Search

Better time-resolved imaging of stent grafts in the ascending aorta and arch accounting for cardiac motion is necessary to understand device-related complications and endoleaks. This report describes dynamic time-resolved computed tomographic angiography (d-CTA) and its combination with electrocardiography gating (d-gated CTA) to image stent grafts in the ascending aorta and to characterize endoleaks more clearly.d-CTA involves multiple scans acquired at different time points along the contrast enhancement curve. d-Gated CTA involves concomitant electrocardiography gating in a predefined cardiac phase minimizing motion-induced artifacts.This report illustrates the utility of d-CTA and d-gated CTA in 2 clinical cases. d-CTA demonstrated a type 1A endoleak in a patient with an aortic arch aneurysm treated with total arch debranching and a thoracic stent graft. d-gated CTA demonstrated a type 1A endoleak in a patient with an ascending aortic pseudoaneurysm treated with aortic cuff placement.Dynamic, cardiac-gated CTA enables time-resolved angiographic imaging of the ascending aorta and arch without any cardiac motion-related artifacts. Such advanced imaging techniques help with better characterization of endoleaks after stent graft deployment in the ascending aorta and arch.

The aim of this study was to compare the incremental prognostic value of coronary computed tomography (CT) angiography (CCTA)-derived machine learning fractional flow reserve CT (ML-FFRct) versus that of ischemia detected on single-photon emission-computed tomography (SPECT) myocardial perfusion imaging (MPI) on incident cardiovascular outcomes.SPECT MPI and ML-FFRct are noninvasive tools that can assess the hemodynamic significance of coronary atherosclerotic disease.We studied a retrospective cohort of consecutive patients who underwent clinically indicated CCTA and SPECT MPI. ML-FFRct was computed using a ML prototype. The primary outcome was all-cause mortality and nonfatal myocardial infarction (D/MI), and the secondary outcome was D/MI and unplanned revascularization, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) occurring more than 90 days postimaging. Multiple nested multivariate cox regression was used to model a scenario wherein an initial anatomical assessment was followed by a functional assessment.A total of 471 patients (mean age: 64 ± 13 year; 53% males) were included. Comorbidities were prevalent (78% hypertension, 66% diabetes, 81% dyslipidemia). ML-FFRct was 0.8 in at least 1 proximal/midsegment was present in 41.6% of patients, and ischemia on MPI was present in 13.8%. After a median follow-up of 18 months, 7% of patients (n = 33) experienced D/MI. On multivariate Cox proportional analysis, the presence of ischemia on MPI but not ML-FFRct significantly predicted D/MI (HR: 2.3; 95% CI: 1.0-5.0; P = 0.047; or HR: 0.7; 95% CI: 0.3-1.4; P = 0.306 respectively) when added to CCTA obstructive stenosis. Furthermore, the model with SPECT ischemia had higher global chi-square result and significantly improved reclassification. Results were similar using the secondary outcome and on several sensitivity analyses.In a high-risk patient cohort, SPECT MPI but not ML-FFRct adds independent and incremental prognostic information to CCTA-based anatomical assessment and clinical risk factors in predicting incident outcomes.

The paper discusses a stabilization of a finite element method for the equations of fluid motion in a time-dependent domain. After experimental convergence analysis, the method is applied to simulate a blood flow in the right ventricle of a post-surgery patient with the transposition of the great arteries disorder. The flow domain is reconstructed from a sequence of 4D CT images. The corresponding segmentation and triangulation algorithms are also addressed in brief.

