalence. Reduced AAo longitudinal strain was independently associated with dilation in both BAV and TAV.

Table 1 HV vs. NON-DILATED BAV DILATED BAV vs DILATED TAV HV vs. DILATED BAV HV vs. DILATED TAV HV NON-DILATED BAV Univariate /multivariate p-value DILATED TAV DILATED BAV Univariate /multivariate p-value Univariate/ Multivariate p-value Univariate p-value N 31 20 29 60 Age [years 35 ± 8 49 ± 16 &lt;0.001/ NS 66 ± 13 49 ± 14 &lt;0.001 / &lt;0.001 &lt;0.001 / 0.052 &lt;0.001 / NS Sex [% male] 42 35 0.629 24 42 0.097 / NS 0.969 0.149 BSA [m2] 1.83 ± 0.17 1.81 ± 0.14 0.702 1.95 ± 0.24 1.82 ± 0.22 0.015 / &lt;0.001 0.881 0.030 / NS SBP [mmHg] 119 ± 11 132 ± 16 0.002 / 0.029 133 ± 17 138 ± 19 0.304 &lt;0.001 / NS &lt;0.001 / NS DBP [mmHg] 69 ± 11 73 ± 6 0.099 / NS 77 ± 9 79 ± 11 0.455 &lt;0.001 / 0.016 0.004 / 0.023 Ascending aorta diameter [mm] 26 ± 4 33 ± 3 &lt;0.001 / 0.006 46 ± 7 43 ± 6 0.032 / NS &lt;0.001 / 0.001 &lt;0.001 /0.007 AAo long strain [%] 10.5 ± 3.6 8.4 ± 4.1 0.067/ NS 5.9 ± 2.7 7.7 ± 3.6 0.023 / NS 0.001 / 0.002 &lt;0.001 / 0.023 Demographics and uni- and multivariate analyses of AAo longitudinal strain

Decreased rotational flow and circumferential wall shear stress as early markers of descending aorta dilation in Marfan syndrome: a 4D flow CMR study

BACKGROUND

Diseases of the descending aorta have emerged as a clinical issue in Marfan syndrome following improvements in proximal aorta surgical treatment and the consequent increase in life expectancy. Although a role for hemodynamic alterations in the etiology of descending aorta disease in Marfan patients has been suggested, whether flow characteristics may be useful as early markers remains to be determined.

METHODS

Seventy-five Marfan patients and 48 healthy subjects were prospectively enrolled. In- and through-plane vortexes were computed by 4D flow cardiovascular magnetic resonance (CMR) in the thoracic aorta through the quantification of in-plane rotational flow and systolic flow reversal ratio, respectively. Regional pulse wave velocity and axial and circumferential wall shear stress maps were also computed.

RESULTS

In-plane rotational flow and circumferential wall shear stress were reduced in Marfan patients in the distal ascending aorta and in proximal descending aorta, even in the 20 patients free of aortic dilation. Multivariate analysis showed reduced in-plane rotational flow to be independently related to descending aorta pulse wave velocity. Conversely, systolic flow reversal ratio and axial wall shear stress were altered in unselected Marfan patients but not in the subgroup without dilation. In multivariate regression analysis proximal descending aorta axial (p = 0.014) and circumferential (p = 0.034) wall shear stress were independently related to local diameter.

CONCLUSIONS

Reduced rotational flow is present in the aorta of Marfan patients even in the absence of dilation, is related to aortic stiffness and drives abnormal circumferential wall shear stress. Axial and circumferential wall shear stress are independently related to proximal descending aorta dilation beyond clinical factors. In-plane rotational flow and circumferential wall shear stress may be considered as an early marker of descending aorta dilation in Marfan patients.

