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BACKGROUND AND AIMS: Successful left atrial posterior wall isolation (LAPWI) using only the cryoballoon (CB) is technically challenging for the treatment of atrial fibrillation (AF). This study aimed to evaluate the efficacy of the cross-over technique, wherein an overlapped ablation is performed by placing the CB from both directions in contact with the LAPW. METHODS: This was a single-center, retrospective, observational study of 194 consecutive patients with persistent atrial fibrillation (PerAF) who underwent a first-time procedure of pulmonary vein isolation (PVI) + PWI (108 patients) or PVI-only (86 patients) using the CB. The cross-over technique was applied in all LAPWI. RESULTS: For ablation of the LA roof and bottom, respectively, a mean of 8.6 ± 1.0 (right to left [RâL] 4.3 ± 1.1 and left to right [LâR] 4.3 ± 1.1) and 9.1 ± 1.2 (RâL 4.6 ± 1.6 and LâR 4.5 ± 1.2) CB applications were delivered. LAPW was successfully isolated solely using the CB in 99.1% of patients. Although the PVI + PWI group had significantly longer procedure time, no severe adverse events were observed in either group. During a median follow-up of 19 months, freedom from recurrence of all atrial tachyarrhythmias was achieved in 93.5% of the PVI + PWI group and 72.9% of the PVI-only group (p = .011). CONCLUSIONS: LAPWI performed solely with the CB using the cross-over technique is feasibly, safe, and was independently associated with a significantly higher freedom from recurrence of atrial tachyarrhythmias compared with PVI alone in patients with PerAF.
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BACKGROUND: On-site computed tomography-derived fractional flow reserve (CT-FFR) is a feasible method for examining lesion-specific ischemia, and plaque analysis of coronary CT angiography (CCTA) is useful for predicting future cardiac events. However, their utility and association on a per-vessel level remain unclear. METHODS: We analyzed vessels showing 50-90â¯% stenosis on CCTA where planned revascularization was not performed after CCTA within 90â¯days. Relevant features, including CT-FFR and the plaque burden [necrotic core to the total plaque volume (% necrotic core), and non-calcified plaque (NCP) to vessel volume (% NCP)] using a novel algorithm for analyzing plaque to predict vessel-oriented composite outcomes (VOCO), including cardiac death, non-fatal myocardial infarction, and unplanned vessel-related revascularization, were assessed. RESULTS: In 256 patients (68.7⯱â¯9.4â¯years; 73.8â¯% male) with 354 vessels (10.5â¯% CT-FFRâ¯≤â¯0.80), VOCO occurred in 24 vessels (6.8â¯%) during a median follow-up of 3.6â¯years. Multivariable Cox analysis revealed CT-FFRâ¯≤â¯0.80 had the pronounced impact on VOCO, and moreover, higher % necrotic core and % NCP were independently associated with VOCO [adjusted hazard ratio 3.43 (95â¯% confidence interval 1.42-8.29) and 4.05 (1.19-13.71), respectively], especially for vessels with CT-FFRâ¯>â¯0.80. CONCLUSIONS: In vessels without planned revascularization, per-vessel CT-FFRâ¯≤â¯0.80 was the notable predictor of future cardiac events. Additionally, necrotic core volume and NCP were identified as independent predictors along with CT-FFR.
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Whether malnutrition during the early phase of recovery from acute myocardial infarction (AMI) could be a predictor of mortality or morbidity has not been ascertained. We examined 289 AMI patients. All-cause mortality and composite endpoints (all-cause mortality, nonfatal stroke, nonfatal acute coronary syndrome, and hospitalization for acute decompensated heart failure) during the follow-up duration (median 39 months) were evaluated. There were 108 (37.8%) malnourished patients with GNRIs of less than 98 on arrival; however, malnourished patients significantly decreased to 91 (31.4%) during the convalescence period (p < 0.01). The incidence rates of mortality and primary composite endpoints were significantly higher in the malnourished group than in the well-nourished group both on arrival and during the convalescence period (All p < 0.05). Nutrition guidance significantly improved GNRI in a group of patients who were undernourished (94.7 vs. 91.0, p < 0.01). Malnourished patients on admission who received nutritional guidance showed similar all-cause mortality with well-nourished patients, whereas malnourished patients without receiving nutritional guidance demonstrated significantly worse compared to the others (p = 0.03). The assessment of GNRI during the convalescence period is a useful risk predictor for patients with AMI. Nutritional guidance may improve the prognoses of patients with poor nutritional status.
