Designing the Optimal Procedure: Role of CT Scan in the Planning of Transcatheter Structural Heart Interventions

Round 1

Reviewer 1 Report

As we seen the title"Designing the optimal procedure: role of CT scan in the plan3 ning of transcatheter structural heart intervention" can we compare CT modality between some parameters.

No Tabulation data mentioned in manuscript.

No sequencing of all headings.

Section and contribution sections are missing.

Explain the scope of Landing zone?

 Figure 11: CT assessment of the tricuspid annulus using a semiautomated software-based     missing caption and proper description.

Add and include some data from this sources:

Hu, S., Hoffman, E. A., & Reinhardt, J. M. (2001). Automatic lung segmentation for accurate quantitation of volumetric X-ray CT images. IEEE transactions on medical imaging, 20(6), 490-498.

Diwakar, M., Tripathi, A., Joshi, K., Memoria, M., & Singh, P. (2021). Latest trends on heart disease prediction using machine learning and image fusion. Materials Today: Proceedings, 37, 3213-3218.

Bae, K. T., Giger, M. L., Chen, C. T., & Kahn Jr, C. E. (1993). Automatic segmentation of liver structure in CT images. Medical physics, 20(1), 71-78.

Mir, A. H., Hanmandlu, M., & Tandon, S. N. (1995). Texture analysis of CT images. IEEE Engineering in Medicine and Biology Magazine, 14(6), 781-786.

Diwakar, M., Tripathi, A., Joshi, K., Sharma, A., Singh, P., & Memoria, M. (2021). A comparative review: Medical image fusion using SWT and DWT. Materials Today: Proceedings, 37, 3411-3416.

Ecabert, O., Peters, J., Schramm, H., Lorenz, C., von Berg, J., Walker, M. J., ... & Weese, J. (2008). Automatic model-based segmentation of the heart in CT images. IEEE transactions on medical imaging, 27(9), 1189-1201.

Elaborate the term 3D measurement. 

As you mentioned 126 references so here tabulation data must be included.

 

Author Response

We would like to thank the reviewers for the careful and thorough reading of our manuscript and for the thoughtful comments and constructive suggestions, which help to clarify and improve the quality of this manuscript.

No Tabulation data mentioned in manuscript.

Thank you for the suggestion. We added Table 1 summarizing the main findings of the studies discussed in the text regarding aortic valve disease, specifically focusing on the CT-derived variables analyzed by the authors and the predicted outcomes. By making this change, we hope to have improved the readability and clarity of our manuscript.

No sequencing of all headings.

According to the Reviewer's comment, we included the sequencing of all headings in this revised version of our manuscript. Thank you.

Section and contribution sections are missing

Thanks for the comment. We added the contribution section at the end of the manuscript.

Explain the scope of Landing zone?

We thank the Reviewer for his/her comment. We tried to more clearly explain the concept of landing zone in the setting of mitral prostheses deployment (page 14, lines 627-632).

Figure 11: CT assessment of the tricuspid annulus using a semiautomated software-based missing caption and proper description.

We added a comprehensive description of Figure 11, as requested by the Reviewer.

Add and include some data from this sources:

• ‘Hu, S., Hoffman, E. A., & Reinhardt, J. M. (2001). Automatic lung segmentation for accurate quantitation of volumetric X-ray CT images. IEEE transactions on medical imaging, 20(6), 490-498.’
• Diwakar, M., Tripathi, A., Joshi, K., Memoria, M., & Singh, P. (2021). Latest trends on heart disease prediction using machine learning and image fusion. Materials Today: Proceedings, 37, 3213-3218.
• Bae, K. T., Giger, M. L., Chen, C. T., & Kahn Jr, C. E. (1993). Automatic segmentation of liver structure in CT images. Medical physics, 20(1), 71-78.
• Mir, A. H., Hanmandlu, M., & Tandon, S. N. (1995). Texture analysis of CT images. IEEE Engineering in Medicine and Biology Magazine, 14(6), 781-786.
• Diwakar, M., Tripathi, A., Joshi, K., Sharma, A., Singh, P., & Memoria, M. (2021). A comparative review: Medical image fusion using SWT and DWT. Materials Today: Proceedings, 37, 3411-3416.
• Ecabert, O., Peters, J., Schramm, H., Lorenz, C., von Berg, J., Walker, M. J., ... & Weese, J. (2008). Automatic model-based segmentation of the heart in CT images. IEEE transactions on medical imaging, 27(9), 1189-1201.

