Impact of aortic valve calcification severity on device success after transcatheter aortic valve replacement.

Aortic valvular calcium score (AVCS) can identify severe aortic stenosis (AS) and provide powerful prognostic information. In severe and symptomatic AS, patients can be referred for a transcatheter aortic valve replacement (TAVR). The aim of this study was to determine whether AVCS, measured on the preoperative contrast enhanced multislice computed tomography (MSCT), is associated with device success (DS), major adverse cardiac events (MACEs) and paravalvular leak (PVL) after TAVR. Three hundred and fifty-two consecutive patients who underwent TAVR with a preoperative standardised contrast enhanced MSCT were included in the study. Valvular calcification detection was defined by adding + 100 Hounsfield Unit (HU) to mean HU determined by a region of interest placed in the contrast enhanced ascending aorta. AVCS was then indexed to the aortic annulus surface (AVCSi). Endpoints were DS and 30-day MACE according to Valve Academic Research Consortium-2 consensus document, and moderate to severe PVL. DS was obtained for 305 patients. In multivariate analysis, AVCSi was negatively and independently associated with DS: OR = 0.99, 95% CI 0.99-0.99, p = 0.03. In the subgroup analysis, this association was particularly relevant with self-expanding prostheses [n = 151 (43%), p = 0.018] and in the cases of asymmetric calcium valvular distribution [n = 283 (80%), p 0.002]. There was no association between MACE and AVCS (p = 0.953) and AVCSi (p = 0.757). PVL was positively associated with AVCS (p < 0.001) and AVCSi (p < 0.001). In conclusion, in TAVR, AVCS, measured on preoperative contrast enhanced MSCT, is significantly associated with DS and PVL, but not with 30-day MACE. Its routine use could be relevant to appreciate success chances of TAVR.

Gated blood pool SPECT: The estimation of right ventricular volume and function is algorithm dependent in a clinical setting.

BACKGROUND: Gated blood pool SPECT (GBPS) requires further validation for the assessment of the right ventricle (RV). This study evaluated three algorithms: BP-SPECT, QBS, and TOMPOOL (results are referred using this order). We compared (1) their "quantitative-accuracy": estimation of RV ejection fraction (EF), end-diastolic volume (EDV), and cardiac output (CO); (2) their "qualitative-accuracy": threshold values allowing diagnosing an impairment of the RV function; (3) their reproducibility: inter-observer relative variability (IOV). METHODS AND RESULTS: Forty-eight consecutive patients underwent GBPS. Recommended reference standards were used: cardiac magnetic resonance imaging (CMR) (EDV, EF, n = 48), catheter measurements from thermodilution (TD) (CO, n = 25). (1) "Quantitative-accuracy": r = 0.42, 0.30, 0.42 for RVEF (CMR); r = 0.69, 0.77, 0.53 for RVEDV (CMR); 0.32, 0.36, 0.52 for RCO (TD). (2) "Qualitative-accuracy": optimal thresholds were 54.7%, 38.5%, 45.2% (AUC: 0.83, 0.80, 0.79) for RVEF; 229, 180, 94 mL (AUC: 0.83, 0.81, 0.81) for RVEDV; 4.1, 4.4, 2.6 L·minute(-1) (AUC: 0.73, 0.77, 0.80) for RCO. (3) Reproducibility: IOV was 5% ± 6%, 8% ± 12%, 17% ± 18% for RVEF; 6% ± 8%, 4% ± 4%, 21% ± 18% for RVEDV; 8% ± 8%, 11% ± 15%, 24% ± 20% for RCO. CONCLUSION: Diagnostic accuracies are similar. A CMR-based calibration is required for a quantitative-analysis (cautious interpretation) or an accurate qualitative analysis (thresholds must be adjusted). Automatic procedures (BP-SPECT, QBS) offer the best compromise accuracy/reproducibility.

Is TOMPOOL (gated blood-pool SPECT processing software) accurate to diagnose right and left ventricular dysfunction in a clinical setting?

