The management of patients with aortic stenosis (AS) crucially depends on accurate diagnosis. The main aim of this study were to validate the four-dimensional flow (4D flow) cardiovascular magnetic ...resonance (CMR) methods for AS assessment. Eighteen patients with clinically severe AS were recruited. All patients had pre-valve intervention 6MWT, echocardiography and CMR with 4D flow. Of these, ten patients had a surgical valve replacement, and eight patients had successful transcatheter aortic valve implantation (TAVI). TAVI patients had invasive pressure gradient assessments. A repeat assessment was performed at 3-4 months to assess the remodelling response. The peak pressure gradient by 4D flow was comparable to an invasive pressure gradient (54 ± 26 mmHG vs 50 ± 34 mmHg, P = 0.67). However, Doppler yielded significantly higher pressure gradient compared to invasive assessment (61 ± 32 mmHG vs 50 ± 34 mmHg, P = 0.0002). 6MWT was associated with 4D flow CMR derived pressure gradient (r = -0.45, P = 0.01) and EOA (r = 0.54, P < 0.01) but only with Doppler EOA (r = 0.45, P = 0.01). Left ventricular mass regression was better associated with 4D flow derived pressure gradient change (r = 0.64, P = 0.04). 4D flow CMR offers an alternative method for non-invasive assessment of AS. In addition, 4D flow derived valve metrics have a superior association to prognostically relevant 6MWT and LV mass regression than echocardiography.
Doppler echocardiographic aortic valve peak velocity and peak pressure gradient assessment across the aortic valve (AV) is the mainstay for diagnosing aortic stenosis. Four-dimensional flow ...cardiovascular magnetic resonance (4D flow CMR) is emerging as a valuable diagnostic tool for estimating the peak pressure drop across the aortic valve, but assessment remains cumbersome. We aimed to validate a novel semi-automated pipeline 4D flow CMR method of assessing peak aortic value pressure gradient (AVPG) using the commercially available software solution, CAAS MR Solutions, against invasive angiographic methods.
We enrolled 11 patients with severe AS on echocardiography from the EurValve programme. All patients had pre-intervention doppler echocardiography, invasive cardiac catheterisation with peak pressure drop assessment across the AV and 4D flow CMR. The peak AVPG was 51.9 ± 35.2 mmHg using the invasive pressure drop method and 52.2 ± 29.2 mmHg for the 4D flow CMR method (semi-automated pipeline), with good correlation between the two methods (r = 0.70, p = 0.017). Assessment of AVPG by 4D flow CMR using the novel semi-automated pipeline method shows excellent agreement to invasive assessment when compared to doppler-based methods and advocate for its use as complementary to echocardiography.
Measurement of peak velocities is important in the evaluation of heart failure. This study compared the performance of automated 4D flow cardiac MRI (CMR) with traditional transthoracic Doppler ...echocardiography (TTE) for the measurement of mitral inflow peak diastolic velocities.
Patients with Doppler echocardiography and 4D flow cardiac magnetic resonance data were included retrospectively. An established automated technique was used to segment the left ventricular transvalvular flow using short-axis cine stack of images. Peak mitral E-wave and peak mitral A-wave velocities were automatically derived using in-plane velocity maps of transvalvular flow. Additionally, we checked the agreement between peak mitral E-wave velocity derived by 4D flow CMR and Doppler echocardiography in patients with sinus rhythm and atrial fibrillation (AF) separately.
Forty-eight patients were included (median age 69 years, IQR 63 to 76; 46% female). Data were split into three groups according to heart rhythm. The median peak E-wave mitral inflow velocity by automated 4D flow CMR was comparable with Doppler echocardiography in all patients (0.90 ± 0.43 m/s vs 0.94 ± 0.48 m/s, P = 0.132), sinus rhythm-only group (0.88 ± 0.35 m/s vs 0.86 ± 0.38 m/s, P = 0.54) and in AF-only group (1.33 ± 0.56 m/s vs 1.18 ± 0.47 m/s, P = 0.06). Peak A-wave mitral inflow velocity results had no significant difference between Doppler TTE and automated 4D flow CMR (0.81 ± 0.44 m/s vs 0.81 ± 0.53 m/s, P = 0.09) in all patients and sinus rhythm-only groups. Automated 4D flow CMR showed a significant correlation with TTE for measurement of peak E-wave in all patients group (r = 0.73, P < 0.001) and peak A-wave velocities (r = 0.88, P < 0.001). Moreover, there was a significant correlation between automated 4D flow CMR and TTE for peak-E wave velocity in sinus rhythm-only patients (r = 0.68, P < 0.001) and AF-only patients (r = 0.81, P = 0.014). Excellent intra-and inter-observer variability was demonstrated for both parameters.
