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Cardiac computed tomography (CCT) has rapidly evolved, becoming a powerful integrated tool for the evaluation of coronary artery disease (CAD), and being superior to other noninvasive methods due to its high accuracy and ability to simultaneously assess both lumen stenosis and atherosclerotic plaque burden. Furthermore, CCT is regarded as an effective gatekeeper for coronary angiography, and carries independent important prognostic information. In the last decade, the introduction of new functional CCT applications, namely CCT perfusion (CCTP) imaging and CT-derived fractional flow reserve (FFR CTA ), has opened the door for accurate assessment of the haemodynamic significance of stenoses. These new CCT technologies, thus, share the unique advantage of assessing both myocardial ischemia and patient-specific coronary artery anatomy, providing an integrated anatomical/functional analysis. In the present review, starting from the pathophysiology of myocardial ischemia, we evaluate the existing evidence for functional CCT imaging and its value in relation to alternative, well-established, non-invasive imaging modalities and invasive indices of ischemia (currently the gold-standard). The knowledge of clinical applications, benefits, and limitations of these new CCT technologies will allow efficient and optimal use in clinical practice in the near future., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/cdt-20-414). The series “Clinical Impact of Cardiac CT in Clinical Practice” was commissioned by the editorial office without any funding or sponsorship. AIS reports grants from FORTH during the conduct of the study. FC serves as an unpaid editorial board member of Cardiovascular Diagnosis and Therapy from Jul 2019 to Jun 2021. FC served as the unpaid Guest Editors of the series. The other authors have no other conflicts of interest to declare., (2020 Cardiovascular Diagnosis and Therapy. All rights reserved.)

The normal and pathological anatomy of the heart and coronary arteries are nowadays widely developed topics and constitute a fundamental part of the cultural background of the radiologist. The introduction of cardiac ECG-gated synchronized CT scanners with an ever-increasing number of detectors and with increasingly high structural characteristics (increase in temporal resolution, increase in contrast resolution with dual-source, dual energy scanners) allows the virtual measurement of anatomical in vivo structures complying with heart rate with submillimetric precision permitting to clearly depict the normal anatomy and follow the pathologic temporal evolution. Accordingly to these considerations, cardiac computed tomography angiography (CCTA) asserts itself as a gold standard method for the anatomical evaluation of the heart and permits to evaluate, verify, measure and characterize structural pathological alterations of both congenital and acquired degenerative diseases. Accordingly, CCTA is increasingly used as a prognostic model capable of modifying the outcome of diseased patients in planning interventions and in the post-surgical/interventional follow-up. The profound knowledge of cardiac anatomy and function through highly detailed CCTA analysis is required to perform an efficient and optimal use in real-world clinical practice., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/cdt-20-530). The series “Clinical Impact of Cardiac CT in Clinical Practice” was commissioned by the editorial office without any funding or sponsorship. FC served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Cardiovascular Diagnosis and Therapy from Jul 2019 to Jun 2021. All authors declares that they have never received payment or services from a third party for any aspect of the submitted work, that they didn’t have financial relationships with entities during the 36 months prior to publication, they do not have any patents, whether planned, pending or issued, broadly relevant to the work, that no other relationships/conditions/circumstances are present a potential conflict of interest are present., (2020 Cardiovascular Diagnosis and Therapy. All rights reserved.)

In the past decades, coronary computed tomography angiography (CCTA) has become a powerful tool in the management of coronary artery disease. The diagnostic and prognostic value of CCTA has been extensively demonstrated in both large observational studies and clinical trials among stable chest pain patients. The quantification of coronary artery calcium score (CACS) is a well-established predictor of cardiovascular morbidity and mortality in asymptomatic subjects. Besides CACS, the main strength of CCTA is the accurate assessment of the individual total atherosclerotic plaque burden, which holds important prognostic information. In addition, CCTA, by providing detailed information on coronary plaque morphology and composition with identification of specific high-risk plaque features, may further improve the risk stratification beyond the assessment of coronary stenosis. The development of new CCTA applications, such as stress myocardial CT perfusion and computational fluids dynamic applied to standard CCTA to derive CT-based fractional flow reserve (FFR) values have shown promising results to guide revascularization, potentially improving clinical outcomes in stable chest pain patients. In this review, starting from the role of CACS and moving beyond coronary stenosis, we evaluate the existing evidence of the prognostic effectiveness of the CCTA strategy in real-world clinical practice.

