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To compare the image quality, evaluability, diagnostic accuracy, and radiation exposure of high-spatial-resolution (HR, 0.23-mm) computed tomographic (CT) coronary angiography with standard spatial resolution (SR, 0.625-mm) 64-section imaging in patients at high risk for coronary artery disease (CAD) by using invasive coronary angiography (ICA) as the reference method.Written informed consent was obtained from all patients, and the study protocol was approved by the institutional ethical committee. Patients at high risk for CAD (n = 184) who were scheduled for ICA were randomly assigned for study with SR (n = 91) or HR (n = 93) coronary CT angiography before they underwent ICA. To compare the two groups, the Student t test or Wilcoxon test were used to evaluate differences in continuous variables. The χ(2) test or Fisher exact test were used, as appropriate, for categorical data. The McNemar test was used to compare the diagnostic performance of coronary CT angiography versus that of ICA in each group.HR coronary CT angiography showed a higher image quality score (3.7 vs 3.4, P.001) and evaluability (97% vs 92%, P.002). In a segment-based analysis, HR coronary CT angiography showed a higher specificity, positive predictive value, and accuracy in comparison with SR coronary CT angiography (98%, 91%, and 99% vs 95%, 80%, and 95%, respectively; P.001). Moreover, HR coronary CT angiography showed a better agreement with ICA for calcified plaques compared with SR coronary CT angiography and ICA (83% vs 53%, P.001). In a patient-based analysis, HR coronary CT angiography showed higher specificity and accuracy compared with SR coronary CT angiography (91% and 98% vs 46% and 92%, respectively; P.01). No differences in radiation exposure were found between the two groups.Improved evaluability and accuracy were seen with HR compared with SR coronary CT angiography of calcified coronary artery lesions, suggesting a potential use for this technology in patients at high risk for CAD.

The goal of this study was to determine the long-term prognostic value of coronary computed tomography angiography (CTA) in a large coronary artery bypass graft (CABG) population.Coronary CTA has shown prognostic utility in patients without previous revascularization. However, prognostication with coronary CTA in CABG patients has not been fully assessed.Between March 2005 and April 2009, 887 consecutive CABG patients (mean age 66.8 ± 8.4 years) were considered for the inclusion in the study. Patients were classified by the number of unprotected coronary territories (UCTs) and a summary of native vessel disease and graft patency: the coronary artery protection score (CAPS). A primary endpoint (cardiovascular [CV] death, nonfatal myocardial infarction [MI]) and a secondary combined adverse events endpoint (CV death, MI, unstable angina, and late revascularizations) were recorded.Among the 887 evaluated, 166 did not meet the inclusion criteria. The final study population consisted of 721 subjects. Ten patients were excluded for unevaluable coronary CTA images. Of the remaining 711 patients, follow-up (mean 73.5 ± 14 months) was obtained in 698. Three hundred forty-seven events were recorded. By univariable analysis, the strongest coronary CTA predictors of events were UCT 2 and 3 (hazard ratio [HR] for CV death/MI: 7.5 and 10.19, p0.0001 and p0.0003, respectively) and CAPS 4 (HR for CV death/MI: 24.1, p0.0001). A high number of UCTs was also a strong multivariable independent predictor of CV death/MI (HR: 7.78 and 10.18 for UCT 2 and 3, p0.0001 and p0.0007, respectively). Cumulative survival rates for CV death/MI and composite adverse CV events were 86% and 73% with UCT 0, 84% and 49% with UCT 1, 53% and 3% with UCT 2, and 29% and 0% with UCT 3, respectively.Coronary CTA appears to be a promising tool for long-term risk stratification of CABG patients. The UCT score has significant prognostic value to predict CV deaths/MI.

Background Multidetector computed tomography (MDCT) provides detailed assessment of valve annulus and iliofemoral vessels in transcatheter aortic valve replacement (TAVR) patients. However, data on diagnostic performance of MDCT coronary angiography (MDCT-CA) are scarce. The aim of the study is to assess diagnostic performance of MDCT for coronary artery evaluation before TAVR. Methods A total of 325 consecutive patients (234 without previous myocardial revascularization, 49 with previous coronary stenting, and 42 with previous coronary artery bypass graft [CABG]) underwent invasive coronary angiography and MDCT before TAVR. MDCT-CA was performed using the same data set dedicated to standard MDCT aortic annulus evaluation. Multidetector computed tomography-CA evaluability and diagnostic accuracy in comparison with invasive coronary angiography as criterion standard were assessed. Results The MDCT-CA evaluability of native coronaries was 95.6%. The leading cause of unevaluability was beam-hardening artifact due to coronary calcifications. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for detecting ≥50% stenosis of 91%, 99.2%, 83.4%, 99.6% and 98.8%, respectively. The MDCT-CA evaluability of coronary stents was 82.1%. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy for detecting ≥50% in-stent restenosis of 94.1%, 86.7%, 66.7%, 98.1%, and 88.3%, respectively. All CABGs were correctly assessed by MDCT-CA. In a patient-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy of 89.7%, 90.8%, 80.6%, 95.4%, and 90.5%, respectively. Conclusions Multidetector computed tomography–CA allows to correctly rule out the presence of significant native coronary artery stenosis, significant in-stent restenosis, and CABG disease in patients referred for TAVR.

