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ObjectivesAutopsy rates worldwide have dropped significantly over the last five decades. Imaging based autopsies are increasingly used as alternatives to conventional autopsy (CA). The aim of this study was to investigate the effect of the introduction of minimally invasive autopsy, consisting of CT, MRI and tissue biopsies on the overall autopsy rate (of CA and minimally invasive autopsy) and the autopsy rate among different ethnicities.MethodsWe performed a prospective single center before-after study. The intervention was the introduction of minimally invasive autopsy as an alternative to CA. Minimally invasive autopsy consisted of MRI, CT, and CT-guided tissue biopsies. Autopsy rates over time and the effect of introducing minimally invasive autopsy were analyzed with a linear regression model. We performed a subgroup analysis comparing the autopsy rates of two groups: a group of western-European ethnicity versus a group of other ethnicities.ResultsAutopsy rates declined from 14.0% in 2010 to 8.3% in 2019. The linear regression model showed a significant effect of both time and availability of minimally invasive autopsy on the overall autopsy rate. The predicted autopsy rate in the model started at 15.1% in 2010 and dropped approximately 0.1% per month (β = -0.001, p < 0.001). Availability of minimally invasive autopsy increased the overall autopsy rate by 2.4% (β = 0.024, p < 0.001). The overall autopsy rate of people with an ethnic background other than western-European was significantly higher in years when minimally invasive autopsy was available compared to when it was not (22/176 = 12.5% vs. 81/1014 (8.0%), p = 0.049).ConclusionsThe introduction of the minimally invasive autopsy had a small, but significant effect on the overall autopsy rate. Furthermore, the minimally invasive autopsy appears to be more acceptable than CA among people with an ethnicity other than western-European.

ObjectivesAutopsy rates worldwide have dropped significantly over the last decades and imaging-based autopsies are increasingly used as an alternative to conventional autopsy. Our aim was to evaluate the clinical performance and cost of minimally invasive autopsy.MethodsThis study was part of a prospective cohort study evaluating a newly implemented minimally invasive autopsy consisting of MRI, CT, and biopsies. We calculated diagnostic yield and clinical utility-defined as the percentage successfully answered clinical questions-of minimally invasive autopsy. We performed minimally invasive autopsy in 46 deceased (30 men, 16 women; mean age 62.9±17.5, min-max: 18-91).ResultsNinety-six major diagnoses were found with the minimally invasive autopsy of which 47/96 (49.0%) were new diagnoses. CT found 65/96 (67.7%) major diagnoses and MRI found 82/96 (85.4%) major diagnoses. Eighty-four clinical questions were asked in all cases. Seventy-one (84.5%) of these questions could be answered with minimally invasive autopsy. CT successfully answered 34/84 (40.5%) clinical questions; in 23/84 (27.4%) without the need for biopsies, and in 11/84 (13.0%) a biopsy was required. MRI successfully answered 60/84 (71.4%) clinical questions, in 27/84 (32.1%) without the need for biopsies, and in 33/84 (39.8%) a biopsy was required. The mean cost of a minimally invasive autopsy was €1296 including brain biopsies and €1087 without brain biopsies. Mean cost of CT was €187 and of MRI €284.ConclusionsA minimally invasive autopsy, consisting of CT, MRI and CT-guided biopsies, performs well in answering clinical questions and detecting major diagnoses. However, the diagnostic yield and clinical utility were quite low for postmortem CT and MRI as standalone modalities.

Purpose To compare the diagnostic performance of minimally invasive autopsy with that of conventional autopsy. Materials and Methods For this prospective, single-center, cross-sectional study in an academic hospital, 295 of 2197 adult cadavers (mean age: 65 years [range, 18-99 years]; age range of male cadavers: 18-99 years; age range of female cadavers: 18-98 years) who died from 2012 through 2014 underwent conventional autopsy. Family consent for minimally invasive autopsy was obtained for 139 of the 295 cadavers; 99 of those 139 cadavers were included in this study. Those involved in minimally invasive autopsy and conventional autopsy were blinded to each other's findings. The minimally invasive autopsy procedure combined postmortem MRI, CT, and CT-guided biopsy of main organs and pathologic lesions. The primary outcome measure was performance of minimally invasive autopsy and conventional autopsy in establishing immediate cause of death, as compared with consensus cause of death. The secondary outcome measures were diagnostic yield of minimally invasive autopsy and conventional autopsy for all, major, and grouped major diagnoses; frequency of clinically unsuspected findings; and percentage of answered clinical questions. Results Cause of death determined with minimally invasive autopsy and conventional autopsy agreed in 91 of the 99 cadavers (92%). Agreement with consensus cause of death occurred in 96 of 99 cadavers (97%) with minimally invasive autopsy and in 94 of 99 cadavers (95%) with conventional autopsy (P = .73). All 288 grouped major diagnoses were related to consensus cause of death. Minimally invasive autopsy enabled diagnosis of 259 of them (90%) and conventional autopsy 224 (78%); 200 (69%) were found with both methods. At clinical examination, the cause of death was not suspected in 17 of the 99 cadavers (17%), and 124 of 288 grouped major diagnoses (43%) were not established. There were 219 additional clinical questions; 189 (86%) were answered with minimally invasive autopsy and 182 (83%) were answered with conventional autopsy (P = .35). Conclusion The performance of minimally invasive autopsy in the detection of cause of death was similar to that of conventional autopsy; however, minimally invasive autopsy has a higher yield of diagnoses. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Krombach in this issue.

Aims The autopsy rate worldwide is alarmingly low (0-15%). Mortality statistics are important, and it is, therefore, essential to perform autopsies in a sufficient proportion of deaths. The imaging autopsy, non-invasive, or minimally invasive autopsy (MIA) can be used as an alternative to the conventional autopsy in an attempt to improve postmortem diagnostics by increasing the number of postmortem procedures. The aim of this study was to determine the diagnostic accuracy of postmortem magnetic resonance imaging (MRI), computed tomography (CT), and CT-guided biopsy for the detection of acute and chronic myocardial ischaemia. Methods and results We included 100 consecutive adult patients who died in hospital, and for whom next-of-kin gave permission to perform both conventional autopsy and MIA. The MIA consists of unenhanced total-body MRI and CT followed by CT-guided biopsies. Conventional autopsy was used as reference standard. We calculated sensitivity and specificity and receiver operating characteristics curves for CT and MRI as the stand-alone test or combined with biopsy for detection of acute and chronic myocardial infarction (MI). Sensitivity and specificity of MRI with biopsies for acute MI was 0.97 and 0.95, respectively and 0.90 and 0.75, respectively for chronic MI. MRI without biopsies showed a high specificity (acute: 0.92; chronic: 1.00), but low sensitivity (acute: 0.50; chronic: 0.35). CT (total Agatston calcium score) had a good diagnostic value for chronic MI [area under curve (AUC) 0.74, 95% confidence interval (CI) 0.64-0.84], but not for acute MI (AUC 0.60, 95% CI 0.48-0.72). Conclusion We found that the combination of MRI with biopsies had high sensitivity and specificity for the detection of acute and chronic myocardial ischaemia.

