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Objectives It remains still unclear whether the use of modern noninvasive diagnostic modalities for evaluation of coronary artery disease (computed tomography coronary angiography (CTCA), nuclear myocardial perfusion imaging (MPI)) were able to change the 'diagnostic yield' of invasive coronary angiography (ICA). Methods The total number of ICA in the years 2000-2009 was related to the number of percutaneous interventions (PCIs) and we assessed whether there was a significant trend over time using time series analyses. We compared these data with the number of patients undergoing CTCA and nuclear MPI in the same time period. Results During the 10-year observational period, 23,397 ICA were performed. The proportion of purely diagnostic ICA (without PCI) remained stable over the whole study period (tau = −0.111, P = 0.721). A CTCA program was initiated in 2005 and 1,407 examinations were performed until 2009. Similarly, the number of nuclear MPI increased from 2,284 in the years 2000-2004 to 5,260 in the years 2005-2009 (P = 0.009). Conclusion Despite increasing availability, noninvasive testing modalities did not significantly alter the rate of purely diagnostic ICA, and still are underused as gatekeeper to ICA. Further effort is needed to optimize the use of noninvasive imaging modalities in the work-up process for coronary artery disease. (J Interven Cardiol 2014;27:50-57) [ABSTRACT FROM AUTHOR]

Objectives The purpose of this study was to evaluate the differences in the clinical and angiographic characteristics of chronic total occlusion (CTO) lesions among the 3 major coronary arteries (LAD, LCx, and RCA). Background The success rate of percutaneous coronary intervention (PCI) of CTO lesions is not uniform among the 3 major coronary arteries and this may be influenced by the differences in angiographic and clinical characteristics that may exists between them. Methods We retrospectively evaluated clinical and angiographic characteristics of patients who underwent PCI of CTO lesions at our 2 centers between 2003 and 2010. Results We analyzed 708 CTO-PCI procedures between 2003 and 2010. The CTO lesions were located in LAD: 222 (31.4%), LCx: 167 (23.6%), and RCA: 319 (45.0%). Patients with CTO in LAD had lower incidence of previous history of PCI and CABG compared to those with CTO lesions in LCx or RCA. In regard to angiographic findings, LAD lesions tended to have more side branches and blunt occlusion stump. The LCx lesions presented more frequently as a part of multivessel disease. RCA lesions were significantly longer, more severely angulated, and calcified. Good collateral circulations were more often encountered in the RCA. In regard to success rates, RCA showed lower procedural success rates (71.8%) followed by LAD (74.8%) and LCx (79.0%). Conclusions There were several differences in the clinical and angiographic characteristics of CTO lesions among the 3 major coronary arteries. These differences can explain the discrepancy in procedure success rates. (J Interven Cardiol 2014;27:44-49) [ABSTRACT FROM AUTHOR]

The article focuses on a proposed elastic registration algorithm involving multiresolution search strategy for registration of digital X-ray angiography images. It mentions the use of digital subtraction angiography (DSA) in vascular imaging and treatment, some key processes in the algorithm including affine registration, affine parameter validation and thin-plate spline warping, and results of an experiment indicating the significant removal of motion artifacts in the original DSA images.

Objectives: To assess the effect of lower volumes of contrast medium (CM) on image quality in high-pitch dual-source computed tomography coronary angiography (CTCA). Methods: One-hundred consecutive patients (body weight 65-85 kg, stable heart rate ≤65 bpm, cardiac index ≥2.5 L/min/m) referred for CTCA were prospectively enrolled. Patients were randomly assigned to one of five groups of different CM volumes (G, 30 mL; G, 40 mL; G, 50 mL; G, 60 mL; G, 70 mL; flow rate 5 mL/s each, iodine content 370 mg/mL). Attenuation within the proximal and distal coronary artery segments was analysed. Results: Mean attenuation for men and women ranged from 345.0 and 399.1 HU in G to 478.2 and 571.8 HU in G. Mean attenuation values were higher in groups with higher CM volumes ( P < 0.0001) and higher in women than in men ( P < 0.0001). The proportions of segments with attenuation of at least 300 HU in G, G, G, G and G were 89 %, 95 %, 98 %, 98 % and 99 %. CM volume of 30 mL in women and 40 mL in men proved to be sufficient to guarantee attenuation of at least 300 HU. Conclusions: In selected patients high-pitch dual-source CTCA can be performed with CM volumes of 40 mL in men or 30 mL in women. Key Points: • High- pitch dual- source coronary angiography is feasible with low contrast media volumes. • Traditional injection rules still apply: higher volumes result in higher enhancement. • The patient' s gender is a co- factor determining the level of contrast enhancement. • Volumes can be reduced down to 30- 40 mL in selected patients. [ABSTRACT FROM AUTHOR]

A systematic imaging protocol of coronary angiography, optical coherence tomography, and cardiac MRI in women clinically diagnosed with myocardial infarction with non-obstructive coronary artery disease revealed a cause in 84%, with three-quarters exhibiting an ischemic etiology. [ABSTRACT FROM AUTHOR]

In image-guided cardiac interventions, X-ray imaging and intravascular ultrasound (IVUS) imaging are two often used modalities. Interventional X-ray images, including angiography and fluoroscopy, are used to assess the lumen of the coronary arteries and to monitor devices in real time. IVUS provides rich intravascular information, such as vessel wall composition, plaque, and stent expansions, but lacks spatial orientations. Since the two imaging modalities are complementary to each other, it is highly desirable to co-register the two modalities to provide a comprehensive picture of the coronaries for interventional cardiologists. In this paper, we present a solution for co-registering 2-D angiography and IVUS through image-based device tracking. The presented framework includes learning-based vessel detection and device detections, model-based tracking, and geodesic distance-based registration. The system first interactively detects the coronary branch under investigation in a reference angiography image. During the pullback of the IVUS transducers, the system acquires both ECG-triggered fluoroscopy and IVUS images, and automatically tracks the position of the medical devices in fluoroscopy. The localization of tracked IVUS transducers and guiding catheter tips is used to associate an IVUS imaging plane to a corresponding location on the vessel branch under investigation. The presented image-based solution can be conveniently integrated into existing cardiology workflow. The system is validated with a set of clinical cases, and achieves good accuracy and robustness. [ABSTRACT FROM AUTHOR]

There is an ongoing research and clinical interest in the development of reliable and easily accessible software for the 3D reconstruction of coronary arteries. In this work, we present the architecture and validation of IVUSAngio Tool, an application which performs fast and accurate 3D reconstruction of the coronary arteries by using intravascular ultrasound (IVUS) and biplane angiography data. The 3D reconstruction is based on the fusion of the detected arterial boundaries in IVUS images with the 3D IVUS catheter path derived from the biplane angiography. The IVUSAngio Tool suite integrates all the intermediate processing and computational steps and provides a user-friendly interface. It also offers additional functionality, such as automatic selection of the end-diastolic IVUS images, semi-automatic and automatic IVUS segmentation, vascular morphometric measurements, graphical visualization of the 3D model and export in a format compatible with other computer-aided design applications. Our software was applied and validated in 31 human coronary arteries yielding quite promising results. Collectively, the use of IVUSAngio Tool significantly reduces the total processing time for 3D coronary reconstruction. IVUSAngio Tool is distributed as free software, publicly available to download and use. [ABSTRACT FROM AUTHOR]

Abstract: Objectives/Purpose: Aim of this study was to retrospectively compare the image quality and the radiation dose of an ultra high pitch CT scan for the evaluation of pulmonary embolism and visualization of cardiac structures in comparison to our institution's standard pulmonary embolism protocol. Method and materials: The study cohort consisted of 115 consecutive patients, 57 underwent CT pulmonary angiography on a dual source 128 slice scanner (Siemens Somatom Definition FLASH) via an ultra high pitch mode (Pitch 2.8) while 58 were scanned on a dual source 64 slice scanner (Siemens Somatom Definition Dual Source) with standard pitch (Pitch 0.9). Qualitative image assessment was determined by two blinded radiologists with 3 and 15 years&#x2019; experience in chest and cardiac CT. Quantitative image assessment was determined by the signal to noise ratio (SNR) and contrast to noise ratio (CNR). Effective radiation dose was calculated via the product of the dose length product. Results: For the ultra high pitch protocol, 14% (8/57) were positive for pulmonary embolus compared to 13.7% (8/58) for the standard pitch group. 98.2% of the ultra high pitch scans were diagnostic for pulmonary embolus vs. 94.8% of the standard protocol. Visualization of cardiac structures was significantly improved with the ultra high pitch protocol (p &lt;0.0001). Significantly more lung parenchymal motion was observed on the standard protocol (p &lt;0.0001). The mean pulmonary vessel attenuation, SNR, and CNR were not significantly different. The mean effective dose was lower for the ultra high pitch studies (4.09mSv±0.78 vs. 7.72mSv±2.60, p &lt;0.0001). Conclusion: Ultra high pitch CT imaging for pulmonary embolus is a technique which has potential to assess motion free evaluation of most cardiac structures and proximal coronary arteries at lower radiation doses. [ABSTRACT FROM AUTHOR]

