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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.

Purpose: To illustrate dynamic, time-resolved CTA (d-CTA) imaging technique in characterizing aortic endoleak type/inflow using quantitative parameters and its value in providing image guidance for targeted treatment approach. Technique: Dedicated endoleak protocol involved acquiring multiple time-resolved contrast enhanced scans using third-generation CT scanner (Somatom Force®, Siemens Healthineers). Parameters such as scan field of view (FOV), kV, number/timing of scans were customized based on patient’s body-mass-index, timing bolus, and prior imaging findings. D-CTA image datasets were evaluated qualitatively and quantitatively using time-attenuation curves (TAC) analysis after motion correction using a dedicated software ( syngo.via®, Siemens). D-CTA findings from 4 illustrative cases demonstrating type I, type II (inferior mesenteric and lumbar artery inflow), and type III endoleak were illustrated. TAC analysis with time to peak parameter enabled better characterization of endoleak type and inflow. During endoleak intervention, target vessels from d-CTA images were electronically annotated and overlaid on fluoroscopy using 2D−3D image fusion to provide image guidance for targeted treatment. Conclusion: D-CTA imaging with TAC analysis characterizes aortic endoleak type and inflow, in addition to providing image guidance for targeted endoleak treatment. Such dynamic, time-resolved imaging techniques may provide further insights into understanding aortic endoleak that remains an Achilles heel for endovascular aortic aneurysm repair.

Coronary computed tomography angiography (CCTA) derived machine learning fractional flow reserve (ML-FFRCT) can assess the hemodynamic significance of coronary artery stenoses. We aimed to assess sex differences in the association of ML-FFRCT and incident cardiovascular outcomes. We studied a retrospective cohort of consecutive patients who underwent clinically indicated CCTA and single photon emission computed tomography (SPECT). Obstructive stenosis was defined as ≥ 70% stenosis severity in non-left main vessels or ≥ 50% in the left main coronary. ML-FFRCT was computed using a machine learning algorithm with significant stenosis defined as ML-FFRCT CT CT (0.76 (0.53–0.86) vs. 0.71 (0.47–0.84); p = 0.047). In multivariable adjusted models, there was no significant association between ML-FFRCT CT was higher in women than men. There was no significant association between ML-FFRCT and incident mortality or MI and no evidence that the prognostic value of ML-FFRCT differs by sex.

In the United States, more than 80% of all abdominal aortic aneurysms are treated by endovascular aortic aneurysm repair (EVAR). The endovascular approach warrants good early results, but adequate follow-up imaging after EVAR is imperative to maintain long-term positive outcomes. Potential graft-related complications are graft migration, infection, fraction, and endoleaks, with the last one being the most common. The most frequently used imaging after EVAR is computed tomography angiography (CTA) and duplex ultrasound. Dynamic, time-resolved computed tomography angiography (d-CTA) is a reasonably new technique to characterize the endoleaks. Multiple scans are done sequentially around the endograft during acquisition that grants good visualization of the contrast passage and graft-related complications. This high diagnostic accuracy of d-CTA can be implemented into therapy via image fusion and reduce additional radiation and contrast material exposure. This protocol describes the technical aspects of this modality: patient selection, preliminary image review, d-CTA scan acquisition, image processing, qualitative and quantitative endoleak characterization. The steps of integrating dynamic CTA into intra-operative fluoroscopy using 2D-3D fusion-imaging to facilitate targeted embolization are also demonstrated. In conclusion, time-resolved, dynamic CTA is an ideal modality for endoleak characterization with additional quantitative analysis. It can reduce radiation and iodinated contrast material exposure during endoleak treatment by guiding interventions.

The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial showed no difference in outcomes between medical therapy vs coronary revascularization in the management of patients with stable coronary artery disease. We aimed to determine the percentage of patients with at least moderate ischemia that would have been eligible for enrollment and evaluate the outcomes of those who would not.Consecutive patients who underwent cardiac single-photon emission computed tomography (SPECT) between April 2016 and September 2019 were identified and all-cause mortality was determined.There were a total of 1508 patients (mean age 67 ± 11.6 years, 69.5% males) with any perfusion defect on SPECT. Patients had a high prevalence of cardiac risk factors (73.4% with hypertension and 54.4% with diabetes mellitus.) Nearly half (709, 47%) had moderate-to-severe ischemia but over two-thirds (479/709, 66.3%) had at least one ISCHEMIA trial exclusion criteria. Patients meeting ISCHEMIA enrollment criteria had a significantly lower all-cause mortality than those who would have been excluded (3.91% vs. 11.3%, respectively, P .001).Our results show that ISCHEMIA selected a relatively small subset of lower risk patients among the larger higher risk group of patients with moderate-to-severe ischemia typical to most cardiology centers.

New data suggests long term outcomes of coronary revascularization based on instantaneous wave free ratio (iFR) are equivalent to invasive fractional flow reserve (FFR). We aimed to evaluate the correlation between non-invasive FFR derived from cardiac CT (FFRData from 21 patients with 26 vessels, who underwent both FFRIn a per vessel analysis, the average diameter stenosis was 59%, mean FFRFFR

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.

