Dr.S.Venkatesan MD

HFrEF vs HFpEF : Can we Bio-chemically differentiate the two ?

September 15, 2025 by dr s venkatesan

Some times I wished, I could have become a Nephrologist. This thought comes whenever we face a patient with unexplained dyspnea, normal EF, and heart size. Am I missing a HFpEF? The heart is not like the kidney, which injects the all too familiar BUN & creatinine into blood promptly (with a high degree of reliability). Even a medical neophyte can diagnose renal failure just like that.

Cardiologists don’t have that luxury. Of course, we do have NT-Pro BNP recently , which nowhere comes near to renal failure markers . Still, many of the youngsters are tuned to believe NT-Pro BNP is equivalent to creatinine for the heart. Remember, biochemical diagnosis is always an adjunct and never confirmatory This is because NT-Pro BNP is universal cardiac stretch molecule , that can elevate in big list of conditions. Similarly , to appear in the blood, there can be a time lag unlike creatinine. (Read the universal definition of heart failure below).

“The universal definition of HF , defines HF is a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion”

* Though , a key link word and /or is used widely, unfortunately , the definition fails to reiterate clinical signs will prevail over biochemistry at any given point of time. It has inadvertantly ? given some over wiegtage to biochemistry.

Also, the new definition has gotten rid of hemodynamic, metabolic, and chamber-wise RV, LV classification systems. I think the committee wanted to remove the clutter of terms. In a broad sense, it’s good. By using the word structural, it includes valve defects or pericardial pathology into the basket of HF.

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Now getting deeper, can we differentiate differentiate HFpEF from HFrEF, based on biochemical markers ?

Differentiating HFpEF and HFrEF is vital but looks complex. One may say it is not really complex. Funnily , the purpose of the above chart becomes redundant if the EF of 50% has already differentiated the two conditions . what is the big deal about this table ? It is purely for prognostic and etiological purposes.

Summary

NT-proBNP is typically lower in HFpEF due to reduced ventricular wall stress, while MR-proANP which originates in the atria are expected to be more in HFpEF . Inflammatory and fibrotic markers and MicroRNA panels are high and more specific to HFpEF.

*Growth differentiation factor-15 . **ADM -Adrenomedulin a biomarker for arterial stiffness and arterial calcification . ***ucMGP refers Uncarboxylated Matrix Gla Protein. MGP to function as a calcification inhibitor,

Final message

Recognizing and confirming HFpEF, itself can be considered a partial clinical success. (Since more often it is missed) As mentioned earlier, biochemical differentiation is largely an academic exercise but gives us an idea of systemic pro-inflammatory and local fibrotic status.

There is a rough pathological rule of thumb (Note the word rough again). HFpEF is more often a systemic condition where the heart is affected. (In contrast to HFrEF where the pathology of the heart is central, and all systemic features are secondary to it.) Treatment options for heart failure have improved overall .However it is more limited in HFpEF as Inotropic agents are redundant here. Prognosis is highly variable and not necessarily better.

Reference

1.Ho JE, Lyass A, Lee DS, et al. Circulating biomarkers of incident heart failure with preserved ejection fraction: the ARIC study. JAMA Cardiol. 2018;3(5):415-423.

2.Zile MR, Desantis SM, Baldauff N, et al. Biomarker-guided risk assessment for the diagnosis and treatment of heart failure with reduced ejection fraction and preserved ejection fraction. JACC Heart Fail. 2021;9(12):893-903.

For Fellows . How do you diagnose HFpEF ?

1. Clinical features of heart failure (Apply some criteria , ex-Framingham )
2. Some evidence of elevated LV filling pressure at rest or exercise (Diastolic stress test)
3. Normal LVEF > 50% (Must ensure this should not be a recovered and improved EF from HFrEF condition)
4. NT-ProBNP -Supportive

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Posted in Uncategorized | Tagged HFpEF, HFpEF vsHFrEF, HFrEF |

Who decides the final landing spot of TAVI ?