BACKGROUND: The assessment of right ventricular function is crucial for management of heart disease. TOMPOOL is a software that processes data acquired with Tomographic Equilibrium Radionuclide Ventriculography. In this report, TOMPOOL's diagnostic accuracy and inter-observer reproducibility were assessed in a cohort of patients with various etiologies of ventricular dysfunction. METHODS AND RESULTS: End-diastolic volume (EDV), ejection fraction (EF), and cardiac output (CO) were calculated for the right ventricle (RV) and the left ventricle (LV) using TOMPOOL in 99 consecutive patients. Thirty-five patients underwent cardiac magnetic resonance imaging (CMR) considered as the reference-standard to measure EDV and EF; the Spearman's rho correlation coefficients were r = 0.73/0.80 and 0.67/0.73 for right/left EF and EDV, respectively. Twenty-one patients had thermodilution measurements of right CO (reference-standard), the correlation was r = 0.57. The best cut-off points (sensitivity/specificity) in order to diagnose a ventricular dysfunction or enlargement were 46% for RVEF (67%/89%), 62% for LVEF (100%/90%), 94 mL for RVEDV (77%/73%), and 84 mL for LVEDV (100%/91%). The areas under the ROC curve were, respectively, 0.79, 0.91, 0.83, and 0.99. Inter-observer reproducibility was r = 0.81/0.94, 0.77/0.90, and 0.78/0.75 for Right/Left EF, EDV, and CO, respectively. CONCLUSION: TOMPOOL is accurate: measurements of EDV, EF, and CO are reproducible and correlate with CMR and thermodilution. However, thresholds must be adjusted.

Transseptal implantation of a left ventricular pacing lead for an ectopic location of the coronary sinus ostium in the left atrium.

Congenital abnormalities of the coronary sinus (CS) are rare but can be responsible for unsuccessful implantation of a cardiac resynchronization therapy device. We report the case of an ectopic drainage of the CS in the left atrium. A left ventricular lead was implanted by the transseptal route.

Early triage of emergency department patients with acute coronary syndrome: contribution of 64-slice computed tomography angiography.

BACKGROUND: Multislice computed tomography coronary angiography (MSCT-CA) is feasible in the emergency department (ED) for ruling out obstructive coronary artery disease (CAD). AIM: To investigate a diagnostic strategy using MSCT-CA for the early triage of patients presenting to the ED with acute chest pain suggestive of acute coronary syndrome (ACS), according to the medium-term incidence of clinical events. METHODS: We conducted a single-centre, prospective, observational cohort study in 123 patients with low-risk to intermediate-risk acute chest pain suggestive of ACS. MSCT-CA was performed using dual-source 64-slice computed tomography with retrospective electrocardiographic gating. Patients without coronary artery lesions were discharged from the ED. The incidences of death, myocardial infarction and myocardial revascularization were collected during a mid-term follow-up. RESULTS: According to MSCT-CA, 93 patients (75.6%) had no CAD or coronary artery stenosis less or equal to 50% and 28 patients (22.8%) had stenosis more or equal to 50%. Invasive coronary angiography was performed in 29 patients (23.6%). MSCT-CA accurately identified ten patients (8.13%) with obstructive CAD requiring myocardial revascularization; all had a low TIMI score (0-2) and eight had a low GRACE score. The mean estimated effective dose of MSCT-CA was 16.3±6.4 mSv. Median follow-up was 15 months. No patient (95% CI 0-3.0%) had major adverse cardiovascular events during follow-up. CONCLUSION: MSCT-CA appears to be a useful initial triage tool in the ED. When the MSCT-CA result is negative, it allows safe early discharge because of its high negative predictive value. In a significant number of cases of low-risk ACS, MSCT-CA detects severe coronary lesions and allows further dedicated diagnostic and therapeutic intervention. Reduction of radiation exposure would help acceptance in clinical practice.

Type B intramural hematoma of the aorta: evolution and prognostic value of intimal erosion.