Although several studies have demonstrated the association between coronary artery calcification (CAC) and coronary artery disease events, the underlying mechanism has not been fully elucidated. Furthermore, extensive CAC still remains a poorly understood phenomenon. The objective of this study is to determine the clinical characteristics and differences between 831 asymptomatic individuals with very high CAC scores (CACS ≥1000) and 497 asymptomatic individuals with CAC scores of 400 to 999. Individuals with CACS ≥1000 were more likely to have hypertension ([HTN]; P = .0004), hypercholesterolemia (P = .0001), diabetes mellitus ([DM] P = .005), and high body mass index ([BMI]; P = .03) compared with individuals with CACS = 400-999. On multivariable analysis, age (P < .0001) and BMI (P = .01) were found to be significant risk factors for the presence of very high CAC. While for males, age (P < .0001), hypercholesterolemia (P = .001), DM (P = .002), and obesity (P = .003) were independent risk factors; in females only HTN (P = .04) was independent risk factor. [ABSTRACT FROM AUTHOR]

Coronary CT angiography (CTA) is increasingly used worldwide for direct, non-invasive evaluation of the coronary arteries. Advances in computed tomography (CT) technology over the last decade have enabled such reliable imaging of the coronary arteries. Beyond arterial stenosis, coronary CTA also permits assessment of atherosclerotic plaque (including plaque burden) and coronary artery remodeling, previously only achievable through invasive means. It has been shown that coronary plaque volumes for non-calcified and mixed plaques and the arterial remodeling index, correlate closely with invasive intravascular ultrasound. Several studies have also shown a strong relationship of adverse plaque features imaged by coronary CTA with acute coronary syndrome, all-cause death, major adverse cardiovascular events and myocardial ischemia. The aim of this review is to summarize current methods for quantitative measurement of atherosclerotic plaque features from coronary CTA and to discuss their clinical implications. [ABSTRACT FROM AUTHOR]

Objectives: Shorter distances from coronary ostia to the calcified aortic valve may result in occlusion with potential infarction during transcatheter aortic valve implantation. We hypothesized that preoperative CT-scan measurements might predict coronary occlusion. Methods: Distances from the coronary ostia to the calcified aortic valve were measured during open heart aortic valve replacement in 60 consecutive patients. Distances were compared to preoperative CT-scan measurements evaluating distance of the coronary ostia as well in = 15). Results: The distances of the lower lip of the left and the right coronary artery ostia measured from the aortic annulus were 14.7 ± 3.9 mm and 13.4 ± 4.0 mm, respectively. The left, right and noncoronary cusp heights were 13.9 ± 2.5 mm, 12.8 ± 3.0 mm and 13.3 ± 3.1 mm, respectively. Coronary ostia topography indicated variations from the middle to the noncoronary commissure in 40% for the left and 63% for the right coronary ostium. CT-scan based measurements resulted in a distance of 12.8 ± 3.5 mm for the left and 13.9 ± 4.0 mm for the right coronary ostium, compared to 14.2 ± 4.2 mm and 13.5 ± 4.3 mm measured intraoperatively. A mild correlation between both measurements could be observed (r = 0.374, P= 0.188, left and r = 0.46, P= 0.09, n = 15). Conclusions: CT-scan-based measurements differed from the intraoperative measurements, however preoperative CT-scan evaluation may be a useful tool to identify patients with short distance of coronaries. [ABSTRACT FROM AUTHOR]

Abstract: Use of coronary CT angiography (CTA) in the early evaluation of low-intermediate risk chest pain in the emergency department represents a common, appropriate application of CTA in the community. Three large randomized trials (CT-STAT, ACRIN-PA, and ROMICAT II) have compared a coronary CTA strategy with current standard of care evaluations in >3000 patients. These trials consistently show the safety of a negative coronary CT angiogram to identify patients for discharge from the emergency department with low rates of major adverse cardiovascular events, at significantly lower cost, and greater efficiency in terms of time to discharge. Together, these trials provide definitive evidence for the use of coronary CTA in the emergency department in patients with a low-to-intermediate pretest probability of coronary artery disease. Clinical practice guidelines that recommend the use of coronary CTA in the emergency department are warranted. [Copyright &y& Elsevier]

Aim We tried to understand whether or not there was a gender difference in coronary artery interventions in coronary heart disease (CHD) cases in the present study. Methods The study was performed in two phases. The first phase was performed at the Internal Medicine Polyclinic of the Dumlupinar University between August 2005 and March 2007. CHD was diagnosed either angiographically or with history of coronary artery stenfing (CAS) and/or coronary artery bypass graft (CABG) surgery. The second phase was performed at the Internal Medicine Polyclinic of the Mustafa Kemal University between March 2007 and April 2012. During the second phase, the CHD patients with CAS and/or CABG surgery were detected and divided into two groups according to the gender. Results Mean age and prevalence of CHD were similar in both genders (p>0.05 for both) in the first phase. Smoking was higher in males with CHD, in 30 cases (54.5%) of males versus six (9.6%) cases of females (p<0.001), as well as chronic obstructive pulmonary disease (COPD), in ten (18.1%) cases of males versus four (6.4%) cases of females (p<0.05). Although the body mass index (BMI) and white coat hypertension OVCH) were insignificantly higher (p>0.05 for both), low density lipoprotein cholesterol (LDL-C) and triglyceride (TG) were significantly higher in females with CHD (p= 0.008 and p= 0.002, respectively). Hypertension (HT) and diabetes mellitus (DM) were higher in females with CHD, too (p<0.001 and p<0.05, respectively). On the other hand, CAS and/or CABG surgery were significantly higher in male CHD cases (21.8% versus 1.6%, p<0.001). Parallel to the first phase cases, majority of CAS and/or CABG surgery cases were males in the second phase cases too (90.2% versus 9.7%, p<0.001). Conclusion As some components of the metabolic syndrome, smoking and COPD were higher in males whereas BMI, WCH, LDL-C, TG, HT and DM were higher in females. Despite similar prevalences of CHD in both sexes, CAS and/or CABG surgery were significantly higher in males probably due to fear of loss of power required for their dominant roles in life and sexuality. [ABSTRACT FROM AUTHOR]

Aim To evaluate the efficacy of the Cardiac Magnetic Resonance Perfusion (CMRP) method in detection of Coronary Artery Disease (CAD) by comparing CMRP findings with the results of Coronary Computed Tomography Angiography (CCTA) or Catheter Coronary Angiography (CCA). Methods Thirty one patients in whom CMRP was performed along with CCTA or CCA within a month after CMRP between December 2009 and November 2010 were selected for the study. In CMRP, after adenosine administration as a stress agent Balanced TFE sequences were used to gather dynamic images that include the myocardial first pass of contrast media. Image analysis was performed visually. CMRP findings were compared to CCTA or CCA results for each coronary artery territories and for all territories. Results Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CMRP test in the identification of patients with significant (≥70%) coronary artery stenosis were 94.7%, 83%, 90.3%, 90%, and 90.9% for all coronary arteries, respectively; 94.4%, 84.6%, 90.3%, 89.4%, and 91.6% for left anterior descending artery, respectively; and 100%, 100%, 100%, 100%, and 100% for circumflex and right coronary artery, respectively. There was no statistically significant difference between angiography methods (CCTA/CCA) and CMRP (p>0.05). Methods had good to perfect consistency (κ = 0.79-1.00). Conclusion CMRP test seems to be a reasonable alternative for catheter angiography, which is considered the gold standard for evaluation of CAD and exclusion of significant coronary artery obstruction. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To investigate the potential of noise-based tube current reduction method with iterative reconstruction to reduce radiation exposure while achieving consistent image quality in coronary CT angiography (CCTA). Materials and methods: 294 patients underwent CCTA on a 64-detector row CT equipped with iterative reconstruction. 102 patients with fixed tube current were assigned to Group 1, which was used to establish noise-based tube current modulation formulas, where tube current was modulated by the noise of test bolus image. 192 patients with noise-based tube current were randomly assigned to Group 2 and Group 3. Filtered back projection was applied for Group 2 and iterative reconstruction for Group 3. Qualitative image quality was assessed with a 5 point score. Image noise, signal intensity, volume CT dose index, and dose-length product were measured. Results: The noise-based tube current modulation formulas were established through regression analysis using image noise measurements in Group 1. Image noise was precisely maintained at the target value of 35.00HU with small interquartile ranges for Group 2 (34.17–35.08HU) and Group 3 (34.34–35.03HU), while it was from 28.41 to 36.49HU for Group 1. All images in the three groups were acceptable for diagnosis. A relative 14% and 41% reduction in effective dose for Group 2 and Group 3 were observed compared with Group 1. Conclusion: Adequate image quality could be maintained at a desired and consistent noise level with overall 14% dose reduction using noise-based tube current reduction method. The use of iterative reconstruction further achieved approximately 40% reduction in effective dose. [Copyright &y& Elsevier]