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Insuficiência Cardíaca , Desnutrição , Infarto do Miocárdio , Humanos , Idoso , Estado Nutricional , Estudos Retrospectivos , Convalescença , Desnutrição/diagnóstico , Desnutrição/etiologia , Desnutrição/epidemiologia , Infarto do Miocárdio/complicações , Prognóstico , Avaliação Nutricional , Avaliação Geriátrica , Fatores de RiscoRESUMO
Aims: To develop an artificial intelligence (AI)-model which enables fully automated accurate quantification of coronary artery calcium (CAC), using deep learning (DL) on electrocardiogram (ECG)-gated non-contrast cardiac computed tomography (gated CCT) images. Methods and results: Retrospectively, 560 gated CCT images (including 60 synthetic images) performed at our institution were used to train AI-model, which can automatically divide heart region into five areas belonging to left main (LM), left anterior descending (LAD), circumflex (LCX), right coronary artery (RCA), and another. Total and vessel-specific CAC score (CACS) in each scan were manually evaluated. AI-model was trained with novel Heart-labelling method via DL according to the manual-derived results. Then, another 409 gated CCT images obtained in our institution were used for model validation. The performance of present AI-model was tested using another external cohort of 400 gated CCT images of Stanford Center for Artificial Intelligence of Medical Imaging by comparing with the ground truth. The overall accuracy of the AI-model for total CACS classification was excellent with Cohen's kappa of k = 0.89 and 0.95 (validation and test, respectively), which surpasses previous research of k = 0.89. Bland-Altman analysis showed little difference in individual total and vessel-specific CACS between AI-derived CACS and ground truth in test cohort (mean difference [95% confidence interval] were 1.5 [-42.6, 45.6], -1.5 [-100.5, 97.5], 6.6 [-60.2, 73.5], 0.96 [-59.2, 61.1], and 7.6 [-134.1, 149.2] for LM, LAD, LCX, RCA, and total CACS, respectively). Conclusion: Present Heart-labelling method provides a further improvement in fully automated, total, and vessel-specific CAC quantification on gated CCT.
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Purpose: To investigate whether vorticity could predict functional plaque progression better than high-risk plaque (HRP) and lesion length (LL) in individuals with type 2 diabetes mellitus. Materials and Methods: This single-center prospective study included 61 participants (mean age, 61 years ± 9 [SD]; 43 male participants) who underwent serial coronary CT angiography at 2 years, with 20%-70% stenosis at initial CT between October 2015 and March 2020. The number of the following HRP characteristics was recorded: low attenuation, positive remodeling, spotty calcification, and napkin-ring sign. Vorticity was calculated using a mesh-free simulation. A decrease in CT fractional flow reserve larger than 0.05 indicated functional progression. Models using HRP and LL and vorticity were compared using receiver operating characteristic curve analysis. Results: Of the 94 vessels evaluated, 25 vessels (27%) showed functional progression. Vessels with functional progression showed higher vorticity at distal stenosis (984 sec-1; IQR: 730-1253 vs 443 sec-1; IQR: 295-602; P < .001) than vessels without progression. The area under the receiver operating characteristic curve of vorticity (0.91; 95% CI: 0.84, 0.97) was higher than that of HRP and LL (0.69; 95% CI: 0.56, 0.82; P < .01). Diagnostic accuracy of vorticity (85%; 80 of 94 vessels; 95% CI: 76, 92) was higher than that of HRP and LL (72%; 68 of 94 vessels; 95% CI: 62, 81; P = .004). Conclusion: In participants with type 2 diabetes mellitus, vorticity at distal stenosis was a better predictor of functional plaque progression than HRP and LL.Keywords: Coronary Artery, Vorticity, Functional Plaque Progression, Type 2 Diabetes, Vasculature, CT Angiography, Computational Fluid Dynamics, Fractional Flow Reserve Supplemental material is available for this article. © RSNA, 2023.
