The impact of calcium volume and distribution in aortic root injury related to balloon- expandable transcatheter aortic valve replacement Nicolaj C. Hansson,

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The impact of calcium volume and distribution in aortic root injury related to balloon- expandable transcatheter aortic valve replacement Nicolaj C. Hansson, MD, Bjarne L. Nørgaard, MD, PhD, Marco Barbanti, MD, Niels Erik Nielsen, MD, Tae-Hyun Yang, MD, Corrado Tamburino, MD, Danny Dvir, MD, Hasan Jilaihawi, MD, Phillip Blanke, MD, Raj R. Makkar, MD, Azeem Latib, MD, Antonio Colombo, MD, Giuseppe Tarantini, MD, Rekha Raju, MD, David Wood, MD, Henning R. Andersen, MD, DMSci, Henrique B. Ribeiro, MD, Samir Kapadia, MD, James Min, MD, Gudrun Feuchtner, MD, Ronen Gurvitch, MD, Faisal Alqoofi, MD, Marc Pelletier, MD, Gian Paolo Ussia, MD, Massimo Napodano, MD, Fabio Sandoli de Brito, MD, Susheel Kodali, MD, Gregor Pache, MD, Sergio J. Canovas, MD, Adam Berger, MD, Darra Murphy, MD, Lars G. Svensson, MD, Josep Rodés-Cabau, MD, Martin B. Leon, MD, John G. Webb, MD, Jonathon Leipsic, MD Journal of Cardiovascular Computed Tomography Volume 9, Issue 5, Pages 382-392 (September 2015) DOI: 10.1016/j.jcct.2015.04.002 Copyright © 2015 Society of Cardiovascular Computed Tomography Terms and Conditions

Fig. 1 Multidetector CT aortic root dimensions. (A) Stretched MPR view of the aortic root demonstrating analysis levels. (B) Short-axis view of the sinotubular junction level. (C) Short-axis view of the sinus of Valsalva level. (D) Short-axis view of the aortic annulus level. (E) Short-axis view of the LVOT level 5 mm below the aortic annulus. (F) Stretched MPR displaying the distance from the aortic annulus to the right coronary ostium. (G) Stretched MPR displaying the distance from the aortic annulus to the left coronary ostium. LVOT, left ventricular outflow tract; MPR, multiplanar reformation. Journal of Cardiovascular Computed Tomography 2015 9, 382-392DOI: (10.1016/j.jcct.2015.04.002) Copyright © 2015 Society of Cardiovascular Computed Tomography Terms and Conditions

Fig. 2 A representative example of an image histogram of the normal blood pool region. (A) A 200 m3 VOI is placed in the uniform normal blood pool region at the level of the left coronary ostium. (B) A Gaussian curve (green) is fitted to the image histogram (brown) of the VOI, and the patient-specific calcium detection threshold is calculated based on meanfit and SDfit (see Methods section). HU, Hounsfield units; VOI, volume of interest. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.) Journal of Cardiovascular Computed Tomography 2015 9, 382-392DOI: (10.1016/j.jcct.2015.04.002) Copyright © 2015 Society of Cardiovascular Computed Tomography Terms and Conditions

Fig. 3 Quantitative analysis of calcium distribution. (A) Stretched MPR view of the aortic root. Three regions are defined: the overall LVOT (from the aortic annulus and 10 mm into the left ventricle), the upper LVOT (from the aortic annulus and 2 mm into the left ventricle), and the aortic valve region (from the aortic annulus to the left coronary ostia). (B1, B2) Long- and short-axis views of the aortic valve region demonstrating calcium in relation to the 3 cusps. (C1, C2) Long- and short-axis views of the upper LVOT demonstrating calcium below the NC. (D1, D2) Long- and short-axis views of the overall LVOT demonstrating calcium below the NC and LC. LVOT, left ventricular outflow tract; LC, left coronary cusp; MPR, multiplanar reformation; NC, noncoronary cusp; RC, right coronary cusp. Journal of Cardiovascular Computed Tomography 2015 9, 382-392DOI: (10.1016/j.jcct.2015.04.002) Copyright © 2015 Society of Cardiovascular Computed Tomography Terms and Conditions

Fig. 4 Multidetector CT (MDCT) scans in 3 patients (A, B, and C) experiencing aortic root injury. (A1, A2) Double-oblique transverse and sagittal oblique views displaying calcium in the upper LVOT. (B1, B2) Double-oblique transverse and coronal oblique views displaying calcium extending through the overall left ventricular outflow tract. (C1, C2) Double-oblique transverse and sagittal oblique views displaying left ventricular outflow tract calcium below the noncoronary cusp. (C3, C4) Post-TAVR MDCT double-oblique transverse and coronal oblique views demonstrating contained aortic root injury (white arrows) in relation to the left sinus of Valsalva in the patient depicted in panels C1 and C2. Journal of Cardiovascular Computed Tomography 2015 9, 382-392DOI: (10.1016/j.jcct.2015.04.002) Copyright © 2015 Society of Cardiovascular Computed Tomography Terms and Conditions

Fig. 5 Individual patient calcium volumes in the control and aortic root injury groups in the upper LVOT (A), the overall LVOT (B), and aortic valve regions (C). Orange lines indicate median values (see also Table 4). *P < .0001 vs control group. LVOT, left ventricular outflow tract. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.) Journal of Cardiovascular Computed Tomography 2015 9, 382-392DOI: (10.1016/j.jcct.2015.04.002) Copyright © 2015 Society of Cardiovascular Computed Tomography Terms and Conditions

Fig. 6 Receiver operating curves assessing the predictive value of calcium volumes for aortic root injury. (A) Overall LVOT, upper LVOT, and aortic valve region calcium and (B) upper LVOT calcium below the noncoronary cusp, right coronary cusp, and left coronary cusp, respectively (see also Table 4). LVOT, left ventricular outflow tract. Journal of Cardiovascular Computed Tomography 2015 9, 382-392DOI: (10.1016/j.jcct.2015.04.002) Copyright © 2015 Society of Cardiovascular Computed Tomography Terms and Conditions