A 54-year-old woman with a mechanical mitral valve replacement presented with recurrent admissions for pneumonia and pulmonary edema. Multimodality imaging revealed mobile masses on the prosthesis and discrepant point of care and inpatient international normalized ratio levels owing to antiphospholipid antibody cross-reactivity on the outpatient assay. The prosthetic valve thromboses resolved with therapeutic anticoagulation. (Level of Difficulty: Beginner.), Graphical abstract, A 54-year-old woman with a mechanical MVR presented with recurrent admissions for pneumonia and pulmonary edema. Multimodality imaging revealed…

Introduction Cardiac computed tomography angiography (CCTA) derived fractional flow reserve (FFRCT) has been shown to add incremental diagnostic value by providing functional severity of coronary lesion in patients with coronary artery disease (CAD). Purpose We aimed to assess the prognostic value of FFRCT in patients with suspected CAD. Methods Consecutive patients who had clinically indicated CCTA and FFRCT determination at a tertiary care cardiology practice were included. FFRCT was determined off-site using computational flow dynamics. Patients were followed for major adverse cardiovascular events (MACE, inclusive of all-cause death, non-fatal myocardial infarction, and late percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) 90-days after imaging test.) Results A total of 667 patients with at least Coronary Artery Disease Reporting & Data System (CAD-RADS) 2 were included. Mean age was 68±10 years, 37% were women, 73% had hypertension, 12% had diabetes and 61% had dyslipidemia. More than half (57%) of the patients had moderate (CAD-RADS 3) stenosis. FFRCT Conclusion Our results suggest that in a real-world cohort of patients with suspected CAD, FFRCT can identify patients at higher risk of incident cardiovascular outcomes. Funding Acknowledgement Type of funding sources: None.

Highlights • There are protean manifestations of cardiac involvement with COVID 19 • Hemorrhagic pericardial effusion may be the sole cardiac manifestation of COVID 19

Cardiac computed tomography angiography (CCTA) has evolved into a versatile imaging modality that can depict atherosclerosis burden, determine functional significance of a stenotic lesion, and guide the management and treatment of stable coronary artery disease.1 With newer-generation scanners, diagnostic CCTA can be obtained in the majority of patients with a very acceptable radiation dose. We discuss the ability of CCTA to provide comprehensive assessment of a patient with suspected CAD, including functional techniques of stress-rest myocardial perfusion assessment using a vasodilator and a purely post-processing approach that assesses fractional flow reserve derived by CCTA. In addition, recent data validated the role of CCTA in managing stable patients with chest pain and suspected CAD, serving as a gatekeeper for invasive coronary angiogram as well as optimizing the preprocedural planning of percutaneous coronary revascularization and coronary artery bypass surgery.

Of the 100,000-plus valve surgeries performed each year in the United States, up to 6% of those develop complications from prosthetic valve dysfunction. Prosthetic valve dysfunction (PVD) can be life threatening and often challenging to diagnose. In this review, we discuss the prevalence and incidence of PVD, explore its different etiologies, and assess the role of multimodality imaging with an emphasis on cardiac multidetector computed tomography (MDCT) for evaluating patients with PVD. We also investigate the utility of MDCT in preprocedural planning for transcatheter devices and redo surgical planning and discuss management strategies for patients with PVD.

Coronary computed tomographic angiography (CCTA) with prospective electrocardiographic gating reduces radiation exposure, but its prognostic power for predicting cardiovascular risk in patients with suspected CAD has not been fully validated. To determine whether prospective gating performs as well as retrospective gating in this population, we compared these scan modes in patients undergoing 64-slice CCTA. From January 2009 through September 2011, 1,407 patients underwent CCTA; of these, 915 (mean age, 57.8 ± 13.5 yr; 54% male) had suspected coronary artery disease at the time of CCTA and were included in the study. Prospective gating was used in 195 (21%) and retrospective gating in 720 (79%). The mean follow-up duration was 2.4 ± 0.9 years. Overall, 390 patients (42.6%) had normal results on CCTA, 382 (41.7%) had nonobstructive coronary artery disease, and 143 (15.6%) had obstructive disease. Major adverse cardiac events occurred in 32 patients (3.5%): 11 cardiac deaths, 15 late revascularizations, and 6 nonfatal myocardial infarctions. Total event occurrences were similar in both groups (retrospective, 3.8%; prospective, 2.6%; P=0.42), as were the occurrences of each type of event. On adjusted multivariate analysis, nonobstructive (P=0.015) and obstructive (P The prognostic value of CCTA with prospective electrocardiographic gating compares favorably with that of retrospective gating, and it involves significantly less radiation exposure.