P4131Abnormal flow pattern in the main pulmonary artery of Marfan patients is related to local dilation

Introduction

Marfan syndrome (MFS) is a hereditary connective tissue disorder caused by mutation in the FBN1 gene. Main pulmonary artery (MPA) dilation is very prevalent in MFS patients. Indeed, the old Ghent nosology considered main pulmonary artery (MPA) dilation as diagnostic criterion of MFS patients. Although clinical complications related to pulmonary dilation in MFS are rare, this may potentially lead to MPA dissection or be a marker of vascular disease in MFS. Studies regarding potential causes of MPA dilation in MFS patients are very scarce.

Purpose

Through 4D flow CMR, we aimed to assess whether flow abnormalities exist in the MPA of MFS patients and their relation to local diameter.

Methods

Fifty-five consecutive Marfan syndrome adults (MFS) and 22 healthy volunteers (HV) were prospectively enrolled. All subjects underwent non-contrast-enhanced 4D flow-MRI, obtaining 4D flow field and a 3D angiography. The MPA was segmented from the 3D angiography, and the segmentation was used to mask 4D velocity data. Four, equidistant analysis planes were placed in the MPA between the pulmonary valve and the pulmonary artery bifurcation. Common descriptors of large arteries hemodynamics were computed at each plane: maximum velocity, systolic flow reversal ratio (a descriptor of the amount of systolic backward flow) and circumferentially-averaged axial and circumferential wall shear stress (WSS). Pulmonary artery diameters were measured on axial images. MPA dilation was defined as a diameter larger than 27 mm in women and 29 mm in men. Systolic (SBP) and diastolic (DBP) systemic blood pressure were measured at the brachial artery with a calibrated cuff immediately after the scan.

Results

Compared with HV, MFS patients presented similar age, BSA, SBP and maximum blood velocity, but had larger MPA diameter (27.8 vs 25.1 mm, p<0.001) and higher DBP (75.5 vs 66.8 mmHg, p=0.003). According to the used threshold, 45% (27) of MFS patients had MPA dilation. Compared with HV, Marfan patients presented an increased systolic flow reversal ratio in the proximal part of the MPA (Figure 1). In MFS patients axial WSS was reduced in central sections of the MPA, while the circumferential component was not difference with respect to HV. All these flow abnormalities were also present in the subset of 28 MFS patients without pulmonary artery dilation. In multivariable analysis, MPA diameter was independently related to age (B=0.056; p=0.032), sex (B=−2.3; p=0.02) and axial (B=6.4; p=0.039) and circumferential (B=33.9; p<0.001) WSS.

Figure 1

Conclusions

Dilation of the main pulmonary artery is prevalent in Marfan syndrome patients. Abnormal increase in systolic vortexes and reduction in axial WSS were present in dilated and non-dilated MPA in MFS patients. Axial and circumferential WSS were independently related to MPA diameter. The eventual predictive role of abnormal pulmonary flow pattern in pulmonary artery dilation in MFS patients remain to be established

Acknowledgement/Funding

Instituto de Salud Carlos III (PI14/0106), La Maratό de TV3 (20151330), CIBERCV and FP7/People (267128)

P1827Maximum systolic flow deceleration rate in the false lumen by 4D-flow MRI is associated with aortic dilatation in patients with chronic descending aorta dissection

Introduction

Patent false lumen (FL) in aortic dissection has been associated with poor prognosis mainly due to aortic expansion. Although morphologic variables have been related to aortic dilatation as expression of high pressure in the FL, they do not reflect flow characteristics. We propose the maximum systolic flow deceleration rate (MSDR) in the FL, quantified by 4Dflow, assuming that flow should be strongly decelerated during systole under high pressure.

Methods

Twenty-nine patients with a patent FL after aortic dissection (no Marfan syndrome) and with a follow-up of at least 3 years underwent a contrast-enhanced 4D-flow MR. FL acceleration was calculated during the cardiac cycle in a sub-volume of the descending aorta (5 cm around the level of the pulmonary bifurcation). MSDR was determined as the maximum minus the minimum acceleration in systole over the corresponding time interval (Figure 1a). Aortic growth rate (GR) was defined as the difference between final and initial aortic diameters obtained by angio-CT over the period of follow-up. Population was divided into tertiles based on GR.