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PURPOSE: The presence of severely calcified plaque remains problematic in endovascular therapy, and no specific endovascular treatment strategy has been established. Estimating plaque solidity before the procedure may help operators penetrate calcified plaque with a guide wire. The aim of this study was to establish a method of measuring plaque solidity with noncontrast computed tomography (CT). METHODS: This retrospective, single-center study included consecutive patients who, between October 2020 and July 2022, underwent noncontrast 5 mm and 1 mm CTs before endovascular therapy to penetrate calcified plaque with a wire in the common femoral, superficial femoral, and popliteal arteries. Three cross-sectional CT slices were selected. To target a calcified plaque lesion, the operator identified a region of interest, which corresponded to 24×24 pixels, and Hounsfield unit (HU) values of each pixel were displayed on the CT image. The average HU values and the ratio of number of pixels of lower values (130-599 HU) represented plaque solidity. We used the Mann-Whitney-Wilcoxon rank-sum test and the chi-square test to compare the solidity of plaques penetrated and not penetrated by the wire. RESULTS: We evaluated 108 images of 36 calcified plaque lesions (in 19 patients). The wire penetrated 28 lesions (77.8%) successfully. The average HU value was significantly lower in the lesions that the wire penetrated than in the others, in both the 5 mm CT slices (434.7±86.8 HU vs 554.3±112.7 HU, p=0.0174) and 1 mm slices (497.8±103.1 HU vs 593.5±114.5 HU, p=0.0381). The receiver operating curve revealed that 529.9 and 533.9 HU in the 5 and 1 mm slices, respectively, were the highest values at which wires could penetrate. Moreover, at the lesions that were penetrates successfully, the ratio of number of lower HU value pixels was significantly higher both in 5 mm slice CTs (74.7±13.4 vs 61.7±13.1%, p=0.0347) and 1 mm (68.7±11.8 vs 57.1±11.4%, p=0.0174). CONCLUSION: The use of noncontrast CT to evaluate plaque solidity was associated with successful wire penetration of calcified lesions in peripheral arteries. CLINICAL IMPACT: This study revealed an association between the wire penetration inside calcified plaque and plaque solidity estimated using non-contrasted computed tomography. The mean Hounsfield unit values of three cross-sections in calcified plaques were associated with the successful wire penetration. This wire penetration difficulty is associated with extended procedure time, excessive radiation exposure, usage of extra contrast agents, and increased medical costs. Therefore, estimating calcified plaque solidity before procedure enables us to choose effective and lean procedures. In addition, to predict the success of dilating calcified plaque from the inside is also beneficial when the operator wants to avoid extra scaffold implantation for target lesions.
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BACKGROUND: A new image reconstruction process termed the MUS method (masking process on unsmoothed images) was developed to eliminate artifacts, especially those in the inferior wall. We compared diagnostic performance between the MUS and conventional method in stress myocardial perfusion SPECT (MPS). METHODS: Enrolled were 126 patients who underwent stress-rest MPS with 99 m Tc-MIBI. Patients were divided into two groups: 91 with < 50% stenosis in the RCA or LCX (non-ischemia group) and 35 patients with ≥ 90% stenosis or FFR-positive in the RCA (ischemia group), according to coronary CT or coronary angiography within 3 months of MPS. Ischemic heart disease (IHD) was considered positive when the summed difference score of five segments corresponding to the inferior wall region was ≥ 2. RESULTS: Sensitivity was comparable between the MUS method and the conventional method (ordered subset expectation maximization; OSEM) (51% vs 54%, respectively; (p = 0.366), specificity was significantly higher using the MUS method (87% vs 77%, respectively; p < 0.05), and diagnostic performance was higher using the MUS method (area under curve [AUC], conventional 0.61 vs. MUS 0.69, p = 0.138). In evaluation of 87 patients after excluding 39 who received additional prone imaging, sensitivity using the MUS method was 44%, which was comparable to 44% using the conventional method but specificity was 90%, which was significantly higher than 77% using the conventional method (p < 0.05). The diagnostic performance of the MUS method was higher (AUC, conventional 0.60 vs. MUS 0.67, p = 0.185). CONCLUSION: Use of the MUS method improved specificity in diagnosis of IHD while maintaining sensitivity, compared with the conventional method. The MUS method can achieve an improvement in diagnostic accuracy equivalent to the supine position, particularly in patients who have difficulty performing the prone position, without increasing the patient burden.