Abstract: Aim: To evaluate the potential of SPECT myocardial perfusion imaging (MPI)–computed tomography coronary angiography (CTCA) hybrid fusion imaging to improve the diagnostic performance of cardiac SPECT/MPI and CTCA alone in order to act as more accurate gate keeper to further investigation invasive or not. Methods and results: Twenty-five patients were subjected to SPECT/MPI and CTCA within a period of 1 month without any medical treatment modification. A fusion software package was used for cardiac SPECT–CTCA image fusion. Semiquantitative analysis was performed for cardiac SPECT, CTCA and SPECT/MPI–CTCA fusion images. Patients were classified in 2 groups according to the clinical decision for further investigation (group A), or not (group B). Statistically significant differences were observed when SPECT/MPI–CTCA fusion images were used instead of cardiac SPECT alone (p <0.05). No statistically significant differences were observed comparing CTCA alone to SPECT/MPI–CTCA fusion images (p =0.25). A mid-term follow-up (mean 3.58±0.24 years) showed that all patients classified in group A based on the interpretation of SPECT MPI–CTCA fused images underwent conventional coronary angiography with further necessity for PTCA or CABG whereas absence of major or minor cardiac events was revealed for all patients of group B. Conclusion: In patients suspected for coronary artery disease, cardiac SPECT/MPI–CTCA fusion imaging was found to considerably alter the clinical decision for referral to further investigation derived from SPECT/MPI. [Copyright &y& Elsevier]

Objective: To prospectively compare subjective and objective image quality in 20% tube current coronary CT angiography (cCTA) datasets between an iterative reconstruction algorithm (SAFIRE) and traditional filtered back projection (FBP). Materials and methods: Twenty patients underwent a prospectively ECG-triggered dual-step cCTA protocol using 2nd generation dual-source CT (DSCT). CT raw data was reconstructed using standard FBP at full-dose (Group_1a) and 80% tube current reduced low-dose (Group_1b). The low-dose raw data was additionally reconstructed using iterative raw data reconstruction (Group_2). Attenuation and image noise were measured in three regions of interest and signal-to-noise-ratio (SNR) as well as contrast-to-noise-ratio (CNR) was calculated. Subjective diagnostic image quality was evaluated using a 4-point Likert scale. Results: Mean image noise of group_2 was lowered by 22% on average when compared to group_1b (p <0.0001–0.0033), while there were no significant differences in mean attenuation within the same anatomical regions. The lower image noise resulted in significantly higher SNR and CNR ratios in group_2 compared to group_1b (p <0.0001–0.0232). Subjective image quality of group_2 (1.88±0.63) was also rated significantly higher when compared to group_1b (1.58±0.63, p =0.004). Conclusions: Image quality of 80% tube current reduced iteratively reconstructed cCTA raw data is significantly improved when compared to standard FBP and consequently may improve the diagnostic accuracy of cCTA. [ABSTRACT FROM AUTHOR]

The problem of quantitatively assessing cardiac motion including global and local dynamic performances during cardiac cycles is addressed. In vivo X-ray coronary angiographic image sequences covering several cardiac cycles are used as source image data. The three-dimensional (3-D) surface of the heart based on extended superquadrics (ESQ) surface model in each phase is constructed from 3-D coronary vessel skeletons, which are reconstructed from a pair of nearly orthogonal angiographic sequences. Complex dynamic performances of the heart are decomposed into global and local components according to a priori anatomical and dynamic knowledge that have been confirmed by medical observations and non-rigid motion theory. Parameters of all components are quantitatively estimated through motion decomposition and compensation. Consequently, cardiac dynamics during cardiac cycles are comprehensively depicted with quantitative parameters. Validation of the proposed method with clinically acquired in vivo image data has been carried out, the results of which have verified the feasibility and accuracy of the proposed method. [ABSTRACT FROM AUTHOR]

Introduction: Computed tomography coronary angiography (CTCA) is a diagnostic method used for exclusion of coronary artery disease. However, lower accuracy of CTCA in assessment of calcified lesions is a significant factor impeding applicability of CTCA for assessment of coronary atherosclerosis. Aim: To provide insight into lumen and calcium characteristics assessed with CTCA, we compared these parameters to the reference of intravascular ultrasound (IVUS). Material and methods: Two hundred and fifty-two calcified lesions within 97 arteries of 60 patients (19 women, age 63 ±10 years) underwent assessment with both 2 x 64 slice CT (Somatom Definition, Siemens) and IVUS (s5, Volcano Corp.). Coronary lumen and calcium dimensions within calcified lesions were assessed with CTCA and compared to the reference measurements made with IVUS. Results: On average CTCA underestimated mean lumen diameter (2.8 ±0.7 mm vs. 2.9 ±0.8 mm for IVUS), lumen area (6.4 ±3.4 mm² vs. 7.0 ±3.7 mm² for IVUS, p < 0.001) and total calcium arc (52 ±35° vs. 83 ±54°). However, analysis of tertiles of the examined parameters revealed that the mean lumen diameter, lumen area and calcium arc did not significantly differ between CTCA and IVUS within the smallest lumens (1st tertile of mean lumen diameter at 2.1 mm, and 1st tertile of lumen area at 3.7 mm²) and lowest calcium arc (mean of 40°). Conclusions: Although, on average, CTCA underestimates lumen diameter and area as well as calcium arc within calcified lesions, the differences are not significant within the smallest vessels and calcium arcs. The low diagnostic accuracy of CTCA within calcified lesions may be attributed to high variance and not to systematic error of measurements. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the economic impact of integrating coronary CT angiography (cCTA) or whole chest “triple-rule-out” CTA (TRO-CTA) in the work-up of patients with acute chest pain. Materials and methods: 100 consecutive emergency department patients with acute chest pain and an intermediate cardiac risk for ACS underwent cCTA or TRO-CTA (cCTA group). Diagnostic performance, rate and length of hospitalization, hospital costs, hospital reimbursement and hospital profit were analyzed. All findings were compared to those of 100 different patients with acute chest pain that were evaluated with a standard of care (SOC) diagnostic algorithm (SOC group) that did not include cCTA. Diagnostic performance (“safety”) of both algorithms was defined as the absence of major adverse cardiac events (MACE) over a 90-day follow-up period. Results: In the cCTA group 60/100 patients were safely discharged at the same day. 19/100 patients were hospitalized due to significant coronary stenosis on cCTA, which was confirmed by invasive coronary catheterization (ICC) in 17/19 patients. Relevant non-coronary disease that led to hospitalization were found in 21 patients of the cCTA group. In the SOC group all patients were hospitalized. 87 of these hospitalized patients underwent ICC for exclusion of coronary artery stenosis. A significant coronary artery stenosis was found in only 25 of these patients. Within the cCTA group no patient suffered from MACE over the 90-day follow-up period. In the SOC group 2 patients were rehospitalized during the 90-day follow-up period due to recurrent chest pain and 1 patient because of a pseudoaneurym of the left femoral artery after ICC. The median hospital costs per patient were significantly lower in the cCTA group than in the SOC group (428.9€ vs. 1575.0€, p <0.001). The median reimbursement of the cCTA group was less compared to the SOC group (589.8€ vs. 2412.1€, p <0.001) and patients in the cCTA group gained less profit than patients in the SOC group (57.0€ vs. 448.4€, p <0.001). Conclusion: Integrating cCTA or TRO-CTA in a SOC algorithm can safely reduce the number of hospitalized patients and reduce total health care costs. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the impact of coronary CT angiography (coronary CTA) or “triple-rule-out” CT angiography (TRO-CTA) on patient management in the work-up of patients with acute chest pain and an intermediate cardiac risk profile. Materials and methods: 100 patients with acute chest pain and an intermediate cardiac risk for acute coronary syndrome (ACS) underwent coronary CTA or TRO-CTA for the evaluation of chest pain. Patients with a high and low cardiac risk profile were not included in this study. All patients with significant coronary stenosis >50% on coronary CTA underwent invasive coronary catheterization (ICC). Important other pathological findings were recorded. All patients had a 90-day follow-up period for major adverse cardiac events (MACE). Results: Based on a negative coronary CTA 60 of 100 patients were discharged on the same day. None of the discharged patients showed MACE during the 90-day follow-up. Coronary CTA revealed a coronary stenosis >50% in 19 of 100 patients. ICC confirmed significant coronary stenosis in 17/19 patients. Among the 17 true positive patients, 9 underwent percutaneous coronary intervention with stent implantation, 7 were received intensified medical therapy, and 1 patient underwent coronary artery bypass surgery. A TRO-CTA protocol was performed in 36/100 patients due to elevated d-dimer levels. Pulmonary embolism was present in 5 patients, pleural effusion of unknown etiology in 3 patients, severe right ventricular dysfunction with pericardial effusion in 1 patient, and an incidental bronchial carcinoma was diagnosed in 1 patient. Conclusion: Coronary CTA and TRO-CTA allow a rapid and safe discharge in the majority of patients presenting with acute chest pain and an intermediate risk for ACS while at the same time identifies those with significant coronary artery stenosis. [Copyright &y& Elsevier]