Background Coronary artery calcium score (CACS) is a well-established test for risk stratifying asymptomatic patients for overall cardiovascular or coronary events. However; the prognostic value for incident stroke remains controversial. The objective of this study was to investigate the predictive value of CACS obtained by non-contrast electrocardiogram-gated computed tomography for incident stroke. Methods We searched PubMed, EMBASE, Cochrane databases for prospective longitudinal studies of CACS which reported the incidence of stroke. Incidence of stroke was compared in patients with and without coronary calcification. Results Three studies evaluated 13,262 asymptomatic patients (mean age=60years, 50% men) without apparent cardiovascular diseases. During a follow-up of 7.2years (median 5years, range 4.4–9.5years, 95,434patient-years), the overall pooled incidence of stroke was 0.26%/year. The pooled risk ratio of CACS>0 for incident stroke was 2.95 (95% CI: 2.18–4.01, p 2 =0%). The pooled incidence rate of stroke categorized by CACS was 0.12%/year for CACS 0, 0.26%/year for CACS 1–99, 0.41%/year for CACS 100–399 and 0.70%/year for CACS ≥400. Conclusions In asymptomatic patients without apparent cardiovascular diseases, the incidence of stroke was overall low. The presence and severity of coronary artery calcification were associated with incident stroke over mid-long term follow-up.

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.

The objective of this study was to examine prevalence and clinical implications of subclinical coronary artery disease (CAD) detected by coronary artery calcium score (CACS) testing in patients with atrial fibrillation (AF). CACS was assessed in patients without history of CAD undergoing catheter ablation of AF. Age- and gender-matched patients with normal sinus rhythm (NSR) presenting with chest pain served as controls. Predicted arterial age using the Multi-Ethnic Study of Atherosclerosis registry was also compared to the chronologic age. A total of 860 patients (430 AF and 430 NSR, age 63 ± 10 years, 65% men) were included. Subclinical CAD prevalence (CACS >0) was 74% (319 of 430) in the AF group. Compared to the patients with NSR, patients with AF had higher prevalence of Subclinical CAD (74% vs 63%; p

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

Purpose of review Chest pain and myocardial ischemia are common features in patients with hypertrophic cardiomyopathy (HCM). This review addresses diagnostic roles of computed tomography and nuclear stress testing (NST) in patients with HCM. Recent findings Current evidence showed the limitation of NST in the diagnosis of epicardial coronary artery stenosis due to the prevalent microvascular dysfunction. In this context, the excellent negative predictive value of coronary computed tomography angiography (CCTA) makes it very attractive to serve as a gatekeeper to invasive angiography in low-risk symptomatic patients, either as the first noninvasive imaging test of choice or after the presence of perfusion defect seen in NST. Furthermore, the identification of coronary atherosclerosis process in the absence of obstructive lesion could have impacts on the management of risk factors for coronary artery disease. We also propose an algorithm for evaluation of ischemia in HCM patients based on the recent evidence. Summary In low-intermediate-risk symptomatic patients with HCM, both NST and CCTA are acceptable diagnostic tools for the evaluation of myocardial ischemia. In the presence of nuclear perfusion defect, CCTA can be used to rule out significant epicardial stenosis. Presence of significant major epicardial artery stenosis on CCTA or high-risk patients could be considered for invasive angiography.

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.

Malfunction of a continuous-flow left ventricular assist device (CF-LVAD) due to device thrombosis is a potentially life-threatening event that currently presents a diagnostic challenge. We aimed to propose a practical echocardiographic assessment to diagnose LVAD malfunction secondary to pump thrombosis.Among 52 patients implanted with a CF-LVAD from a single center who underwent echocardiographic pump speed-change testing, 12 had suspected pump thrombosis as determined by clinical, laboratory, and/or device parameters. Comprehensive echocardiographic evaluation was performed at baseline pump speed and at each 1,000-rpm interval from the low setting of 8,000 rpm to the high setting of 11,000 rpm in 11 of these patients.Receiver operating characteristic curves and stepwise logistic regression analyses showed that the best diagnostic parameters included changes in the LV end-diastolic diameter (0.6 cm), aortic valve opening time (80 msec), and deceleration time of mitral inflow (70 msec) from lowest to highest pump speed. One parameter was predictive of pump malfunction, with 100% sensitivity and 89% specificity, whereas 2 of 3 parameters increased the sensitivity to 100% and specificity to 95%.The 3 echocardiographic variables of measured changes in LV end-diastolic diameter, aortic valve opening time, and deceleration time of mitral inflow between the lowest (8,000 rpm) and highest pump speed settings (11,000 rpm) during echo-guided pump speed-change testing appear highly accurate in diagnosing device malfunction in the setting of pump thrombosis among patients supported with CF-LVAD. Further investigation is warranted to create and validate a prediction score.