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Doença da Artéria Coronariana , Isquemia Miocárdica , Imagem de Perfusão do Miocárdio , Humanos , Constrição Patológica , Sensibilidade e Especificidade , Tecnécio Tc 99m Sestamibi , Tomografia Computadorizada de Emissão de Fóton Único/métodos , Angiografia Coronária , Isquemia Miocárdica/diagnóstico por imagem , Imagem de Perfusão , Imagem de Perfusão do Miocárdio/métodos , Doença da Artéria Coronariana/diagnóstico por imagemRESUMO
Summary: Triglyceride deposit cardiomyovasculopathy (TGCV) is an intractable disease characterized by massive triglyceride (TG) accumulation in the myocardium and coronary arteries caused by genetic or acquired dysfunction of adipose TG lipase (ATGL). A phase IIa trial has been conducted involving patients with idiopathic TGCV using CNT-01 (tricaprin/trisdecanion) by the Japan TGCV study group, which showed that CNT-01 improved myocardial lipolysis as demonstrated by iodine-123-beta-methyl iodophenyl-pentadecanoic acid (BMIPP) scintigraphy. We evaluated changes in myocardial TG content using proton magnetic resonance spectroscopy (1H-MRS) before/after CNT-01. This report describes a male patient with hypertension, diabetes, angina pectoris, repeated percutaneous coronary intervention, chest pain, and exertional dyspnea that persisted despite standard medications and nitroglycerin. Idiopathic TGCV was diagnosed based on a remarkably reduced washout rate (WR) for BMIPP scintigraphy, high myocardial TG content on 1H-MRS, and no ATGL mutation. After an 8-week, 1.5 g/day CNT-01 administration, the WR of BMIPP increased from 5.1 to 13.3% and the myocardial TG content decreased from 8.4 to 5.9%, with no adverse effects. CNT-01 corrected myocardial lipolysis and subsequently reduced TG content in idiopathic TGCV as evaluated using 1H-MRS, which may be a useful, noninvasive evaluation of therapeutic efficacy. Learning points: Triglyceride deposit cardiomyovasculopathy (TGCV) is an intractable disease characterized by massive triglyceride accumulation in the myocardium and coronary arteries, caused by genetic or acquired dysfunction of adipose triglyceride lipase. Japan TGCV Study Group developed a specific treatment for idiopathic TGCV using CNT-01 (tricaprin/trisdecanion), a type of medium-chain fatty acid. CNT-01 corrected myocardial lipolysis and reduced TG content in idiopathic TGCV using proton magnetic resonance spectroscopy, which may be a useful noninvasive evaluation of therapeutic efficacy.
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BACKGROUND AND AIMS: We aimed to develop a method for quantifying pericoronary adipose tissue (PCAT) on electrocardiogram (ECG)-gated non-contrast CT (NC-PCAT) and validate its efficacy and prognostic value. METHODS: We retrospectively studied two independent cohorts. PCAT was quantified conventionally. NC-PCAT was defined as the mean CT value of epicardial fat tissue adjacent to right coronary artery ostium on ECG-gated non-contrast CT. In cohort 1 (n = 300), we evaluated the correlation of two methods and the association between NC-PCAT and CT-verified high-risk plaque (HRP). We dichotomized cohort 2 (n = 333) by the median of NC-PCAT, and assessed the prognostic value of NC-PCAT for primary endpoint (all-cause death and non-fatal myocardial infarction) by Cox regression analysis. The median duration of follow-up was 2.9 years. RESULTS: NC-PCAT was correlated with PCAT (r = 0.68, p<0.0001). In multivariable logistic regression analysis, high NC-PCAT (OR:1.06; 95%CI:1.03-1.10; p = 0.0001), coronary artery calcium score (CACS) (OR:1.01 per 10 CACS increase, 95%CI:1.00-1.02; p = 0.013), and current smoking (OR:2.58; 95%CI:1.03-6.49; p = 0.044) were independent predictors of HRP. Among patients with CACS>0 (n = 193), NC-PCAT (OR:1.06; 95%CI:1.03-1.10; p = 0.0002), current smoking (OR:3.02; 95%CI:1.17-7.82; p = 0.027), and male sex (OR:2.81; 95%CI:1.06-7.48; p = 0.028) were independent predictors of HRP, whereas CACS was not (p = 0.15). Multivariable Cox regression analysis revealed high NC-PCAT as an independent predictor of the primary endpoint, even after adjustment for sex and age (HR:4.3; 95%CI:1.2-15.2; p = 0.012). CONCLUSIONS: There was a positive correlation between NC-PCAT and PCAT, with high NC-PCAT significantly associated with worse clinical outcome (independent of CACS) as well as presence of HRP.
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Doença da Artéria Coronariana , Placa Aterosclerótica , Humanos , Masculino , Doença da Artéria Coronariana/diagnóstico por imagem , Angiografia Coronária/métodos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Tecido Adiposo/diagnóstico por imagem , Eletrocardiografia , Angiografia por Tomografia Computadorizada/métodos , Vasos Coronários/diagnóstico por imagemRESUMO
BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) requires a large amount of economic and human resources. The presence of bystander cardiopulmonary resuscitation (CPR) was focused on selecting appropriate V-A ECMO candidates. RESULT: This study retrospectively enrolled 39 patients with V-A ECMO due to out-of-hospital cardiac arrest (CA) between January 2010 and March 2019. The introduction criteria of V-A ECMO included the following: (1) < 75 years old, (2) CA on arrival, (3) < 40 min from CA to hospital arrival, (4) shockable rhythm, and (5) good activity of daily living (ADL). The prescribed introduction criteria were not met by 14 patients, but they were introduced to V-A ECMO at the discretion of their attending physicians and were also included in the analysis. Neurological prognosis at discharge was defined using The Glasgow-Pittsburgh Cerebral Performance and Overall Performance Categories of Brain Function (CPC). Patients were divided into good or poor neurological prognosis (CPC ≤ 2 or ≥ 3) groups (8 vs. 31 patients). The good prognosis group had a significantly larger number of patients who received bystander CPR (p = 0.04). The mean CPC at discharge was compared based on the combination with the presence of bystander CPR and all five original criteria. Patients who received bystander CPR and met all original five criteria showed significantly better CPC than patients who did not receive bystander CPR and did not meet some of the original five criteria (p = 0.046). CONCLUSION: Considering the presence of bystander CPR help in selecting the appropriate candidate of V-A ECMO among out-of-hospital CA cases.