Rationale and Objectives The aim of this study was to automatically detect and quantify calcium lesions for the whole heart as well as per coronary artery on non-contrast-enhanced cardiac computed tomographic images. Materials and Methods Imaging data from 366 patients were randomly selected from patients who underwent computed tomographic calcium scoring assessments between July 2004 and May 2009 at Erasmum MC, Rotterdam. These data included data sets with 1.5-mm and 3.0-mm slice spacing reconstructions and were acquired using four different scanners. The scores of manual observers, who annotated the data using commercially available software, served as ground truth. An automatic method for detecting and quantifying calcifications for each of the four main coronary arteries and the whole heart was trained on 209 data sets and tested on 157 data sets. Statistical testing included determining Pearson's correlation coefficients and Bland-Altman analysis to compare performance between the system and ground truth. Wilcoxon's signed-rank test was used to compare the interobserver variability to the system's performance. Results Automatic detection of calcified objects was achieved with sensitivity of 81.2% per calcified object in the 1.5-mm data set and sensitivity of 86.6% per calcified object in the 3.0-mm data set. The system made an average of 2.5 errors per patient in the 1.5-mm data set and 2.2 errors in the 3.0-mm data set. Pearson's correlation coefficients of 0.97 ( P R values over Agatston, mass, and volume scores for each of the arteries (left circumflex coronary artery, right coronary artery, and left main and left anterior descending coronary arteries) were 0.93, 0.96, and 0.99, respectively, for the 1.5-mm scans. Similarly, for 3.0-mm scans, R values were 0.94, 0.94, and 0.99, respectively. Risk category assignment was correct in 95% and 89% of the data sets in the 1.5-mm and 3-mm scans. Conclusions An automatic vessel-specific coronary artery calcium scoring system was developed, and its feasibility for calcium scoring in individual vessels and risk category classification has been demonstrated.

To compare the diagnostic performance and radiation exposure of 128-slice dual-source CT coronary angiography (CTCA) protocols to detect coronary stenosis with more than 50 % lumen obstruction. We prospectively included 459 symptomatic patients referred for CTCA. Patients were randomized between high-pitch spiral vs. narrow-window sequential CTCA protocols (heart rate below 65 bpm, group A), or between wide-window sequential vs. retrospective spiral protocols (heart rate above 65 bpm, group B). Diagnostic performance of CTCA was compared with quantitative coronary angiography in 267 patients. In group A (231 patients, 146 men, mean heart rate 58 ± 7 bpm), high-pitch spiral CTCA yielded a lower per-segment sensitivity compared to sequential CTCA (89 % vs. 97 %, P = 0.01). Specificity, PPV and NPV were comparable (95 %, 62 %, 99 % vs. 96 %, 73 %, 100 %, P > 0.05) but radiation dose was lower (1.16 ± 0.60 vs. 3.82 ± 1.65 mSv, P 0.05). Radiation dose of sequential CTCA was lower compared to retrospective CTCA (6.12 ± 2.58 vs. 8.13 ± 4.52 mSv, P

To investigate the predictive value of 64-slice computed tomography coronary angiography (CTCA) for major adverse cardiac events (MACEs) in patients with suspected or known coronary artery disease (CAD).Seven hundred and sixty-seven consecutive patients (496 men, age 62±11 y) with suspected or known heart disease referred to an outpatient clinic underwent 64-slice CTCA. The patients were followed for the occurrence of MACE (ie, cardiac death, nonfatal myocardial infarction, unstable angina).Eleven thousand five hundred and sixty-four coronary segments were assessed. Of these, 178 (1.5%) were not assessable because of insufficient image quality. Overall, CTCA revealed the absence of CAD in 219 (28.5%) patients, nonobstructive CAD (coronary plaque ≤50%) in 282 (36.8%) patients, and obstructive CAD in 266 (34.7%) patients. A total of 21 major cardiac events (4 cardiac deaths, 12 myocardial infarctions, and 5 unstable angina) occurred during a mean follow-up of 20 months. One noncardiac death occurred. Seventeen events occurred in the group of patients with obstructive CAD, and 4 events occurred in the group with nonobstructive CAD. The event rate was 0% among patients with normal coronary arteries at CTCA. In multivariate analysis, the presence of obstructive CAD and diabetes were the only independent predictors of MACE.Coronary plaque evaluation by CTCA provides an independent prognostic value for the prediction of MACE. Patients with normal CTCA findings have an excellent prognosis at follow-up.

This study was undertaken to evaluate the diagnostic accuracy of computed tomography coronary angiography (CTCA) for detecting significant coronary artery stenosis (≥50% lumen reduction) compared with conventional coronary angiography (CAG) in a male and female population.A total of 1,372 patients (882 men, 490 women; mean age 59.3 ± 11.9 years) in sinus rhythm imaged with CTCA (64-slice technology) and CAG were enrolled. Diagnostic accuracy and likelihood ratios (LR+ and LR-) of CTCA were assessed against CAG for the male and female populations.The prevalence of obstructive disease was 53% (men 58%; women 43%). CAG demonstrated the absence of significant coronary artery disease (CAD) in 47% (men 42%; women 56%), single-vessel disease in 25% (men 36%; women 22%) and multivessel disease in 29% (men 32%; women 23%) of patients. In the per-patient analysis, sensitivity, specificity and positive (PPV) and negative (NPV) predictive values of CTCA were 99% (men 98%; women 100%), 92% (men 92%; women 92%), 94% (men 95%; women 90%) and 99% (men 98%; women 100%), respectively. The per-patient likelihood ratios (LR) in the total population (LR+=12.4 and LR-=0.011), the male (LR+=12.9 and LR-=0.016) and female (LR =11.9 and LR-=0) populations were very good. We observed no significant differences in diagnostic accuracy between male and female populations.CTCA is a reliable diagnostic modality with high sensitivity and NPV in the female population.

Purpose: To compare image quality, radiation dose, and their relationship with heart rate of computed tomographic (CT) coronary angiographic scan protocols by using a 128-section dual-source CT scanner. Materials and Methods: Institutional review board approved the study; all patients gave informed consent. Two hundred seventy-two patients (175 men, 97 women; mean ages, 58 and 59 years, respectively) referred for CT coronary angiography were categorized according to heart rate: less than 65 beats per minute (group A) and 65 beats per minute or greater (group B). Patients were randomized to undergo prospective high-pitch spiral scanning and narrow-window prospective sequential scanning in group A (n = 160) or wide-window prospective sequential scanning and retrospective spiral scanning in group B (n = 112). Image quality was graded (1 = nondiagnostic; 2 = artifacts present, diagnostic; 3 = no artifacts) and compared (Mann-Whitney and Student t tests). Results: In group A, mean image quality grade was significantly lower with high-pitch spiral versus sequential scanning (2.67 +/- 0.38 [standard deviation] vs 2.86 +/- 0.21; P < .001). In a subpopulation (heart rate

This study assessed the accuracy of computed tomography coronary angiography (CT-CA) for detecting significant coronary artery disease (CAD; a parts per thousand yen50% lumen reduction) in intermediate/high-risk asymptomatic patients. A total of 183 consecutive asymptomatic individuals (92 men; mean age 54 +/- 11 years) with more than one major risk factor (obesity, hypertension, diabetes, hypercholesterolaemia, family history, smoking) and an inconclusive or nonfeasible noninvasive stress test result (stress electrocardiography, stress echocardiography, nuclear stress scintigraphy) underwent CT-CA in an outpatient setting. All patients underwent conventional coronary angiography (CAG) within 4 weeks. Data from CT-CA were compared with CAG regarding the presence of significant CAD (a parts per thousand yen50% lumen reduction). Mean calcium score was 177 +/- 432, mean heart rate during the CT-CA scan was 58 +/- 8 bpm and the prevalence (per-patient) of obstructive CAD was 19%. CT-CA showed single-vessel CAD in 9% of patients, two-vessel CAD in 9% and three-vessel CAD in 0%. Per-patient sensitivity, specificity, positive predictive value and negative predictive value of CT-CA were 100% (90-100), 98% (96-99), 97% (85-99), 100% (97-100), respectively. Positive and negative likelihood ratios were 151 and 0, respectively. CT-CA is an excellent noninvasive imaging modality for excluding significant CAD in intermediate/ high-risk asymptomatic patients with inconclusive or nonfeasible noninvasive stress test.