The past two decades have witnessed rapid and remarkable technical improvement of multidetector computed tomography (CT) in both image quality and diagnostic accuracy. These improvements include higher temporal resolution, high-definition and wider detectors, the introduction of dual-source and dual-energy scanners, and advanced postprocessing. Current new generation multidetector row (≥64 slices) CT systems allow an accurate and reliable assessment of both coronary epicardial stenosis and myocardial CT perfusion (CTP) imaging at rest and during pharmacologic stress in the same examination. This novel application makes CT the unique noninvasive "one-stop-shop" method for a comprehensive assessment of both anatomical coronary atherosclerosis and its physiological consequences. Myocardial CTP imaging can be performed with different approaches such as static arterial first-pass imaging, and dynamic CTP imaging, with their own advantages and disadvantages. Static CTP can be performed using single-energy or dual-energy CT, employing qualitative or semiquantitative analysis. In addition, dynamic CTP can obtain quantitative data of myocardial blood flow and coronary flow reserve. The purpose of this review was to summarize all available evidence about the emerging role of myocardial CTP to identify ischemia-associated lesions, focusing on technical considerations, clinical applications, strengths, limitations, and the more promising future fields of interest in the broad spectra of ischemic heart disease.

Objective: To investigate the influence of different CT reconstruction parameters on coronary artery calcium scoring (CACS) values and reclassification of predicted cardiovascular (CV) risk., Methods: CACS was evaluated in 113 patients undergoing ECG-gated 64-slice CT. Reference CACS protocol included standard kernel filter (B35f) with slice thickness/increment of 3/1.5 mm, and field-of-view (FOV) of 150-180 mm. Influence of different image reconstruction algorithms (reconstructed slice thickness/increment 2.0/1.0-1.5/0.8-3.0/2.0-3.0/3.0 mm; slice kernel B30f-B45f; FOV 200-250 mm) on Agatston score was assessed by Bland-Altman plots and concordance correlation coefficient (CCC) analysis. Classification of CV risk was based on the Mayo Clinic classification., Results: Different CACS reconstruction parameters showed overall good accuracy and precision when compared with reference protocol. Protocols with larger FOV, thinner slices and sharper kernels were associated with significant CV risk reclassification. Use of kernel B45f showed a moderate positive correlation with reference CACS protocol (Agatston CCC = 0.67), and yielded significantly higher CACS values (p < .05). Reconstruction parameters using B30f or B45f kernels, 250 mm FOV, or slice thickness/increment of 2.0/1.0 mm or 1.5/0.8 mm, were associated with significant reclassification of CV risk (p < .05)., Conclusions: Kernel, FOV, slice thickness and increment are major determinants of accuracy and precision of CACS measurement. Despite high agreement and overall good correlation of different reconstruction protocols, thinner slices thickness and increment, and sharper kernels were associated with significant upward reclassification of CV risk. Larger FOV determined both upward and downward reclassification of CV risk., (Copyright © 2018 Elsevier B.V. All rights reserved.)

During the last decade coronary computed tomography angiography (CTA) has become the preeminent non-invasive imaging modality to detect coronary artery disease (CAD) with high accuracy. However, CTA has a limited value in assessing the hemodynamic significance of a given stenosis due to a modest specificity and positive predictive value. In recent years, different CT techniques for detecting myocardial ischemia have emerged, such as CT-derived fractional flow reserve (FFR-CT), transluminal attenuation gradient (TAG), and myocardial CT perfusion (CTP) imaging. Myocardial CTP imaging can be performed with a single static scan during first pass of the contrast agent, with monoenergetic or dual-energy acquisition, or as a dynamic, time-resolved scan during stress by using coronary vasodilator agents (adenosine, dipyridamole, or regadenoson). A number of CTP techniques are available, which can assess myocardial perfusion in both a qualitative, semi-quantitative or quantitative manner. Once used primarily as research tools, these modalities are increasingly being used in routine clinical practice. All these techniques offer the substantial advantage of combining anatomical and functional evaluation of flow-limiting coronary stenosis in the same examination that would be beneficial for clinical decision-making. This review focuses on the state-of the-art and future trends of these evolving imaging modalities in the field of cardiology for the physiologic assessments of CAD., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Since its introduction about 15 years ago, coronary computed tomography angiography has become today the most accurate clinical instrument for noninvasive assessment of coronary atherosclerosis. Important technical developments have led to a continuous stream of new clinical applications together with a significant reduction in radiation dose exposure. Latest generation computed tomography scanners (≥ 64 slices) allow the possibility of performing static or dynamic perfusion imaging during stress by using coronary vasodilator agents (adenosine, dipyridamole, or regadenoson), combining both functional and anatomical information in the same examination. In this article, the emerging role and state-of-the-art of myocardial computed tomography perfusion imaging are reviewed and are illustrated by clinical cases from our experience with a second-generation dual-source 128-slice scanner (Somatom Definition Flash, Siemens; Erlangen, Germany). Technical aspects, data analysis, diagnostic accuracy, radiation dose and future prospects are reviewed., (Copyright © 2015 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