Congenital abnormalities of coronary arteries are an uncommon cause of sudden cardiac death and are difficult to detect at coronary angiography. We describe two patients with acute coronary syndrome and non-occlusive coronary artery disease in which a 64-multidetector computed tomography (MDCT) coronary angiography showed the presence of a malignant coronary anomaly. Sixty-four-MDCT with the possibility of 3D reconstructions allows for easier diagnosis of coronary anomalies and provides essential details necessary for operative intervention. [ABSTRACT FROM AUTHOR]

Background: The covered stent is one of the most promising tools for the treatment of intracranial fusiform aneurysms. We developed an in vivo model of fusiform aneurysms and evaluated the effectiveness of double telescoping Willis covered stents for their treatment.Materials and Methods: An external jugular vein graft was anastomosed with the common carotid artery (CCA) to construct the fusiform aneurysm model. After at least 4 weeks, two Willis covered stents were implanted in a telescopic fashion. Angiography follow-up was performed at 2 weeks and 1 and 3 months to examine the grafts. The animals were sacrificed at 1 or 3 months of the follow-up period, and the stents were examined histologically.Results: A total of eight fusiform aneurysms in four canines were created and 16 covered stents were implanted successfully. No technical or device-related difficulties occurred. The angiographic follow-up results showed that six fusiform aneurysms were completely occluded, and a minimal endoleak occurred in two fusiform aneurysms. Histological examination revealed endothelial progress and all aneurysm sacs were filled with thrombi.Conclusion: Vein graft anastomosis with CCA to construct a model of fusiform aneurysm may reproduce the clinical conditions. This study demonstrated that the implantation of two Willis covered stents in a telescoping fashion is an effective way to treat an experimental model of fusiform aneurysm. [ABSTRACT FROM AUTHOR]

Abstract: Background: Coronary angiography (CA) has been the gold standard technique for studying coronary artery disease. It is based on the analysis of bidimensional orthogonal projections that may not be optimal to estimate determinate coronary segments. Rotational angiography “Xperswing” (DARCA) is a new technique that allows the visualization of the coronary arteries from multiple views, with a single contrast injection. The aim of this study is to evaluate the coronary lesions quantification with DARCA. Methods: Quantitative coronary analysis of significant coronary stenosis (>50%) was performed. Every lesion was measured in two different projections: the “optimal projection”, obtained by DARCA and defined by the operator as the one with a better lesion qualification, and the “standard projection”, corresponding to the usual projection closer to the optimal one in obliquity and angulation. Measures were performed twice and by two independent operators. Intra- and inter-observer correlation was estimated by Kappa index and variables were compared with t Student test (SPSS 14.0). Results: 205 lesions in 147 patients were analyzed. Kappa coefficient intra-observer was 0.80 and 0.86 respectively with an inter-observer correlation index of 0.72. Lesion length and maximal diameter of the vessel were significantly greater in the group of RA. In the segments analysis, calculated length was longer for the first diagonal branch, first marginal obtuse artery, middle circumflex, middle and distal RCA and posterior descending artery, with greater reference diameters for proximal LAD and distal RCA. There were no significant differences for coronary stenosis grade. Conclusions: RA XperSwing provides a better visualization of coronary arteries improving lesions characterization, with longer measured lesions length and greater vessel diameters, especially in coronary segments with more angulation. [Copyright &y& Elsevier]

Abstract: An increase of biomarkers of myocardial necrosis is observed frequently after percutaneous coronary interventions (PCI) even when the procedure seems angiographically successful and otherwise uncomplicated. The recently updated Universal Definition of Myocardial infarction (MI) arbitrarily defined periprocedural MI (type 4a) by elevation of cardiac troponin (cTn) values >5 × the upper reference limit (URL) in patients with normal baseline values or a rise of cTn values >20% if the baseline values are elevated, together with either angina or new ECG changes or angiographic loss of patency of a coronary artery or a side branch or persistent slow or no-flow or embolization, or imaging demonstration of new loss of viable myocardium. Most frequent causes of such event are side-branch closure and/or plaque microembolization. The present review is focused on the prognostic implication of periprocedural necrosis. The risk related to a PCI-induced MI is significantly lower as compared to a spontaneous event where a similar increase of biomarkers is detected. Moreover, although an association between CK-MB elevations and adverse prognosis after PCI has been documented, existing data do not support the statement that an isolated elevation of troponins after PCI is associated with an adverse prognosis after PCI; increased troponin levels before PCI seem far more predictive of future events than a peri-procedural itself. Caution should be paid in the interpretation of clinical trials using type 4a MI as a primary endpoint. Nevertheless, patients with periprocedural myocardial damage should be treated as a higher-risk cohort, carefully monitored and receive an intensified secondary prevention program. [Copyright &y& Elsevier]

Abstract: Background: The presence of large thrombus burden in patients presenting with acute myocardial infarction (AMI) is common and associated with poor prognosis. This study aimed to describe the feasibility and safety of the novel ‘mother-in-child’ thrombectomy (MCT) technique in patients presenting with AMI and large thrombus burden undergoing percutaneous coronary intervention (PCI). Methods: We studied 13 patients presenting with AMI who underwent PCI with persistent large intracoronary thrombus after standard thrombectomy. The procedure was performed using a 5F ‘Heartrail II-ST01’ catheter (Terumo Medical) into a 6F guiding system. Angiographic assessment of thrombus burden and coronary flow was obtained at baseline, immediately after thrombectomy and at the end of the procedure. Results: The mean age was 55.9±13.0years and involved mostly males (76.9%). All patients underwent PCI via radial approach. Following MCT Thrombolysis In Myocardial Infarction (TIMI) flow improved by 2 or more degrees in 11 patients (84.5%), while visible angiographic thrombus was reduced in 11 patients (84.5%). In the final angiogram, normal TIMI flow was restored in 11 patients (84.5%), with normal myocardial ‘blush’ in 7 patients (53.8%) and total clearance of a visible thrombus in 7 patients (53.8%). Overall, 6 patients received thrombectomy as ‘stand-alone’ procedure. All patients were discharged alive after a mean of 5.6±2days. Conclusion: This initial report suggests that significant reduction in thrombus burden and improvement of the coronary flow can be safely achieved in patients presenting with AMI and large thrombus burden by using the novel MCT technique. [Copyright &y& Elsevier]

Background: Controlling intracoronary computed tomography (CT) number for coronary CT angiography (CCTA) has been difficult. Objective: The study assessed whether intracoronary CT number of CCTA could be estimated. Methods: One hundred twenty six patients were randomly assigned to either CCTA with 30 rnL of contrast media (CM) following 5 mL of CM at timing bolus or CCTA with 50 mL of CM following lOmL of CM at timing bolus. The relationships between intracoronary CT number and patients' characteristics and peak time and peak CT number at timing bolus in patients who showed valid time-density curve were analyzed in both groups. Then, the multiple regression equation best described was made. The prediction system was validated by 112 patients randomly targeted between 250 HU and 430 HU of CT number. Results: In group 5/30, intracoronary CT number was positively correlated with peak CT number at timing bolus (correlation coefficient, 1.42, p<0.001), negatively correlated with body surface area (-109.19, p< 0.001 ) and peak time (-6.93, p <0.001). Whereas, intracoronary CT number was positively correlated with only peak CT number at timing bolus ( 1.33, p< 0.001 ) in group 10/50. Then, CT number-controlling system using the simple equation best described CT number was established for CCTA following 5 mL of CM at timing bolus. Of 112 patients, there was good correlation between target CT number and measured CT number (r=0.85, p < 0.0001 ) in 96 patients (85.7%), having valid time-density curve at timing bolus. Conclusions: Controlling CT number may be enabled by CT number-controlling system following 5 mL of CM at timing bolus. [ABSTRACT FROM AUTHOR]