We thank the Reviewer for notifying us of such interesting references that we have discussed and added in this revised version of our manuscript (now references 3-4-5-6-129-130).

Elaborate the term 3D measurement. 

Thanks for the comment. We tried to more clearly explain the term 3 D measurement of vena contracta (pag.18, lines 835-836).

As you mentioned 126 references so here tabulation data must be included.

Thank you for your comment. We are aware that the references included in our manuscript are 130 but we tried to perform an exhaustive revision of the literature regarding the role of CT in structural heart interventions. Such a number of references surely denotes interest in this research topic. Tabulation data doesn’t represent a specific requirement according to the Instruction for Authors of the Applied Sciences journal. Thus, we used a standard program to manage references among those proposed by the journal. However, in this revised version of the manuscript, we included, also according to the Reviewers’ comments, a new table in order to summarize the main studies cited in the manuscript.

Reviewer 2 Report

I have gone through the manuscript. The topic is indeed interesting but it needs to be fine-tuned. At various places authors have improperly explained the findings. These aspects have to be double-checked. Additionally, how authors envision the strategies to reduce the toxicity linked with radiations. 

It is essential to provide generalized paragraphs for the non-clinicians. For instance personals and researchers working on advancements in these technologies should benefit from these expert opinions to improve the technique. 

Author Response

We would like to thank the reviewers for the careful and thorough reading of our manuscript and for the thoughtful comments and constructive suggestions, which help to clarify and improve the quality of this manuscript.

I have gone through the manuscript. The topic is indeed interesting but it needs to be fine-tuned. At various places authors have improperly explained the findings. These aspects have to be double-checked. Additionally, how authors envision the strategies to reduce the toxicity linked with radiations. 

Thanks for the suggestion. We tried to modify and improve the clarity of the text when it results cumbersome.

Radiation toxicity doesn’t represent a crucial point with the new CT detectors as reported also in the text on page 3, lines 152-153, especially considering the importance of the information provided by CT in the setting of transcatheter heart valvular interventions.

However, these patients are usually exposed also to fluoroscopy during the interventional procedure, the length of which strongly depends on the operator’s expertise. To reduce the cumulative dose of radiations, further studies are needed to investigate the role of new software technologies for multimodality imaging that will consent to integrate CT with fluoroscopy in the catheterization laboratory.

It is essential to provide generalized paragraphs for the non-clinicians. For instance personals and researchers working on advancements in these technologies should benefit from these expert opinions to improve the technique. 

We thank the Reviewer for his/her helpful comment. We tried to include general information for non-clinicians, specifically regarding CT protocols used for aortic, mitral, and tricuspid valve assessment. These concepts have been reviewed by two radiologists, included among the authors of the manuscript. For the readability of the manuscript also by non-clinicians, we provided a paragraph on radiological anatomy at the beginning of each main section. Finally, we tried to perform an exhaustive revision of the literature regarding the role of CT in structural heart interventions according to our competence and cardiology expertise.

Reviewer 3 Report

Line 40	“[4]. Thus” instead of “ [4] .Thus”.  Error of space in the sentence
Line 54	Better rephrase in simplistic anatomical language the joining level of the leaflets edges.
Line 71	Schematic instead of schematic
Line 73-74	Better rephrase the sentence about prevalence of Aortic stenosis in Europe and US
Line 77-78	The statement about other factors should be backed by reference.
Line 87-88	[10-12] instead of [10]–[12]
Line 98	May mention what BSA means here?  = Body surface area…… like mentioned for BMI in line 102
Line 128	MDCT used for the first time. Must write what this abbreviation means. Previously authors have mentioned multidetector CCT in line 90. Either keep that or this one or if they two are different things, must define accordingly.
Line 131-132	“We discuss” instead of “we deeply discuss”
Line 45-187	Different findings by authors may better be shown in a tabulated form. E.g findings of Corcione et al., Spaziano et al., Gama et al. etc. can be shown in a tabulated form with their findings. Same applies for Jurenkak et al. in “Aortic Annulus” (Line 154). So authors may develop a table where they can show the anatomical site, relevant study, and their brief findings with relevant imaging modalities used. The text is quite cumbersome to comprehend like this.
Figures	All figures footnotes should start with capital. Also the authors may see that if there are more than one images in one figure, there should be more explanation provided in the footnote rather than relying on text (like for figure 9 where a means transverse and b means sagittal section)
Line 732	What is CCTA??... used for first time and thereafter….
The figures are optimal but there should be some information in a well designed table about different studies, the imaging techniques, interpretations and the anatomical sites….