A 49-year-old man presented with chest pain, dyspnea, and lactic acidosis. Left ventricular hypertrophy and myocardial fibrosis were detected. The sequencing of mitochondrial genome (mtDNA) revealed the presence of A to G mtDNA point mutation at position 3243 (m.3243A>G) in tRNA Leu(UUR) gene. Diagnosis of cardiac involvement in a patient with Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes syndrome (MELAS) was made. Due to increased risk of sudden cardiac death, cardioverter defibrillator was implanted., Competing Interests: The authors report no financial relationships or competing interests regarding the content herein.

Cardiac CT has developed into a robust clinical tool during the past 15 years. Of the fields in which the potential of cardiac CT has raised more interest is chest pain in acute settings. In fact, the possibility to exclude with high reliability obstructive coronary artery disease (CAD) in patients at low-to-intermediate risk is of great interest both from the clinical standpoint and from the management standpoint. Several other modalities, with or without imaging, have been used during the past decades in the settings of new onset chest pain or in acute chest pain for both diagnostic and prognostic assessment of CAD. Each one has advantages and disadvantages. Most imaging modalities also focus on inducible ischaemia to guide referral to invasive coronary angiography. The advent of cardiac CT has introduced a new practice diagnostic paradigm, being the most accurate non-invasive method for identification and exclusion of CAD. Furthermore, the detection of subclinical CAD and plaque imaging offer the opportunity to improve risk stratification. Moreover, recent advances of the latest generation CT scanners allow combining both anatomical and functional imaging by stress myocardial perfusion. The role of cardiac CT in acute settings is already important and will become progressively more important in the coming years.

We report a case of an accidental finding of an aberrant right subclavian artery diagnosed in an adult man during a 4-French coronary angiography performed by right transradial access, then confirmed by multi-slice computed tomography. Tips and tricks have been suggested to complete the 4-French procedure avoiding changing the vascular access., (Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

An 18-year-old male, involved in a car accident, underwent a non-gated contrast enhanced CT with apparently no evidence of significant abnormalities of the thoracic aorta. The later onset of aortic valve regurgitation prompted a prospectively ECG-triggered high-pitch spiral acquisition using a dual-source CT system which showed a tear with a huge pseudoaneurysm of the aortic root. The patient underwent successful urgent conservative surgical repair. CT is the primary screening modality for aortic injuries. Cardiac motion artifacts may hamper sensitivity at the root/ascending aorta level when a non ECG-gated technique is used, thus masking a potentially life-threatening condition. ECG-gated-CT should be mandatorily performed in patients with a high suspicion for an aortic root trauma thus allowing timely repair and avoiding a catastrophic event., (Copyright © 2015 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Purpose: This study was undertaken to evaluate primary stenting in patients with inferior vena cava torsion after orthotopic liver transplantation performed with modified piggyback technique., Materials and Methods: From November 2003 to October 2010, six patients developed clinical, laboratory and imaging findings suggestive of caval stenosis, after a mean period of 21 days from an orthotopic liver transplantation performed with modified piggyback technique. Vena cavography showed stenosis due to torsion of the inferior vena cava at the anastomoses and a significant caval venous pressure gradient. All patients were treated with primary stenting followed by in-stent angioplasty in three cases., Results: In all patients, the stents were successfully positioned at the caval anastomosis and the venous gradient pressure fell from a mean value of 10 to 2 mmHg. Signs and symptoms resolved in all six patients. One patient died 3 months after stent placement due to biliary complications. No evidence of recurrence or complications was noted during the follow-up (mean 49 months)., Conclusions: Primary stenting of inferior vena cava stenosis due to torsion of the anastomoses in patients receiving orthotopic liver transplantation with modified piggyback technique is a safe, effective and durable treatment.