Study objective Coronary artery calcium score (CACS) is a well-established test for risk stratifying asymptomatic patients. Recent studies also indicate that CACS may accurately risk stratify stable patients presenting to the emergency department (ED) with acute chest pain; however, many were underpowered. The purpose of this systematic review and meta-analysis is to evaluate the prognostic value and accuracy of a zero (normal) CACS for identifying patients at acceptable low risk for future cardiovascular events who might be safely discharged home from the ED. Methods We searched multiple databases for longitudinal studies of CACS in symptomatic patients without known coronary artery disease that reported major adverse cardiovascular events (MACEs), including death and myocardial infarction. Pooled risk ratios, sensitivity, specificity, and likelihood ratios were analyzed. Results Eight studies evaluated 3,556 patients, with a median follow-up of 10.5 months. Pooled prevalence of zero CACS was 60%. Patients with CACS=0 had a significantly lower risk of cardiovascular events compared with those with CACS greater than 0 (MACEs: relative risk 0.06, 95% confidence interval 0.04 to 0.11, I2=0%; death/myocardial infarction: relative risk 0.19; 95% confidence interval 0.08 to 0.47, I2=0%). The pooled event rates for CACS=0 (MACEs 0.8%/year; death/myocardial infarction 0.5%/year) were significantly lower than for CACS greater than 0 (MACEs 14.6%/year; death/myocardial infarction 3.5%/year). Analysis of summary testing parameters showed a sensitivity of 96%, specificity of 60%, positive likelihood ratio of 2.36, and negative likelihood ratio of 0.07. Conclusion Acute chest pain patients without history of coronary artery disease, ischemic ECG changes, or increased cardiac enzyme levels commonly have a CACS of zero, with a very low subsequent risk of MACEs or death or myocardial infarction. This meta-analysis proffers the potential role of initial CACS testing for avoiding unnecessary hospitalization and further cardiac testing in acute chest pain patients with a CACS of zero.

Transesophageal echocardiography (TEE) is recommended for diagnosis in patients suspected of prosthetic valve dysfunction, but could be limited in its ability to identify the etiology of these dysfunctions and to assess extracardiac structures. Our objective is to examine the usefulness of multidetector computed tomography (MDCT) in establishing the etiology of the dysfunctions and its clinical utility in preoperative assessment in these patients.Twenty-two prosthetic heart valves from 20 consecutive patients who had a preoperative MDCT and underwent redo prosthetic valve procedures from December 2008 to February 2013 were examined retrospectively. Results from MDCT and TEE were compared to intraoperative findings. Extravalvular MDCT findings including coronary artery/bypass graft, high-risk features for reoperative cardiac surgery, and extracardiac findings were also assessed.MDCT correctly identified 15 valve regurgitation and seven valve obstructions compared to intraoperative findings. Both TEE and MDCT were able to correctly identify the etiologies in 93% (14/15) of regurgitant valves. However, MDCT was better able to identify the etiology of obstructive valves than TEE (86% [6/7] vs. 43% [3/7]) compared to intraoperative findings. In patients who had preoperative invasive angiography, MDCT correctly identified two patients with significant coronary artery disease (CAD) and ruled out 11 without significant CAD. Furthermore, MDCT detected five high-risk features for postoperative complications and eight clinically relevant extracardiac findings.MDCT displayed comparable or better diagnostic performance than TEE for identifying the type of dysfunction and its etiology, as well as providing additional coronary and other extravalvular evaluations useful for preoperative planning.

Advances in the field of device support have led to increased use of continuous-flow left ventricular assist devices (LVADs) to improve outcomes in patients with end-stage heart disease. Newer-generation LVADs have become the pump of choice for bridging to heart transplantation and as destination therapy for patients with contraindications to transplantation.1 Different imaging modalities have played a major role in LVAD preoperative, early postoperative, and long-term follow-up management. The primary imaging modality to monitor patients with continuous-flow LVADs is echocardiography. The present review highlights the role of echocardiography and the other imaging modalities in the assessment of ventricular size and function, intracardiac hemodynamics, and myocardial recovery of patients with continuous-flow LVADs. The evolving role of echocardiography in facilitating the identification of optimal pump speed settings in patients supported by continuous-flow LVADs will be discussed, along with a summary of the protocol we use for image acquisition and reporting. Furthermore, we will provide a summary of echocardiographic findings associated with continuous-flow LVAD-related complications and device dysfunction. Second-generation continuous-flow LVAD rotary pumps offer several advantages over pulsatile first-generation pumps, including smaller size and, importantly, greater long-term mechanical reliability. The different types of continuous-flow LVADs and device characteristics, including pump speeds, are listed in Table 1. The rotating impeller within the pump generates either axial flow (blood flow parallel to the impeller axis) or centrifugal flow (blood flow at a right angle to the impeller axis) from the left ventricular (LV) apex, through the device, to the ascending aorta. The HeartMate II (HM II; Thoratec Corp, Pleasanton, CA) is the only continuous-flow pump approved by the US Food and Drug Administration to act as a bridge to cardiac transplantation and as destination therapy. Operating speeds for this device are between 6000 and 15 000 revolutions per minute (rpm), which clinically translates …

Background— 3D stereolithographic printing can be used to convert high-resolution computed tomography images into life-size physical models. We sought to apply 3D printing technologies to develop patient-specific models of the anatomic and functional characteristics of severe aortic valve stenosis. Methods and Results— Eight patient-specific models of severe aortic stenosis (6 tricuspid and 2 bicuspid) were created using dual-material fused 3D printing. Tissue types were identified and segmented from clinical computed tomography image data. A rigid material was used for printing calcific regions, and a rubber-like material was used for soft tissue structures of the outflow tract, aortic root, and noncalcified valve cusps. Each model was evaluated for its geometric valve orifice area, echocardiographic image quality, and aortic stenosis severity by Doppler and Gorlin methods under 7 different in vitro stroke volume conditions. Fused multimaterial 3D printed models replicated the focal calcific structures of aortic stenosis. Doppler-derived measures of peak and mean transvalvular gradient correlated well with reference standard pressure catheters across a range of flow conditions ( r =0.988 and r =0.978 respectively, P r =0.985, P P =0.002). Conclusions— By combing the technologies of high-spatial resolution computed tomography, computer-aided design software, and fused dual-material 3D printing, we demonstrate that patient-specific models can replicate both the anatomic and functional properties of severe degenerative aortic valve stenosis.