Objectives: We sought to evaluate the prevalence of fibromuscular dysplasia (FMD) and other predisposing conditions among spontaneous coronary artery dissection (SCAD) patients. Background: Spontaneous coronary artery dissection is considered rare. However, we observed many young women with SCAD and concomitant FMD. Methods: Spontaneous coronary artery dissection patients were identified prospectively and retrospectively at Vancouver General Hospital over the past 6 years. Coronary angiograms were meticulously reviewed by 2 senior interventional cardiologists. Identified patients were contacted for prospective evaluation at our SCAD clinic, and screening for FMD of renal, iliac, and cerebrovascular arteries was performed with computed tomography angiography or magnetic resonance angiography, if not already screened during the index angiogram. Potential predisposing and precipitating conditions for SCAD were extracted from clinical history. Results: We identified 50 patients with nonatherosclerotic SCAD from April 2006 to March 2012. Average age was 51.0 years, and almost all were women (98.0%). All presented with myocardial infarction (MI), 30.0% had ST-segment elevation, and 70.0% had non–ST-segment elevation MI. Only 1 was postpartum, and 2 were involved in intense isometric exercises. Emotional stress was reported in 26.0% before the MI. Twelve percent had >1 dissected coronary artery. Most SCAD patients had FMD of ≥1 noncoronary territory (86.0%): 25 of 43 (58.1%) renal, 21 of 43 (48.8%) iliac, and 20 of 43 (46.5%) cerebrovascular (6 of 43, 14.0% had intracranial aneurysm). Five had incomplete FMD screening. Conclusions: Nonatherosclerotic SCAD predominantly affects women, and most have concomitant FMD. We suspect these patients have underlying coronary FMD that predisposed them to SCAD, but this requires proof from histology or intracoronary imaging of the affected coronary arteries. [ABSTRACT FROM AUTHOR]

Background: Optimal contrast enhancement is crucial for the detection of coronary artery stenoses and atherosclerotic changes in coronary CT angiography (CTA). Purpose: To demonstrate the feasibility of using the cardiac output (CO) obtained from the test bolus injection data-set (COtest) as a factor in contrast injection rate revision of the following coronary CTA. Material and Methods: The test bolus injection data-sets of 52 consecutive coronary CTAs were examined. COtest was calculated from the test bolus data-set. Aortic peak enhancement (APE) was measured on the following coronary CTA. We simulated the APE at a fixed contrast injection rate of 4 mL/s (simAPE) in each patient. Results: The ranges of COtest and simAPE were 2.82-7.56 L/min and 194-527 Hounsfield Units, respectively. There was a significant negative correlation (R = -0.802, P < 0.001) between simAPE and COtest. Conclusion: COtest can be used for injection rate revision on coronary CTA. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to determine the accuracy of plaque pattern assessment by coronary computed tomography angiography (CCTA) to differentiate between early and advanced atherosclerotic lesions as defined by histology. Background: A ringlike attenuation pattern of coronary atherosclerotic plaques termed as napkin-ring sign (NRS) was described in CCTA of patients who had acute coronary syndrome. Methods: All procedures were performed in accordance with local and federal regulations and the Declaration of Helsinki. Approval of the local ethics committees was obtained. We investigated 21 coronary arteries of 7 donor hearts. Overall, 611 histological sections were obtained and coregistered with CCTA images. The CCTA cross sections were read in random order for conventional plaque categories (noncalcified [NCP], mixed [MP], calcified [CP]) and plaque patterns (homogenous, heterogeneous with no napkin-ring sign [non-NRS], and heterogeneous with NRS). Results: No plaque was detected in 134 (21.9%), NCP in 254 (41.6%), MP in 191 (31.3%), and CP in 32 (5.2%) CCTA cross sections. The NCP and MP were further classified into homogenous plaques (n = 207, 46.5%), non-NRS plaques (n = 200, 44.9%), and NRS plaques (n = 38, 8.6%). The specificities of NCP and MP to identify advanced lesions were moderate (57.9%, 95% confidence interval [CI]: 50.1% to 65.6%, and 72.1%, 95% CI: 64.7% to 79.4%, respectively), which were similar to the homogenous and heterogeneous plaques (62.6%, 95% CI: 54.8% to 70.3%, and 67.3%, 95% CI: 58.6% to 76.1%, respectively). In contrast, the specificity of the NRS to identify advanced lesions was excellent (98.9%, 95% CI: 97.6% to 100%). The diagnostic performance of the pattern-based scheme to identify advanced lesions was significantly better than that of the conventional plaque scheme (area under the curve: 0.761 vs. 0.678, respectively; p = 0.001). Conclusions: The assessment of the plaque pattern improves diagnostic accuracy of CCTA to identify advanced atherosclerotic lesions. The CCTA finding of NRS has a high specificity and high positive predictive value for the presence of advanced lesions. [Copyright &y& Elsevier]

Background: Intramural coronary artery course (IMCA) is associated with an increased risk of coronary event and mortality after the arterial switch operation (ASO). We describe early and late outcomes at our institution from 1996 to 2006. Methods: Operation notes for all patients who underwent ASO within 60 days of birth were reviewed, and those with IMCA were identified. Mortality and morbidity were obtained from discharge summary, predischarge electrocardiogram, and echocardiogram. Follow-up included clinical review, electrocardiogram, echocardiography, dobutamine stress echocardiography, and angiography. Results: Eighteen patients of 215 in the cohort (8.4%) had IMCA. Intramural coronary artery course was more common in patients from French Polynesia (6 of 17; 35.3% versus 12 of 198; 6.1%; p = 0.001). Early mortality for patients with IMCA was 1 of 18 (5.6%) compared with 6 of 197 (3%) for those without IMCA (p = 0.46). One IMCA patient was lost to follow-up. The remaining 16 are alive and asymptomatic. Of the 13 who underwent angiography, 2 had minor coronary artery stenoses at initial nonselective aortic root angiography. Both stenoses resolved at subsequent selective coronary angiography. None of the 11 who underwent dobutamine stress echocardiography had inducible ischemia. Conclusions: We report a high prevalence of IMCA in an ASO population, particularly among patients referred from French Polynesia. Intramural coronary artery course was not a risk factor for mortality after ASO. Angiography demonstrated excellent short-term and long-term structural outcome for IMCA. [ABSTRACT FROM AUTHOR]

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Objectives: This study was designed to determine the prognostic value of multidetector coronary computed tomography angiography (CTA) in relation to exercise electrocardiography (XECG) findings. Background: The prognostic usefulness of coronary CTA findings of coronary artery disease in relation to XECG findings has not been explored systematically. Methods: Patients with suspected coronary artery disease who had undergone both coronary CTA and XECG (<90 days between tests) from 2003 through 2009 were enrolled retrospectively. Coronary CTA results were classified according to the severity of maximal stenosis (normal, mild: <40% of luminal stenosis, moderate: 40% to 69%, severe: ≥70%), XECG results were categorized as positive and negative, and Duke XECG score was calculated. Clinical follow-up data were collected for major adverse cardiac events (MACE): cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, and revascularization after 90 days from index coronary CTA. C-statistics were calculated to compare discriminatory values of each test. Results: Among the 2,977 (58 ± 10 years) study patients, 12% demonstrated positive XECG results. By coronary CTA, patients were categorized as normal (56%) or having mild (26%), moderate (13%), or severe (5%) disease. During a median follow-up of 3.3 years (interquartile range: 2.3 to 4.6), 97 MACE were observed and the 5-year cumulative event rate was 3.6% (95% confidence interval: 3.0 to 4.3). Although both XECG (C-statistic: 0.790) and coronary CTA (C-statistic: 0.908) improved risk stratification beyond clinical risk factors (C-statistic: 0.746, p < 0.05 for all), XECG in addition to coronary CTA (C-statistic: 0.907) did not provide better discrimination than coronary CTA alone (p = 0.389). In subgroup analyses, coronary CTA stratified risk of MACE in groups with both positive and negative XECG results (all p < 0.001 for trend). However, positive XECG results predicted risk of MACE on coronary CTA only in the moderate stenosis group (hazard ratio: 2.58, 95% confidence interval: 1.29 to 5.19, p = 0.008) and severe stenosis group (hazard ratio: 2.28, 95% confidence interval: 1.19 to 4.38, p = 0.013). Conclusions: In patients with suspected coronary artery disease, coronary CTA discriminates future risk of MACE in patients independent of XECG results. Compared with coronary CTA, XECG has an additive prognostic value only in patients with moderate to severe stenosis on coronary CTA. [Copyright &y& Elsevier]