BACKGROUND: An 81-year-old male with symptoms of angina and dyspnoea (NYHA 3), a history of coronary bypass surgery, a transaortic peak gradient of 109 mmHg on transthoracic echocardiography and a logistic Euro-SCORE of 21.6 was deemed suboptimal for surgery by a multidisciplinary team and was accepted for TAVI. INVESTIGATION: Preprocedural diameter of the native aortic root was 24.4 mm on transthoracic echocardiography (TTE), 26.9 mm on contrast angiography and 26.8 mm by 30.2 mm on multislice computed tomography (MSCT). DIAGNOSIS: Heavy calcification of the aortic root and coronary arteries by MSCT. TREATMENT: Transcatheter aortic valve replacement with an 29 mm CoreValve prosthesis.

Objective To assess the influence of sex on the diagnostic performance of computed tomography coronary angiography (CTCA). Methods A total of 916 symptomatic patients (30.5% women) without earlier history of coronary artery intervention underwent both CTCA and invasive coronary angiography. Descriptive diagnostic parameters, to detect obstructive coronary artery disease (CAD; >= 50% lumen diameter narrowing) on CTCA, were compared between women and men on a per-patient, per-vessel, and per-segment level. Adjusted values were calculated for clustered segments and differences in sex variables using logistic multivariate regression models in general estimated equations. Results Women were older, had less typical chest complaints, and had a lower prevalence, extent, and severity of CAD compared with men. Multivariate analysis on a per-patient level revealed no difference in sensitivity (98 vs. 99%, P = 0.15), specificity (78 vs. 82%, P = 0.65), positive predictive value (PPV; 87 vs. 95%, P = 0.10), negative predictive value (NPV; 97 vs. 98%, P = 0.63), and diagnostic odds ratio (DOR; 198 vs. 721, P = 0.07). No difference was found on per-vessel level analysis (sensitivity 95 vs. 97%, P = 0.14; specificity 89 vs. 87%, P = 0.93; PPV 73 vs. 79%, P = 0.06; NPV 98 vs. 98%, P = 0.72; and DOR 143 vs. 240, P = 0.08). Per-segment analysis revealed a lower sensitivity (88 vs. 94%, P < 0.001) and DOR (163 vs. 302, P = 0.002) in women compared with men, without a difference in specificity (96 vs. 95%, P = 0.19), PPV (64 vs. 69%, P = 0.07), and NPV (99 vs. 99%, P = 0.08). Conclusion CTCA can accurately rule out obstructive CAD in both women and men. CTCA is less accurate in women to detect individual obstructive disease. Coron Artery Dis 22:421-427 (C) 2011 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

Objective To determine the calcium score and coronary plaque burden in asymptomatic statin-treated patients with heterozygous familial hypercholesterolaemia (FH) compared with a control group of patients with low probability of coronary artery disease, having non-anginal chest pain, using CT. Design, setting and patients 101 asymptomatic patients with FH (mean age 53 +/- 7 years; 62 men) and 126 patients with non-anginal chest pain (mean age 56 +/- 7 years; 80 men) underwent CT calcium scoring and CT coronary angiography. All patients with FH were treated with statins during a period of 10 +/- 8 years before CT. The coronary calcium score and plaque burden were determined and compared between the two patient groups. Results The median total calcium score was significantly higher in patients with FH (Agatston score=87, IQR 5-367) than in patients with non-anginal chest pain (Agatston score=7, IQR 0-125; p

Contrast-enhanced CT coronary angiography (CTCA) has evolved as a reliable alternative imaging modality technique and may be the preferred initial diagnostic test in patients with stable angina with intermediate pre-test probability of CAD. However, because CTCA is moderately predictive for indicating the functional significance of a lesion, the combination of anatomic and functional imaging will become increasingly important. The technology will continue to improve with better spatial and temporal resolution at low radiation exposure, and CTCA may eventually replace invasive coronary angiography. The establishment of the precise role of CTCA in the diagnosis and management of patients with stable angina requires high-quality randomised study designs with clinical outcomes as a primary outcome.

OBJECTIVE: To assess the feasibility of single-breath-hold three-dimensional cine b-SSFP (balanced steady-state free precession gradient echo) sequence (3D-cine), accelerated with k-t BLAST (broad-use linear acquisition speed-up technique), compared with multiple-breath-hold 2D cine b-SSFP (2D-cine) sequence for assessment of left ventricular (LV) function. METHODS: Imaging was performed using 1.5-T MRI (Achieva, Philips, The Netherlands) in 46 patients with different cardiac diseases. Global functional parameters, LV mass, imaging time and reporting time were evaluated and compared in each patient. RESULTS: Functional parameters and mass were significantly different in the two sequences [3D end-diastolic volume (EDV) = 129 ± 44 ml vs 2D EDV = 134 ± 49 ml; 3D end-systolic volume (ESV) = 77 ± 44 ml vs 2D ESV = 73 ± 50 ml; 3D ejection fraction (EF) = 43 ± 15% vs 2D EF = 48 ± 15%; p

Purpose: Computed tomography angiography (CTA) is increasingly used for the diagnosis of coronary artery disease (CAD). However, CTA is not commonly used for the assessment of ventricular and atrial function, although functional information extracted from CTA data is expected to improve the diagnostic value of the examination. In clinical practice, the extraction of ventricular and atrial functional information, such as stroke volume and ejection fraction, requires accurate delineation of cardiac chambers. In this paper, we investigated the accuracy and robustness of cardiac chamber delineation using a multiatlas based segmentation method on multicenter and multivendor CTA data. Methods: A fully automatic multiatlas based method for segmenting the whole heart (i.e., the outer surface of the pericardium) and cardiac chambers from CTA data is presented and evaluated. In the segmentation approach, eight atlas images are registered to a new patient's CTA scan. The eight corresponding manually labeled images are then propagated and combined using a per voxel majority voting procedure, to obtain a cardiac segmentation. Results: The method was evaluated on a multicenter/multivendor database, consisting of (1) a set of 1380 Siemens scans from 795 patients and (2) a set of 60 multivendor scans (Siemens, Philips, and GE) from different patients, acquiredmore » in six different institutions worldwide. A leave-one-out 3D quantitative validation was carried out on the eight atlas images; we obtained a mean surface-to-surface error of 0.94{+-}1.12 mm and an average Dice coefficient of 0.93 was achieved. A 2D quantitative evaluation was performed on the 60 multivendor data sets. Here, we observed a mean surface-to-surface error of 1.26{+-}1.25 mm and an average Dice coefficient of 0.91 was achieved. In addition to this quantitative evaluation, a large-scale 2D and 3D qualitative evaluation was performed on 1380 and 140 images, respectively. Experts evaluated that 49% of the 1380 images were very accurately segmented (below 1 mm error) and that 29% were accurately segmented (error between 1 and 3 mm), which demonstrates the robustness of the presented method. Conclusions: A fully automatic method for whole heart and cardiac chamber segmentation was presented and evaluated using multicenter/multivendor CTA data. The accuracy and robustness of the method were demonstrated by successfully applying the method to 1420 multicenter/multivendor data sets.« less