September 11, 2025 by dr s venkatesan

A. The Aortic Radiologist

B. The Principal operator of TAVI

C. The co-operator or the proctor

D. The device type, behavior & destiny

Answer : A. The radiologist, (rather the soft-warist ) tell us best landing zone in the pre procedure work up taking into the account of shape, size, leaflet morphology ,3D analysis of aortic root, and calcium distribution. He plays a vital role. Though B, is the logically correct answer, ie the expertise of the primary Operator it is not to be. Considering the complexity of the anatomy, device, and momentary longitudinal and circumferential alterations in radial forces, In reality, the answer is D.

Evidence? No one has tested so far the true intended landing zone and the final one.

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One may argue , the question need to be reframed as, What are the factors that decide the landing zone in TAVI ?

Though deployment is under the control of primary operator , the valve often defies operators’ hand commands and decides to home in its own place of comfort and peace adjusting to the complex anatomy around. It never bothers about the consequences .The unpredictability of calcium crystals, the annular tensile strength, the distorted native leaflet and the blind plastering against the aortic wall all are responsible for the complications. One less talked dynamism of aortic root which finetunes micro adjustments of the valve. Para valvular leak is primarily determined by either excess (or lack )of this modulatory forces.

Following are some of the crucial factors that determine landing zone.

Anatomy of the Aortic root

 The ascending aortic curvature and angulation is a major factor of the TAVI landing site. , stretching from the aortic annulus to the proximal ascending aorta. This anatomy may vary depending on the patient and affects different types of valves (such as balloon-expandable or self-expanding). For instance, higher aortic angulation (Ex – a horizontal aorta) can influence the final depth of valve implantation, especially for self-expanding valves with longer stent frames.

The invisible radial & longitudinal forces

The resistance offered by the distorted native valve and its delicate balance with the instant radial force of in case of balloon expandable or the gradual built in force of self expandible balloon system. Apart from the radial forces. the longitudinal deformation forces in long axis as the stent expands , in the last few seconds determine the final residence of the valve.

Valve Type and Device Design

The intended implantation depth is usually planned based on the valve type—balloon-expandable valves have a short stent frame and are deployed differently than self-expanding valves with a taller frame. More precision is required in balloon expandable valves. This is because the anchoring mechanisms and the metallurgy is entirely different between the two.(SE-TAVI uses Nitinol frame, and it has wide contact area so more stable ,)

Intra-Procedural Adjustments: 

The final landing zone is also influenced by the need to avoid complications such as valve migration, aortic regurgitation, and coronary obstruction.

Final mesage

Some times, TAVI landing looks like SpaceX Dragon docking with a space station. Extreme precision is required to avoid complications. The bulk of the complications are due to inappropriate landing (too high or too low). Fortunately, aortic annulus exists in multiple transverse planes; patients can often tolerate some geographical miss. Still even a few mm error can crash the patient as well as our reputation.

Postamble

What are the chances of immediate post -procedural movement and late migration of the valve from the landing site in TAVI ?

The chances of immediate post-procedural movement and late migration of the valve from the landing site in Transcatheter Aortic Valve Implantation (TAVI) are generally low but represent serious complications when they occur. Incidence is up to 7.5%

Reference

https://www.frontiersin.org/journals/cardiovascular-medicine/articles/10.3389/fcvm.2022.928740/full

* Video source and courtesy

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Posted in Uncategorized | Tagged annular disruption, basillica procedure, core valve, medtronic resilia, partent study, sapien edwards, supra annular or annular tavi, tavi, tavi landing zone, tavi proctor, TAVR landing zone |

Why some Right ventricles hypertrophy, while others dilate in response to pulmonary hypertension ?

September 8, 2025 by dr s venkatesan

There is no simple answer. We hide behind two terms, adaptive and maladaptive RVH. While the former is beneficial for an unknown period of time, the latter rapidly goes into a downward spiral.