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Background: We aimed to investigate the diagnostic value of energy loss (EL) and baseline CT fractional flow reserve (CT-FFR) computed using computational fluid dynamics to predict functional progression of coronary stenosis in patients with type 2 diabetes mellitus. Methods: This single-center prospective study included 61 patients with type 2 diabetes mellitus (mean age, 61 years ±9 [SD]; 43 men) showing 20-70 % stenosis who underwent serial coronary CT performed at 2-year interval between October 2015 and March 2020. A mesh-free simulation was performed to calculate the CT-FFR and EL. Functional progression was defined as ≥ 0.05 decrease in CT-FFR on the second coronary CT. Models using baseline CT-FFR and EL were compared by analyzing the receiver operating characteristic (ROC) curve. Results: Of the 94 vessels evaluated, 25 vessels (27 %) showed functional progression. EL at distal stenosis (ELdis) of vessels with functional progression was higher than that of vessels without functional progression (27.6 W/m3 [interquartile range (IQR): 15.0, 53.0] vs. 5.7 W/m3 [IQR: 2.3, 10.1], p < 0.001). Multivariable analysis showed that ELdis (per unit Ln(EL); odds ratio, 11.8; 95 % CI: 4.0-34.9; p < 0.001) remained as a predictor of functional progression after adjustment for diameter stenosis and baseline CT-FFR. The area under the ROC curve using ELdis (0.89; 95 % CI: 0.82-0.96) was higher than that using baseline CT-FFR (0.71; 95 % CI: 0.59-0.83; p < 0.001). Conclusion: When ELdis and baseline CT-FFR were considered, ELdis was a better predictor of functional progression of coronary stenosis.
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OBJECTIVES: Vorticity calculated using computational fluid dynamics (CFD) could assess the flow disturbance generated by coronary stenosis. The purpose of this study was to investigate whether vorticity would be an underlying cause of functionally significant stenosis assessed by invasive fractional flow reserve (FFR). METHODS: This retrospective study included 113 patients who underwent coronary CT angiography showing intermediate stenosis and subsequent invasive FFR between December 2015 and March 2020. Vorticity at the stenosis site was calculated using a mesh-free CFD method. We also evaluated the minimum lumen area (MLA) and diameter stenosis (DS) of the lesion. Invasive FFR of ≤ 0.80 was considered functionally significant. Data were compared using Student's t-test and logistic regression analysis was performed. RESULTS: Of the evaluated 144 vessels, 53 vessels (37%) showed FFR ≤ 0.80. Vorticity of significant stenosis was significantly higher than non-significant stenosis (569 ± 78 vs. 328 ± 34 s-1, p < 0.001). A significant negative relationship was present between vorticity and invasive FFR (R2 = 0.31, p < 0.001). Multivariate logistic regression analysis including MLA and DS showed that vorticity (per 100 s-1, odds ratio: 1.36, 95% confidence interval: 1.21-1.57, p < 0.001) was a statistically significant factor to detect functional significance. The area under the receiver operating characteristic curve statistically significantly increased when vorticity was combined with DS and MLA (0.76 vs. 0.87, p = 0.001). CONCLUSIONS: Vorticity had a statistically significant negative relationship with invasive FFR independent of geometric stenosis. KEY POINTS: ⢠Flow disturbance caused by coronary stenosis could be evaluated by calculating vorticity which is defined as the norm of the rotation of the velocity vector. ⢠Vorticity was statistically significantly higher in stenosis with functional significance than stenosis without. ⢠Vorticity has an additive value to detect functionally significant stenosis over geometrical stenosis.