The authors investigated the prognostic value of computed tomography coronary angiography (CTCA) for major adverse cardiac events (MACE) in patients with suspected or known coronary artery disease (CAD), with particular focus on left main (LM) disease and obstructive vs. nonobstructive disease.A total of 727 consecutive patients (485 men, age 62 ± 11 years) with suspected (514; 70.1%) or known (213; 29.9%) CAD underwent CTCA. Patients were followed up for the occurrence of MACE (i.e. cardiac death, nonfatal myocardial infarction, unstable angina, percutaneous/surgical revascularisation).A total of 117 MACE [five cardiac deaths, 11 acute myocardial infarctions (AMI), five unstable angina, 86 percutaneous coronary interventions, ten coronary artery bypass grafts] occurred during a mean follow-up of 20 months. Severity and extension of CAD was associated with a progressively worse prognosis. The event rate was 0% among patients with normal coronary arteries at CTCA. The presence of LM disease was not associated with a worse prognosis either in patients with no history of CAD or in those with a history of CAD. At multivariate analysis, presence of obstructive CAD and diabetes were the only independent predictors of MACE.Evaluation of atherosclerotic burden by CTCA provides an independent prognostic value for prediction of MACE. Patients with normal CTCA findings have an excellent prognosis at follow-up.

Purpose This study compared cardiac computed tomography (CT) and two-dimensional transthoracic echocardiography (ECC) for assessing left ventricular ejection fraction (LVEF) using real-world data from a large patient population.

To evaluate the diagnostic accuracy of 64-slice CT coronary angiography (CT-CA) for the detection of significant coronary artery stenosis in patients with zero on the Agatston Calcium Score (CACS). We enrolled 279 consecutive patients (96 male, mean age 48 +/- 12 years) with suspected coronary artery disease. Patients were symptomatic (n = 208) or asymptomatic (n = 71), and underwent conventional coronary angiography (CAG). For CT-CA we administered an IV bolus of 100 ml of iodinated contrast material. CT-CA was compared to CAG using a threshold for significant stenosis of a parts per thousand yen50%. The prevalence of disease demonstrated at CAG was 15% (1.4% in asymptomatic). The population at CAG showed no or non-significant disease in 85% (238/279), single vessel disease in 9% (25/279), and multi-vessel disease in 6% (16/279). Sensitivity, specificity, and positive and negative predictive values of CT-CA vs. CAG on the patient level were 100%, 95%, 76%, and 100% in the overall population and 100%, 100%, 100%, and 100% in asymptomatic patients, respectively. CT-CA proves high diagnostic performance in patients with or without symptoms and with zero CACS. The prevalence of significant disease detected by CT-CA was not negligible in asymptomatic patients. The role of CT-CA in asymptomatic patients remains uncertain.

Objectives: To validate published prediction models for the presence of obstructive coronary artery disease (CAD) in patients with new onset stable typical or atypical angina pectoris and to assess the incremental value of the CT coronary calcium score (CTCS). Methods: We searched the literature for clinical prediction rules for the diagnosis of obstructive CAD, defined as ≥50% stenosis in at least one vessel on conventional coronary angiography. Significant variables were re-analysed in our dataset of 254 patients with logistic regression. CTCS was subsequently included in the models. The area under the receiver operating characteristic curve (AUC) was calculated to assess diagnostic performance. Results: Re-analysing the variables used by Diamond & Forrester yielded an AUC of 0.798, which increased to 0.890 by adding CTCS. For Pryor, Morise 1994, Morise 1997 and Shaw the AUC increased from 0.838 to 0.901, 0.831 to 0.899, 0.840 to 0.898 and 0.833 to 0.899. CTCS significantly improved model performance in each model. Conclusions: Validation demonstrated good diagnostic performance across all models. CTCS improves the prediction of the presence of obstructive CAD, independent of clinical predictors, and should be considered in its diagnostic work-up.

Purpose. This study aimed to evaluate the diagnostic accuracy of stress electrocardiogram (ECG) and computed tomography coronary angiography (CTCA) for the detection of significant coronary artery stenosis (>= 50%) in the real world using conventional CA as the reference standard. Materials and methods. A total of 236 consecutive patients (159 men, 77 women; mean age 62.8 +/- 10.2 years) at moderate risk and with suspected coronary artery disease (CAD) were enrolled in the study and underwent stress ECG, CTCA and CA. The CTCA scan was performed after i.v. administration of a 100-ml bolus of iodinated contrast material. The stress ECG and CTCA reports were used to evaluate diagnostic accuracy compared with CA in the detection of significant stenosis >= 50%. Results. We excluded 16 patients from the analysis because of the nondiagnostic quality of stress ECG and/or CTCA. The prevalence of disease demonstrated at CA was 62% (n=220), 51% in the population with comparable stress ECG and CTCA (n=147) and 84% in the population with equivocal stress ECG (n=73). Stress ECG was classified as equivocal in 73 cases (33.2%), positive in 69 (31.4%) and negative in 78 (35.5%). In the per-patient analysis, the diagnostic accuracy of stress ECG was sensitivity 47%, specificity 53%, positive predictive value (PPV) 51% and negative predictive value (NPV) 49%. On stress ECG, 40 (27.2%) patients were misclassified as negative, and 34 (23.1%) patients with nonsignificant stenosis were overestimated as positive. The diagnostic accuracy of CTCA was sensitivity 96%, specificity 65%, PPV 74% and NPV 94%. CTCA incorrectly classified three (2%) as negative and 25 (17%) as positive. The difference in diagnostic accuracy between stress ECG and CTCA was significant (p

The aim of the study was to compare the coronary artery calcium score (CACS) and computed tomography coronary angiography (CTCA) for the assessment of non-obstructive/obstructive coronary artery disease (CAD) in high-risk asymptomatic subjects. Two hundred and thirteen consecutive asymptomatic subjects (113 male; mean age 53.6 +/- 12.4 years) with more than one risk factor and an inconclusive or unfeasible non-invasive stress test result underwent CACS and CTCA in an outpatient setting. All patients underwent conventional coronary angiography (CAG). Data from CACS (threshold for positive image: Agatston score 1/100/1,000) and CTCA were compared with CAG regarding the degree of CAD (non-obstructive/obstructive