Results

Demographic, clinical variables or basal aortic diameter did not show differences among GR groups (Table 1). MSDR was statistically different in patients with a GR <1mm/year (group 1) compared to fast-dilating patients (groups 2, 3) (Figure 1c). MSDR showed a positive linear correlation with GR resulting in a Pearson's correlation of 0.481 (p=0.008) (Figure 1b).

Table 1. Demographic and other variables Tertile 1 Tertile 2 Tertile 3 p-value Age (year) 63.4 (±13.5) 62.5 (±13.6) 64.6 (±6.7) 0.902 BSA (m2) 2.0 (±0.2) 1.8 (±0.2) 1.9 (±0.1) 0.213 Men 6 (86%) 4 (57%) 4 (100%) 0.210 Hypertension 4 (66%) 5 (71%) 4 (100%) 0.438 Atherosclerosis 1 (17%) 1 (14%) 0 (0%) 0.699 Initial diameter 45.0 (±7.69) 36.0 (±4.2) 37.0 (±6.5) 0.078 Final diameter 49.5 (±6.74) 44.9 (±5.7) 59.2 (±9.8) 0.049* Follow-up (year) 11.8 (±8.79) 7.9 (±3.3) 8.1 (±4.0) 0.921 Aortic GR (mm/year) 0.3 (±0.3) 1.2 (±0.3) 2.6 (±1.0) 0.001* MSDR (cm/s3) 1212 (±468) 2411 (±1034) 2558 (±1098) 0.005* Values are mean (±SD) or n (%).

Conclusion

MSDR of flow in the FL derived from 4D-flow RM is related to GR of dissected descending aorta. It is useful to discriminate mild vs. significant aorta enlargement and identify patients who may benefit from earlier therapy.

P1821Proximal aorta longitudinal but not circumferential strain predicts aortic events and aortic root dilation rate in marfan syndrome patients

Background

The most common cardiovascular complications in Marfan syndrome (MFS) are aortic root dilation and type A aortic dissections. Elective aortic root surgery is indicated when maximum aortic diameter is larger than a defined threshold or in the case of fast-progressing dilation. However, maximum aortic diameter is limited for the prediction of aortic events. Indeed, a large international registry of acute aortic syndromes reported that as much as 40% of aortic dissections happen with maximum aortic diameter lower than 50 mm. Consequently, there is a need for new, non-invasive biomarkers to improve the prediction of aortic complications.

Purpose

The aim of the present study was to assess if proximal aorta circumferential and longitudinal strain and ascending aorta distensibility were associated with progressive aortic dilation and incidence of aortic events in Marfan syndrome patients.

Methods

Eighty seven Marfan syndrome patients free from previous cardiac/aortic surgery or dissection, were prospectively included in a multicenter follow-up. Patients were diagnosed by original Ghent criteria. Proximal aorta longitudinal and circumferential strain and distensibility were computed from baseline cine CMR images by means of feature-tracking. The predictive capacity of each stiffness biomarkers was separately tested with multivariable linear regression analysis (aortic growth) and with Cox logistic regression analysis (aortic events), both corrected for clinical and demographic variables, including baseline maximum aortic diameter.

Results

During a follow-up of 81.6±17 months, mean diameter growth-rate was 0.65±0.67 mm/year and z-score growth rate was 0.07±0.13 / year. Elective aortic root replacement was performed in 11 patients while two patients presented type A aortic dissection.Baseline proximal aorta longitudinal strain was independently related to diameter growth-rate (p=0.001), z-score growth-rate (p=0.018) and aortic events (p=0.018). Conversely, neither circumferential strain nor distensibility were independent predictors of diameter growth-rate (p=0.385 and p=0.381, respectively), z-score growth-rate (p=0.515 and p=0.484, respectively) and aortic events (p=0.064 and p=0.205, respectively).