Purpose: Cardiac computed tomographic angiography (CCTA) - derived measures of coronary artery disease (CAD) burden such as segment involvement score (SIS), which quantifies the number of segments with plaque, have been shown to independently predict incident cardiovascular events. We aimed to compare the added prognostic value of plaque burden to CCTA anatomic assessment and single photon emission computed tomography (SPECT) physiologic assessment in a high-risk cohort undergoing both tests.Methods: Consecutive patients who underwent clinically indicated CCTA and SPECT myocardial imaging for suspected CAD at a tertiary care cardiology practice were included. Stenosis severity and SIS were determined from CCTA, and presence of ischemia was determined from SPECT. Patients were followed for major adverse cardiovascular events (MACE, inclusive of all-cause death, non-fatal myocardial infarction, and percutaneous coronary intervention or coronary artery bypass grafting 90-days after imaging test.)Results: A total of 956 patients were included. Mean age was 61.1 ± 14.2 years, 54% were men, 89% had hypertension, 81% had diabetes, 84% had dyslipidemia and 56% had recorded chest pain. Obstructive stenosis (left main ≥ 50%, all other coronary segments ≥ 70%) and ischemia were observed in similar number of patients (14%). After a median follow-up of 31 months, 102 patients (11%, 29.2 events per 1000 person-year) experienced a MACE. In multivariable Cox regression models, SIS significantly predicted outcomes and improved risk discrimination in models with CCTA obstructive stenosis (HR 1.15 95% CI 1.09 - 1.21 p= Conclusion: Our results suggest that in high-risk patients with suspected CAD, plaque burden adds incremental prognostic value over established measures in predicting incident cardiovascular outcomes.

The purpose of this study was to determine whether stress myocardial perfusion (SPECT) optimized with stress-only (SO) imaging is comparable to cardiac CT angiography (CTA) for evaluating patients with acute chest pain (ACP).This was a prospective randomized observational study in 598 ACP patients who underwent CTA versus SPECT. The primary endpoint was length of hospital stay, and secondary endpoints were test feasibility, time to diagnosis, diagnostic accuracy, radiation exposure, and overall cost. Median follow-up was 6.5 mo, with a 3.8% cardiac event rate defined as death or an acute coronary syndrome.Of 2,994 patients screened, 1,703 (56.9%) were not candidates for CTA because of prior cardiac disease (41%) or imaging contraindications (16%). Time to diagnosis (8.1 ± 8.5 vs. 9.4 ± 7.4 h) and length of hospital stay (19.7 ± 27.8 vs. 23.5 ± 34.4 h) were significantly shorter with CTA than with SPECT (P = 0.002). However, time to diagnosis (7.0 ± 6.2 vs. 6.8 ± 5.9 h, P = 0.20), length of stay (15.5 ± 17.2 vs. 16.7 ± 15.3 h, P = 0.36), and hospital costs ($4,242 ± $3,871 vs. $4,364 ± 1781, P = 0.86) were comparable with CTA versus SO SPECT, respectively. SO was also superior to conventional SPECT regarding all of the above metrics and significantly reduced radiation exposure (5.5 ± 4.4 vs. 12.5 ± 2.7 mSv, P0.0001).Stress SPECT when optimized with SO imaging is similar to CTA in time to diagnosis, length of hospital stay, and cost, with improved prognostic accuracy and less radiation exposure. Our results emphasize the importance of SO imaging, particularly in low-intermediate-risk emergency room patients who are a population likely to have a normal test result.