Purpose. Our purpose in this study was to compare the impact of contrast material volume in delayed-enhancement computer tomography (CT) imaging for assessing acute reperfused myocardial infarction. Materials and methods. In five domestic pigs (20-30 kg) the circumflex coronary artery (CX) was balloon-occluded for 2 h followed by reperfusion. After 5 days, CT imaging was performed after intravenous administration of iodinated contrast material (Iomeprol 400mgI/ml; Bracco, Italy). A 64-slice multidetector CT (MDCT) (Sensation 64, Siemens) scanner was used for imaging, with standard angiography characteristics. Three scans were performed: first, coronary angiography at first pass with 1.25 gl/kg of contrast material (ART); and remaining delayedenhancement (DE1-DE2) 15 min after administration of 1.25 (DE1) and 15 min after additional administration of 2.50 gI/kg (=total 3.75 gI/kg - DE2). Mean heart rate decreased to 51 +/- 9 bpm after intravenous administration of Zatebradine (10 mg/kg). Data sets were reconstructed during the end-diastolic phase of the cardiac cycle. Areas of infarction-enhanced (DE), no-reflow (no-reflow) and remote myocardial [remote left ventricle (LV)] were manually contoured. CT attenuation values (Hounsfield units) were measured using five regions of interest: DE, no-reflow, remote LV, left ventricular cavity (lumen LV) and in air. Differences, correlations, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Results. We found significant differences between the attenuation of DE, no-reflow and remote LV (p

Purpose: The application and large-scale evaluation of minimum cost path approaches for coronary centerline extraction from computed tomography coronary angiography (CTCA) data and the development and evaluation of a novel method to reduce the user-interaction time. Methods: A semiautomatic method based on a minimum cost path approach is evaluated for two different cost functions. The first cost function is based on a frequently used vesselness measure and intensity information, and the second is a recently proposed cost function based on region statistics. User interaction is minimized to one or two mouse clicks distally in the coronary artery. The starting point for the minimum cost path search is automatically determined using a newly developed method that finds a point in the center of the aorta in one of the axial slices. This step ensures that all computationally expensive parts of the algorithm can be precomputed. Results: The performance of the aorta localization procedure was demonstrated by a success rate of 100% in 75 images. The success rate and accuracy of centerline extraction was quantitatively evaluated on 48 coronary arteries in 12 images by comparing extracted centerlines with a manually annotated reference standard. The method was able to extract 88% and 47% of the vessel centerlines correctly using the vesselness/intensity and region statistics cost function, respectively. For only the proximal part of the vessels these values were 97% and 86%, respectively. Accuracy of centerline extraction, defined as the average distance from correctly automatically extracted parts of the centerline to the reference standard, was 0.64 mm for the vesselness/intensity and 0.51 mm for the region statistics cost function. The interobserver variability was 99% for the success rate measure and 0.42 mm for the accuracy measure. Qualitative evaluation using the best performing cost function resulted in successful centerline extraction for 233 out of the 252 coronaries (92%) in 63 additional CTCA images. Conclusions: The presented results, in combination with minimal user interaction and low computation time, show that minimum cost path approaches can effectively be applied as a preprocessing step for subsequent analysis in clinical practice and biomedical research.

Objectives We sought to evaluate the contribution of noninvasive dual-source computed tomography angiography (CTA) in the comprehensive assessment of symptomatic patients after coronary artery bypass grafting (CABG). Background Assessment of bypass grafts and distal runoffs by invasive coronary angiography is cumbersome and often requires extra procedure time, contrast load, and radiation exposure. Methods Dual-source CTA was performed in 52 (41 men, mean age 66.6 ± 13.2 years) symptomatic post-CABG patients scheduled for invasive coronary angiography. No oral or intravenous beta blockers or sedation were administered before the scan. Mean interval between CABG surgery and CTA was 9.6 ± 7.2 (range 0 to 20) years. Mean heart rate during scanning was 64.5 ± 13.2 (range 48 to 92) beats/min. Seventy-five percent of patients had both arterial and venous grafts. A total of 152 graft segments and 142 distal runoffs vessels were analyzed. Native coronary segments were divided into nongrafted (n = 118) and grafted segments (n = 289). A significant stenosis was defined as ≥50% lumen diameter reduction, and quantitative coronary angiography served as reference standard. Results The diagnostic accuracy of CTA for the detection or exclusion of significant stenosis in arterial and venous grafts on a segment-by-segment analysis was 100%. Sensitivity, specificity, positive predictive value, and negative predictive value to detect significant stenosis were 95% (95% confidence interval [CI]: 73% to 100%), 100% (95% CI: 96% to 100%), 100% (95% CI: 79% to 100%), 99% (95% CI: 95% to 100%) in distal runoffs respectively; 100% (95% CI: 97% to 100%), 96% (95% CI: 90% to 98%), 97% (95% CI: 93% to 99%), 100% (95% CI: 95% to 100%) in grafted native coronary arteries respectively; and 97% (95% CI: 83% to 100%), 92% (95% CI: 83% to 96%), 83% (95% CI: 67% to 92%), 99% (95% CI: 92% to 100%) in nongrafted native coronary arteries, respectively. Conclusions Noninvasive CTA is successful for evaluating bypass grafts in symptomatic post-CABG patients, whereas invasive coronary angiography is still required for the assessment of significant stenosis in distal runoffs and native coronary arteries.

PURPOSE: This study compared the role of multislice computed tomography coronary angiography (MSCT-CA) and stress electrocardiography (ECG) in the diagnostic workup of patients with chronic chest pain. MATERIALS AND METHODS: MSCT-CA was performed in 43 patients (31 men, 12 women, mean age 58.8+/-7.7 years) with stable angina after a routine diagnostic workup involving stress ECG and conventional CA. The following inclusion criteria were adopted: sinus rhythm and ability to hold breath for 12 s. Beta-blockers were administered in patients with heart rate>or=70 beats/minute. In order to identify or exclude patients with significant stenoses (>or=50% lumen), we determined posttest likelihood ratios of stress test and MSCT-CA separately and of MSCT-CA performed after the stress test. RESULTS: The pretest probability of significant coronary artery disease (CAD) was 74%. Positive and negative likelihood ratios were 2.3 [95% confidence interval (CI) 1.0-5.3] and 0.3 (95% CI: 0.2-0.7) for the stress test and 10.0 (95% CI: 1.8-78.4) and 0.0 (95% CI: 0.0-infinity) for MSCT-CA, respectively. MSCT-CA increased the posttest probability of significant CAD after a negative stress test from 50% to 86% and after a positive stress test from 88% to 100%. MSCT-CA correctly detected all patients without CAD. CONCLUSIONS: Noninvasive MSCT-CA is a potentially useful tool in the diagnostic workup of patients with stable angina owing to its capability to detect or exclude significant CAD.

Aims: There is no mention in the current "appropriateness criteria for CTCA" of the need of CTCA investigation prior to an attempt at recanalisation of a CTO. To define better the role of CTCA in the treatment of patients with CTOs, we performed CTCA in a consecutive cohort of eligible patients who were scheduled for percutaneous recanalisation of a CTO. Methods and results: Symptomatic patients due to a CTO suitable for percutaneous treatment were included. One hundred and thirty-nine (142 CTOs) patients were studied. Overall success rate was 62.7%. By CTCA, the occlusion length was 24.9±18.3 vs. 30.7±20.7mm in successful and failed cases (p=0.1), but the frequency of patients with an occlusion length >15 mm was different, i.e. 63.2% vs. 82.7%, respectively (p=0.02). Severe calcification, (>50% CSA) was more prevalent in failed cases (54.7% vs. 35.9%, p=0.03). Calcification at the entry of the occlusion was present in 58.5% of the failures vs. 41.6% of the successful cases (p=0.04), while calcium at the exit was not different. The length of calcification was 8.5±8.4 vs. 5.5±6.6 mm in the failed and successful cases respectively (p=0.027). By multivariable analysis, the only independent predictor of procedural success was the absence of severe calcification as defined by CTCA. The mean effective radiation dose of the PCI was 39.3±30.1 mSv. The mean effective radiation dose of CT scan was 22.4 mSv: 19.2±6.5 mSv for contrast-enhanced scan 3.2±1.7 mSv for calcium scoring scan. Conclusions: More severe calcified patterns, as assessed by CTCA, are seen in failed cases. The radiation exposure during a CT scan prior to a CTO PCI is considerable, and further studies are required to determine whether this extra diagnostic study is warranted.