• Adaptive RVH (A-RVH) occurs when the RV responds to chronic pressure overload by increasing muscle mass concentrically. This adaptation maintains RV contractility and cardiac output despite increased pulmonary vascular resistance. RVH is typically concentric with less chamber dilation, preserved coronary perfusion,
• Mal-adoptive RVH (M-RVH)occurs If afterload is excessive, prolonged and the RV cannot maintain sufficient contractile function . For some unknown reason, in M-RVH, the impact of PA pressure is not uniform the chamber dilates asymmetrically this leads to wall stress increase, fibrosis, ischemia, and contractile failure.

I am unable to find the exact incidence of the above two entities. In COPD, it is more adaptive; in cardiac conditions, it is more maladaptive. A new thinking is that the LV plays a significant role in determining RV function, as both are interdependent. (Both arms of Bernheim effect)

The third entity is acute RV dilatation to sudden elevation of PA pressure as in PE. (Recall the 60/60 sign) Though we think it is purely a hemodynamic response, there are reasons to believe an ultra-rapid predetermined genetic response is also possible by recruiting messenger RNA and growth factors.

*It is worthwhile to note the complexity of RV dynamics. Chronic RV dilatation, (without pressure load)need not be a major pathology, as they are meant to dilate with excess venous return (We also see ASD patients live their entire lives with baggy right ventricles.)

Various shapes of RV in PH .Image source : Llucià-Valldeperas A, de Man FS, Bogaard HJ. Adaptation and Maladaptation of the Right Ventricle in Pulmonary Vascular Diseases. Clin Chest Med. 2021 Mar;42(1):179-194.

Mechansims of adoptive RVH

The following mechanisms are believed to be responsible.

• Concentric hypertrophy with preserved contractile function involving mainly fast myosin heavy chain (MHC) α isoform expression.
• Metabolic remodeling with a switch to glycolytic metabolism but preserved energy supply through compensatory mechanisms like increased GLUT-1 expression.
• Maintenance of angiogenesis and oxygen supply through vascular endothelial growth factor (VEGF) signaling.
• Self restricting fibrosis and balanced extracellular matrix remodeling.

Is there any Clinical and echocardiographic clues to adoptive RVH ?

Of course yes. But all are common sense related.

• Patients with adaptive RVH often maintain higher exercise tolerance.
• Elevated levels of BNP or NT-proBNP correlate with maladaptive RVH.
• In echocardiography , Adoptive RVH is characterized by increased RV wall thickness (>5 mm) with relatively preserved RV chamber size and function. TR is less common as shape is preserved and annular distortion is minimal.

How long the Adoptive RVH phase can lasts ?

Law of Laplace states, wall thickness will reduce the after-load, balance out the RV-PA coupling mis match. How long this can last? A wild guess is that it can last even up to a decade. Studies in conditions like surgically repaired congenital heart disease and Eisenmenger syndrome have shown adaptive RVH with preserved contractility and normal chamber size for many years. However, this phase eventually transits to maladaptive state.

Can we Induce adaptive RVH as a therapeutic measure ?
As of now , this possible only on paper .Research should target therapeutically, controlled pressure overload and neurohormonal modulation can promote beneficial RV hypertrophy. Strategies to support favorable metabolic pathways, enhance angiogenesis, and reduce oxidative stress are under investigation

Final message

Whether the RV is going to fight or flight the raising afterload of pulmonary HT is not in our hands. It is pre-programmed and switches are controlled by destiny. We can only do whatever, to lower the PA pressure and PVR by treating the primary cause if any. Though, the pharmacological strategies in PH has shown tremendous progress in recent times , the behavior of RV will define the outcome.

Reference

1.Khassafi, F., Chelladurai, P., Valasarajan, C. et al. Transcriptional profiling unveils molecular subgroups of adaptive and maladaptive right ventricular remodeling in pulmonary hypertension. Nat Cardiovasc Res 2, 917–936 (2023). https://doi.org/10.1038/s44161-023

2.Ren X, Johns RA, Gao WD. EXPRESS: Right Heart in Pulmonary Hypertension: From Adaptation to Failure. Pulm Circ. 2019 Apr 3;9(3):2045894019845611. doi: 10.1177/2045894019845611. Epub ahead of print. PMID: 30942134; PMCID: PMC6681271.