Aims The long-term prognosis of angina in patients without obstructive coronary artery disease (CAD) is uncertain. To assess the incidence of long-term adverse outcomes in such patients. Methods and results We searched PubMed, Cochrane Library, the Embase database, and the Clinical Trials Registry for studies published in English until January 2017, assessing the composite primary outcome of all-cause death and non-fatal myocardial infarction using random-effects models to estimate pooled incidences. We identified 54 studies, reporting outcomes in overall 35 039 patients (mean age 56, male/female ratio 0.51, 99 770 person-years) with angina and no obstructive CAD. After a median follow-up of 5 years (interquartile range 3-7 years), the pooled incidence of the primary outcome was 0.98/100 person-years [95% confidence interval (CI) 0.77-1.19%], with considerable heterogeneity among studies (I2 = 91%, P

Paravalvular leaks (PVL) occur in 2–12% of patients after mitral valve replacement and in 1–5% after aortic valve replacement 1,2 and can cause heart failure and/or hemolytic anemia. Redo surgery h...

To investigate incidence and timing, risk factors, prognostic significance, and electrophysiological mechanisms of atrial arrhythmia (AA) after lung transplantation.Although new-onset AA is common after thoracic surgery and is associated with poorer outcomes, prognostic and mechanistic data is sparse in lung transplant populations.A total of 293 consecutive isolated lung transplant recipients without known AA were retrospectively reviewed. Mean follow-up was 28±17 months. Electrophysiology studies (EPS) were performed in 25 patients with AA.The highest incidence of new-onset AA after lung transplantation occurred within 30 days postoperative AA, (25 % of all patients). In multivariable analysis, postoperative AA was associated with double lung transplantation (OR 2.79; p=0.005) and lower mean pulmonary artery pressure (OR 0.95; p=0.027). Patients with postoperative AA had longer hospital stays (21 days vs 12 days; p0.001). Postoperative AA was independently associated with late AA (HR 13.52; p0.001) but not mortality (HR 1.55; p=0.14). In EPS, there were 14 patients with atrial flutter alone and 11 with atrial flutter and fibrillation. Of all EPS patients, 20 (80%) had multiple AA mechanisms, including peritricuspid flutter (48%), perimitral flutter (36%), right atrial incisional reentry (24%), focal tachycardia from recipient pulmonary vein (PV) antrum (32 %), focal PV fibrillation (24%), and left atrial roof flutter (20%). Left atrial mechanisms were present in 80% (20/25) of EPS patients and originated from the anastomotic PV antrum.Postoperative AA was independently associated with longer length of stay and late AA but not mortality. Pleomorphic PV antral arrhythmogenesis from native PV antrum is the main cause of AA after lung transplantation.

Objectives This prospective, observational study in 988 asymptomatic or symptomatic low-risk patients without prior coronary artery disease was conducted to define the relative value of coronary artery calcium score (CACS), exercise treadmill testing (ETT), and stress myocardial perfusion single-photon emission computed tomography (SPECT) variables in predicting long-term risk stratification. Background CACS, ETT, and stress myocardial perfusion SPECT results predict patients9 outcome. There are currently no data comparing their relative value in long-term risk stratification. Methods Patients were stratified by Framingham risk score (FRS), with a median follow-up of 6.9 years. Cardiac events were defined as a composite of cardiac death, nonfatal myocardial infarction, and the need for coronary revascularization. Most patients (87%) were considered appropriate candidates for functional testing as defined by current appropriate use criteria. Results The long-term cardiac event rate was 11.2% (1.6% per year). Multivariate risk predictors in all patients and in the appropriate use cohort were abnormal SPECT (hazard ratio [HR]: 1.83 and 1.99), ETT ischemia (HR: 1.70 and 1.76), decreasing exercise capacity (HR: 1.11 and 1.17), decreasing Duke treadmill score (HR: 1.07 for both), and CACS severity (HR: 1.29 for both), respectively. Throughout the 10-year follow-up, CACS improved risk prediction, with event rates ranging from 0.6% per year (CACS ≤10) to 3.7% per year (CACS >400) (p Conclusions CACS significantly improved long-term risk stratification beyond FRS, ETT, and SPECT results across the spectrum of clinical risk and importantly even among those who are currently considered appropriate candidates for functional testing or have low-risk functional test results. Our findings support CACS as a first-line test over ETT or SPECT for accurately assessing long-term risk in such patients.