Automated dynamic peak mitral inflow diastolic velocity tracing using 4D flow CMR is comparable to Doppler echocardiography and has excellent repeatability for clinical use. However, 4D flow CMR can potentially underestimate peak velocity in patients with AF.
Abstract Background Due to aging of the population, the prevalence of aortic valve stenosis will increase drastically in upcoming years. Consequently, transcatheter aortic valve implantation (TAVI) ...procedures will also expand worldwide. Optimal selection of patients who benefit with improved symptoms and prognoses is key, since TAVI is not without its risks. Currently, we are not able to adequately predict functional outcomes after TAVI. Quality of life measurement tools and traditional functional assessment tests do not always agree and can depend on factors unrelated to heart disease. Activity tracking using wearable devices might provide a more comprehensive assessment. Objective This study aimed to identify objective parameters (eg, change in heart rate) associated with improvement after TAVI for severe aortic stenosis from a wearable device. Methods In total, 100 patients undergoing routine TAVI wore a Philips Health Watch device for 1 week before and after the procedure. Watch data were analyzed offline—before TAVI for 97 patients and after TAVI for 75 patients. Results Parameters such as the total number of steps and activity time did not change, in contrast to improvements in the 6-minute walking test (6MWT) and physical limitation domain of the transformed WHOQOL-BREF questionnaire. Conclusions These findings, in an older TAVI population, show that watch-based parameters, such as the number of steps, do not change after TAVI, unlike traditional 6MWT and QoL assessments. Basic wearable device parameters might be less appropriate for measuring treatment effects from TAVI.
Four-dimensional flow cardiac magnetic resonance (4D flow CMR) is an emerging non-invasive imaging technology that can be used to quantify mitral regurgitation (MR) volume. Current methods of ...quantification have demonstrated limitations in accurate analysis, particularly in difficult cases such as complex congenital heart disease. 4D flow CMR methods aim to circumvent these limitations and allow accurate quantification of MR volume even in complex cases. This systematic review aims to summarize the available literature on 4D flow CMR MR quantification methods and examine their ability to accurately classify MR severity.
Structured searches were carried out on Medline and EMBASE in December 2018 to identify suitable research outcome studies. The titles and abstracts were screened for relevance, with a third adjudicator utilized when study suitability was uncertain.
Seven studies met the eligibility criteria and were included in the systematic review. The most widely used 4D flow MRI method was retrospective valve tracking (RVT) which was examined in five papers. The key finding of these papers was that RVT is a reliable and accurate method of regurgitant volume quantification.
MR quantification through 4D flow MRI is both feasible and accurate. The evidence gathered suggests that for MR assessment, 4D flow MRI is potentially as accurate and reliable to echocardiography and may be complementary to this technique. Further work on MR quantification 4D flow image analysis is needed to determine the most accurate analysis technique and to demonstrate 4D flow MRI as a predictor of clinical outcome.
CRD42019122837, http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019122837.
Rationale, aims, and objectives
Previous studies have shown a lack of engagement in the reporting process. There is limited evidence about whether attitudes and behaviours of doctors in the UK ...towards incident reporting have changed following the events at Mid Staffordshire National Health Service Foundation Trust and the recommendations that followed. We conducted a relatively large survey of doctors, aiming to assess whether doctors recognised incidents and reported them accordingly, along with their behaviours towards reporting and their suggestions of how incident reporting may be improved.
Methods
A cross‐sectional survey of doctors was undertaken in 11 hospitals in the north of England. The participants (n = 581) were invited to take part in an electronic questionnaire. Demographics were obtained, and engagement with the incident reporting process was assessed, including an estimate of the number of incidents which were witnessed but not actually reported. Factors which influenced reporting behaviours were recorded. Free‐text comments were encouraged. A mixed method analysis of the responses was performed.