Purpose: To determine the cost-effectiveness of computed tomographic (CT) coronary angiography as a triage test, performed prior to conventional coronary angiography, by using a Markov model. Materials and Methods: A Markov model was used to analyze the cost-effectiveness of CT coronary angiography performed as a triage test prior to conventional coronary angiography from the perspective of the patient, physician, hospital, health care system, and society by using recommendations from the United Kingdom, the United States, and the Netherlands for cost-effectiveness analyses. For CT coronary angiography, a range of sensitivities (79%-100%) and specificities (63%-94%) were used to help diagnose significant coronary artery disease (CAD). Optimization criteria (ie, outcomes considered) were: revised posttest probability of CAD, life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs). Extensive sensitivity analysis was performed. Results: For a prior probability of CAD of less than 40%, the probability of CAD after CT coronary angiography with negative results was less than 1%. The Markov model calculations from the patient/physician perspective suggest that CT coronary angiography maximizes life-years respectively in 60-year-old men and women at a prior probability of less than 38% and 24% and maximizes QALYs at a prior probability of less than 17% and 11%. From the hospital/health care perspective, CT coronary angiography helps reduce health care and direct nonhealth care-related costs (according to UK/U.S. recommendations), regardless of prior probability, and lowers all costs, including production losses (Netherlands recommendations) at a prior probability of less than 87%-92%. Analysis performed from a societal perspective by using a willingness-to-pay threshold level of (sic)80 000/QALY suggests that CT coronary angiography is cost-effective when the prior probability is lower than 44% and 37% in men and women, respectively. Sensitivity analyses showed that results changed across the reported range of sensitivity of CT coronary angiography. Conclusion: The optimal diagnostic work-up depends on the optimization criterion, prior probability of CAD, and the diagnostic performance of CT coronary angiography. (C) RSNA, 2009

The aim of this study was to investigate the value of coronary calcium detection by computed tomography compared to computed tomographic angiography (CTA) and exercise testing to detect obstructive coronary artery disease (CAD) in patients with stable chest pain. A total of 471 consecutive patients with new stable chest complaints were scheduled to undergo dual-source multislice computed tomography (Siemens, Germany; coronary calcium score [CCS] and coronary CTA) and exercise electrocardiography (XECG). Clinically driven invasive quantitative angiography was performed in 98 patients. Only 3 of 175 patients (2%) with a negative CCS had significant CAD on CT angiogram, with only 1 confirmed by quantitative angiography. In patients with a high calcium score (Agatston score >400), CTA could exclude significant CAD in no more than 4 of 65 patients (6%). In patients with a low-intermediate CCS, CTA more often yielded diagnostic results compared to XECG and could rule out obstructive CAD in 56% of patients. For patients with CAD on CT angiogram, those with abnormal exercise electrocardiographic results more often showed severe CAD (p 50% quantitative angiographic diameter stenosis were 100% and 15% for CCS >0, 82% and 64% for CCS >100, 97% and 36% for CTA, and 70% and 76% for XECG, respectively. In conclusion, nonenhanced computed tomography for calcium detection is a reliable means to exclude obstructive CAD in stable, symptomatic patients. Contrast-enhanced CTA can exclude significant CAD in patients with a low-intermediate CCS but is of limited value in patients with a high CCS. (C) 2009 Elsevier Inc. All rights reserved. (Am J Cardiol 2009;104:1499-1504)

Purpose: To investigate the effect of heart rate frequency (HRF) and heart rate variability (HRV) on radiation exposure, image quality, and diagnostic performance to help detect significant stenosis (>= 50% lumen diameter reduction) by using adaptive electrocardiographic (ECG) pulsing at dual-source (DS) spiral computed tomographic (CT) coronary angiography. Materials and Methods: Institutional review committee approval and informed consent were obtained. No prescan beta-blockers were applied. Unenhanced CT and CT coronary angiography with adaptive ECG pulsing were performed in 927 consecutive patients (600 men, 327 women; mean age, 60.3 years +/- 11.0 [standard deviation]) divided in three HRF groups: low, intermediate, and high (= 80 beats/min, respectively), and four HRV groups given mean interbeat difference (IBD) during CT coronary angiography: normal, minor, moderate, and severe (IBDs of 0-1, 2-3, 4-10, and >10, respectively). Radiation exposure and image quality were also evaluated. In 444 of these, diagnostic performance was presented as sensitivity, specificity, positive predictive values (PPVs), and negative predictive values and likelihood ratios with corresponding 95% confidence intervals by using quantitative coronary angiography as the reference standard. Results: CT coronary angiography yielded good image quality in 98% of patients and no significant differences in image quality were found among HRF and HRV groups. Radiation exposure was significantly higher in patients with low versus high HRF and in patients with severe versus normal HRV. No significant differences among HRF and HRV groups in image quality and diagnostic performance were found. A nonsignificant trend was found toward a lower specificity and PPV in patients with a high HRF or severe HRV when compared with low HRF or normal HRV in patients with a low calcium score (Agatston score

Objective: To compare the diagnostic performance of CT angiography (CTA) and exercise electrocardiography (XECG) in a symptomatic population with a low-intermediate prevalence of coronary artery disease (CAD). Design: Prospective registry. Setting: Tertiary university hospital. Patients: 471 consecutive ambulatory patients with stable chest pain complaints, mean (SD) age 56 (10), female 227 (48%), pre-test probability for significant CAD > 5%. Intervention: All patients were intended to undergo both 64-slice, dual-source CTA and an XECG. Clinically driven quantitative catheter angiography was performed in 98 patients. Main outcome measures: Feasibility and interpretability of, and association between, CTA and XECG, and their diagnostic performance with invasive coronary angiography as reference. Results: CTA and XECG could not be performed in 16 (3.4%) vs 48 (10.2%, p < 0.001), and produced non-diagnostic results in 3 (0.7%) vs 140 (33%, p < 0.001). CTA showed >= 1 coronary stenosis (>= 50%) in 140 patients (30%), XECG was abnormal in 93 patients (33%). Results by CTA and XECG matched for 185 patients (68%, p = 0.63). Catheter angiography showed obstructive CAD in 57/98 patients (58%). Sensitivity, specificity, positive and negative predictive value of CTA to identify patients with >= 50% stenosis was 96%, 37%, 67% and 88%, respectively; compared with XECG: 71%, 76%, 80% and 66%, respectively. Quantitative CTA slightly overestimated diameter stenosis: 6 (21)% (R = 0.71), compared with QCA. Of the 312 patients (66%) with a negative CTA, 44 (14%) had a positive XECG, but only 2/17 who underwent catheter angiography had significant CAD. Conclusion: CTA is feasible and diagnostic in more patients than XECG. For interpretable studies, CTA has a higher sensitivity, but lower specificity for detection of CAD.