Aim: The aim of this study is to assess the image quality and diagnostic accuracy of computed tomography (CT) coronary angiography (CTCA) in different hospital settings with the same trained team., Materials and Methods: Four hundred patients were consecutively enrolled for CTCA in a large academic hospital (Group 1; Sensation 64 Cardiac, Siemens - Iomeprol 400, Bracco; 200 patients) and in a small local hospital (Group 2; VCT, GE Healthcare - Iodixanol 320, GE Healthcare; 200 patients). All patients were enrolled for suspected coronary artery disease (CAD) and patients with stents or who had previously undergone coronary bypass were excluded. Scan protocols (retrospectively ECG-gated; no dose reduction modulation applied) were performed in accordance with standards reported in the international literature with the best solution available on site. Image quality was assessed in each coronary segment with a 4-point Likert scale: 0, not assessable; 1, low; 2, average; 3, good. Diagnostic accuracy was calculated against conventional coronary angiography with a threshold of at least 50% for significant stenosis., Results: There was no significant difference between demographics, BMI, prevalence of obstructive CAD, calcium score and heart rate between the two populations. The average image quality was 2.83 ± 0.37 for Group 1 and 2.86 ± 0.31 for Group 2 (P > 0.05). Per-segment sensitivity, specificity, positive and negative predictive values were 92.6% (87-95), 97.9% (97-98), 75.9% (69-81) and 99.5% (99-99), respectively, for Group 1, and 90.4% (85-93), 98.6% (98-99), 84.2% (78-88) and 99.2% (98-99), respectively, for Group 2 (P > 0.05)., Conclusion: There is no significant difference in image quality and diagnostic accuracy of CTCA when the investigation is performed by the same properly trained team. CTCA is a robust imaging modality for the detection of coronary artery stenosis.

Several studies have been carried out on vulnerable plaque as the main culprit for ischaemic cardiac events. Historically, the most important diagnostic technique for studying coronary atherosclerotic disease was to determine the residual luminal diameter by angiographic measurement of the stenosis. However, it has become clear that vulnerable plaque rupture as well as thrombosis, rather than stenosis, triggers most acute ischaemic events and that the quantification of risk based merely on severity of the arterial stenosis is not sufficient. In the last decades, substantial progresses have been made on optimisation of techniques detecting the arterial wall morphology, plaque composition and inflammation. To date, the use of a single technique is not recommended to precisely identify the progression of the atherosclerotic process in human beings. In contrast, the integration of data that can be derived from multiple methods might improve our knowledge about plaque destabilisation. The aim of this narrative review is to update evidence on the accuracy of the currently available non-invasive and invasive imaging techniques in identifying components and morphologic characteristics associated with coronary plaque vulnerability.

Aortic dissection is a challenging medical and surgical problem. Its evolution depends on size and location of its intimal tears. We describe a case of contrast enhanced MD-CT with low out flow of the false lumen for an unbalanced between the entry and the reentry tears. This determined a delayed filling up of the false lumen on the arterial phase that was complete on the venous one., (Copyright © 2013 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Chronic mesenteric ischemia (CMI) is a rare disorder that is commonly caused by progressive atherosclerotic stenosis or occlusion of one or more mesenteric arteries. Endovascular treatment for symptomatic CMI represents a viable option, especially in high-operative risk patients. We report a case of acute symptomatic CMI with chronic totally occlusion of the superior mesenteric artery (SMA) associated with significant stenosis of celiac trunk (CT) and inferior mesenteric artery (IMA) that underwent endovascular treatment of all the three mesenteric arteries: stenting of CT and IMA stenosis, and recanalization of the SMA occlusion by retrograde crossing via the Villemin arcade.

Aneurysm of the jejunal artery (JA) is very uncommon with few specific symptoms, but can be a lethal entity. When at risk to rupture, it must be treated expeditiously to avoid mortality. We report a case of a 76-year-old male patient that underwent contrast-enhanced multi-detector computed tomography (MDCT) which incidentally reveals a 12 mm saccular aneurysm of the third JA at the bifurcation of the first arcade. Patient underwent successful endovascular embolization using the isolation technique with the Amplatzer Vascular Plug 4. The patient's recovery was unremarkable and he was discharged on postoperative day 5. Follow-up MDCT reveals total exclusion of the saccular aneurysm of the third jejunal artery with patency of the distal branches., (Copyright © 2012 Wiley Periodicals, Inc.)