Abstract: Background: The aim of this study was to investigate whether high epicardial adipose tissue (EAT) volume is related to the presence of vulnerable coronary plaque components as assessed by computed tomography (CT). Methods: We evaluated 357 patients referred for 64-slice CT, and assessed coronary plaque components and EAT volume. Vulnerable coronary plaque components were defined as the presence of non-calcified plaque (NCP), including low-density plaque (LDP: <39 HU) and positive remodeling (PR: remodeling index >1.05). In accordance with a previous report, patients were assigned to two groups: low (<100ml) or high (≥100ml) EAT volume. Results: Compared to the low EAT volume group, the high EAT volume group had a higher prevalence of NCP (74% vs. 59%, p =0.003). Additionally, the high EAT volume group had a higher prevalence of LDP with PR than the low EAT volume group (46% vs. 25%, p <0.001). Interestingly, a high EAT volume was an independent predictor of LDP with PR (odds ratio 2.56, 95% confidence interval 1.38–4.85, p =0.003) after adjusting for age, gender, traditional cardiovascular risk factors, body mass index (BMI), abdominal visceral adipose tissue (VAT), and coronary artery calcium (CAC) scores. Conclusions: A high EAT volume was associated with the presence of vulnerable plaque components, independent of obesity measurements (BMI and VAT) and CAC scores. [Copyright &y& Elsevier]

Abstract: Objective: The effect of statins on coronary artery plaque features beyond stenosis severity is not known. Coronary CT angiography (CCTA) is a novel non-invasive method that permits direct visualization of coronary atherosclerotic features, including plaque composition. We evaluated the association of statin use to coronary plaque composition type in patients without known coronary artery disease (CAD) undergoing CCTA. Methods: From consecutive individuals, we identified 6673 individuals (2413 on statin therapy and 4260 not on statin therapy) with no known CAD and available statin use status. We studied the relationship between statin use and the presence and extent of specific plaque composition types, which was graded as non-calcified (NCP), mixed (MP), or calcified (CP) plaque. Results: The mean age was 59 ± 11 (55% male). Compared to the individuals not taking statins, those taking statins had higher prevalence of risk factors and obstructive CAD. In multivariable analyses, statin use was associated with increased the presence of MP [odds ratio (OR) 1.46, 95% confidence interval (CI) 1.27–1.68), p < 0.001] and CP (OR 1.54, 95% CI 1.36–1.74, p < 0.001), but not NCP (OR 1.11, 95% CI 0.96–1.29, p = 0.1). Further, in multivariable analyses, statin use was associated with increasing numbers of coronary segments possessing MP (OR 1.52, 95% CI 1.34–1.73, p < 0.001) and CP (OR 1.52, 95% CI 1.36–1.70, p < 0.001), but not coronary segments with NCP (OR 1.09, 95% CI 0.94–1.25, p = 0.2). Conclusion: Statin use is associated with an increased prevalence and extent of coronary plaques possessing calcium. The longitudinal effect of statins on coronary plaque composition warrants further investigation. [Copyright &y& Elsevier]

Absence of the left circumflex coronary artery (LCX) is a very rare coronary anomaly. The anomaly has been reported in only 0.003% of all patients who underwent routine coronary angiography. Although rare, the failure to visualize a coronary artery in its expected anatomical location might cause life-threatening complications such as total occlusion with acute coronary syndromes. In the present paper, we report a patient with absent LCX and discuss the previously reported cases in terms of diagnostic and clinical importance, association with atherosclerosis and other anomalies. We searched Medline (www.ncbi.nlm.nih.gov) for cases of absent LCX and found that so far absence of LCX has been reported 27 times and in 32 cases. Here in this case report and minireview we discuss the characteristics of the present case and previous 32 cases with absence of LCX. The majority of the patients were over 30 years old at the time of diagnosis and the condition is more common in females. Although absence of LCX is generally considered as a benign entity, it might be atherosclerotic and can cause acute coronary syndromes including myocardial infarction and be associated with other anomalies. Proper diagnosis of the absence of LCX is very important because it can be misinterpreted as a totally occluded LCX. In subjects with absent LCX, infarction in the superdominant RCA might be more dangerous. It is more common in females and although conventional coronary angiography is the most widely used diagnostic modality, multidetector computed tomography might also be helpful. [ABSTRACT FROM AUTHOR]

The article presents a study to assess the diagnostic performance of fractional flow reserve (FFR) and computed tomography (CT) for diagnosis of coronary stenosis. It informs that the coronary computed tomographic (CT) angiography is a noninvasive anatomic test for diagnosis of coronary artery disease (CAD) or stenosis irrespective of ischemia. It further adds that the fractional flow reserve (FFR) is a physiologic measure of coronary stenosis reflecting the amount of coronary flow stenosis and an invasive procedure. It is concluded that the use of noninvasive FFR and CT among stable patients of CAD are associated with improved diagnostic accuracy.

Abstract: Rationale and objective: To evaluate the feasibility of transthoracic Doppler echocardiography to determine the optimal pulsing windows for CT coronary angiography to narrow the pulsing windows further, especially in higher heart rate. Materials and methods: Doppler was performed on 135 patients before CT scanning. For Doppler, the intervals with minimal motion were evaluated during both systole and diastole integrating electrocardiogram (ECG) intervals. For CT scanning, the retrospective ECG-gating was applied and the optimal reconstruction intervals were determined. The accuracy of Doppler analysis to predict the optimal reconstruction intervals was tested. The predicted length of pulsing windows was compared between Doppler analysis and traditional prospective ECG-gating protocol (heart rate≦65bpm, 60–76%; 66–79bpm, 30–77%; ≧80bpm, 31–47%). Results: According to Doppler analysis, the mean length of intervals with minimal motion in systole was 106.4±39.2ms and 125.2±92.0ms in diastole. When the intervals with minimal motion during diastole>90ms, the optimal reconstruction intervals were located at diastole; otherwise, at systole (P <0.001). The optimal reconstruction intervals in 93.8% (132/135) patients could be predicted accurately by Doppler analysis. If the optimal reconstruction intervals predicted by Doppler were applied as the exposure windows, the mean length of pulsing windows should has been 105.2±69.4ms (range: 26.9–510.3ms), which was significantly shorter than that of traditional prospective ECG-gating protocol (232.0±120.2ms, range: 93.2–427.3ms, P <0.001). Conclusion: Doppler can help detecting the optimal pulsing windows accurately. Prospective ECG-gating incorporating Doppler analysis may narrow pulsing windows significantly while maintaining image quality. [Copyright &y& Elsevier]

Background: Coronary artery anomalies are not common, but could be very serious. Objectives: This study determines the frequency of coronary anomalies and normal variants by multi-detector-row computed tomography (MDCT). Patients and Methods: The results of cardiac MDCT study in 2697 consecutive patients were analyzed retrospectively. Acquisition was performed by a 64-detector row CT machine. Imaging results were assessed by experienced radiologists. Results: Myocardial bridging was by far the most frequent coronary variant (n = 576, 21.3%). Eighty-three subjects (3.1%) showed other coronary anomalies and variants. Anomalies of origination and course of the left main coronary artery (LMCA) were detected in 1.09% of the subjects. The frequency of these anomalies in the right coronary artery (RCA), left circumflex artery (LCx), left anterior descending artery (LAD), posterior descending artery (PDA) and obtuse marginal (OM) artery were 1.24%, 0.33%, 0.1%, 0.07% and 0.03%, respectively. The single coronary pattern was seen in 0.18% and coronary fistulas in 0.07%. Conclusions: Based on the fact that coronary CT-angiography using MDCT can display different coronary anomalies, this study shows similar results to other reports on the subject. Future advances in the performance of CT machines will further improve the quality of CT-based cardiac imaging. [ABSTRACT FROM AUTHOR]

Objectives: The goal of this analysis was to determine the association between intraprocedural complications and clinical outcomes among patients with high-risk non–ST-segment elevation acute coronary syndrome (NSTEACS) undergoing percutaneous coronary intervention (PCI). Background: Among patients undergoing PCI for NSTEACS, the relationship between intraprocedural complications and clinical outcomes, independent of epicardial and myocardial perfusion, has not been well characterized. Methods: The EARLY ACS (Early Glycoprotein IIb/IIIa Inhibition in Non–ST-Segment Elevation Acute Coronary Syndrome) trial enrolled 9,406 patients with high-risk NSTEACS undergoing an early invasive strategy. Of these, 1,452 underwent angiographic assessment in an independent core laboratory and did not have a myocardial infarction (MI) between enrollment and angiography. We assessed the relationship between abrupt closure, loss of side branch(es), distal embolization, and no-reflow phenomenon and 30-day clinical outcomes in these patients. Results: Of the patients, 166 (11.4%) experienced an intraprocedural complication. Baseline clinical characteristics were similar between patients who did and did not have complications. The 30-day composite of death or MI was significantly higher among patients with an intraprocedural complication (28.3% vs. 7.8%, odds ratio [OR]: 4.68, 95% confidence interval [CI]: 3.2 to 7.0, p < 0.001). Individually, both mortality (3.0% vs. 0.9%, OR: 3.60, 95% CI: 1.2 to 10.5, p = 0.019) and MI (27.1% vs. 7.4%, OR: 4.66, 95% CI: 3.1 to 7.0, p < 0.001) were significantly increased. After adjusting for differences in post-PCI epicardial and myocardial perfusion, the association with 30-day death or MI remained significant. Conclusions: Among high-risk NSTEACS patients undergoing an invasive strategy, the incidence of intraprocedural complications is high, and the occurrence of these complications is associated with worse clinical outcomes independent of epicardial and myocardial perfusion. (Early Glycoprotein IIb/IIIa Inhibition in Patients With Non–ST-segment Elevation Acute Coronary Syndrome [EARLY ACS]; NCT00089895) [Copyright &y& Elsevier]