Conclusions

Proximal aorta longitudinal strain predicts aortic root dilation and major aortic events in Marfan syndrome patients beyond aortic root diameter and clinical and demographic characteristics.

Acknowledgement/Funding

ISCIII PI14/0106, La Maratό de TV3 (20151330) and CIBERCV. Guala A. FP7/People n° 267128

P5555Predictors of systemic embolisms in a large cohort of left ventricular noncompaction patients

Background

Left ventricular noncompaction (LVNC) is associated with an increased risk of systemic embolisms (SE). However, incidence and risk factors are not well established.

Purpose

To evaluate the rate of SE in LVNC and describe risk factors.

Methods

LNVC patients were included in a multicentric registry. Those with SE were considered for the analysis.

Results

514 patients with LVNC from 10 Spanish centres were recruited from 2000 to 2018. During a median follow-up of 4.2 years (IQR 1.9–7.1), 23 patients (4.5%) had a SE. Patients with SE (Table 1) were older at diagnosis, with no differences in gender and had similar cardiovascular risk factors. They were more frequently under oral anticoagulation (OAC). Besides, they had a more reduced LVEF, and more dilated LV and left atrium (LA). Late gadolinium enhancement (LGE) was more frequent, altogether suggesting a more severe phenotype.

Patients with SE had non-significantly higher rates of hospitalization for heart failure (33% vs 24%, p=0.31) and atrial fibrillation (35% vs 19%, p=0.10). In multivariate analysis, only LA diameter was an independent predictor of SE (OR 1.04, p=0.04). A LA diameter>45 mm had an independent 3 fold increased risk of SE (OR 3.04, p=0.02) (Image 1).

Table 1 Systemic embolisms (n=23) No systemic embolisms (n=491) p Men, n (%) 15 (65) 289 (56) 0.52 Median age at diagnosis (IQR), yr 60 (48–76) 48 (30–64) 0.02 Median follow up (IQR), yr 5.9 (3.1–7.8) 4.2 (1.8–7.1) 0.18 Hypertension, % 8 (33) 118 (24) 0.31 Diabetes mellitus, % 3 (14) 39 (8) 0.41 OAC, % 19 (83) 118 (24) 0.01 LVEF (SD), % 37 (15) 48 (17) 0.01 LVEDD (SD), mm 58 (11) 54 (10) 0.04 LVESD (SD), mm 45 (13) 38 (11) 0.01 LA diameter (SD), mm 46 (9) 39 (9) 0.01 LVEDV CMR (SD), mL 193 (75) 163 (70) 0.12 LVESV CMR (SD), mL 121 (64) 85 (64) 0.04 LGE, % 9 (40) 88 (18) 0.04

Conclusions

LVNC carries a moderate mid-term risk of SE, which appears to be irrespective of atrial fibrillation and associated with age, LV dilatation and systolic dysfunction and mainly LA dilatation. This subgroup of patients should be considered for oral anticoagulation in primary prevention.

6126Peripheral aneurysms in Marfan patients are common and are related to age and advanced aortic disease

Background

Peripheral aneurysms are not included in the diagnostic criteria for Marfan syndrome (MFS); however, their real prevalence in MFS is unknown. Furthermore, they are commonly seen in other genetic entities such as Loeys-Dietz syndrome.

We aimed to investigate the prevalence of peripheral aneurysm in Marfan syndrome.

Methods

Patients with clinical criteria of Marfan syndrome and identified FBN1 mutation were evaluated. Only patients with either MRI or CT angiography assessing peripheral vessels were included in this study. MRI and CT angiography studies were retrospectively evaluated to detect the presence of peripheral aneurysms. Aortic dissection-related arterial dilations were excluded. Aortic events and those related to aneurysm complications were collected during follow-up.