To prospectively assess the clinical value of stress-gated myocardial single photon emission computed tomography (SPECT) for triaging patients admitted through the emergency department (ED) with acute chest pain (ACP).Prospective, observational cohort study in 1,576 consecutive patients who were evaluated for ACP over a 29-month period. Stress SPECT was performed within 24 hours of admission from the ED. Analysis included quantification of total and ischemic left ventricular perfusion defect size (PDS). Cardiac events were defined as an acute coronary syndrome during the index hospitalization or in follow-up over 7.3 ± 2.8 months.Eighty-five cardiac events occurred in 77 patients (4.9%). SPECT was abnormal in 135 patients (8.6%) of whom 83 (61.5%) had a reversible defect. Event rates were significantly higher in patients with an abnormal (40%) versus a normal (1.6%) SPECT (P.0001); and in those with a (1) large (15%) versus small (≤15%) PDS (50.0% vs 33.7%, P = .05) and (2) large (10%) versus small (≤10%) ischemic PDS (87.5% vs 42.4%, P.0001, respectively). SPECT best predicted cardiac events by multivariate analysis. The addition of SPECT to clinical variables significantly improved overall risk prediction (global χ(2) 103.6 vs 207.1, P.001).Stress SPECT can accurately assess risk in a heterogeneous group of patients with ACP of unclear cardiac etiology, and beyond that provided by a clinical risk assessment alone. Our results support the use of stress SPECT for identifying very low-risk ACP patients with normal study results who can be safely discharged home.

Purpose of review Significant limitations exist for traditional noninvasive cardiac imaging with regard to equivocal or indeterminate findings that result in repetitive testing or unnecessary referral to invasive coronary angiography (ICA). Recent hardware and software advances in multislice computed tomography angiography have achieved high spatial and temporal resolution to allow accurate noninvasive assessment of coronary arteries. This poses a paradigm shift in management of patients with suspected coronary artery disease (CAD). Recent findings Multicenter studies showed that coronary computed tomography angiography (CCTA) has a very high diagnostic accuracy, and, in particular, a very high negative predictive value (>98%) in detecting coronary stenosis when compared with ICA. In addition to its diagnostic ability, recent evidence-based outcome data have also validated the value of CCTA in predicting cardiac events. Absence of CAD on CCTA conveys excellent prognosis, whereas increasing disease severity and extent are associated with worsening outcome. Furthermore, CCTA allows comprehensive assessment of coronary stenosis, plaque burden, left ventricular morphology, function, perfusion and viability. One concern with CCTA is the issue of ionizing radiation exposure. Recent technical progress allows dramatic reduction of radiation dose. The newest generation scanner is capable of producing CCTA of diagnostic quality with a dose of less than 1 mSv. A multisociety guideline for appropriate clinical indications for cardiac computed tomography was recently published. Summary When used appropriately, CCTA has been established as a valid noninvasive imaging alternative to ICA in selected patients at low to intermediate risk of CAD.

ObjectivesThe aim of this study was to evaluate the impact of renal function by estimated glomerular filtration rate (eGFR) on risk stratification of diabetic and nondiabetic patients undergoing myocardial perfusion imaging (MPI) by single-photon emission computed tomography for suspected ischemia.BackgroundCoronary artery disease is the leading cause of death among diabetic persons; however, diabetic persons are a very heterogeneous group in terms of cardiovascular risk, necessitating further risk stratification.MethodsPatients (n = 1,747, age 65 ± 10 years, 37% diabetic) undergoing MPI were followed for cardiac death (CD) for a mean of 2.15 ± 0.8 years. Chronic kidney disease (CKD) was defined by an eGFR

Aims It is unknown whether there is an interaction between aspirin and angiotensin receptor blockers on outcomes in patients with heart failure (HF). Methods and results The efficacy and safety of candesartan vs. placebo was assessed in 7599 patients with symptomatic HF and reduced or preserved left ventricular ejection fraction enrolled in the CHARM programme according to baseline aspirin use. Patients were randomized to candesartan or matching placebo and were followed for a median of 38 months. Aspirin was used in 4246 (55.9%) of patients at baseline. When compared with placebo, candesartan use was associated with lower event rates for cardiovascular (CV) death or HF hospitalization (primary outcome) in both the aspirin group (28 vs. 31.9%, HR 0.81, 95% CI 0.72–0.90) and non-aspirin group (33 vs. 38%, HR 0.81, 95% CI 0.72–0.91). Baseline aspirin use did not modify the effectiveness of candesartan in reducing the risk of CV death or HF hospitalization in CHARM overall (P = 0.64) or in the CHARM individual trials. In addition, there was no significant interaction between aspirin therapy and candesartan in terms of discontinuation of study drug due to adverse reactions (P = 0.72). Conclusion There appears to be no significant modification of the benefit of candesartan on CV mortality and morbidity outcomes or safety by concomitant use of aspirin in patients with chronic HF.