3.Llucià-Valldeperas A, de Man FS, Bogaard HJ. Adaptation and Maladaptation of the Right Ventricle in Pulmonary Vascular Diseases. Clin Chest Med. 2021 Mar;42(1):179-194. doi: 10.1016/j.ccm.2020.11.010. Epub 2021 Jan 12. PMID: 33541611.

4.Magoon, Rohan; Dey, Souvik; ItiShri, ; Kashav, Ramesh. Evolution of Ventricular Interdependence Concept: Bernheim, Reverse-Bernheim Effect and Beyond!. Journal of the Practice of Cardiovascular Sciences 6(1):p 90-91, Jan–Apr 2020. | DOI: 10.4103/jpcs.jpcs_55_19

Post-amble : How the new age interventions help tackle the RV failure

TR clips, and tricuspid valve reconstruction, either surgical or percutaneous, RV assist devices are THE interventions done in a failing RV before the last resort of heart/Lung transplantation.

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Posted in Uncategorized | Tagged copd, dan point, ph managment, pulmonary hypertension guidelines, rvh eccentric vs concentric, rvh vs rv dilatation, vennice ph seminar |

Routine Echocardiography for all pregnant women to rule out heart disease ? What does the latest ESC 2025 guidelines say ?

September 3, 2025 by dr s venkatesan

There has been recent increase in number of women undergoing echocardiography, apparently for ruling out any hidden heart disease. In some parts of India it reached epidemic proportions that raised some concern. The folllowing post was written about this recently in this site , which evoked mixed reactions.

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Now, in 2025 the new ESC guidelines for pregnancy and heart disease is released. Let us see what it says about this . Being pregnant never makes a women eligible for an echocardiogram. (No guidelines ever supported it ) It is true, cardio vascular morbidity is increasing in pregnancy as we have moved on from traditional maternal risks. May be, the new guidelines suggest we can do Echocardiography more liberally , but definitely not as routine .Please note ,it is still backed up by that mystery 1-C evidence base.

The three key words used in the guideline are

In any pregnant women

1.Unexplained cardiac symptoms

2 New cardio vascular sign

3. New cardio vascular symptom

What about women with pre-existing heart disease ?

I think, they could have included these indication in the same table. Any pregnant women with a known history of past heart disease, with or without symptoms, must undergo a detailed Echo evaluation to know the current hemodynamic status. Also, Echo should be used liberally in all in all women at high risk for cardiac morbidity (Like PIH, GDM, Obesity elderly primi, etc)

Final message

Echocardiography is simple and accurate methodology to rule out structural heart disease in pregnancy. It has great potential to detect hidden heart disease. But, it should be judiciously. Routine echocardiography to rule out a cardiac condition is becoming a non professional fad in many parts of our country What is more ironic is this practice is rampant in low and middle income countries where financial resources are scarce. It is a clearly a pathway to avoid .Let us follow the guidelines as for as possible.

Postamble

What could be the new symptom or sign in pregnancy ?

1. Mild exertional dyspnea , which was not there before . 2.A grade 1 systolic murmur across the RVOT or rumble in AV valve ? This will make every other patient (Then may be 50% of 25 million pregnancy that occur in India every year) .Still there is room to misuse the guidelines .I would argue the committee to , address the critical importance of clinical assessment and these guidelines should instill confidence to ignore physiological symptoms.

Counterpoint( Expert comment in real time from an Obstetrician)

A leading obstetrician, practicing In Chennai says she is sorry to say this. It seems many of us have lost confidence in clinical skills. In this technological era, we are unable to rely only on clinical opinion. So, echo is an easy way out. Also we are worried about legal aspects of potential miss.

I don’t know where the problem lies. In fact, one of my colleague cardiologist said , though they are  confident enough to diagnose a normal heart in pregnancy by clinical means ,the referring doctor (obstetrician) often Insists an Echo.