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Estenose Coronária , Reserva Fracionada de Fluxo Miocárdico , Constrição Patológica/patologia , Angiografia Coronária/métodos , Estenose Coronária/diagnóstico , Vasos Coronários , Humanos , Valor Preditivo dos Testes , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
BACKGROUND: Coronary computed tomography angiography examinations are increasingly becoming established as a minimally invasive method for diagnosing coronary diseases. However, although various imaging and processing methods have been developed, coronary artery calcification remains a major limitation in the evaluation of the vascular lumen. Subtraction coronary computed tomography angiography (Sub-CCTA) is a method known to be able to reduce the influence of coronary artery calcification and is therefore feasible for improving the diagnosis of significant stenosis in patients with severe calcification. However, Sub-CCTA still involves some problems, such as the increased radiation dose due to plain (mask) imaging, extended breath-holding time, and misregistration due to differences in the imaging phase. Therefore, we considered using artificial intelligence instead of Sub-CCTA to visualize the coronary lumen with high calcification. Given this background, the present study aimed to evaluate the diagnostic performance of a deep learning-based lumen extraction method (DL-LEM) to detect significant stenosis on CCTA in 99 consecutive patients (891 segments) with severe coronary calcification from November 2015 to March 2018. We also estimated the impact of DL-LEM on the medical economics in Japan. RESULTS: The DL-LEM slightly improved the per-segment diagnostic accuracy from 74.5 to 76.4%, and the area under the curve (AUC) slightly improved from 0.752 to 0.767 (p = 0.030). When analyzing the 228 segments that could not be evaluated because of severe calcification on the original CCTA images, the DL-LEM improved the accuracy from 35.5 to 42.5%, and the AUC improved from 0.500 to 0.587 (p = 0.00018). As a result, DL-LEM analysis could have avoided invasive coronary angiography in 4/99 cases (per patient). From the calculated results, it was estimated that the number of exams that can be avoided in Japan in one year is approximately 747 for invasive coronary angiography, 219 for fractional flow reserve, and 248 for nuclear exam. The total amount of medical fee that could be reduced was 225,629,368 JPY. CONCLUSIONS: These findings suggest that the DL-LEM may improve the diagnostic performance in detecting significant stenosis in patients with severe coronary calcification. In addition, the results suggest that not a small medical economic effect can be expected.
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BACKGROUND: On-site computed tomography-derived fractional flow reserve (CT-FFR), using fluid structure interaction during multiple optimal diastolic phases, is of incremental diagnostic value. However, few studies have investigated prognosis, with the appropriate measurement location of CT-FFR, as a stand-alone modality. The aim of the present study was to assess the clinical impact on CT-FFR with an appropriate measurement. METHODS: A total of 370 consecutive patients (68⯱â¯10â¯years, 75% male) who underwent coronary CT angiography (CCTA), showing 50-90% stenosis in at least one major epicardial vessel, were retrospectively analyzed and followed up for a median 2.9â¯years. CT-FFR values were measured at three points: 1 to 2â¯cm distal to the target lesion (CT-FFR1cm, 2cm) and the vessel terminus (CT-FFRlowest), and a CT-FFR value ≤0.80 was considered to be abnormal. The endpoint was major adverse cardiovascular events (MACE), a composite of cardiac death, non-fatal myocardial infarction, and unplanned revascularization. RESULTS: The incidence of MACE was 6.8% (25/370 patients). The Kaplan-Meier survival analysis in negative CT-FFR1/2cm revealed no significant difference in MACE between negative and positive CT-FFRlowest [pâ¯=â¯0.11/0.23 (1/2â¯cm vs lowest)]. Among 221 patients who did not undergo planned revascularization within 90â¯days of CCTA, no significant differences were noted in the incidence of MACE between negative and positive CT-FFRlowest (pâ¯=â¯0.11). In contrast, the risk of MACE was significantly higher with positive CT-FFR1/2cm [pâ¯=â¯0.0198/0.0002 (1/2â¯cm)]. CONCLUSIONS: In terms of the prognosis of patients with moderate to severe stenosis on CCTA, CT-FFR measured 1 to 2â¯cm distal to the target lesion may be feasible for the safe deferral of unnecessary invasive coronary angiography. Moreover, CT-FFR1/2cm showed better risk stratification than CT-FFRlowest based on future adverse cardiac events.