The aim was to evaluate the safety of stress echocardiography using contrast (CE) for endocardial enhancement compared with a noncontrast (NCE) cohort in a large nonselect population. The recent Food and Drug Administration warning cited lack of data for safety regarding the use of contrast in conjunction with stress echocardiography. A detailed record review was performed for 5,069 consecutive patients who underwent stress echocardiography (58% pharmacologic, 42% exercise) during an 8-year period. Contrast use, hemodynamics, and adverse clinical and electrocardiographic events were evaluated until time of discharge from the laboratory. Contrast was administered to 2,914 patients (58%) and was higher in in-patients (66%) and during dobutamine stress (67%). Compared with the NCE group, the CE group was older (median age 61 vs 58 years) and had more depressed left ventricular ejection fraction

A 54-year-old man with a history of coronary artery bypass grafting (CABG) presented with chest pain and was found to have non—ST-segment elevation myocardial infarction. Left heart catheterization with coronary angiography demonstrated 100% occlusion of the right internal mammary artery (IMA) to the right coronary artery graft in its midsegment and a patent left IMA to the left anterior descending graft. An unusually large extensive fistulous collateral formation was observed between the right IMA and the left IMA to the pulmonary arterial system, causing left to right shunting. His angina was attributed to substantial coronary steal caused by the shunt. The patient refused any further intervention or surgery and opted for medical treatment. As a complication of CABG, IMA to pulmonary artery (PA) fistulas are rare. Thus far, more than 20 cases have been reported; most have been unilateral. This is the second reported case to date of bilateral IMA-PA fistula formation after CABG. An IMA-PA fistula should be considered in the differential diagnosis of patients presenting with chest pain after CABG and can be diagnosed by selective angiography of IMA grafts.

Background and Purpose— Although a great deal of literature has been generated regarding left ventricular wall abnormalities, ECG changes and cardiac enzyme leaks associated with subarachnoid hemorrhage (SAH), there have been only a few reports of true transient left ventricular apical ballooning syndrome in patients with SAH. Several pathophysiological mechanisms have been proposed to explain the unusual features of this syndrome, such as multivessel coronary vasospasm, abnormalities in coronary microvascular function, and catecholamine-mediated cardiotoxicity. Summary of Case— A previously healthy 64-year-old woman with no history of vascular disease was found unresponsive at home. She was taken to the emergency room where a CT head revealed an SAH due to a ruptured aneurysm of the posterior communicating artery. On admission, an ECG showed deeply inverted T-waves and QT prolongation, typical of SAH. Cardiac troponin was measured at 1.2 ng/mL, and later increased to 3.7 ng/mL. A transthoracic echocardiogram on the next day revealed a large left ventricular wall abnormality, characteristic of apical ballooning with an ejection fraction of 25% to 30%. The patient remained hemodynamically stable and was started on low dose β-blocker and angiotensin-converting enzyme inhibitor. She had an uneventful cardiac recovery within 5 days at which time a repeat transthoracic echocardiogram revealed a normal ejection fraction with no wall motion abnormality. Conclusions— This report adds to the growing list of “stressors” for Takotsubo cardiomyopathy. Clinicians should be aware of the existence and the typical clinical manifestations of this syndrome, which is increasingly recognized in various populations. In particular, neurologists should consider this syndrome in the differential diagnosis of ECG changes and apical wall motion abnormalities in patients with SAH. Prognosis is generally very good with full recovery in most patients; however, there may be increased morbidity associated in patients with SAH.

Persistent left superior vena cava (PLSVC) is a very rare and yet the most commonly described thoracic venous anomaly in medical literature. It has a 10-fold higher incidence with congenital heart disease. PLSVC often becomes apparent when an unknown PLSVC is incidentally discovered during central venous line placement, intracardiac electrode/pacemaker placement or cardiopulmonary bypass, where it may cause technical difficulties and life-threatening complications. PLSVC is also associated with disturbances of cardiac impulse formation and conduction including varying degrees of heart blocks, supraventricular arrhythmias and Wolff Parkinson White syndrome. We describe the case of an 86-year-old male with a history of coronary artery disease and chronic atrial fibrillation who presented with worsening dyspnea and syncopal episodes. An ECG was consistent with complete heart block. During lead placement for the pacemaker, a left subclavian approach was unsuccessful. A left venogram was performed through the brachial vein that demonstrated a left superior vena cava. The diagnosis was confirmed with echocardiography using a bubble study and also a chest CT. The anatomy was unique as there was anomalous left hepatic vein drainage into the right atrium. The case provides insight into the diagnostic modalities and clinical considerations of this unusual thoracic venous anomaly.

Aim Diastolic dysfunction is a common problem in patients with obesity, hypertension, diabetes, or coronary artery disease. The purpose of this study was to evaluate the association of left ventricular diastolic dysfunction with an abnormal coronary artery calcium score (CAC score). Methods This study considered a cohort of patients ≥ 18 years of age with normal ejection fraction who were admitted to the hospital with chest pain. All patients underwent regadenoson myocardial perfusion stress imaging and had no evidence of ischemia or infarction. Patients then underwent cardiac CT for measurement of CAC score. Patients were excluded if they had prior history of coronary artery disease, ECG findings diagnostic of an acute coronary syndrome, an elevated troponin level, or hemodynamic instability. Results A total of 114 patients were included and 52 (45.6%) patients had echocardiographic evidence of diastolic dysfunction. Patients with diastolic dysfunction were more likely to have an abnormal calcium score (79.6% vs 20%; OR 15.10, 95% CI 5.70 to 43.85; p ＜ 0.001). In multivariable analysis, the presence of diastolic dysfunction on echocardiogram was significantly associated with an abnormal calcium score (OR 13.82, 95% CI 5.57 to 37.37; p ＜ 0.001) after adjusting for Framingham Risk Score or clinical risk factors (age, gender, diabetes mellitus, dyslipidemia, and obesity; OR 19.06,95% CI 4.66 to 107.97; p ＜ 0.001). Conclusions Our study demonstrates that left ventricular diastolic dysfunction is associated with an abnormal CAC score even after adjusting for Framingham Risk Score or clinical risk factors. Patients without known coronary artery disease that present with chest pain and have normal perfusion imaging with evidence of abnormal diastolic function on echocardiogram may warrant more thorough evaluation for coronary atherosclerotic disease with CAC score assessment.