Background: Coronary angiography (CAG) remains the gold standard to diagnose coronary artery disease (CAD). However, it is associated with multiple risks and its utility is not well defined in the liver transplant population. Alternatives to evaluate for CAD such as coronary artery calcium score (CACS) are being increasingly investigated. Hypothesis: To determine if the absence of coronary arterial calcium (CACS=0) on non-contrast, non-ECG gated chest CT scan can exclude obstructive CAD in liver transplant patients. Methods: We performed a retrospective analysis of data collected from liver transplant recipients. We included patients who had a CT chest without contrast and CAG less than one year apart. Agatston score was derived from non-IV contrast, non-ECG gated chest CT’s utilizing the syngo.via platform (Siemens Healthcare). CACS was compared against CAG. Patients with coronary stents were excluded. We determined NPV, PPV, sensitivity and specificity of using CACS = 0 as predictor of the absence of obstructive CAD. Results: Mean age at date of transplant was 59.03 and males accounted for 68.8% of our population. The negative predictive value for CACS=0 as a predictor of non-obstructive CAD was 100%. Positive predictive value for CACS≥1 was 6.8%. Sensitivity and specificity for the correlation between CACS and CAD were 100% and 33% respectively (Figure 1). CACS was stratified into four subgroups based severity, and we found that all patients with obstructive CAD had scores >400 (Figure 2). Conclusion: The absence of coronary arterial calcium (CACS=0) on non-contrast, non ECG gated chest CT has a high negative predictive value and can exclude the presence of obstructive CAD.

Background: Annual or biannual coronary angiography is recommended after heart transplantation. This is associated with radiation and contrast exposure in addition to being invasive. Absence of coronary calcium on CT in non-transplanted patients has a high negative predictive value (NPV) to rule out obstructive CAD. Objective: To determine whether the absence of coronary calcium on non-contrast, non-gated MDCT has a high NPV to rule out obstructive CAD in heart transplant recipients. Methods: We included patients with a non-contrast, non-gated chest CT within 1 year of undergoing a coronary angiogram from 2006 to 2016. Obstructive CAD was defined as stenosis >50%. Coronary artery calcium scores (CACS) were calculated by the Agatston method using the syngo.via platform (Siemens Healthcare GmbH, Germany). For analysis, CACS were categorized based on a) presence or absence of coronary calcium (i.e., CACS=0 or CACS>0) or b) severity of calcification (i.e., CACS=0, CACS 0-100 and CACS>100). Results: We reviewed 76 consecutive angiograms and corresponding CTs. Prevalence of obstructive CAD was 9.2% (n=7). Prevalence of CACS=0 was 89.5% (n=68) of which 5 had obstructive CAD presenting a NPV of 93%. 8 patients had CACS>0 of which 2 had obstructive CAD on angiogram (positive predictive value=25%). CACS was found to correlate with severity of CAD by angiography(p50% was found in 10 vessels - 5 LAD, 1 D1, 1 LCx, 2 OM branches and 1 RCA. Calculating CACS enabled detection of 1/5 LAD lesions; lesion in D1 was detected as an LAD lesion; lesions in the OM branches and RCA were not detected. Conclusion: Absence of coronary calcium on MDCT has a high NPV in ruling out obstructive CAD in heart transplant recipients. However, only 2/10 obstructive lesions on angiogram had calcification plaques detected on corresponding vessels on CT. The clinical significance of this is yet to be determined.