Results
Doctors do not appear to be engaging with the incident reporting process—in particular, junior doctors. The main reason given for not completing forms was not having enough time (38.2% of respondents), primarily due to the length and complexity of forms. Many doctors, 43.7%, witnessed more than 5 incidents, but only 13.3% of doctors submitted more than 5 reports. Free text comments revealed 4 themes which impact upon reporting behaviours: organisational issues, form structure, a culture of blame, and a lack of feedback. Several suggestions for improvement were made.
Conclusions
Little has changed in the attitudes and behaviours of doctors. Improving incident reporting form structure to make it more user‐friendly and improving feedback may engage doctors and lead to an improved safety culture. The way the medical profession reports serious and other incidents still needs to be improved.
Left ventricular (LV) kinetic energy (KE) assessment by four-dimensional flow cardiovascular magnetic resonance (4D flow CMR) may offer incremental value over routine assessment in aortic stenosis ...(AS). The main objective of this study is to investigate the LV KE in patients with AS before and after the valve intervention. In addition, this study aimed to investigate if LV KE offers incremental value for its association to the six-minute walk test (6MWT) or LV remodelling post-intervention.
We recruited 18 patients with severe AS. All patients underwent transthoracic echocardiography for mean pressure gradient (mPG), CMR including 4D flow and 6MWT. Patients were invited for post-valve intervention follow-up CMR at 3 months and twelve patients returned for follow-up CMR. KE assessment of LV blood flow and the components (direct, delayed, retained and residual) were carried out for all cases. LV KE parameters were normalised to LV end-diastolic volume (LVEDV).
For LV blood flow KE assessment, the metrics including time delay (TD) for peak E-wave from base to mid-ventricle (14±48
2.5±9.75 ms, P=0.04), direct (4.91±5.07
1.86±1.72 µJ, P=0.01) and delayed (2.46±3.13
1.38±1.15 µJ, P=0.03) components of LV blood flow demonstrated a significant change between pre- and post-valve intervention. Only LV KEi
(r=-0.53, P<0.01), diastolic KEi
(r=-0.53, P<0.01) and E
KEi
(r=-0.38, P=0.04) demonstrated association to the 6MWT. However, Pre-operative LV KEi
(r=0.67, P=0.02) demonstrated association to LV remodelling post valve intervention.
LV blood flow KE is associated with 6MWT and LV remodelling in patients with AS. LV KE assessment provides incremental value over routine LV function and pressure gradient (PG) assessment in AS.
Wrist-worn devices with heart rate monitoring have become increasingly popular. Although current guidelines advise to consider clinical symptoms and exercise tolerance during decision-making in heart ...disease, it remains unknown to which extent wearables can help to determine such functional capacity measures. In clinical settings, the 6-minute walk test has become a standardized diagnostic and prognostic marker. We aimed to explore, whether 6-minute walk distances can be predicted by wrist-worn devices in patients with different stages of mitral and aortic valve disease. A total of n = 107 sensor datasets with 1,019,748 min of recordings were analysed. Based on heart rate recordings and literature information, activity levels were determined and compared to results from a 6-minute walk test. The percentage of time spent in moderate activity was a predictor for the achievement of gender, age and body mass index-specific 6-minute walk distances (p < 0.001; R
= 0.48). The uncertainty of these predictions is demonstrated.
Background:
The reproducibility of mitral regurgitation (MR) quantification by cardiovascular magnetic resonance (CMR) imaging using different software solutions remains unclear. This research aimed ...to investigate the reproducibility of MR quantification between two software solutions: MASS (version 2019 EXP, LUMC, Netherlands) and CAAS (version 5.2, Pie Medical Imaging).
Methods:
CMR data of 35 patients with MR (12 primary MR, 13 mitral valve repair/replacement, and ten secondary MR) was used. Four methods of MR volume quantification were studied, including two 4D-flow CMR methods (MR
MVAV
and MR
Jet
) and two non-4D-flow techniques (MR
Standard
and MR
LVRV
). We conducted within-software and inter-software correlation and agreement analyses.
Results:
All methods demonstrated significant correlation between the two software solutions: MR
Standard
(r=0.92, p<0.001), MR
LVRV
(r=0.95, p<0.001), MR
Jet
(r=0.86, p<0.001), and MR
MVAV
(r=0.91, p<0.001). Between CAAS and MASS, MR
Jet
and MR
MVAV
, compared to each of the four methods, were the only methods not to be associated with significant bias.
Conclusions:
We conclude that 4D-flow CMR methods demonstrate equivalent reproducibility to non-4D-flow methods but greater levels of agreement between software solutions.
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