We also know how a routine Echo might detect some innocuous entities like MVPS, a trivial TR, a dilated ventricle, a mild pericardial effusion, a small PFO, a bicuspid aortic valve, and create huge anxieties in our patients. Still… we do it to relieve ours at the cost of patients.

Reference

https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehaf193

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Posted in ESC ACC Guidelines, pregnancy and heart disease | Tagged acc esc, acog criteria, bcog, echocardiography guidelines during pregnancy for mother, ESC 2025 GUIDLINES ON PREGNACY, fogsi, Is routine antenatal echocardiography Indicated in pregnancy ?, maternal echocardiography is not routine, ogsi, ROUTINE ECHO IN PREGNANCY, when to do echo in pregnancy, why echo in pregnancy |

Live from ESC 2025, Madrid : Digoxin is toxic  to heart ,while Digitoxin is not !

September 1, 2025 by dr s venkatesan

Breaking the science of Heart failure :

Heart failure (HFrEF) remains a gigantic clinico-pharmacological entity. In the last decade, pharmacological strategies to tame HF turned out to be a multi-billion global block buster. Industry constructed multiple evidence-based pillars to lift the drowning patients from HF. To be precise, there were four (Some wanted to insert a fifth pillar : Riociguat a sensitizer of soluble guanylate cyclase (sGC) which play mimicry with Nitic oxide ). All sounds good and right on paper .

But, what was hidden from the public was, that they were built displacing the foundation on which heart failure was managed for centuries if not decades. Yes, it’s about the foxglove-derived grand old drug Digoxin, a Na+ /K+ATPase blocker in the myocyte cell membrane, that exchanges calcium for stable Inotropy. Digoxin is only positive Inotropic with vago -mimitic action that calms the heart. Though the efficacy to safety margin is low in terms of pro arrhythmia , if used properly Digoxin had been a key drug in HF especially if AF is associated. Over time, we have developed RASS sympathetic blockade system in various forms. One poorly done study in 1990s, DIG-Trail, was enough to paint black on the wonder drug.

Now, In 2025, it seems apparent, lack of that vital foundation might shake the pillars, built with ornamental ARNI’s and the flimsy Flozins (Which are essentially renal glycosuric agents also playing a diuretic role , in the process partly stealing the benefits from time-tested diuretics)

This post was written in this site about long back, questioning the DIG trial conclusion (Click here)

Delighted to note , the observations were ratified today.

Now in 2025, the ESC congress in Madrid, some sensible study group from Germany and France found Digoxin indeed saves lives, confirming the suspicius results of DIG trial results done in 1997.(Which claimed no mortality benafit )

The NEJM article ACC website

Back to Catch 22 situation

This time, in DIGIT -HF they used Digitoxin instead of Digoxin. Why ? again, something sounds fishy. Digoxin is the true universal generic available for a peanut price. I am not sure about the availability and price of Digitoxin. This trial is is really kick all those modern cardiologists who get humiliated to write this old drug.

Meanwhile, a near foolish argument is already on , questioning Digitoxin cannot be compared with Digoxin as the former is more stable, has a hepatic route to eliminate if HF patients are renally compromised, etc. I checked with the pharma guys. Digitoxin is difficult to get. My fear is someone may patent this new improved German Digitoxin that was used in this study. (Digitoxin -Trade Name Crystodigin)

Final message

It is glad to see Digoxin continue to defy the death sentence passed by modern day scientists. Though DIGIT-HF is a good come back, we need to allow more truths to come out from the secret scientific cupboards.

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Posted in Uncategorized | Tagged dig trial, DIGT -HF TRIAL ESC 2025 |

Pulmonary atresia with VSD : Is it a cono-truncal anomaly ?