Purpose: To describe when and how to perform endovascular embolization of aortic branch artery pseudoaneurysms associated with type A and type B intramural hematoma (IMH) involving the descending thoracic and abdominal aorta (DeBakey I and III) that increased significantly in size during follow-up., Materials and Methods: Sixty-one patients (39 men; mean ± standard deviation age 66.1 ± 11.2 years) with acute IMH undergoing at least two multidetector computed tomographic examinations during follow-up for 12 months or longer were enrolled. Overall, 48 patients (31 men, age 65.9 ± 11.5) had type A and type B IMH involving the descending thoracic and abdominal aorta (DeBakey I and III)., Results: Among the 48 patients, 26 (54 %; 17 men, aged 64.3 ± 11.4 years) had 71 aortic branch artery pseudoaneurysms. Overall, during a mean follow-up of 22.1 ± 9.5 months (range 12-42 months), 31 (44 %) pseudoaneurysms disappeared; 22 (31 %) decreased in size; two (3 %) remained stable; and 16 (22 %) increased in size. Among the 16 pseudoaneurysms with increasing size, five of these (three intercostal arteries, one combined intercostobronchial/intercostal arteries, one renal artery), present in five symptomatic patients, had a significant increase in size (thickness >10 mm; width and length >20 mm). These five patients underwent endovascular embolization with coils and/or Amplatzer Vascular Plug. In all patients, complete thrombosis and exclusion of aortic pseudoaneurysm and relief of back pain were achieved., Conclusion: Aortic branch artery pseudoaneurysms associated with type A and type B IMH involving the descending thoracic and abdominal aorta (DeBakey I and III) may be considered relatively benign lesions. However, a small number may grow in size or extend longitudinally with clinical symptoms during follow-up, and in these cases, endovascular embolization can be an effective and safe procedure.

Objectives: This study sought to evaluate the prevalence and potential role of myocardial bridging in the pathogenesis of apical ballooning syndrome (ABS)., Background: ABS is characterized by reversible left ventricular dysfunction, frequently precipitated by a stressful event, but the pathogenesis remains still unclear., Methods: Forty-two consecutive patients (40 female, mean age 66 ± 7 years) with ABS underwent echocardiography, cardiac magnetic resonance, coronary angiography (CA) with intravascular ultrasound, and computed tomography angiography (CTA). Myocardial bridging was diagnosed by CA when a dynamic compression phenomenon was observed in the coronary artery and by CTA when a segment of coronary artery was completely (full encasement) or incompletely (partial encasement) surrounded by the myocardium. The prevalence of myocardial bridging detected by CTA and CA in ABS patients was compared with 401 controls without ABS who underwent both CTA and CA., Results: Myocardial bridging by CTA was observed in 32 ABS patients (76%): 23 with partial encasement and 9 with full encasement. All myocardial bridging was located in the mid segment of the left anterior descending coronary artery (LAD) with a mean length of 17 ± 9 mm. CA revealed myocardial bridging in 17 subjects (40%) (9 with partial encasement and 8 with full encasement by CTA). All subjects in which dynamic compression was observed by CA showed myocardial bridging by CTA, while none of the subjects with negative findings for myocardial bridging by CTA revealed dynamic compression by CA. Compared with controls, ABS patients showed a significant higher prevalence of myocardial bridging in the LAD either by CA (40% vs. 8%; p < 0.001) or by CTA (76% vs. 31%; p < 0.001)., Conclusions: Our study showed that myocardial bridging of the LAD is a frequent finding in ABS patients as revealed both by CA and, mostly, by CTA, suggesting a role of myocardial bridging as potential substrate in the pathogenesis of ABS., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

We describe a case of nonocclusive mesenteric ischemia in a 37-year-old man with hemodialysis-dependent chronic kidney disease due to diabetes who was admitted to our hospital with abdominal pain. A plain radiograph of the abdomen showed distended loops of small bowel and gas in the hepatic portal vein. Multidetector computed tomography showed massive wall calcification of the superior mesenteric artery and its collaterals, pneumatosis intestinalis of a segment of the jejunum, and porto-mesenteric vein gas. Urgent laparotomy confirmed segmental necrosis of the jejunum, which was resected. Pathologic examination showed whole-layer necrosis of the resected bowel without arterial or venous thrombosis. Nonocclusive mesenteric ischemia is an increasingly recognized and potentially lethal complication in hemodialysis patients. In the present case, critical factors for the development of nonocclusive mesenteric ischemia may have included prolonged hypotension during hemodialysis treatments that reduced blood flow to the small bowel and massive vascular calcification that negatively affected compliance of the superior mesenteric artery and its branches., (Copyright © 2012 National Kidney Foundation, Inc. All rights reserved.)