Background Reliability of coronary angiography by multidetector row CT (MDCT-CA) for stent evaluation is still a matter for debate, and it is unknown whether contrast medium characteristics may affect diagnostic performance of MDCT-CA. Objective We compared iomeprol-400 with iodixanol-320 to evaluate coronary stents with MDCT-CA. Methods We randomly assigned 254 patients undergoing coronary stent follow-up with the use of MDCT-CA to iomeprol-400 at 5.0 mL/sec flow rate (group 1; n = 83), iodixanol-320 at 6.2 mL/sec flow rate (group 2; n = 87), and iodixanol-320 at 5.0 mL/sec flow rate (group 3; n = 84). Heart rate (HR) immediately before and at the end of scanning, HR variation, premature heart beats, and heat sensation by visual analog scale during scanning were recorded. Mean attenuation was measured in the aortic root and coronary arteries. Image quality score and type of artifacts were assessed. Results Mean attenuation was significantly lower in group 3 than in the other groups. In group 3, stent evaluability was significantly higher and artifact rate was significantly lower than in group 2 (99% vs 91% and 4% vs 15%) and group 1 (99% vs 92% and 4% vs 17%), respectively, mainly because of a significant lower rate of beam-hardening artifacts (3 cases in group 3 vs 22 and 27 in groups 2 and 3, respectively). In group 3, visual analog scale, HR at the end of imaging, and number of patients with premature heart beats during the scan were significantly lower than in the other groups. Conclusions Iodixanol-320 provides better image quality of coronary stents, allowing higher MDCT-CA evaluability, than iomeprol-400.

OBJECTIVE To assess the prognostic role of multidetector computed tomography coronary angiography (MDCT-CA) in patients with diabetes with suspected coronary artery disease (CAD). Use of MDCT-CA is increasing in patients with suspected CAD. However, data supporting its prognostic value in patients with diabetes are limited. RESEARCH DESIGN AND METHODS Between January 2006 and September 2007, 429 consecutive diabetic patients were prospectively studied with MDCT-CA for detecting the presence and assessing the extent of CAD (disease extension and coronary plaque scores). Patients were classified according to the presence of normal coronary arteries and nonobstructive (

Aims Recent studies suggested that even non-obstructive coronary artery disease (CAD) increases major cardiovascular adverse events (MACE) rate. Aim of this study was to evaluate whether coronary computed tomography angiography (CCTA) may detect specific plaque characteristics that may affect prognosis in patients with non-obstructive CAD. Methods We enrolled 245 patients who underwent CCTA between April 2004 and April 2007 for suspected CAD and were found to have non-obstructive CAD. Positive remodelling index (PRI), low-attenuation plaque (LAP), plaque burden (PB), spotty calcification (SC), and napkin-ring sign (NRS) have been evaluated for each coronary plaque detected. Acute coronary syndrome, all-cause/cardiac death, and very late elective revascularization (vl-ER) were the endpoints of the study. Results A total of 28 events were recorded (2 STEMI, 4 NSTEMI, 6 UA, 2 cardiac deaths, 4 non-cardiac death, and 10 vl-ERs) at long-term follow-up (98 ± 20 months). When adjusted for significant clinical variables PRI > 1.4 (HR 3.31 CI 95% 1.11–9.91, P = 0.0392), LAP (HR 8.45 CI 95% 2.22–32.21, P = 0.0019), PB > 0.7 (HR 5.25 CI 95% 1.45–19.03, P = 0.0120), and NRS (HR 12.52 CI 95% 1.51–103.90, P = 0.0198) were still significantly associated with higher rate of hard cardiac events at follow-up. The Kaplan–Meyer curves confirmed lower cumulative hard cardiac events-free survival in patients presenting at least one coronary plaque with two or more high-risk characteristics when compared with patients with no lesion with more than one high-risk plaque characteristics (log-rank P < 0.0001). Conclusions High-risk plaque characteristics at CCTA (PRI > 1.4, PB > 0.7, LAP, and NRS) seem to be promising for risk stratification of patients with non-obstructive CAD.