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Doença da Artéria Coronariana , Estenose Coronária , Reserva Fracionada de Fluxo Miocárdico , Angiografia por Tomografia Computadorizada/efeitos adversos , Constrição Patológica/complicações , Angiografia Coronária/efeitos adversos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico por imagem , Estenose Coronária/diagnóstico por imagem , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Recently, triglyceride deposit cardiomyovasculopathy (TGCV) with defective intracellular lipolysis was found to be a disease that causes heart failure. As a diagnostic criterion for TGCV, an Iodaine-123-ß-methyl iodophenyl-pentadecanoic acid washout rate (BMIPP WOR) of < 10% is used, but its clinical significance in patients with heart failure remains to be clarified. METHODS: In 62 hospitalized patients with chronic heart failure, 123I-BMIPP myocardial single-photon emission computed tomography (SPECT) was performed predischarge state. The prevalence of TGCV was investigated. Subsequently, follow-up was conducted for ≥ 90 days (mean: 724.6 ± 392.7 days), and the association between the BMIPP WOR and cardiac events was examined, establishing all-cause mortality and admission due to heart failure as endpoints. RESULTS: Of the 62 patients, the WOR was < 10% in 41 (66.1%). Of these, 26 (41.9%) were diagnosed with definite TGCV. Furthermore, cardiac events were noted in 12 patients (19.4%). Analysis with Cox proportional hazards models showed that the BMIPP WOR < 4.5% was a significant event-predicting factor [HR 4.29, 95% CI: 1.20-16.87; p = 0.0245]. On a Kaplan-Meier curve, the WOR was 4.5%; there was a significant difference in the incidence of events (p = 0.0298). CONCLUSION: In the predischarge state of heart failure, 123I-BMIPP myocardial SPECT was performed. In approximately 40% of the patients, a diagnosis of TGCV was made. The results suggested that the BMIPP WOR is useful for predicting the prognosis of chronic heart failure patients regardless of TGCV.
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Insuficiência Cardíaca , Iodobenzenos , Doença Crônica , Ácidos Graxos , Coração , Insuficiência Cardíaca/diagnóstico por imagem , Humanos , Radioisótopos do Iodo , Tomografia Computadorizada de Emissão de Fóton Único/métodosRESUMO
BACKGROUND: Patients with diabetes mellitus (DM) are a high-risk group for coronary artery disease (CAD). In the present study, we investigated predictive factors to identify patients at high risk of CAD among asymptomatic patients with type 2 DM based on coronary computed tomographic angiography (CCTA) findings. METHODS: A single-center prospective study was performed on 452 consecutive patients with type 2 DM who were provided with a weekly hospital-based diabetes education program between 3 October 2015, and 31 March 2020. A total of 161 consecutive asymptomatic patients (male/female: 111/50, age: 57.3 ± 9.3 years) with type 2 DM without any known CAD underwent CCTA. Based on conventional coronary risk factors and non-invasive examination, i.e., measurement of intima-media thickness, subcutaneous and visceral fat area, a stress electrocardiogram test, and the Agatston score, patients with obstructive CAD, CT-verified high-risk plaques (CT-HRP), and optimal revascularization within 90 days were evaluated. RESULTS: Current smoking (OR, 4.069; 95% C.I., 1.578-10.493, p = 0.0037) and the Agatston score ≥100 (OR, 18.034; 95% C.I., 6.337-51.324, p = 0.0001) were independent predictive factors for obstructive CAD, while current smoking (OR, 5.013; 95% C.I., 1.683-14.931, p = 0.0038) was an independent predictive factor for CT-HRP. Furthermore, insulin treatment (OR, 5.677; 95% C.I., 1.223-26.349, p = 0.0266) was the only predictive factor that correlated with optimal revascularization within 90 days. CONCLUSIONS: In asymptomatic patients with type 2 DM, current smoking, an Agatston score ≥100, and insulin treatment were independent predictive factors of patients being at high-risk for CAD. However, non-invasive examinations except for Agatston score were not independent predictors of patients being at high risk of CAD.
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Purpose: To investigate whether coronary flow kinetic energy has incremental value over simulated fractional flow reserve (sFFR) in diagnosing hemodynamically significant stenosis assessed with coronary CT angiography and invasive fractional flow reserve (FFR). Materials and Methods: This single-center retrospective study included 113 patients (mean age, 68 years ± 9 [SD]; 80 men) who underwent coronary CT angiography showing intermediate stenosis (30%-70% stenosis) and subsequent invasive FFR between December 2015 and March 2020. Kinetic energy was calculated using proximal coronary diameter and myocardial mass of the stenotic region. A mesh-free simulation was performed to calculate the sFFR. Invasive FFR of 0.80 or less indicated hemodynamically significant stenosis. Models using diameter stenosis, kinetic energy, and sFFR were compared by analyzing the receiver operating characteristic curve. Results: Of the 144 vessels evaluated, 53 vessels (37%) had hemodynamically significant stenosis. Kinetic energy of vessels with significant stenosis was higher than that of vessels with nonsignificant stenosis (79 mJ/kg [IQR, 58-104 mJ/kg] vs 36 mJ/kg [IQR, 23-59 mJ/kg]; P < .001). Multivariable analysis including diameter stenosis and sFFR showed that kinetic energy (per 20 mJ/kg; odds ratio, 1.92; 95% CI: 1.37, 2.95; P < .001) was a predictor of hemodynamically significant stenosis. Adding kinetic energy to diameter stenosis and sFFR improved the area under the receiver operating characteristic curve from 0.89 (95% CI: 0.84, 0.95) to 0.93 (95% CI: 0.89, 0.97) (P = .04). Conclusion: Kinetic energy had incremental value over sFFR in detecting hemodynamically significant stenosis assessed with invasive FFR.Keywords: Coronary CT Angiography, Coronary Arteries, Fractional Flow Reserve, Kinetic Energy, Cardiac Supplemental material is available for this article © RSNA, 2022.