Aim: To assess the attenuation of non-calcified atherosclerotic coronary artery plaques with computed tomography coronary angiography (CTCA)., Methods: Four hundred consecutive patients underwent CTCA (Group 1: 200 patients, Sensation 64 Cardiac, Siemens; Group 2: 200 patients, VCT GE Healthcare, with either Iomeprol 400 or Iodixanol 320, respectively) for suspected coronary artery disease (CAD). CTCA was performed using standard protocols. Image quality (score 0-3), plaque (within the accessible non-calcified component of each non-calcified/mixed plaque) and coronary lumen attenuation were measured. Data were compared on a per-segment/per-plaque basis. Plaques were classified as fibrous vs lipid rich based on different attenuation thresholds. A P < 0.05 was considered significant., Results: In 468 atherosclerotic plaques in Group 1 and 644 in Group 2, average image quality was 2.96 ± 0.19 in Group 1 and 2.93 ± 0.25 in Group 2 (P ≥ 0.05). Coronary lumen attenuation was 367 ± 85 Hounsfield units (HU) in Group 1 and 327 ± 73 HU in Group 2 (P < 0.05); non-calcified plaque attenuation was 48 ± 23 HU in Group 1 and 39 ± 21 HU in Group 2 (P < 0.05). Overall signal to noise ratio was 15.6 ± 4.7 in Group 1 and 21.2 ± 7.7 in Group 2 (P < 0.01)., Conclusion: Higher intra-vascular attenuation modifies significantly the attenuation of non-calcified coronary plaques. This results in a more difficult characterization between lipid rich vs fibrous type.

Objectives: To compare Magnetic Resonance (MR) and Computed Tomography (CT) for the assessment of left (LV) and right (RV) ventricular functional parameters., Methods: Seventy nine patients underwent both Cardiac CT and Cardiac MR. Images were acquired using short axis (SAX) reconstructions for CT and 2D cine b-SSFP (balanced-steady state free precession) SAX sequence for MR, and evaluated using dedicated software., Results: CT and MR images showed good agreement: LV EF (Ejection Fraction) (52  ±  14% for CT vs. 52  ±  14% for MR; r  =  0.73; p  >  0.05); RV EF (47  ±  12% for CT vs. 47 ± 12% for MR; r  =  0.74; p > 0.05); LV EDV (End Diastolic Volume) (74  ±  21 ml/m² for CT vs. 76  ±  25 ml/m² for MR; r  =  0.59; p > 0.05); RV EDV (84  ±  25 ml/m² for CT vs. 80  ±  23 ml/m² for MR; r  =  0.58; p > 0.05); LV ESV (End Systolic Volume)(37  ±  19 ml/m² for CT vs. 38  ±  23 ml/m² for MR; r  =  0.76; p  >  0.05); RV ESV (46  ±  21 ml/m² for CT vs. 43  ±  18 ml/m² for MR; r  =  0.70; p  >  0.05). Intra- and inter-observer variability were good, and the performance of CT was maintained for different EF subgroups., Conclusions: Cardiac CT provides accurate and reproducible LV and RV volume parameters compared with MR, and can be considered as a reliable alternative for patients who are not suitable to undergo MR., Key Points: • Cardiac-CT is able to provide Left and Right Ventricular function. • Cardiac-CT is accurate as MR for LV and RV volume assessment. • Cardiac-CT can provide accurate evaluation of coronary arteries and LV and RV function.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastro-intestinal tract (approximately 2% of population), and arises from improper closure and absorption of the omphalomesenteric duct. Very few cases of Meckel's diverticulitis on the mesenteric side have been reported in the surgical literature, and no reported cases have been documented on preoperative imaging. We report a 65-year-old woman presenting symptoms and signs of acute abdomen with an initial suspicion of acute appendicitis. MDCT imaging revealed a mesenteric abscess in the right lower quadrant at the level of the distal ileum as a complication of Meckel's diverticulitis on the mesenteric side. The patient recovered after a diverticulectomy without the need for a small bowel resection. This case demonstrates that MDCT is a fast imaging technique that may be helpful in the emergency setting for the preoperative diagnosis of an unusual complicated MD on the mesenteric side.

We describe a case of endovascular treatment in a 64-year-old woman affected by a penetrating atherosclerotic ulcer (PAU) of the abdominal aorta with a 26-mm pseudoaneurysm involving the celiac trunk (CT) origin and with superior mesenteric artery (SMA) occlusion in the first 30 mm. The patient underwent stenting to treat the SMA occlusion and subsequent deployment of a custom-designed fenestrated endovascular stent-graft to treat the PAU involving the CT origin. Follow-up at 6 months after device placement demonstrated no complications, and there was complete thrombosis of the PAU and patency of the two branch vessels.