 

Comments for author File: Comments.docx

Author Response

We would like to thank the reviewers for the careful and thorough reading of our manuscript and for the thoughtful comments and constructive suggestions, which help to clarify and improve the quality of this manuscript.

Line 40 “[4]. Thus” instead of “ [4] .Thus”.  Error of space in the sentence:

We thank the Reviewer for his/her suggestion. We inserted the proposed correction

Line 54: Better rephrase in simplistic anatomical language the joining level of the leaflets edges.

Thank you for your comment. We rephrased the sentence in order to improve clarity and readability (page 2, lines 64-65 in the revised version of the manuscript). In the attempt to improve the clarity of the text, we also added arrows in Fig 1 to specify aortic cusps anatomy.

Line 71: Schematic instead of schematic

Thanks for the comment. We modified the suggested correction.

Line 73-74: Better rephrase the sentence about prevalence of Aortic stenosis in Europe and US

We thank the Reviewer for his/her suggestion. We rephrased the sentence according to the reviewer's comment (page 3, lines 121-122 in the revised version of the manuscript).

Line 77-78: The statement about other factors should be backed by reference.

Thanks for the comment. We added an appropriate reference (reference number 12 in this revised version of the manuscript).

Line 87-88: [10-12] instead of [10]–[12]

 We thank the Reviewer for the suggestion. We edited the reference style (page 3, lines 118-119).

Line 98: May mention what BSA means here?  = Body surface area…… like mentioned for BMI in line 102

Thanks for the comment. We inserted the proposed correction (page 3, line 147).

Line 128: MDCT used for the first time. Must write what this abbreviation means. Previously authors have mentioned multidetector CCT in line 90. Either keep that or this one or if they two are different things, must define accordingly.

Thank you for the suggestion. The two terms refer to the same imaging technology. Thus, we replaced multidetector CCT with MDCT throughout the manuscript.

Line 131-132: “We discuss” instead of “we deeply discuss”

We thank the reviewer for the comment. We inserted the suggested correction.

Line 45-187: Different findings by authors may better be shown in a tabulated form. E.g findings of Corcione et al., Spaziano et al., Gama et al. etc. can be shown in a tabulated form with their findings. Same applies for Jurenkak et al. in “Aortic Annulus” (Line 154). So authors may develop a table where they can show the anatomical site, relevant study, and their brief findings with relevant imaging modalities used. The text is quite cumbersome to comprehend like this.

We thank the Reviewer for his/her comment. As suggested, we added Table 1 reporting the main findings of the studies discussed in the text, specifically focusing on the CT-derived variables analyzed by the authors and the predicted outcomes.

Figures: All figures footnotes should start with capital. Also the authors may see that if there are more than one images in one figure, there should be more explanation provided in the footnote rather than relying on text (like for figure 9 where a means transverse and b means sagittal section)

According to the Reviewer’s comment, we started all figures with capital. Furthermore, we added more explanation in the footnotes when the figures included two panels (Fig 1-2-4-6-7-8-11 in this revised version of the manuscript).

Line 732: What is CCTA??... used for first time and thereafter….

Thank you for the suggestion. CCTA refers to MDCT and we replaced CCTA with MDCT, computed tomography and CT with the same meaning.

The figures are optimal but there should be some information in a well designed table about different studies, the imaging techniques, interpretations and the anatomical sites….

According to the Reviewer’s comment, we added a new table resuming the various CT variables and the predicted outcomes in order to improve the readability of our manuscript.

Round 2

Reviewer 1 Report

Title"Designing the optimal procedure: role of CT scan in the plan3 ning of transcatheter structural heart interve" incorporate the following corrections:

-Explain the term CT and Aortic Valve more.