Transcatheter mitral valve-in-valve implantation (TMVIV) is an option for patients with mitral prosthetic valve dysfunction who are at high risk for surgical valve replacement. Efficacy and safety of TMVIV is at its infancy. We report a high-risk symptomatic dialysis-dependent end-stage renal disease patient with severe bioprosthetic mitral valve stenosis who had TMVIV performed successfully.

Long-term incremental prognostic value of renal function over coronary artery calcium score (CACS) in symptomatic patients without known coronary artery disease (CAD) is unclear. The objective of this study was to examine additive prognostic value of renal function over CACS in patients with acute chest pain suspected of CAD. Renal function and CACS were assessed in patients without known CAD who presented to the emergency department with chest pain from 2005 to 2008. Renal function was assessed using estimated glomerular filtration rate (eGFR), and chronic kidney disease (CKD) was defined as eGFR60 mL/min/1.73 m(2). A total of 949 patients (804 non-CKD and 145 CKD, age 54 ± 13 years) were included. During the follow-up period of up to 5.3 years, major adverse cardiac events (MACE) occurred in 5.7% of patients (19 cardiac deaths, 6 myocardial infarction and 29 late coronary revascularization). Annualized MACE rate was higher in patients in higher CACS categories with and without CKD (p = 0.011 and p0.001 respectively). In multivariate logistic regression analysis, CACS categories (CACS 1-100: HR 3.17, p = 0.005; CACS 101-400: HR 7.68, p0.001; CACS400: HR 8.88, p0.001) and CKD (HR 10.18, p0.001) were independent predictors for MACE. Both adding renal function and CACS significantly improved the overall predictive performance (p0.001 for global Chi square increase) from Framingham risk categories or thrombolysis in myocardial infarction (TIMI) risk score. Both CACS and renal function were independent predictors for future cardiac events and provided additive prognostic value to each other and over either Framingham risk categories or TIMI risk score.

Correlacionar los parametros del ventriculo izquierdo obtenidos con la tomografia computarizada volumetrica (TCV) de 64 cortes con el estandar de referencia, la resonancia magnetica cardiaca (RMC). Metodos: Se uso una TCV de 64 cortes y una RMC de 3.0 Teslas. Ambos estudios fueron interpretados de manera independiente por dos cardiologos. Los datos se analizaron con la prueba t de Student y una correlacion lineal, resultando significativo valores de P < 0.05. Resultados: Treinta pacientes consecutivos fueron evaluados con TCV y RMC. Los indices del ventriculo izquierdo mediante RMC y TCV fueron, respectivamente, masa 86.4 ± 25.8 vs. 82.7 ± 27.6 g (P = 0.31); volumen telesistolico 45.5 ± 27.8 vs. 48.7 ± 40.4 ml (P = 0.405); volumen telediastolico 101.3 ± 32.7 vs. 105.1 ± 44.0 ml (P = 0.475); volumen latido 55.9 ± 16.1 vs. 56.8 ± 15.6 ml (P = 0.713); fraccion de eyeccion de ventriculo izquierdo 57.5 ± 13.2% vs. 56.9 ± 12.4% (P = 0.630). No hubo diferencias entre la variabilidad intraobservador para ambos metodos, CT r = 0.96 r2= 0.92 P < 0.0001 y MR r = 0.96 r2r = 0.93, P < 0.0001. No se encontraron diferencias significativas en la presencia de artefactos. Conclusion: Hay correlacion estrecha entre RMC y TCV en la evaluacion de la funcion ventricular. La TCV es tan util como la RMC y pudiera incorporarse como otro recurso para valorar la funcion ventricular

Nuclear cardiac imaging is acknowledged as a robust technique for clinically assessing patients with a wide spectrum of cardiac illnesses. Recent technical, radiotracer, and stressor advancements continue to expand the role of nuclear cardiology for the accurate diagnosis and prognostication of patients with known or suspected coronary artery disease. The introduction of I-123 MIBG represents another advance for assessing risk in patients with congestive heart failure and depressed left ventricular (LV) function. Software and hardware innovations and recent shifts in acquisition protocols have greatly improved image quality, reduced cost and radiation exposure, and continue to promote patient and physician satisfaction. The following article will highlight recent achievements in the field that continue to foster a patient-centered imaging approach.