Objectives: This study sought to compare everolimus-eluting stents (EES) with zotarolimus-eluting stents (ZES) in patients with acute myocardial infarction (AMI). Background: There is a paucity of data to exclusively evaluate the safety and efficacy of second-generation drug-eluting stents (DES) in the setting of AMI. Methods: The present study enrolled 3,309 AMI patients treated with ZES (n = 1,608) or EES (n = 1,701) in a large-scale, prospective, multicenter registry—KAMIR (Korea Acute Myocardial Infarction Registry). Propensity score matching was applied to adjust for differences in baseline clinical and angiographic characteristics, producing a total of 2,646 patients (1,343 receiving ZES, and 1,343 receiving EES). Target lesion failure (TLF) was defined as the composite of cardiac death, recurrent nonfatal myocardial infarction, or target lesion revascularization. Major clinical outcomes at 1 year were compared between the 2 propensity score-matched groups. Results: After propensity score matching, baseline clinical and angiographic characteristics were similar between the 2 groups. Clinical outcomes of the propensity score-matched patients showed that, despite similar incidences of recurrent nonfatal myocardial infarction and in-hospital and 1-year mortality, patients in the EES group had significantly lower rates of TLF (6.5% vs. 8.7%, p = 0.029) and probable or definite stent thrombosis (0.3% vs. 1.6%, p < 0.001), compared with those in the ZES group. Furthermore, there was a numerically lower rate of target lesion revascularization (1.2% vs. 2.2%, p = 0.051) in the EES group than in the ZES group. Conclusions: In this propensity-matched comparison, EES seems to be superior to ZES in reducing TLF and stent thrombosis in patients with AMI. [Copyright &y& Elsevier]

Objectives: This study sought to determine the risk versus benefit ratio of an early aggressive (EA) approach in elderly patients with non–ST-segment elevation acute coronary syndromes (NSTEACS). Background: Elderly patients have been scarcely represented in trials comparing treatment strategies in NSTEACS. Methods: A total of 313 patients ≥75 years of age (mean 82 years) with NSTEACS within 48 h from qualifying symptoms were randomly allocated to an EA strategy (coronary angiography and, when indicated, revascularization within 72 h) or an initially conservative (IC) strategy (angiography and revascularization only for recurrent ischemia). The primary endpoint was the composite of death, myocardial infarction, disabling stroke, and repeat hospital stay for cardiovascular causes or severe bleeding within 1 year. Results: During admission, 88% of the patients in the EA group underwent angiography (55% revascularization), compared with 29% (23% revascularization) in the IC group. The primary outcome occurred in 43 patients (27.9%) in the EA group and 55 (34.6%) in the IC group (hazard ratio [HR]: 0.80; 95% confidence interval [CI]: 0.53 to 1.19; p = 0.26). The rates of mortality (HR: 0.87; 95% CI: 0.49 to 1.56), myocardial infarction (HR: 0.67; 95% CI: 0.33 to 1.36), and repeat hospital stay (HR: 0.81; 95% CI: 0.45 to 1.46) did not differ between groups. The primary endpoint was significantly reduced in patients with elevated troponin on admission (HR: 0.43; 95% CI: 0.23 to 0.80), but not in those with normal troponin (HR: 1.67; 95% CI: 0.75 to 3.70; p for interaction = 0.03). Conclusions: The present study does not allow a definite conclusion about the benefit of an EA approach when applied systematically among elderly patients with NSTEACS. The finding of a significant interaction for the treatment effect according to troponin status at baseline should be confirmed in a larger size trial. (Italian Elderly ACS Study; NCT00510185) [Copyright &y& Elsevier]

Abstract: Background: Coronary artery ectasia (CAE) is well-recognized, angiographic finding of abnormal coronary artery dilatation, and detected in 0.3–5.3% of angiographic studies. The gold standard for diagnosis this type of aneurysm is coronary angiography, which provides information about the size, sample, location and number of aneurysms. Despite growing prevalence in recent years, controversy still exists as to the pathogenetic mechanisms that underlie this entity. In this study we search the effect of isolated CAE on P-wave and QT interval dispersion. Patients and methods: Twenty patients (mean age: 60±9.7years) with isolated CAE (group I) were included in the study and 18 control subjects (group II) matched in sex and age. Both groups underwent a standard 12-lead surface electrocardiogram recorded at 50mm/s. Maximal (P max) and minimal P-wave durations (P min) are measured. P dispersion (PD) was defined as the difference between P max and P min. QT interval was measured from the onset of the QRS complex to the end of the T-wave, defined as the return to the T–P isoelectric line. The mean of three consecutive intervals in each analyzable lead was taken for analysis. QT dispersion was defined as the difference between the longest and shortest QT intervals and the rate corrected with Bazett’s formula. Results: P max (117.1±4.6) and PD (34.2±5.4) were significantly higher in ectatic patients (group I) than those of the control (group II) [P max (100.5±5) and PD (18±5.4)], while no significant difference between the two groups as regards P min. C QT duration (401±4.4), QT dispersion (31.7±3), and C QT dispersion (33.9±3.3) were significantly higher in group I than those of group II [C QT duration (391.9±2), QT dispersion (27.3±1), and C QT dispersion (29±0.9)]. While there were no statistically significant difference between the two groups as regards echo data (EDD, ESD, EF, LA, LVMI, and AO). Conclusion: Isolated CAE were found to be associated with prolonged dispersion of P-wave and QT interval. [Copyright &y& Elsevier]

Abstract: Objective: To investigate the clinical significance of reciprocal ST segment depression on the presenting electrocardiogram in patients with acute inferior myocardial infarction. Design and setting: A prospective, randomized, controlled single center study done in the critical care department, Cairo university Hospital. Subjects: Forty consecutive patients with acute inferior myocardial infarction were enrolled in this study divided into two groups, 20 patients with reciprocal ST depression (group 1) and 20 patients without such depression (group 2). Interventions: All patients were investigated with serial ECG, cardiac biomarkers, echocardiography and coronary angiography. Results: There was no significant difference in the proportion of coronary disease risk factors in patients in group 1, versus those in group 2. Patients in group 1 had significant higher degree ST elevation (in inf. Leads) than patients in group 2, higher levels of peak total CPK and CKMB was also seen. In addition patients in group 1 developed complication more frequently than those in group 2. Although no statistically significant difference between the two groups was seen as regard the ejection fraction sought by echocardiography, it did show a higher incidence of mitral regurge in group 1 [14 (70%)] versus 6 (30%) in group 2 with P value of 0.01. In group 1 left anterior descending artery lesions was significantly more frequent than in group 2 with P value<0.001, also multivessel disease was significantly more frequent in group 1. Conclusion: The significance of reciprocal ST depression on the electrocardiogram during the course of inferior MI remains uncertain, opinion is divided as to whether it is a benign electrical phenomenon or a sign of a greater myocardial necrosis and more frequent left coronary artery disease, from our study we support the latter opinion. This simple ECG finding may be used to differentiate high risk patients for a more aggressive approach. [Copyright &y& Elsevier]