- Introduction section must be improved in terms of more contribution of author.

- many times manuscript corrected as red line marked?

- Figure 2 (a-b): (a) Ppre-operative evaluation measurements of peripheral ac157 cesses for TAVI feasibility. (b) Pre-operative femoral and iliac courses evaluated----diagram visibility required.

Missing citation [48][49][50]

No tabulation data in terms of value.

 

Latest reference must be add:

Zhao, J., Zhang, Y., He, X., & Xie, P. (2020). Covid-ct-dataset: a ct scan dataset about covid-19.

Diwakar, M., Tripathi, A., Joshi, K., Sharma, A., Singh, P., & Memoria, M. (2021). A comparative review: Medical image fusion using SWT and DWT. Materials Today: Proceedings, 37, 3411-3416.

Sarma, A., Heilbrun, M. E., Conner, K. E., Stevens, S. M., Woller, S. C., & Elliott, C. G. (2012). Radiation and chest CT scan examinations: what do we know?. Chest, 142(3), 750-760.

Joshi, K., Kumar, M., Tripathi, A., Kumar, A., Sehgal, J., & Barthwal, A. (2022). Latest Trends in Multi-modality Medical Image Fusion: A Generic Review. Rising Threats in Expert Applications and Solutions, 663-671.

O'Connor, J. F., & Cohen, J. O. N. A. T. H. A. N. (1978). Computerized tomography (CAT scan, CT scan) in orthopaedic surgery. JBJS, 60(8), 1096-1098.

Author Response

We would like to thank the reviewers for the careful and thorough reading of our manuscript and for the thoughtful comments and constructive suggestions, which help to clarify and improve the quality of this manuscript.

 

-Explain the term CT and Aortic Valve more.

Thanks for the suggestion. We spelled out the term CT with ‘computed tomography’ in the three main paragraphs.

 

- Introduction section must be improved in terms of more contribution of author.

We thank the reviewer for the useful suggestion. We briefly inserted the contribution of our group about this interesting topic in the introduction section in this revised version of the manuscript (page 1, lines 39-41, references 11-12-13), other than in specific paragraphs according to the topic (aortic, mitral and tricuspid).

 

- many times manuscript corrected as red line marked?

We thank the reviewer for the comment. As requested by Editorial Guidelines, we edited the manuscript using the ‘Track changes’ function. These changes shouldn’t appear in the definitive version.

 

- Figure 2 (a-b): (a) Ppre-operative evaluation measurements of peripheral ac157 cesses for TAVI feasibility. (b) Pre-operative femoral and iliac courses evaluated----diagram visibility required.

We thank the Reviewer for his/her comment. We edited the image’s quality and size to improve diagram visibility.

 

Missing citation [48][49][50]

Thanks for the comment. We added proper references.

 

No tabulation data in terms of value.

Thanks for the comment. We decided to not include values in tabulation data since cited studies provide different outcomes using different definitions. According to our opinion, this wouldn’t allow a consistent comparison between the considered parameters.

 

Latest reference must be add:

• Zhao, J., Zhang, Y., He, X., & Xie, P. (2020). Covid-ct-dataset: a ct scan dataset about covid-19.
• Diwakar, M., Tripathi, A., Joshi, K., Sharma, A., Singh, P., & Memoria, M. (2021). A comparative review: Medical image fusion using SWT and DWT. Materials Today: Proceedings, 37, 3411-3416.
• Sarma, A., Heilbrun, M. E., Conner, K. E., Stevens, S. M., Woller, S. C., & Elliott, C. G. (2012). Radiation and chest CT scan examinations: what do we know?. Chest, 142(3), 750-760.
• Joshi, K., Kumar, M., Tripathi, A., Kumar, A., Sehgal, J., & Barthwal, A. (2022). Latest Trends in Multi-modality Medical Image Fusion: A Generic Review. Rising Threats in Expert Applications and Solutions, 663-671.
• O'Connor, J. F., & Cohen, J. O. N. A. T. H. A. N. (1978). Computerized tomography (CAT scan, CT scan) in orthopaedic surgery. JBJS, 60(8), 1096-1098.

We thank the Reviewer for notifying us of such interesting references that we have added in this revised version of our manuscript (now references 7-8-9-134-136)