The objective of this study was to examine the additive prognostic performance of coronary artery calcium score (CACS) over coronary computed tomography angiography (CCTA) stenosis assessment in symptomatic patients suspected for coronary artery disease (CAD) undergoing CCTA. A total of 805 symptomatic patients without known history of CAD who underwent coronary evaluation by multidetector cardiac CT were analyzed. Mean age of the cohort was 58 ± 13 years. A total of 44% (354 of 805) of the patients had a 0 CACS, 27% (215 of 805) had CACS 1 to 100, 14% (111 of 805) had CACS 101 to 400, and 15% (125 of 805) had CACS400. CCTA showed normal coronary arteries in 43% (349 of 805) of patients, ≤50% stenosis in 42% (333 of 805), and50% stenosis in 15% (123 of 805). Patients were followed for 2.3 ± 0.9 years. Major adverse cardiac event (MACE) was defined as cardiac death, nonfatal myocardial infarction, and late coronary revascularization. Overall incidence of MACE was 1.4% per year. Both CACS and CCTA stenosis were independently associated with increased MACE (p0.05 for both). Addition of CACS into the model with clinical risk factors and CCTA stenosis significantly improved predictive performance for MACE from the model with clinical risk factors and CCTA stenosis only (global chi-square score 108 vs 70; p = 0.019). In conclusion; in symptomatic patients without known CAD, both CACS and CCTA stenosis were independently associated with increased cardiac events, and performing non-contrast-enhanced CACS evaluation in addition to contrast-enhanced CCTA improved predictive ability for future cardiac events compared to CCTA stenosis assessment alone.

Myocardial ischemia leads to changes in regional wall stress. Induction of ischemia during a treadmill exercise, although brief, may lead to transient elevation in the plasma level of B-type natriuretic peptide (BNP) from baseline levels, which could serve as a biochemical marker of myocardial ischemia.Sixty subjects (mean age 57, 41 men) undergoing myocardial single-photon emission computed tomography (SPECT) in conjunction with Bruce protocol treadmill exercise for evaluation of chest pain or screening for ischemia had their BNPs measured (Triage Biosite Test) at baseline, immediately postexercise, and 10 to 15 minutes after exercise.Of the 60 patients, 10 had ischemic perfusion defects by SPECT (mean 14%, range 5%-37%). In patients with no evidence of ischemia, median BNP level at baseline was 15.05 pg/mL (interquartile range 7-37.7), increased significantly immediately postexercise median level (34.7 pg/mL [14.9-67.6]), and decreased toward baseline levels within 10 to 15 minutes postexercise (20.3 pg/mL [8.6-48.5], analysis of variance P.001). This transient rise in BNP level during exercise was also observed in patients with ischemia but was more pronounced. Percent change in BNP level from baseline for each minute of exercise was significantly higher in patients with evidence of ischemia compared with those without (14% +/- SEM 2.3 vs 7% +/- SEM 1.2, P = .014). Patients with and without ischemia did not differ in age, exercise time, peak systolic or diastolic blood pressure, peak heart rate, or other baseline characteristics. A10% change in BNP level from rest per minute of exercise had a sensitivity of 80%, a specificity of 71%, and a negative predictive value of 92% to detect reversible ischemia by SPECT.Transient elevation in BNP occurs during treadmill exercise and is more pronounced in patients with ischemia. B-type natriuretic peptides may therefore be used in combination with treadmill exercise for the evaluation of coronary artery disease.

Background— Alcohol septal ablation (ASA) therapy results in clinical and hemodynamic improvement in patients with hypertrophic obstructive cardiomyopathy. However, a subset remains symptomatic afterward, requiring additional procedures. We sought to examine the determinants of an unsatisfactory outcome, defined as unchanged symptoms with Methods and Results— Of 173 consecutive hypertrophic obstructive cardiomyopathy patients who underwent ASA, 39 had an unsatisfactory outcome after the first procedure. Patients with an unsatisfactory outcome had a higher baseline LVOT gradient, fewer septal arteries injected with ethanol, lower peak creatine kinase (CK), smaller septal area opacified by contrast echocardiography, and higher residual gradient in the catheterization laboratory after ASA (all P P =0.01) and peak CK P =0.04) were the independent predictors of an unsatisfactory outcome. Conclusions— The residual LVOT gradient in the catheterization laboratory and peak CK leak after ASA are the independent predictors of ASA outcome.

Primary and secondary prevention with statins reduce major cardiac events in patients with coronary artery disease. The impact of pretreatment with statins prior to percutaneous coronary intervention (PCI) is not well established. The objective of this study was to determine if pretreatment with statins prior to PCI reduce myonecrosis and improve clinical outcome. One hundred nineteen consecutive patients with acute coronary syndrome who underwent PCI were identified. We compared the incidence of myonecrosis defined as peak elevation of CK-MB or CK three time above upper limit of normal within 24 hr and the 6-month cardiovascular event rate (death, nonfatal myocardial infarction unrelated to PCI, target vessels revascularization, and unstable angina requiring hospitalization) among patients who received statins prior to PCI (n = 63) to those who did not (n = 56). Pretreated patients were more likely to have history of myocardial infarction or revascularization (63% vs. 43%; P = 0.015), hyperlipidemia (80% vs. 48%; P = 0.001), hypertension (83% vs. 49%; P = 0.02), and use of angiotensin-converting enzyme inhibitor (62% vs. 38%; P = 0.008). The rest of baseline characteristics were similar between the two groups, including use of glycoprotein IIb/IIIa inhibitors, number of diseased vessels, and type of lesions. Patients pretreated with statins had a significantly lower incidence of myonecrosis (2% vs. 10%; P = 0.04) at 24 hr and a significantly lower clinical event (CE) rate at 6 months (17% vs. 21%; P = 0.015). Of patients not pretreated with statins, 72% were taking statins at 6 months as compared to 98% of pretreated patients. After adjusting for all baseline characteristics, use of statins prior to PCI was associated with a marked decrease in risk of all CEs (OR = 0.2; CI = 0.06-0.63; P = 0.006). Statin therapy prior to PCI may reduces peri-PCI myonecrosis and late cardiac events. These results need to be confirmed in large prospective randomized trials.