Objectives Using multislice computed tomography (MSCT), we sought to evaluate the geometry and apposition of the CoreValve ReValving System (CRS, Medtronic, Luxembourgh, Luxembourgh) in patients with aortic stenosis. Background There are no data on the durability of percutaneous aortic valve replacement. Geometric factors may affect durability. Methods Thirty patients had MSCT at a median 1.5 months (interquartile range [IQR] 0 to 7 months) after percutaneous aortic valve replacement. Axial dimensions and apposition of the CRS were evaluated at 4 levels: 1) the ventricular end; 2) the nadir; 3) central coaptation of the CRS leaflets; and 4) commissures. Orthogonal smallest and largest diameters and cross-sectional surface area were measured at each level. Results The CRS (26-mm: n = 14, 29-mm: n = 16) was implanted at 8.5 mm (IQR 5.2 to 11.0 mm) below the noncoronary sinus. None of the CRS frames reached nominal dimensions. The difference between measured and nominal cross-sectional surface area at the ventricular end was 1.6 cm(2) (IQR 0.9 to 2.6 cm(2)) and 0.5 cm(2) (IQR 0.2 to 0.7 cm(2)) at central coaptation. At the level of central coaptation the CRS was undersized relative to the native annulus by 24% (IQR 15% to 29%). The difference between the orthogonal smallest and largest diameters (degree of deformation) at the ventricular end was 4.4 mm (IQR 3.3 to 6.4 mm) and it decreased progressively toward the outflow. Incomplete apposition of the CRS frame was present in 62% of patients at the ventricular end and was ubiquitous at the central coaptation and higher. Conclusions Dual-source MSCT demonstrated incomplete and nonuniform expansion of the CRS frame, but the functionally important mid-segment was well expanded and almost symmetrical. Undersizing and incomplete apposition were seen in the majority of patients. (J Am Coll Cardiol 2009; 54: 911-8) c 2009 by the American College of Cardiology Foundation

The aim of this study was to determine the predictive value of 64-slice computed tomography coronary angiography (CTCA) for major cardiac events in patients with suspected coronary artery disease (CAD). A total of 187 consecutive patients (119 men, age 62.5 +/- 10.5 years) without known heart disease underwent single-source 64-slice CTCA (Somatom Sensation 64, Siemens) for clinical suspicion of CAD. Patients underwent follow-up for the occurrence of cardiac death, nonfatal myocardial infarction, unstable angina and cardiac revascularization. In total, 2,822 coronary segments were assessed. Forty-two segments (1.5%) were not assessable because of insufficient image quality. Overall, CTCA revealed absence of CAD in 65 (34.7%) patients, nonobstructive CAD (coronary plaque a parts per thousand currency sign50%) in 87 (46.5%) patients and obstructive CAD (> 50%) in 35 (18.8%) patients. A total of 20 major cardiac events (3 myocardial infarctions, 16 cardiac revascularizations, 1 unstable angina) occurred during a mean follow-up of 24 months. One noncardiac death occurred. Seventeen events occurred in the group of patients with obstructive CAD and three events occurred in the group of nonobstructive CAD. The event rate was 0% among patients with normal coronary arteries at CTCA. CTCA has a 100% negative predictive value for major cardiac events at 24-month follow-up in patients with normal coronary arteries.

Objectives This study sought to determine the diagnostic accuracy of 64-slice computed tomographic coronary angiography (CTCA) to detect or rule out significant coronary artery disease (CAD). Background CTCA is emerging as a noninvasive technique to detect coronary atherosclerosis. Methods We conducted a prospective, multicenter, multivendor study involving 360 symptomatic patients with acute and stable anginal syndromes who were between 50 and 70 years of age and were referred for diagnostic conventional coronary angiography (CCA) from September 2004 through June 2006. All patients underwent a nonenhanced calcium scan and a CTCA, which was compared with CCA. No patients or segments were excluded because of impaired image quality attributable to either coronary motion or calcifications. Patient-, vessel-, and segment-based sensitivities and specificities were calculated to detect or rule out significant CAD, defined as >= 50% lumen diameter reduction. Results The prevalence among patients of having at least 1 significant stenosis was 68%. In a patient-based analysis, the sensitivity for detecting patients with significant CAD was 99% (95% confidence interval [CI]: 98% to 100%), specificity was 64% (95% CI: 55% to 73%), positive predictive value was 86% (95% CI: 82% to 90%), and negative predictive value was 97% (95% CI: 94% to 100%). In a segment-based analysis, the sensitivity was 88% (95% CI: 85% to 91%), specificity was 90% (95% CI: 89% to 92%), positive predictive value was 47% (95% CI: 44% to 51%), and negative predictive value was 99% (95% CI: 98% to 99%). Conclusions Among patients in whom a decision had already been made to obtain CCA, 64-slice CTCA was reliable for ruling out significant CAD in patients with stable and unstable anginal syndromes. A positive 64-slice CTCA scan often overestimates the severity of atherosclerotic obstructions and requires further testing to guide patient management. (J Am Coll Cardiol 2008; 52: 2135-44) c 2008 by the American College of Cardiology Foundation

CT angiography is an emerging technique for the noninvasive assessment of coronary artery disease. The diagnostic performance of different generation CT scanners has been investigated for the detection of significant stenosis (≥ 50% lumen diameter reduction) in patients after coronary artery bypass surgery (CABG). The temporal and spatial resolution of CT scanners are important determinants for reliable evaluation of bypass grafts and native coronary arteries. Important drawbacks of 64-slice CT angiography remain the evaluation of severely calcified native coronary segments and distal graft anastomosis site. Future developments in the latest CT scanners head toward the use of wider detectors and improved coverage, which may be relevant in post-CABG patients. Despite technical advances, the role of CT angiography in the follow-up of patients after bypass surgery has not yet been established.

Objectives We sought to determine the diagnostic accuracy of noninvasive visual (computed tomography coronary angiography [CTCA]) and quantitative computed tomography coronary angiography (QCT) to predict the hemodynamic significance of a coronary stenosis, using intracoronary fractional flow reserve (FFR) as the reference standard. Background It has been demonstrated that CTCA provides excellent diagnostic sensitivity for identifying coronary stenoses, but may lack accurate delineation of the hemodynamic significance. Methods We investigated 79 patients with stable angina pectoris who underwent both 64-slice or dual-source CTCA and FFR measurement of discrete coronary stenoses. CTCA and conventional coronary angiography (CCA), and QCT and quantitative coronary angiography (QCA), were performed to determine the severity of a stenosis that was compared with FFR measurements. A significant anatomical or functional stenosis was defined as ≥50% diameter stenosis or an FFR Results A total of 89 stenoses were evaluated of which 18% (16 of 89) had an FFR Conclusions The anatomical assessment of the hemodynamic significance of coronary stenoses determined by visual CTCA, CCA, or QCT or QCA does not correlate well with the functional assessment of FFR. Determining the hemodynamic significance of an angiographically intermediate stenosis remains relevant before referral for revascularization treatment.