August 26, 2025 by dr s venkatesan

There is a list of conditions that come under cono-truncal anomaly(CTA) in CHD. TOF is the classical example. CTA are group of genetically determined fusion defects between developing right ventricle , septum and the outflows .Many components of outflow are outsourced from cranially located neural crest . In fact, improper migration and fusion of this secondary heart field to the primary is most common cause of many complex heart disease. Microdeletion on chromosome 22, specifically in the 22q11.2 is a major documented gene defect. Traditionally CTA list often includes PA with VSD. This table compares the anatomical and embryological basis of TOF & PA with VSD. You can decide whether to call both as part of cono-truncal anomaly or not.

Add on content.

One important difference is missing in the above table. It is about presence and absence of PDA. In TOF true PDA may be present in early days or months . In PA with VSD , PDA or (MAPCAS mimicking a PDA ) can be part of collateral .A persistent controversy is, how to differentiate a PDA from MAPCAS .That can be challenging. Further, to label a vessel as PDA it should drain into normally formed left pulmonary artery, which is rarely likely.

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Posted in Uncategorized | Tagged collaterals in tof, cono truncal anomaly, mapcas, neural crest defects, pda in tof, pulmonary atresia with vsd, TOF |

Normal BP recorded by an abnormal physician!

August 20, 2025 by dr s venkatesan

This a transcript of a mini-cardiology consult happened in a routine office practice of a physician.

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I am Mr. S. I just went for a preventive health check, specifically to rule out hypertension . I got my BP checked by a physician who is also an experienced cardiologist.

“How is my BP doctor ?

“Its fine , It is 120/76 ”

I asked him, “Is my blood pressure normal doctor?

I thought, the doctor sort of frowned at me for a moment and said , “Oh sure, technically yes , it is normal BP , but academically it is not.” 

“Doctor, make a pardon , I didn’t get it . You mean to say my BP is abnormal ?

“No, not really, it is not abnormal either.”

“Then, why you said it is academically not-normal doctor ?

“I would love to call it normal, in fact it is normal .“

“I am confused doctor. What prevents you to call it as normal BP doctor ?

“Let me tell the truth .The current scientific guidelines (ESC) which we revere , doesn’t allow me to call it as normal BP . It wants to get rid of the term normal BP from the cardiology literature. It asks us to call you guys with perfectly normal BP as having non elevated BP. I want to be loyal to the science and also should not feel out-dated with my peers.“

“I understand doctor, the compulsion to respect science more than your conscience in your day to day practice and admit it too .You are a very rare & frank Doctor I have, ever come across “

Thank you, Mr S. for your complements very kind of you .But, let me go little personal. My colleagues consider me otherwise . They don’t consider me as a normal doctor , because I am frank.

Doctor, please don’t bring that normal curve stuff again. If you are called abnormal, then who is normal , doctor?

Sorry, I don’t have an answer .We shall meet on our next visit. Bye & thanks

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Those who want to dwell deep please go through this 107 page document.

Trying to find out the word normal BP in the latest ESC 2024  Hypertension  guidelines .

What is the logic for removing the term Normal BP in the new ESC guidelines ?

BP is a continuous variable . People with any level of BP can develop cardiovascular events. So there can’t be strict normal.

Why such a classification could be dangerous ?

By avoiding the word normal, are we trying to suggest non-elevated BP is also a potential risk factor? These guidelines misleadingly and unintentionally took a cue from the LDL analogy: i.e., lower is better. They conveniently forgot the J-curves and U-curve of BP. This classification is meant to keep every adult human being as a potential candidate to get ready for elevated BP or HT. Can’t suspect the true intentions, though, as these guidelines stress the importance of good lifestyle choices to keep the BP in control without drugs.

The fact that the new guidelines is avoiding the word normal , implies it hesitates to reassure our public .This, by itself, will make our public anxious, push up the BP, and end up as drug-consuming hypertensives later. Principles of the practice of medicine hinge on trust and reassurance. In the name of scientific preventive medicine, we are unable to call a normal person normal. That is the wages for the sins we pay for the explosive growth of knowledge (Pseudo) and technology.

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Post-amble

Who am I ? to question the credibility of a 107-page document prepared by the best of all experts in the field of cardiology? Just a reminder to mind , what happened to the term pre-hypertension and the fate of JNC across the Atlantic a decade ago.