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Atypical Shone's complex is a rare congenital anomaly involving a left-sided obstructive lesion of two or three cardiovascular levels. A 70-year-old man with dyspnea on exertion was diagnosed with severe aortic stenosis (AS) with a bicuspid valve, complicated by severe aortic coarctation (CoA) and a double-orifice mitral valve. He underwent surgery for AS and CoA in one session. It is important to search for complicated malformations, even in cases of bicuspid aortic valve found in old age.
Assuntos
Coartação Aórtica , Doença da Válvula Aórtica Bicúspide , Cardiopatias Congênitas , Idoso , Humanos , Masculino , Coartação Aórtica/diagnóstico , Coartação Aórtica/diagnóstico por imagem , Valva Aórtica/anormalidades , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Cardiopatias Congênitas/cirurgia , Valva Mitral/anormalidades , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgiaRESUMO
Moving particle semi-implicit (MPS) method is a mesh-free method to perform computational fluid dynamics (CFD). The purpose of this study was to calculate the simulated fractional flow reserve (sFFR) using a coronary stenosis model, and to validate the MPS-derived sFFR against invasive FFR using clinical coronary CT data. Coronary flow simulation included 21 stenosis models with stenosis ranging 30-70%. Patient coronary analysis was performed in 76 consecutive patients (100 vessels) who underwent coronary CT angiography and subsequent invasive FFR between November 2016 and March 2020. Accuracy of sFFR and CT angiography for diagnosis of invasive FFR ≤ 0.80 was compared. Quantitative morphological stenosis data of CT angiography were also obtained. Area stenosis showed a good correlation to sFFR (R2 = 0.996, p < 0.001) in coronary stenosis models. In the patient study, the mean FFR value was 0.82 ± 0.10, and 37 out of 100 vessels showed FFR ≤ 0.80. FFR and sFFR values showed a good correlation (R2 = 0.59, p < 0.001) with a slight underestimation of sFFR as compared with FFR (mean difference - 0.015 ± 0.096, p = 0.12). The sensitivity, specificity, positive predictive value, and negative predictive value of sFFR to predict FFR ≤ 0.80 was 86%, 89%, 82%, 92%, respectively. The accuracy to predict FFR ≤ 0.80 using sFFR was greater than using diameter stenosis and minimum lumen area (88% vs. 74%, p = 0.008). CFD using the MPS method showed feasible results validated against invasive FFR. The accuracy to predict significant stenosis was higher than morphological stenosis.
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Although on-site workstation-based CT fractional flow reserve (CT-FFR) is an emerging method for assessing vessel-specific ischemia in coronary artery disease, severe calcification is a significant factor affecting CT-FFR's diagnostic performance. The subtraction method significantly improves the diagnostic value with respect to anatomic stenosis for patients with severe calcification in coronary CT angiography (CCTA). We evaluated the diagnostic capability of CT-FFR using the subtraction method (subtraction CT-FFR) in patients with severe calcification. This study included 32 patients with 45 lesions with severe calcification (Agatston score >400) who underwent both CCTA and subtraction CCTA using 320-row area detector CT and also received invasive FFR within 90 days. The diagnostic capabilities of CT-FFR and subtraction CT-FFR were compared. The sensitivities, specificities, positive predictive values (PPVs), and negative predictive values (NPVs) of CT-FFR vs. subtraction CT-FFR for detecting hemodynamically significant stenosis, defined as FFR ≤ 0.8, were 84.6% vs. 92.3%, 59.4% vs. 75.0%, 45.8% vs. 60.0%, and 90.5% vs. 96.0%, respectively. The area under the curve for subtraction CT-FFR was significantly higher than for CT-FFR (0.84 vs. 0.70) (p = 0.04). The inter-observer and intra-observer variabilities of subtraction CT-FFR were 0.76 and 0.75, respectively. In patients with severe calcification, subtraction CT-FFR had an incremental diagnostic value over CT-FFR, increasing the specificity and PPV while maintaining the sensitivity and NPV with high reproducibility.