Aim: To assess the prognostic relevance of 64-slice computed tomography coronary angiography (CT-CA) and symptoms in diabetics and non-diabetics referred for cardiac evaluation., Methods: We followed 210 patients with diabetes type 2 (DM) and 203 non-diabetic patients referred for CT-CA for ruling out coronary artery disease (CAD). Patients were without known history of CAD and were divided into four categories on the basis of symptoms at presentation (none, atypical angina, typical angina and dyspnoea). Clinical end points were major cardiac events (MACE): cardiac-related death, non-fatal myocardial infarction, unstable angina and cardiac revascularizations. Cox proportional hazard models, with and without adjustment for risk factors and multiplicative interaction term (obstructive CAD × DM), were developed to predict outcome., Results: DM patients with dyspnoea or who were asymptomatic showed a higher prevalence of obstructive CAD than non-diabetics (p ≤ 0.01). At mean follow-up of 20.4 months, DM patients had worse cardiac event-free survival in comparison with non-DM patients (90% vs. 81%, p = 0.02). In multivariate analysis, CT-CA evidence of obstructive CAD (in DM patients: HR: 6.4; 95% CI: 2.3-17.5; p < 0.001; in non-DM patients: HR: 7.4; 95% CI: 2.1-26.7; p = 0.002) and the presence of typical angina (in DM patients: HR: 2.9; 95% CI: 1.3-6.3; p = 0.007; in non-DM patients: HR: 2.7; 95% CI: 1.1-7.1; p = 0.03) were independent predictors of MACE in both groups. Furthermore, other independent outcome predictors included dyspnoea (HR: 3.8; 95% CI: 1.7-8.5; p = 0.001), the number of segments with any CAD (HR: 1.1; 95% CI: 1.001-1.2; p = 0.04) in DM patients and coronary calcium score >100 in non-DM patients (HR: 5.6; 95% CI: 1.4-21.5; p = 0.01). In Cox regression analysis of the overall population, interaction term obstructive CAD × DM resulted in non-significance., Conclusions: Among DM patients, dyspnoea carried a high event risk with a MACE rate four times higher. CT-CA findings were strongly predictive of outcome and proved valuable for further risk stratification.

Background: Identification and differentiation of coronary atherosclerotic plaques may improve risk stratification for incident coronary events., Objective: We investigated the ability of dual-source computed tomography (CT) to depict and characterize atherosclerotic coronary plaques., Methods: Contrast-enhanced CT was performed in 25 human heart specimens with a total of 322 histologically determined plaques. Coronary plaques were classified on CT as (1) noncalcified, mixed, or calcified and (2) by CT attenuation values. Atherosclerotic plaques were histopathologically characterized according to the Stary classification., Results: CT detected 79% (245/322) of all plaques. Lesions missed by CT were generally early lesions, type I (n = 31), type II (n = 38), or type III (n = 8), according to Stary. CT detected 29% of early (Stary I-III) and 100% of advanced (Stary IV-VIII) plaques. Plaque classification as noncalcified was sensitive (100%) and specific (72%) for early, whereas classification as mixed/calcified was sensitive (92%, 89%) and specific (100%) for advanced plaques. Calcified plaques on CT were detected with high sensitivity (80%) and specificity (95%). Other subtypes were not distinguishable with CT according to the presence or absence of calcification. CT density was significantly higher for advanced (306 ± 470 HU) than for early (42 ± 14 HU; P < 0.01) plaques. The mean CT density value of type VII plaques (512 ± 349 HU) was significantly higher than those of other plaques (34-101 HU; P < 0.001)., Conclusions: CT reliably depicts advanced coronary plaques and allows for the differentiation between early and advanced plaques., (Copyright © 2010. Published by Elsevier Inc.)