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Posted in Uncategorized | Tagged acc aha guidlines hypertension, british society of hupertension, defintion of normal blood pressure, esc hypertension guidelines 2024, hypertesnion grading, hypertesnion nomenclature, pre hypertension vs non eelvated bp, what is eelvated bp, world hypertension league |

TAVR vs TMVR : The differential Anatomic & Scientific Principle

August 17, 2025 by dr s venkatesan

Good bye to Gruentzig … the mercurial genius and the father of Interventional cardiology. The swag attached to PCI has become a bygone era. Percutaneous structural heart disease interventions, though in Infancy, is ruling the world today. Tans catheter heart valves is the new mantra. (THV).We can say Aortic stenosis has been conquered without surgery.(*Note : we means cardiologists, not patients) . Pediatric cardiologists have done the same in percutaneous pulmonary valve delivery in children. However, our quest for percutaneous AV valve implantation is facing tough challenges that sans meaningful outcomes.

It is heartening to witness huge technological innovations in arena of native TMVR*. Still, Mitra clip (TEER ) is the only non surgical solution for MR as of now. We know, It is a terrible alternative for an surgical MVR. The key issue with TMVR is the absence of good native foundation and tackling the extremely dynamic AV ring , which are in continuity with LV/RV muscle (unlike Aortic valve ) Mind you ,the AV valves should withstand the force of TAPSE/MAPSE for tricuspid and mitral valves respectively. May be a dysfunctional left ventricle might co-live with a TMVR with more peace. (Fortunately ,LV dysfunction is common in patients who are considered for TMVR)

*Valve in valve in TMVR is being widely used .The issue discussed here will be for TMVR . native mitral valve diseae.

Here , an attempt is made to differentiate the basic differences in the science of between TAVR vs TMVR . (Not comprehensive, but has compared three promising TMVRs , Intrepid, Tendyne, M-3 and Alta-valve.

Final message

Though TAVR and TMVR share a word ‘transcatheter’ they live in different anatomical and physiological worlds. TAVR is often successful because calcium is mostly friendly , the annulus is near circular, and landing zone is fairly predictable. Implantation of TMVR demands extreme diligence because the annulus is dynamic, calcium is an unstable ally, and of course there is always the fearsome LVOT nearby.

Post-amble

Meanwhile, the inability to dispose of the native disease leaflets is a the common issue in both TAVR and TMVR .( which our surgical colleagues will laugh at) May be we need to wait until an new avatar of BASILICA or LAMPOON, which might have a valve bioptome , to cut and extract native leaflet ,safely through a dedicated port without the risk of embolization.

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Posted in Uncategorized | Tagged dailyprompt, dailyprompt-2033 |

What are the various 3D-CT soft-wares available for pre-procedural TAVR Imaging ? How accurate they are ?

August 11, 2025 by dr s venkatesan

TAVI is becoming like PCI equivalent of aortic valve. The procedure is nothing but stenting and plastering the aortic prothesis ,with all the native diseased aortic leaflet in-situ. Pre procedure CT aortic valve mapping (rather the entire Aorta) is the key to successful outcome.

While the calcium is the essential bonding force of the valve to the aortic annulus, it can also play some serious spoilsport, along with native leaflet debri . Many times, the hardened calcium are like like sharp 3 dimensional knife hanging over there in root of aorta.

Every TAVI operator has this ligering fear . Will that speck of calcium “ice berg”, hiding 2 mm above the NCC, hit the AV node, when I deploy the valve ? Will the distorted leaflet jump few mm above and hit the coronary ostia , however high it may be. (After all , the exact final landing zone is not determined by the operator , but by the ROC curve)

Every severely calcified valve experiences a Titanic effect , fortunately most valves escape.

Realise how important the accuracy these softwares are .It is just a matter of few mm error . . Apart form calcium distribution pattern , more fundamental parameters like the annular size, shape, and optimal imaging angle are critically important. Here is brief report on various software packages available for pre procedure planning of TAVR.