Objectives The purpose of this paper is to examine the incidence and determinants of permanent complete heart block (CHB) after nonsurgical septal reduction therapy (NSRT), and to evaluate the clinical impact of permanent pacemaker (PPM) placement. Background Nonsurgical septal reduction therapy with ethanol improves the clinical and hemodynamic parameters in patients with symptomatic hypertrophic obstructive cardiomyopathy. Complete heart block is a common complication after NSRT. Methods The database of 261 consecutive patients who underwent NSRT at Baylor College of Medicine was reviewed. Clinical variables that were considered as possible determinants for CHB after NSRT were: age, gender, New York Heart Association (NYHA) functional class, left ventricular outflow tract (LVOT) gradient at rest or with provocation, septal thickness, and baseline exercise duration. For electrocardiographic (ECG) variables, the presence of first-degree atrioventricular (AV) block, bifascicular block, left bundle branch block, atrial fibrillation, and left ventricular hypertrophy were analyzed. In addition, the volume of ethanol injected, the method of administration of ethanol (i.e., bolus vs. slow injection [over 30 to 60 s]), number of septal arteries occluded, use of myocardial echocardiography, and infarct size as determined by peak creatine kinase level. Results Of 261 consecutive patients, 37 had PPM or automatic implantable cardiac defibrillator placed before NSRT. Of the remaining 224 patients, 31 (14%) developed CHB after the procedure. Multivariate logistic regression analysis showed that female gender (odds ratio [OR] 4.3; p = 0.02), bolus injection of ethanol (OR 51; p = 0.004), injecting more than one septal artery (OR 4.6; p = 0.016), the presence of left bundle branch block (OR 39; p = 0.002), and first-degree AV block (OR 14; p = 0.001) on the baseline ECG are independent predictors of CHB after NSRT. Patients requiring PPM placement had a similar improvement in their NYHA functional class, septal thickness reduction, LVOT gradient reduction, and improvement of exercise capacity when compared with patients who did not require pacing. Conclusions Multiple demographic, electrocardiographic, and technical factors seem to increase the risk of CHB after NSRT. Patients with CHB after NSRT derive similar clinical and hemodynamic benefit to patients who did not require permanent pacing.

Transcoronary ethanol septal ablation (TESA) is a novel treatment for obstructive hypertrophic cardiomyopathy (HOCM). Our objective was to evaluate the use of gated single photon emission computed tomography (SPECT) in patients with HOCM and the effects of TESA on myocardial perfusion.We performed gated SPECT and Doppler echocardiography before and 6 weeks after TESA in 30 patients with severe HOCM. The lung-to-heart and septal-to-lateral wall count-activity ratios were calculated. Before ablation, SPECT showed perfusion abnormalities in only 6 patients. Asymmetric septal hypertrophy was noted in 21 patients (70%). In patients with a lung-to-heart ratio greater than 0.50 before ablation, the ratio decreased from 0.56 +/- 0.04 to 0.45 +/- 0.08 after ablation (P.01). The septal-to-lateral wall ratio also decreased significantly after ablation. Mean Doppler pressure gradient across the left ventricular outflow tract decreased from 52 +/- 39 mm Hg to 13 +/- 13 mm Hg (P.01) immediately after ablation and to 10 +/- 21 mm Hg 6 weeks later (P.01). There were no significant changes in left ventricular ejection fraction by gated SPECT after the procedure. SPECT studies done after ablation showed fixed septal defects in 29 of 30 patients (96.7%). The defects involved the basal and mid septum in 100% and 38% of patients, respectively, and ranged in size from 2% to 30% of the left ventricle (mean, 8.8% +/- 7.0%).TESA is an effective technique for relieving left ventricular outflow obstruction in patients with HOCM. Myocardial gated SPECT can identify the presence and location of infarction after TESA.

Coronary artery fistulae are rare abnormalities of the coronary arteries that are usually discovered incidentally on coronary angiogram. Most patients remain asymptomatic, and significant hemodynamic consequences are rarely observed. The following report describes the case of a patient presenting with symptoms of congestive cardiac failure due to multiple coronary artery fistulae.

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.CACS, ETT, and stress myocardial perfusion SPECT results predict patients' outcome. There are currently no data comparing their relative value in long-term risk stratification.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.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 (CACS400) (p 0.0001). CACS also improved risk prediction in all patients, in the appropriate use cohort and among those with low-risk ETT and SPECT results (all, p 0.001). Area under the receiver-operating characteristic curve was increased when CACS variables (from 0.63 to 0.70; p = 0.01) but not ETT variables (from 0.63 to 0.65) were added to FRS. Moreover, net reclassification improvement was significantly increased when CACS was added to FRS + functional variables in all patients and in the appropriate use cohort (both, p 0.0001).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.