A 60-year-old man was referred for evaluation of progressive dyspnea and fatigue. He reports shortness of breath for the past 3 months and now experiences this symptom while walking in his house. He prefers to sleep with 2 pillows, a change for him that he felt makes him breathe better. He has diabetes mellitus and is on oral hypoglycemic medications. He is a former smoker but quit 15 years ago. He has no symptoms of chest pain, but he reports one instance of near-syncope. He has a positive family history of HF that affected his father, who was a nonsmoker. The patient is unsure whether his father had coronary artery disease (CAD). On physical examination, heart rate was regular at 85 per minute and blood pressure was 126/80 mm Hg. His respiratory rate was 22 per minute and pulse oximetry at room air was 93%. Jugular venous pressure in the upright position was 14 cm with inspiratory collapse but with systolic expansion. Carotid upstroke was not delayed. Cardiac examination revealed a downward and outward displacement of the point of maximum impulse to the sixth intercostal space at the anterior axillary line. Parasternal uplift was present, and no thrills were noted. Apical auscultation revealed a diminished intensity of S1, an S3, and a grade III/VI holosystolic murmur with radiation to the axilla. Auscultation at the second left intercostal space showed prominent P2. The liver was enlarged at 3 fingerbreadths below the costal margin with a tender edge. Lower extremity examination showed bilateral pitting pretibial edema to the knee level. Peripheral arterial pulses were intact. Laboratory findings showed serum sodium at 131 mEq/L, blood urea nitrogen at 35 mg/dL, and serum creatinine at 1.5 mg/dL. Alanine aminotransferase and aspartate aminotransferase were slightly elevated as was total bilirubin. …

A 65-year-old female with hypertension and diabetes mellitus presented with progressive dyspnea that now occurs with daily activities. The patient has orthopnea and recurrent episodes of wheezing. By examination, her body mass is 220 lbs with a heart rate of 86 bpm and blood pressure of 160/98 mm Hg. Jugular venous pressure was 12 cms, and bilateral pitting edema was noted to the knee level. Point of maximum impulse was located in the left fifth intercostal space mid-clavicular line and P2 was accentuated. Chest radiograph showed central pulmonary congestion, but there were no pulmonary infiltrates. Electrocardiogram showed sinus rhythm with voltage criteria for left ventricular (LV) hypertrophy and strain pattern. Clinical presentation is consistent with heart failure given the signs and symptoms of systemic and pulmonary congestion, although additional testing is reasonable given the presence of wheezing. There are several questions to answer pertaining to LV and right ventricular (RV) size and systolic function, LV diastolic function, left atrial (LA) volumes, pulmonary artery (PA) pressures, and ultimately given the absence of apical displacement whether this patient has heart failure with preserved ejection fraction (HFpEF) or not. In addition to symptoms, HFpEF is diagnosed in the presence of a preserved ejection fraction (EF). There are several cutoffs that have been used to define a preserved EF. Some clinical trials have taken an EF >40% to meet this definition, whereas others have used values of 45% or 50%. Recent guidelines defined preserved EF as LV EF ≥50%.1 They have also recognized that patients with an EF of 40% to 49% represent an intermediate group, which was termed HFmrEF.1 Although this classification is not accepted by all, it is still useful because therapeutic decisions and diagnostic workups depend on EF. LV volumes are usually normal, and patients may have concentric LV …

