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CT-based visualization of aortic valve morphology: from 3D energy-integrating CT to 4D photon counting CT.
No full textBACKGROUND: While 4D contrast-enhanced computed tomography (CT) is used to plan cardiovascular interventions such as transcatheter valve replacement, it is not yet routinely used to characterize minimally calcified aortic valves for planning of surgical valve repair. It is widely recognized that aortic valve morphology has implications for the durability of valve repair surgery.
PURPOSE: The objective is to demonstrate the potential of CT image segmentation for elucidating aortic valve morphology prior to surgery and to illustrate a potential benefit of 4D CT and photon counting CT (PCCT) for patient-specific modeling of dysmorphic aortic valves.
MATERIALS AND METHODS: This observational series includes nine patients who were suspected to have minimally calcified bicuspid aortic valve morphology on transthoracic echocardiography (TTE). Mean age was 53 +/- 13 years and seven patients were male. For the seven patients who underwent aortic root surgery, CT-based segmentation of the aortic valve was compared to echocardiographic interpretation and direct intraoperative visualization of valve morphology. Two patients who have not yet undergone aortic surgery were imaged longitudinally with 4D energy-integrating detector CT (EID-CT) and 4D PCCT, and the morphological interpretation of the aortic valve was compared to previous TTE reports.
RESULTS: In most surgical cases, CT-based segmentation and direct visualization of the valve revealed morphological features not previously confirmed on TTE, particularly related to the cusp fusion pattern. Moreover, 4D CT enabled morphological assessment at both systole and diastole, which captured maximal cusp separation and valve closure. PCCT images were reconstructed with slice thickness as low as 0.2 mm, and revealed detailed dysmorphic features such as a small accessory cusp with fistula and a double raphe in separate patients.
CONCLUSION: 4D CT-based segmentation has the potential to dynamically capture aortic valve features that are relevant to risk stratification and surgical planning at high spatial resolution
The Utility of Gallium Scan in Patients With Perinephric Abscess and Septic Pulmonary Emboli in the Absence of Right-Sided Infective Endocarditis: A Case Report.
No full textA 43-year-old male with newly diagnosed diabetes developed methicillin-sensitiv
Vagus nerve stimulation paired with rehabiliation for post-stroke recovery: a single center experience of patient satisfaction and outcomes
No full textDoes the use of clonidine for asymptomatic severe range blood pressure improve patient outcomes in the inpatient setting?
No full text
Methodological Appraisal of Ongoing Trial of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Younger Patients: From Incentives to Guideline-Informing Evidence.
No full textOBJECTIVES: To critically appraise the design of the ongoing multicentre, randomized START YOUNG trial comparing transcatheter aortic valve implantation (TAVI) with bioprosthetic surgical aortic valve replacement (SAVR) in patients aged 65-75 years with symptomatic severe aortic stenosis (AS).
METHODS: Publicly available trial information (ClinicalTrials.gov: NCT06861361) was reviewed, and the design was benchmarked against the minimum expected methodological standards for generating practice-changing evidence in patients with very long life expectancy (LE) following SAVR. The appraisal domains included objectives and study endpoints; selected non-inferiority (NI) margins; adequacy of follow-up for late events; statistical analysis plans and handling of crossovers/missing data; consistency of surgical comparators; and prespecified sub-groups.
RESULTS: Several major concerns were identified: (1) co-primary safety/efficacy composites mix hard adverse events (death, stroke) with softer outcomes, with rehospitalization likely to dominate; (2) limited duration primary follow-up (30 days/1 year), with only optional survaillance beyond 5 years, inadequate for durability and late hazards; (3) wide NI margins (7%-8%) that could accept clinically meaningful inferiority; (4) an unclear statistical analysis plan; (5) a device-specific TAVI arm versus heterogeneous SAVR comparator; and (6) up to 25% bicuspid anatomy without stratified randomization or powered analyses. Collectively, these choices markedly increase the risks of type I error, and misinterpretation in a population with likely crossing hazard curves and a long median LE comparable to that of the age-matched general population after SAVR.
CONCLUSIONS: In order to generate guideline-informing evidence for extending TAVI to younger patients with severe AS, the trial should prioritise hard adverse endpoints, tighten NI margins, mandate extended follow-up, standardise the surgical comparator, and adequately power the bicuspid subgroup. Without these revisions, continuing the study under the current protocol risks yielding biased, non-guideline informative results