Results

Two hundred and nine patients with Marfan and FBN1 mutation were evaluated. Of these 136 (65.1%) had undergone either MRA or CTA with peripheral artery study during follow-up. Mean age at the last follow-up visit was 42.4±14.1yrs; 54.4% were men, and mean follow-up 7.3±3.1 years. Sixty-six aneurysms were identified in 42 (30.9%) patients. The most common locations were the iliac arteries in 23. The rest were: renal (7), vertebral (5), splenic (5), coeliac (3), brachiocephalic (1), subclavian (3), carotid (3), axillary (2), internal mammary (3), femoral (2), hypogastric (3), bronchial (2), coronary (1), hepatic (1), lumbar (1), gastroduodenal (1) and popliteal (1). Twenty-six patients (61.9%) had more than one peripheral aneurysm, and only 4 required surgery.

Patients with peripheral aneurysms were older (47.2±14.3yrs vs 40.2±13.6yrs, p=0.06) and more frequently men (69.0% vs 47.9% p=0.026). Although patients with peripheral aneurysms did not more frequently have aortic dissection (16.7% vs 17.0%, p=0.586), they did more frequently have aortic surgery (73.8% vs 47.9% p=0.05).

Conclusions

Peripheral aneurysms are present in one third of Marfan syndrome patients and are related to age and more advanced aortic disease. Systematic use of whole-body vascular assessment in Marfan patients can provide a comprehensive evaluation of the entire arterial system, identifying other sites of vascular involvement at risk of potential complications, and the subgroup of patients with more aggressive vascular disease expression.

477Partial fusion of two aortic valve leaflets is related to alterations in ascending aorta flow: 4D flow CMR study

Introduction

Bicuspid aortic valve (BAV) is the most common congenital valve defect. It consists in the fusion of two aortic valve leaflets, and it is associated with a high prevalence of proximal aorta dilation. Dilation is highly prevalent (around 30%) in BAV patient relatives with a tricuspid valve (TAV) identified by echocardiography. However, the presence of partial aortic valve leaflet fusion (also called mini-raphe or forme fruste BAV, see figure 1A) is easily missed by echocardiography. A recent study reported that 44% of patients from a small cohort of BAV patient relatives with aortic dilation followed by CT showed mini-raphe.

Purpose

We aimed to use 4D flow CMR to assess if the presence of mini-raphe is associated with aortic flow alterations, which may be concurs in the etiology of aortic dilation in BAV patient relatives.

Methods

Twenty BAV patients first-degree relatives with partial fusion (<50%) of aortic valve leaflets and proximal aorta dilation were identified by CT or cine CMR and prospectively included. One-hundred twenty-five BAV and 95 patients with TAV from our prospective dataset of 4D flow CMR were included for comparison. Propensity score matching was used throughout the study to correct the comparisons between mini-raphe and BAV and mini-raphe and TAV patients for differences in age, maximum aortic diameter, sex, height, weight, proximal aortic pulse wave velocity and, only for BAV, fusion pattern. The hemodynamic parameters previously related to aortic dilation were computed. They were jet angle, normalized flow displacement and systolic flow reversal ratio (SFRR, identifying through-plane vortexes) were computed and compared in the ascending aorta and in the aortic arch.

Results

The presence of mini-raphe was statistically-significantly associated with increase in jet angle (Figure 1B), flow displacement (Figure 1C) and vortexes (Figure 1D) in most of the ascending aorta and aortic arch when mini-raphe patients were compared with TAV patients. The severity of flow asymmetry found in mini-raphe patients was lower than the one characteristic of BAV patients, but vortexes were even higher in a small region at the distal ascending aorta.

Figure 1

Conclusion

Partial fusion of the aortic valve leaflets is related to increase in proximal aorta flow eccentricity and vorticity. These flow abnormalities are not as marked as those associated with BAV. Data regarding prevalence of mini-raphe as evaluated with CT or cine CMR are needed, especially in familiar of BAV patients.

Acknowledgement/Funding

European FP7/People 267128; Spanish Ministry of Economy and Competitiveness RTC-2016-5152-1 and Instituto de Salud Carlos III PI14/0106