End-stage renal disease (ESRD) is a growing global health problem with major health and economic implications. Cardiovascular complication is the major cause of morbidity and mortality in this population. Clustering of traditional atherosclerotic risk factors, such as diabetes, systemic inflammation, and altered mineral metabolism, contributes to enhanced systemic atherosclerosis in patients with ESRD. Prevalence of obstructive coronary artery disease (CAD) on coronary angiography exceeds 50% in this population. Despite having extensive CAD and vascular disease, patients with ESRD often do not present with classic symptoms because of impaired exercise capacity and diabetes. Furthermore, clinical trial data are exceedingly lacking in this population, resulting in considerable clinical equipoise regarding the optimal approach to the identification and subsequent management of CAD in these patients. Traditional clinical screening tools, including conventional risk prediction models, are significantly limited in their predictive accuracy for cardiovascular events in patients with ESRD. Noninvasive cardiac stress imaging modalities, such as nuclear perfusion and echocardiography, have been shown to improve the traditional clinical model in identifying the presence of CAD. Furthermore, they add incremental prognostic information to angiographic data. Novel imaging techniques and biomarker assays hold significant promise in further improving the ability to identify and risk-stratify for CAD. This review focuses on the current understanding of the clinical risk profile of asymptomatic patients with ESRD with an emphasis on the strengths and limitations of various noninvasive cardiovascular imaging modalities, including the role of novel methods in refining risk prediction. In addition, issues and challenges pertaining to the optimal timing of initial risk assessment (“screening”) and possible repeat screening (“surveillance”) are addressed. We also summarize the current data on the approach to the patient with ESRD being evaluated for transplantation in the context of recent guidelines and position statements by various professional societies.

Obesity paradox has been described in various populations of coronary artery disease, mainly asymptomatic subjects. However, relationship between obesity and coronary artery calcification detected by cardiac CT in symptomatic patients has rarely been demonstrated. This study seeks to investigate whether the paradoxical relationship between obesity and coronary artery calcification exists in patients with acute chest pain. A final cohort of 1030 chest pain patients presenting at our emergency department who underwent coronary evaluation by multidetector cardiac CT were examined. With absent-to-mild coronary calcification (CAC score 0.002), body mass index (OR 0.945; 95% CI 0.920, 0.971; ), body weight (OR 0.987; 95% CI 0.979, 0.995; 0.001), and body surface area (OR 0.582; 95% CI 0.369, 0.920; 0.020) were inversely associated with moderate-to-severe coronary calcification (CAC score ≥ 100). This study extends the concept of obesity paradox to symptomatic patients undergoing coronary artery calcium score assessment. However, biological explanation(s) of this paradox remains unanswered.

Background: Atherosclerotic coronary artery disease (CAD) has long been shown to involve chronic low-grade subclinical inflammation. However, whether there is association between hematological indices assessed by complete blood count (CBC) and coronary atherosclerotic burden has not been well studied. Materials and Methods: Consecutive 868 patients without known CAD who presented with acute chest pain to emergency department and underwent coronary artery calcium (CAC) scoring evaluation by multi-detector cardiac computed tomography were included in our study. Clinical characteristics and CBC indices were compared among different CAC groups. Results: The cohort comprised 60% male with a mean age of 61 (SD = 14) years. Median Framingham risk of CAD was 4% (range 1-16%). Median CAC score was 0 (IQR 0-43). Higher CAC groups had significantly higher Framingham risk of CAD than lower CAC groups (P < 0.001). Among different CAC categories, there was no statistically significant difference in hemoglobin level (p 0.45), mean corpuscular volume (p 0.43), mean corpuscular hemoglobin (p 0.28), mean corpuscular hemoglobin volume (p 0.36), red cell distribution width (0.42), total white blood cell counts (p 0.291), neutrophil counts (p 0.352), lymphocyte counts (p 0.92), neutrophil to lymphocyte ratio (p 0.68), monocyte count (p 0.48), and platelet counts (p 0.25). Conclusion: Our study did not detect significant association between hematological indices assessed with CBC and coronary calcification in symptomatic patients without known CAD.

Cardiac fibromas occur in 3% of patients with nevoid basal cell carcinoma syndrome (NBCCS), an autosomal dominant disorder characterized by multiple basal cell carcinomas, intracranial dural calcifications (Figure 1A), and odontogenic keratocysts (Figure 1B-C). Early diagnosis is essential for

Revascularization of coronary chronic total occlusion (CTO) are challenging as often the vessel course is unclear. Coronary computed tomography angiography (CTA) may overcome this shortcoming. A 70 year old man with a RCA CTO (~100mm) (figure 1(a)) and an occluded bypass graft to the RCA presented