We conducted a meta-analysis evaluating the critical ratio between effective radiation dose (ED), feasibility (Fe) and diagnostic accuracy (Ac) of multidetector computed tomography (MDCT) for the detection of significant coronary artery disease. By using our predetermined criteria, we selected human studies published in English in which the ED and raw data of Ac vs. invasive coronary angiography in a segment based model were specified. Data from 31 studies including 3661 patients (mean age 61.9 ± 4.5 years, heart rate 62.5 ± 6.7 bpm) and 50,236 coronary artery segments were analysed and are reported. Overall, Fe, sensitivity, specificity, negative predictive value, positive predictive value, Ac and ED were 95%, 90%, 96%, 99%, 69%, 95% and 10.4 ± 5.4 mSv, respectively. Multivariate analysis showed that prospective ECG-gating (-8.8 mSv CI95% -13.4 to -4.3 mSv, p=0.001), dual-source (-3.7 mSv CI95% -7.9 to 0 mSv, p=0.05) and BMI-adapted scanning protocols (-4.5 mSv CI95% -8.7 to -2.7 mSv, p=0.03) were independent predictors of ED reduction. In patients with low heart rate, the best compromise between ED, Fe and Ac (2.5 mSv, 97% and 98%, respectively) was obtained combining prospective ECG-gating and BMI-adapted scanning protocols, while in patients with high heart rate the strategy associated with the best results (10 mSv, 98% and 97%, respectively) was the use of dual-source MDCT with retrospective ECG gating and modulation dose. In conclusion, careful selection of CT scanning protocols according to the patient's characteristics is critical for keeping the radiation exposure "as low as reasonably achievable" (ALARA) without impairing Fe and Ac.

Aim To compare the feasibility, accuracy, and effective radiation dose (ED) of multidetector computed tomography (MDCT) in the detection of coronary artery disease using a combined ED-saving strategy including prospective electrocardiogram (ECG) triggering with a short x-ray window and a body mass index (BMI)-adapted imaging protocol using adaptive statistical iterative reconstruction (ASIR; group 1), in comparison with a prospective ECG triggering strategy alone (group 2). Materials and methods One hundred and seventy patients scheduled for invasive coronary angiography (ICA) were evaluated. Fourteen patients were not eligible for MDCT. The remaining 156 patients were randomized to group 1 (78 patients) and group 2 (78 patients). Eight and 11 patients in groups 1 and 2, respectively, were excluded after randomization because the patients’ heart rates were >65 beats/min. MDCT images were assessed for feasibility, signal-to-noise ration (SNR), and contrast-to-noise ratio (CNR), accuracy in detection of coronary stenoses >50% versus ICA and for ED. Results The feasibility, SNR, CNR, accuracy in a segment-based and patient-based model were similar in both groups (97 versus 95%, 14.5 ± 3.9 versus 14.2 ± 4.1, 16 ± 4.6 versus 16.5 ± 4.4, 95 versus 94% and 97 versus 99%, respectively). The ED in group 1 was 72% lower than in group 2 (2.1 ± 1.2 versus 7.5 ± 1.8 mSv, respectively; p Conclusions The use of a multi-parametric ED saving protocol results in a significant reduction in ED without a negative impact on accuracy.

Coronary artery fistulas are unusual congenital or acquired coronary artery abnormalities in which blood is shunted into a cardiac chamber, great vessel, or other structure. We described a case of an asymptomatic 56-year-old hypertensive and diabetic man, with previous bypass surgery, who underwent invasive coronary angiography (ICA) for a positive myocardial nuclear perfusion imaging at the level of inferior-lateral left ventricle wall. ICA showed the patency of bypass and suspected the presence of a fistula originating from left anterior descending …

Background: To compare the accuracy of cardiac magnetic resonance (CMR) evaluation of aortic annulus (AoA) versus multidetector computed tomography (MDCT) in patients referred for transaortic valve implantation (TAVI). Methods: 50 patients were studied with a 1.5-T scanner (Discovery MR450, GE Healthcare, Milwaukee, WI). Steady-state free precession cine acquisitions were acquired to reach two long-axis view of the aortic root and ascending aorta. Thus, serial short-axis cines orthogonal to the AoA (3-mm thickness with 1.5-mm overlapping) were imaged. The following parameters were assessed with CMR and compared with those obtained with MDCT: AoA maximum diameter (AoA-Dmax), minimum diameter (AoADmin), and area (AoA-A), length of the left coronary, right coronary, and non-coronary aortic leaflets, degree (grades 1 to 4) of aortic leaflet calcification and distance between AoA and coronary artery ostia. Results: AoA-Dmax, AoA-Dmin and AoA-A were 26.45±2.83 mm, 20.17±2.20 mm, 444.88±84.61 mm2 and 26.45±2.76 mm, 20.59±2.35 mm and 449.78±86.22 mm2 bv MDCT and CMR. respectivelv. The length of left coronary, right coronary, and non-coronary leaflets were 14.02±2.27 mm, 13.33±2.33 mm, 13.39±1.97 mm, and 13.95±2.18 mm, 13.30±2.14 mm, 13.46±1.80 mm by MDCT and CMR, respectively, while the scores of aortic leaflet calcifications were 3.4.±0.7 vs. 2.97±0.77. Finally, the distance between AoA and left main and right coronary artery ostia was 16.21±3.07 mm, 16.02±4.29 mm and 16.14±2.83 mm, 16.14±4.36 mm by MDCT and CMR, respectively. With regard to AoA-Dmax (r: 0.96, p