Purpose: To evaluate the prognostic value of multidetector computed tomographic (CT) coronary angiography in a diabetic population known to have or suspected of having coronary artery disease (CAD) compared with that in nondiabetic individuals., Materials and Methods: Institutional review board approval and patient informed consent were obtained. Three hundred thirteen patients with type 2 diabetes mellitus (DM) and 303 patients without DM underwent unenhanced 64-detector row CT, at which a calcium score was obtained, followed by CT angiography. Multidetector CT coronary angiograms were retrospectively classified as normal, showing nonobstructive CAD (50% luminal narrowing). During follow-up after CT angiography, major events (cardiac death, nonfatal myocardial infarction, and unstable angina requiring hospitalization) and total events (major events plus coronary revascularizations) were recorded for each patient. Cox proportional hazards analysis and Kaplan-Meier analysis were used to compare survival rates., Results: In the group of 313 patients with DM, there were 213 men, and the mean age was 62 years +/- 11 (standard deviation). In the group of 303 patients without DM, there were 203 men, and the mean age was 63 years +/- 11. The mean number of diseased segments (5.6 vs 4.4, P = .001) and the rate of obstructive CAD (51% vs 37%, P < .001) were higher in patients with DM. Patients were followed up for a mean of 20 months +/- 5.4 (range, 6-44 months). At multivariate analysis, DM (P < .001) and evidence of obstructive CAD (P < .001) were independent predictors of outcome. Obstructive CAD remained a significant multivariate predictor for both patients with DM and patients without DM. In both patients with DM and patients without DM with absence of disease, the event rate was 0%. The event rate increased to 36% in patients without DM but with obstructive CAD and was highest (47%) in patients with DM and obstructive CAD., Conclusion: In both patients with DM and patients without DM, multidetector CT coronary angiography provides incremental prognostic information over baseline clinical variables, and the absence of atherosclerosis at CT coronary angiography is associated with an excellent prognosis. Multidetector CT coronary angiography might be a clinically useful tool for improving risk stratification in both patients with DM and patients without DM.

We report a patient affected by complicated retrograde type A aortic dissection (DeBakey type I) with false lumen rupture and acute right lower limb ischemia treated with fenestration at the aortic bifurcation followed by a hybrid approach, consisting of an elephant trunk procedure and the placement of endoluminal stent graft for the treatment of descending thoracic aorta dissection. In our patient, in spite of the closure of the primary entry site, false lumen failed to remodel in the abdominal aorta, therefore the positioning of the bare stents and aortobisiliac endoprosthesis of the abdominal aorta were performed. Visceral blood flow was preserved and the postoperative course was uneventful at the 6-month follow-up., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the relationship between established cardiovascular risk factors, clinical presentation and the extent of coronary artery disease (CAD), as described with computed tomography coronary angiography., Material and Methods: In this cross-sectional study, we included 567 symptomatic individuals without a history of CAD who consecutively underwent 64-slice computed tomography coronary angiography for evaluation of suspected CAD. We analyzed the prevalence of CAD depending on sex, age, symptoms and risk factors., Results: A total of 8542 segments were analyzed. No evidence of CAD was observed in 225 patients (40%), nonsignificant CAD in 221 patients (39%) and significant CAD (luminal narrowing >50%) in the remaining 121 patients (21%). CAD increased with advancing age, significantly above 50 years (P < 0.05). Female patients had a higher prevalence of normal coronary arteries and males of significant CAD (P < 0.01). With the increase of risk factors, there was a significant increase of the significant disease (P < 0.01). Typical pain with respect to atypical pain had the strongest association with significant CAD (16 vs. 38%; P < 0.05). In multivariate analysis, the number of risk factors, age, male sex and typical pain remained strong predictors of significant CAD (P < 0.0001)., Conclusion: Computed tomography coronary angiography may play an important role in risk stratification of patients with suspected CAD.

The present report describes an unusual case of an aneurysm of a right hepatic artery (RHA) branching from the superior mesenteric artery; the accessory RHA was looped to the left hepatic artery arising from the celiac axis (CA) and was associated with congenital atresia of the CA. The accessory RHA aneurysm was treated with the placement of a bare stent and detachable coils through the mesh of the stent. Complete and prompt exclusion of the aneurysm was achieved with blood flow preservation in the parent artery at midterm follow-up.

Percutaneous transcatheter embolization has become the treatment of choice for pulmonary arteriovenous fistulas (PAVFs), in most cases replacing surgical intervention. However, while "classic" devices, such as intravascular coils and detachable balloons, have proved to be successful for interventional occlusions of small or medium-sized PAVFs, they are not ideal in larger fistulas because of the risk for embolization to the systemic circulation. We describe the case of a 61-year-old woman with a symptomatic huge solitary pulmonary arteriovenous fistula (4.5 cm in diameter), occupying part of the lung in the lower right lobe with two feeding arteries (10 and 4 mm in diameter, respectively), who underwent successful transcatheter closure with an Amplatzer Vascular Plug, a new device designed for the occlusion of vascular abnormalities.