Abstract: Cystatin-C (CYS-C) has emerged as a highly sensitive marker of even a mildly impaired glomerular filtration rate. Experimental studies have suggested that its inhibitory effects on cysteine protease may help to prevent plaque destabilisation. We aimed to evaluate the predictive value of CYS-C level for major adverse cardiac events (MACE) including mortality and morbidity during the hospital stay and 3-month follow-up period. Methods: Seventy-five patients were hospitalised for acute coronary syndrome (ACS). Another control group consisted of patients who were presented with chest pain but no evidence of ischaemic heart disease documented by laboratory markers and angiography. Serum CYS-C levels were measured during the first 24h of admission. Patients with an abnormal creatinine-derived glomerular filtration rate (GFR) were excluded. Coronary angiography was performed for the entire study population. Results: In group I, the mean CYS-C was 1.836±0.782mg/l vs. 0.991±0.163mg/l in the control group (P <0.000). Cystatin-C showed a moderate correlation with total cholesterol in group I (r =0.5) and with LDL (r =0.367, P <0.01). CYS-C showed a moderate positive correlation with the number of diseased vessels (r =0.419, P <0.01) and a moderate significant positive correlation with Killip classification (r =0.349). Smoking was the only predictor associated with a high CYS-C level in the multivariate regression analysis (P =0.033). CYS-C was an independent predictor of MACE and heart failure complications either in-hospital or during follow-up (P <0.05). Conclusions: CYS-C could be a useful marker for diagnosing coronary arteriosclerosis. An elevated CYS-C in patients with ACS is an independent predictor of MACE either in-hospital or during follow-up. [Copyright &y& Elsevier]

Purpose: To compare the features of coronary computed tomography angiography (CCTA) imaging of the patients with acute total occlusion (ATO) of coronary artery with those of chronic total occlusion (CTO). Materials and Methods: CCTA of 26 patients with complete interruption of the coronary artery in CCTA and occlusion in conventional coronary angiography, were retrospectively analyzed. Discrimination between the ATO group (n = 11, patients with non ST-elevation myocardial infarction or unstable angina) and the CTO group (n = 15, patients with stable angina or nonspecific symptom) was arbitrarily determined by clinical diagnosis. Lesion length, remodeling index (RI), plaque density measured by Hounsfield units (HU), plaque composition, percentage attenuation drop across the lesion, and presence of myocardial thinning were evaluated. Results: Comparisons between the ATO and CTO groups revealed significantly shorter lesion length in the ATO group (0.40 cm vs. 1.87 cm, respectively; p = 0.001), and significantly higher RI (1.56 vs. 1.10, respectively; p = 0.004). Plaque density of the ATO group was lower (37.0 HU vs. 104.7 HU, respectively; p < 0.001) and noncalcified plaque was frequently seen in the ATO group (72.7% vs. 26.7%, respectively; p = 0.02). Percentage attenuation drop across the lesion was lower for the ATO group (10.92% vs. 25.44%, respectively; p = 0.005). Myocardial thinning was exclusively observed in the CTO group (seven of 15 patients, p = 0.01). Conclusion: CCTA shows various statistically significant differences between the ATO and CTO groups. [ABSTRACT FROM AUTHOR]

Purpose: We compared the quality, interpretive confidence and interreader agreement between SPECT and PET myocardial perfusion imaging (MPI) in the same group of patients. Methods: The study group comprised 27 patients (age 55 ± 8.5 years, 12 men) with known or suspected coronary artery disease (CAD) who had undergone gated rest/stress MPI with Tc-labelled agent SPECT (with and without attenuation correction, AC), and subsequent clinical confirmation with Rb PET. Three experienced readers blinded to the clinical information interpreted all MPI studies. Results: Interreader agreement was significantly superior for PET studies than for SPECT studies. Following consensus interpretation, the quality of 22 % of the non-AC SPECT studies, 33 % of the AC SPECT studies and 63 % of the PET studies was assessed as excellent or good ( p = 0.016). Interpretations were definitely normal or abnormal in 7 % of non-AC SPECT studies, 30 % of AC SPECT studies and 85 % of PET studies ( p = 0.046). In 13 patients who had received either invasive coronary angiography or CT angiography with no significant CAD, the true-positive rate for significant CAD was higher for PET, and the true-negative rate was equal for PET and AC SPECT, and lower for non-AC SPECT. Conclusion: Rb PET MPI, used as a confirmatory test after SPECT, offers improved image quality, interpretive confidence and interreader agreement. [ABSTRACT FROM AUTHOR]

Purpose: Obesity is a significant and independent risk factor for cardiovascular disease, and assessing ischaemia in obese patients is clinically important but sometimes difficult because of imaging artefacts. The aim of this study was to evaluate the feasibility and diagnostic accuracy of stress/rest imaging with a cadmium-zinc telluride (CZT) camera using a low-dose protocol in a series of consecutive obese patients referred for the evaluation of coronary artery disease. Methods: We considered 148 consecutive obese patients (mean BMI 39 ± 7 kg/m) with known or suspected coronary artery disease referred to our laboratory for stress/rest myocardial perfusion imaging. A subgroup of 103 of the 148 patients underwent invasive coronary angiography for clinical reasons. All patients underwent a single-day stress/rest low-dose ultrafast protocol. Patients were injected with Tc-tetrofosmin at a dose in the range 185-222 MBq during bicycle exercise or dipyridamole stress, and underwent the first scan with an acquisition time of 7 min starting 15 min after the end of the stress. The rest scan with an acquisition time of 6 min was started from 30 to 45 min after Tc-tetrofosmin injection at a dose in the range 370-444 MBq. Images were visually inspected, and the summed stress score (SSS) and summed rest score (SRS) were obtained. Results: Image quality was graded very good or excellent in all patients. Of the 103 patients who underwent coronary angiography, 12 (12 %), 26 (25 %) and 56 (54 %) showed one-, two- and three-vessel disease, and 9 showed normal coronary vessels. In the 103 patients submitted to coronary angiography, the mean SSS and SRS were 7±6 and 2±3, respectively. Semiquantitative regional and global SSS was a good discriminant of coronary artery disease and the area under the overall ROC curve was 0.848 (95 % CI 0.723-0.975). Conclusion: In obese patients, a single-day stress/rest low-dose ultrafast protocol with a CZT camera is clinically feasible and provides high image quality. [ABSTRACT FROM AUTHOR]

Objectives: To prospectively compare induced DNA double-strand breaks by cardiac computed tomography (CT) and conventional coronary angiography (CCA). Methods: 56 patients with suspected coronary artery disease were randomised to undergo either CCA or cardiac CT. DNA double-strand breaks were assessed in fluorescence microscopy of blood lymphocytes as indicators of the biological effects of radiation exposure. Radiation doses were estimated using dose-length product (DLP) and dose-area product (DAP) with conversion factors for CT and CCA, respectively. Results: On average there were 0.12 ± 0.06 induced double-strand breaks per lymphocyte for CT and 0.29 ± 0.18 for diagnostic CCA ( P < 0.001). This relative biological effect of ionising radiation from CCA was 1.9 times higher ( P < 0.001) than the effective dose estimated by conversion factors would have suggested. The correlation between the biological effects and the estimated radiation doses was excellent for CT (r = 0.951, P < 0.001) and moderate to good for CCA (r = 0.862, P < 0.001). One day after radiation, a complete repair of double-strand breaks to background levels was found in both groups. Conclusions: Conversion factors may underestimate the relative biological effects of ionising radiation from CCA. DNA double-strand break assessment may provide a strategy for individualised assessments of radiation. Key Points: • Radiation dose causes concern for both conventional coronary angiography and cardiac CT. • Estimations of the biological effects of ionising radiation may become feasible. • Fewer DNA double-strand breaks are induced by cardiac CT than CCA. • Conversion factors may underestimate the relative effects of ionising radiation from CCA. [ABSTRACT FROM AUTHOR]

Background: It is unclear whether an evaluation incorporating coronary computed tomographic angiography (CCTA) is more effective than standard evaluation in the emergency department in patients with symptoms suggestive of acute coronary syndromes. Methods: In this multicenter trial, we randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department on weekdays during daylight hours between April 2010 and January 2012. The primary end point was length of stay in the hospital. Secondary end points included rates of discharge from the emergency department, major adverse cardiovascular events at 28 days, and cumulative costs. Safety end points were undetected acute coronary syndromes. Results: The rate of acute coronary syndromes among 1000 patients with a mean (±SD) age of 54±8 years (47% women) was 8%. After early CCTA, as compared with standard evaluation, the mean length of stay in the hospital was reduced by 7.6 hours (P<0.001) and more patients were discharged directly from the emergency department (47% vs. 12%, P<0.001). There were no undetected acute coronary syndromes and no significant differences in major adverse cardiovascular events at 28 days. After CCTA, there was more downstream testing and higher radiation exposure. The cumulative mean cost of care was similar in the CCTA group and the standard-evaluation group ($4,289 and $4,060, respectively; P=0.65). Conclusions: In patients in the emergency department with symptoms suggestive of acute coronary syndromes, incorporating CCTA into a triage strategy improved the efficiency of clinical decision making, as compared with a standard evaluation in the emergency department, but it resulted in an increase in downstream testing and radiation exposure with no decrease in the overall costs of care. (Funded by the National Heart, Lung, and Blood Institute; ROMICAT-II ClinicalTrials.gov number, NCT01084239.) [ABSTRACT FROM PUBLISHER]