Beam-hardening artifacts resulting from heavily calcified plaques in patients with a high coronary calcium score (CCS) may reduce coronary computed tomography angiography (CTA) diagnostic accuracy of the increased false-positive rate [(1)][1]. A recently introduced computed tomography (CT)

Background— The aim of this study was to determine the prognostic benefit of cardiac magnetic resonance (CMR) over transthoracic echocardiography (TTE) in ischemic cardiomyopathy and nonischemic dilated cardiomyopathy patients evaluated for primary prevention implantable cardioverter–defibrillator therapy. Methods and Results— We enrolled 409 consecutive ischemic and dilated cardiomyopathy patients (mean age: 64±12 years; 331 men). All patients underwent TTE and CMR, and left ventricle end-diastolic volume, left ventricle end-systolic volume, and left ventricle ejection fraction (LVEF) were evaluated. In addition, late gadolinium enhancement was also assessed. All patients were followed up for major adverse cardiac events (MACE) defined as a composite end point of long runs of nonsustained ventricular tachycardia, sustained ventricular tachycardia, aborted sudden cardiac death, or sudden cardiac death. The median follow-up was 545 days. CMR showed higher left ventricle end-diastolic volume (mean difference: 43±22.5 mL), higher left ventricle end-systolic volume (mean difference: 34±20.5 mL), and lower LVEF (mean difference: −4.9±10%) as compared to TTE ( P P P P Conclusions— CMR provides additional prognostic stratification as compared to TTE, which may have direct impact on the indication of implantable cardioverter–defibrillator implantation.

Background: The clinical feasibility of multidetector computed tomography coronary angiography (MDCT) is limited by motion artifact due to the limited temporal resolution. Recently, GE SnapShot Freeze technology (GE Healthcare, Milwaukee, WI) has been introduced as a new approach to reduce coronary motion artifacts by employing a novel reconstruction and processing technique. The aim of the study is to compare the overall feasibility of MDCT using standard post-processing reconstruction algorithm versus the new Snap Shot Freeze algorithm in patients referred to our hospital for chest pain. Methods and materials: From a cohort of 622 consecutive patients referred to our hospital to perform MDCT (Discovery CT750 HD, GE Healthcare, Milwaukee, WI) for diagnostic evaluation of chest pain, 76 patients (mean age 68.9±10.2 yo, 48 male) with at least proximal or mid segment or more than 3 segments classified as not evaluable for motion artifacts were enrolled in this study. Image MDCT datasets were analyzed with vessel analysis software on dedicated post-processing workstation (AW version 4.5, GE Healthcare) using standard reconstruction algorithm (Group 1) and Snap Shot Freeze algorithm (Group 2). The overall number of artifacts (Art) for each coronary segments was measured defining them as related to non respect of breath hold, blooming effect, motion artifacts, presence of cardiac device, interference of cardiac veins, intramyocardial tract, and impaired signal/image noise ratio. Image quality score (QS) was classified as 1 (no artifacts, unrestricted evaluation), 2 (minor artifacts, good diagnostic quality), 3 (moderate artifacts, acceptable for routine clinical diagnosis), or 4 (severe artifacts impairing accurate evaluation). The coronary artery segments with score 4 were defined as not evaluable. The overall feasibility (Fe) was defined as number of evaluable segments to total number of coronary segments ratio. Art, QS and Fe were compared between the two Groups. Results: Sixty-two patients (81%) received intravenous metoprolol (mean dose 9.8±3.1 mg). The HR during the scan and the HR variability were 68±8.1 bpm and 6±4.8 respectively. Thirty-five (46%) and 41 (54%) were performed using retrospective and prospective ECG-triggering, respectively. Group 2 versus Group 1 showed lower incidence of artifacts (17% vs 34%, p