PURPOSE: The prognosis and treatment of type B intramural hematoma (IMH) remain unclear. Intimal erosions could be the target of preventive endovascular treatment, but we have no therapeutic criterion on which to decide preventive treatment. MATERIALS AND METHODS: A prospective multislice computed tomography (CT) study was carried out in 44 patients with type B IMH to assess morphologic evolution and intimal erosion to determine reliable predictive factors that would permit endovascular treatment. Follow-up range was 24-1,440 days. RESULTS: Intimal anomalies consisted of intimal erosion and aortic branch artery lesions. Fifty-eight intimal anomalies were seen on initial CT in 38 patients (86%). Twenty-five anomalies in 22 patients were considered as intimal erosions, of which nine (36%) were visible only on delayed-phase CT. Hematoma regressed in 23 patients (53%). Twenty-one patients (47%) showed morphologic progression. Eleven of these (52%) required endovascular treatment. Twenty of the 25 initial intimal erosions (80%) progressed and caused 19 of the 21 morphologic evolutions (90%). Progression was related to initial intimal erosion and to IMH thickness. Intimal erosion measuring greater than 10 mm had unfavorable progression at 1 month (positive predictive value, 100%). CONCLUSIONS: Complications or morphologic progression were related to a preexisting intimal anomaly visualized on initial CT. Multislice CT with systematically delayed phase and millimetric thin slices could increase the detection rate of intimal anomalies.

Oxidized low-density lipoproteins trigger endoplasmic reticulum stress in vascular cells: prevention by oxygen-regulated protein 150 expression.

Oxidized low-density lipoproteins (oxLDLs) trigger various biological responses potentially involved in atherogenesis. Disturbing endoplasmic reticulum (ER) function results in ER stress and unfolded protein response, which tends to restore ER homeostasis but switches to apoptosis when ER stress is prolonged. We aimed to investigate whether ER stress is induced by oxLDLs and can be prevented by the ER-associated chaperone ORP150 (150-kDa oxygen-regulated protein). oxLDLs and the lipid oxidation products 7-ketocholesterol and 4-hydroxynonenal induce ER stress in human endothelial cells (HMEC-1), characterized by the activation of ER stress sensors (phosphorylation of Ire1alpha and PERK, nuclear translocation of ATF6) and of their subsequent pathways (eukaryotic initiation factor 2alpha phosphorylation, expression of XBP1/spliced XBP1, CHOP, and KDEL chaperones GRP78, GRP94, ORP150). ER stress was inhibited by the antioxidant N-acetylcysteine. In advanced atherosclerotic lesions, phospho-Ire1alpha, KDEL, and ORP150 staining were localized in lipid-rich areas with 4-hydroxynonenal adducts and CD68-positive macrophagic cells. By comparison, staining for 4-hydroxynonenal, phospho-Ire1alpha, KDEL, and ORP were faint and more diffuse in intimal hyperplasia. ER stress takes part in the apoptotic effect of oxLDLs, through the Ire1alpha/c-Jun N-terminal kinase pathway, as assessed by the protective effect of specific small interfering RNAs and c-Jun N-terminal kinase inhibitor. Forced expression of the chaperone ORP150 reduced both oxLDL-induced ER stress and apoptosis. ER stress markers and ORP150 chaperone are expressed in areas containing oxLDLs in atherosclerotic lesions and are induced by oxLDLs and oxidized lipids in cultured cells. The forced expression of ORP150 highlights its new protective role against oxLDL-induced ER stress and subsequent apoptosis.

Left-circumflex coronary artery to right atrium fistula with saccular aneurysm and its endovascular treatment.

The combination of coronary artery aneurysm and coronary artery fistula is infrequent. A saccular aneurysm of a branch of the left-circumflex coronary artery associated with multiple fistulae to the right atrium was observed on a coronary angiogram performed in a 47-year-old female. Multidetector computed tomography coronary angiography detailed the anatomy of the abnormal coronary artery. An embolization with a microcoil was performed and the aneurysm sac was excluded.