Objective: To evaluate the performance of dual source CT coronary angiography (DSCT-CA) in the detection of in-stent restenosis (>= 50% luminal narrowing) in symptomatic patients referred for conventional angiography (CA). Design/patients: 100 patients (78 males, age 62 (SD 10)) with chest pain were prospectively evaluated after coronary stenting. DSCT-CA was performed before CA. Setting: Many patients undergo coronary artery stenting; availability of a non-invasive modality to detect in-stent restenosis would be desirable. Results: Average heart rate (HR) was 67 (SD 12) (range 46-106) bpm. There were 178 stented lesions. The interval between stenting and inclusion in the study was 35 (SD 41) (range 3-140) months. 39/100 (39%) patients had angiographically proven restenosis. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of DSCT-CA, calculated in all stents, were 94%, 92%, 77% and 98%, respectively. Diagnostic performance at HR,70 bpm (n = 69; mean 58 bpm) was similar to that at HR >= 70 bpm (n = 31; mean 78 bpm); diagnostic performance in single stents (n = 95) was similar to that in overlapping stents and bifurcations (n = 83). In stents >= 3.5 mm (n = 78), sensitivity, specificity, PPV, NPV were 100%; in 3 mm stents (n = 59), sensitivity and NPV were 100%, specificity 97%, PPV 91%; in stents (2.75 mm (n = 41), sensitivity was 84%, specificity 64%, PPV 52%, NPV 90%. Nine stents (2.75 mm were uninterpretable. Specificity of DSCT-CA in stents >= 3.5 mm was significantly higher than in stents (2.75 mm (OR = 6.14; 99%CI: 1.52 to 9.79). Conclusion: DSCT-CA performs well in the detection of in-stent restenosis. Although DSCT-CA leads to frequent false positive findings in smaller stents ((2.75 mm), it reliably rules out in-stent restenosis irrespective of stent size.

Aims: To investigate if three-dimensional (3D) based quantitative techniques are comparable to each other and to explore possible differences with respect to the reference method of 2D-QCA in the acute phase and to study whether non-invasive MSCT could potentially be applied to quantify luminal dimensions of a stented coronary segment with a novel bioabsorable drug-eluting stent made of poly-l-lactic-acid (PLLA). Methods and results: Quantitative imaging data derived from 16 patients enrolled at our institution in a first-in-man trial (ABSORB) receiving a biodegradable stent and who were imaged with standard coronary angiography and intravascular ultrasound were compared. Shortly, after stenting the patients also underwent a MSCT procedure. Standard 2D-QCA showed significant smaller stent lengths (p

Purpose: To retrospectively compare sensitivity and specificity of four generations of multidetector computed tomographic (CT) scanners for diagnosing significant (>= 50%) coronary artery stenosis, with quantitative conventional coronary angiography as reference standard. Materials and Methods: The institutional review :board approved this study. All patients consented to undergo CT studies prior to conventional coronary angiography, after they were informed of the additional radiation dose, and to the use of their data for future retrospective research. Two hundred four patients (157 men 47 women; mean age, 58 year +/- 11 [standard devia tion]), classified in four groups of 51 patients each, underwent coronary CT angiography with four-section; first-and second-generation 16 section, and 64-section CT;scanners., Patients in sinus rhythm scheduled for conventional coronary. angiography (stable angina, atypical chest pain). were included. Patients with bypass grafts and stems were excluded. Two readers unaware of results of conventional coronary angiography evaluated CT scans. Coronary artery:segments of 2 mm: or larger in diameter were included for, comparative evaluation with quantitative coronary angiography: Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for detection of significant stenoses (>= 50% luminal diameter reduction) were calculated. Results: Image quality was rated poor for the following percentages. of coronary artery segments: 33.1% at four-section C 14.4% at first generation 16 section CT, 6.3% at second-generation 16-section CT, and -2.6% at 64 section CT Sensitivity, specificity, PPV, and NPV, respectively, were as follows; 57%; 91%, 60%, and 90% at four section CT 90%, 93%, 65%, and 99% at first-generation 16-section CT; 97%, 98%, 87%, and 100% at second-generation 16-section CT; and 99%, 96%, 80%, and 100% at 64- section CT. Diagnostic performance of four-section CT. was significantly poorer than that of second generation 16-section CT (odds ratio = 4.57) and 64-section CT (odds ratio = 2.89). Conclusion: Diagnostic performance of coronary CT angiography varies among scanners of different generations. Earlier generation scanners (four sections) had significantly poorer perfor. mance; performance of 16-compared with 64-section CT showed progressive, although not significant, improvement: (C) RSNA, 2008.

Purpose: To determine the optimal width and timing of the electrocardiographic (ECG) pulsing window within the cardiac cycle in relation to heart rate (HR), image quality, and radiation exposure in patients who are suspected of having coronary artery disease. Materials and Methods: The institutional review board approved the study, and all patients gave informed consent. Dual-source computed tomography (CT) was performed in 301 patients (mean HR, 70.1 beats per minute +/- 13.3 [standard deviation]; range, 43 - 112 beats per minute) by using a wide ECG pulsing window ( 25% - 70% of the R- R interval). Data sets were reconstructed in 5% steps from 20% - 75% of R-R interval. Image quality was assessed by two observers on a per-segment level and was classified as good or impaired. High-quality data sets were those in which each segment was of good quality. The width and timing of the image reconstruction window was calculated. On the basis of these findings, an optimal HR-dependent ECG pulsing protocol was designed, and the potential dose-saving effect on effective dose (in millisieverts) was calculated. Results: At low HR (= 80 beats per minute), they were obtained during end systole (ES); and at intermediate HR (66 - 79 beats per minute), they were obtained during both ES and ED. Optimal ECG pulsing windows for low, intermediate, and high HR were at 60% - 76%, 30% - 77%, and 31% - 47% of the R- R interval, respectively, and with these levels, the effective dose was decreased at low HR from 18.7 to 6.8 mSv, at intermediate HR from 14.7 to 13.4 mSv, and at high HR from 11.3 to 4.2 mSv. Conclusion: With optimal ECG pulsing, radiation exposure to patients, particularly those with low or high HR, can be reduced with preservation of image quality. (c) RSNA, 2008.

Background: A high diagnostic accuracy of 64-slice CT coronary angiography (CTCA) has been reported in selected patients with stable angina pectoris, but only scant information is available in patients with non-ST elevation acute coronary syndrome (ACS). Objectives: To study the diagnostic performance of 64-slice CTCA in patients with non-ST elevation ACS. Patients and methods: 64-slice CTCA was performed in 104 patients (mean (SD) age 59 (9) years) with non-ST elevation ACS. Two independent, blinded observers assessed all coronary arteries for stenosis, using conventional quantitative angiography as a reference. Coronary lesions with ⩾50% luminal narrowing were classified as significant. Results: Conventional coronary angiography demonstrated the absence of significant disease in 15% (16/104) of patients, and the presence of single-vessel disease in 40% (42/104) and multivessel disease in 44% (46/104) of patients. Sensitivity for detecting significant coronary stenoses on a patient-by-patient analysis was 100% (88/88; 95% CI 95 to 100), specificity 75% (12/16; 95% CI 47 to 92), and positive and negative predictive values were 96% (88/92; 95% CI 89 to 99) and 100% (12/12; 95% CI 70 to 100), respectively. Conclusion: 64-slice CTCA has a high sensitivity to detect significant coronary stenoses, and is reliable to exclude the presence of significant coronary artery disease in patients who present with a non-ST elevation ACS.