Image courtesy : Thoracic Key  Assessment of aortic valve calcification.The stretch view shows dense calcification of the right coronary cusp, noncoronary cusp, and left coronary cusp. The stretch view (A), angiographic overlay (B), cross-sectional view (C), and “hockey puck” view (D) allow quantification of the calcium in the aortic valve.

The following table was curated from the respective company websites. Any further details can visit them.

Software	Vendor/Developer	Key Features for TAVR Pre-Planning
3mensio Structural Heart	Pie Medical Imaging	Dedicated TAVR module for automated aortic root analysis, valve sizing, and access route planning. Provides 3D visualization, calcium scoring, and virtual valve implantation. Widely used for precise measurements and procedural simulation.
OsiriX MD / Horos	Pixmeo (OsiriX) / Open-source (Horos)	DICOM viewer with 3D multiplanar reconstruction (MPR) tools for manual valve sizing, annulus measurement, and aortic root analysis. Horos is a free alternative. Supports plugins like ProSizeAV for semi-automated sizing.
syngo.via CT Cardiac Function – Valve Pilot	Siemens Healthineers	Semi-automated workflow for aortic valve assessment, angulation prediction, and device sizing. Includes valve pilot tools for efficient CT analysis.
HeartNavigator	Philips Healthcare	Automated or semi-automated CT processing for TAVR, including aortic root segmentation, access route simulation, and procedural guidance. Often compared for reliability in measurements.
Valve Assist 2	GE Healthcare	AI-assisted tool for valve sizing, CT analysis, and planning efficiency. Focuses on automating measurements to reduce manual effort.
Mimics Enlight / Mimics Planner	Materialise	Cloud-based 3D modeling software with automated workflows for structural heart interventions, including TAVR-specific measurements, virtual valve implantation, and 3D printing support. Includes AI for segmentation.
cvi42	Circle Cardiovascular Imaging	Advanced CT tools for interventional planning, including TAVR, with automation for aortic valve assessment, flow quantification, and structural heart disease management.
Intuition TAVR Planning	TeraRecon	Comprehensive package for aortic root segmentation, centerline extraction, and pre-operative measurements. Supports advanced 3D/4D visualization for TAVR workflows.
Vitrea CT TAVR Planning	Canon Medical (Vital Images)	AI-leveraged application for automated TAVR assessment, including valve sizing, access planning, and post-operative evaluation. Integrates deep learning for efficiency.

Some questions

1.Which one is most popular ?

With out doubt 3mensio is top software because of its neutrality between various TAVR valve and wide spread usage and comparisons.

2.What is the cost of these software ?

They are substantial has a monthly subscription model. 3Mensio pricing starts at approximately $500/month for 1 user, $4,000/month for 10 users.

3.Is there any Freeware for assessing Aortic root ?

Yes . OsiriX MD / Horos is a free ware, but not getting sufficient attention.

4.What is the error rate of these software ? since they are offline and often images are machine extrapolated ?

Error rate in software are well not reported. (Can’t expect the vendors to do it !) However, It must be acknowledged they are real because of the offline nature of image processing .These tools process DICOM data, in pre-trained algorithms. Errors can arise from poor CT input (e.g., motion artifacts) or extrapolation in 3D reconstruction (e.g., interpolating between slices), but studies show minimal impact with high-quality scans.

Common Error Sources: User variability, calcium blooming artifacts, or phase-specific differences in dynamic CT.

Clinical Implications: Errors in sizing can lead to complications like paravalvular leak (if undersized) or embolism (if oversized), but validation shows risks are low (e.g., <2 mm differences rarely affect outcomes). Multi-reader or expert double check is encouraged to improve accuracy.

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Posted in Uncategorized | Tagged 3mensio, comparison of various ct scan tavi software, cvi42, free tavr tavi soft ware ct scan, heart navigator, horos tavi tavr soft ware, intution tavr planning, osirix md, partner, sapiens vs core valve, syngo vs 3mensio, tavi, tavi software, TAVR, vitrea ct scan tavr tavi |

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