Italian Registry of Cardiac Computed Tomography.

PURPOSE: Cardiac CT (CCT) is an imaging modality that is becoming a standard in clinical cardiology. We evaluated indications, safety, and impact on patient management of routine CCT in a multicenter national registry. MATERIALS AND METHODS: During a period of 6 months, 47 centers in Italy enrolled 3,455 patients. RESULTS: CCT was performed mainly with 64-slice CT scanners (73.02 %). Contrast agents were administrated in 3,185 patients (92.5 %). Mean DLP changes with type of scanner and was lower in >64 row detector scanner. The most frequent indication for CCT was suspected CAD (44.8 %), followed by calcium scoring (9.6 %), post-angioplasty/stenting (8.3 %), post-CABGs (7.5 %), study of cardiac anatomy (4.22 %) and assessment in patients with known CAD (4.1 %) and acute chest pain (1.99 %). Most of the CCTs were performed in outpatient settings (2,549; 74 %) and a minority in inpatient settings (719, 20.8 %). Adverse clinical events (mild-moderate) occurred in 26 examinations (0.75 %). None of them was severe. In 45.3 % of the cases CCT findings impacted patient management. CONCLUSION: CCT is performed with different workloads in participating centers. It is a safe procedure and its results have a strong impact on patient management.

Diagnostic accuracy of multidetector computed tomography coronary angiography in 325 consecutive patients referred for transcatheter aortic valve replacement.

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

Carotid artery stenting in patients with left ICA stenosis and bovine aortic arch: a single-center experience in 60 consecutive patients treated via the right radial or brachial approach.

PURPOSE: To assess the safety and efficacy of carotid artery stenting (CAS) of the left internal carotid artery (LICA) from a right radial/brachial approach in patients with bovine aortic arch. METHODS: Among 505 consecutive CAS patients treated at our facility between June 2007 and December 2012, 60 (11.9%) patients (44 men; mean age 73±9 years) with LICA stenosis and bovine arch were treated from a right radial (n=32) or brachial (n=28) approach. Three quarters of the patients had characteristics qualifying them at high surgical risk; 52 were asymptomatic. The types of cerebral protection (a distal filter or proximal MO.MA system), stent, and technique were at the operation's discretion. RESULTS: The radial/brachial approach was successful in 59 (98.3%) of 60 procedures; 1 case was converted to a femoral approach. Proximal protection was used in 15 cases (11 brachial, 4 radial) with severe, soft plaques, although the MO.MA system proved too short in a tall patient having a radial approach and a filter was used. Clinical success with no adverse events was 96.7% owing to 1 retinal embolism and 1 minor stroke. Vascular complications occurred in 2 (3.3%) brachial group patients. No major bleeding was encountered. Over a mean follow-up of 18.7±17.5 months, midterm event-free survival was 93%. No target vessel revascularization was necessary. CONCLUSION: CAS via a right radial or brachial approach is safe and effective in patients with LICA stenosis and types 1 or 2 bovine arch.

Coronary in-stent restenosis: assessment with CT coronary angiography.

PURPOSE: To compare accuracy and radiation exposure of a new computed tomographic (CT) scanner with improved spatial resolution (scanner A) with those of a CT scanner with standard spatial resolution (scanner B) for evaluation of coronary in-stent restenosis (ISR) by using invasive coronary angiography (ICA) and intravascular ultrasonography (US) as reference methods. MATERIALS AND METHODS: Written informed consent was obtained and study protocol was approved by institutional ethics committee. A total of 180 consecutive patients (154 men [mean age ± standard deviation, 66 years±12; range, 51-79 years] and 36 women [mean age, 70 years±12; range, 55-83 years]) scheduled to undergo ICA for suspected ISR were enrolled. Ninety patients were studied with scanner A (group 1: 72 men [mean age, 65 years±11; range, 52-79], 18 women [mean age, 68 years±12; range, 55-83 years]) and 90 with scanner B (group 2: 74 men [mean age, 64 years±10; range, 51-77 years], 16 women [mean age, 68 years±11; range, 55-82 years). Examination with the two scanners was compared with ICA and intravascular US. Radiation dose exposure was estimated. To compare stent evaluability between the two groups, χ2 test was used. RESULTS: Stent evaluability was higher in group 1 than in group 2 (99% vs 92%, P=.0021). A significantly lower rate of beam-hardening artifact was observed in group 1 (two cases) than group 2 (12 cases, P<.05). For stent-based analysis, sensitivity, specificity, and accuracy of multidetector CT for ISR identification were 96%, 95%, and 96% in group 1 and 90%, 91%, and 91% in group 2, respectively, without statistically significant differences. The correlation between percent ISR evaluated at multidetector CT versus intravascular US was higher in group 1 than in group 2 (r=0.89 vs r=0.58; P=.019). The correlations of diameter and area measurements at reference site and stent maximal lumen narrowing site between multidetector CT and intravascular US were higher in group 1 than in group 2. Radiation dose was low in both multidetector CT groups (1.9 mSv±0.2). CONCLUSION: Scanner A, with improved spatial resolution, allowed reliable detection and quantification of coronary ISR with low radiation exposure.

Aortic annulus area assessment by multidetector computed tomography for predicting paravalvular regurgitation in patients undergoing balloon-expandable transcatheter aortic valve implantation: a comparison with transthoracic and transesophageal echocardiography.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a valid alternative to surgery in high-risk patients with severe aortic stenosis. Aortic annulus (AoA) sizing is crucial for TAVI success. The aim of the study was to compare AoA dimensions measured by multidetector computed tomography (MDCT) vs those obtained with transthoracic (TTE) and transesophageal echocardiography (TEE) for predicting paravalvular aortic regurgitation (PVR) after TAVI. METHODS: Aortic annulus maximum diameter, minimum diameter, and area were assessed using MDCT and compared with TTE and TEE diameter and area for predicting PVR after TAVI in 151 patients (45 men, age 81.2 ± 6.4 years). RESULTS: Aortic annulus maximum, minimum diameter, and area detected by MDCT were 25.04 ± 2.39 mm, 21.27 ± 2.10 mm, and 420.87 ± 76.10 mm(2), respectively. Aortic annulus diameter and area measured by TTE and TEE were 21.14 ± 1.94 mm and 353.82 ± 64.57 mm(2) and 22.04 ± 1.94 mm and 384.33 ± 67.30 mm(2), respectively. A good correlation was found between AoA diameters and area evaluated by MDCT vs TTE and TEE (0.61, 0.65, and 0.69 and 0.61, 0.65, and 0.70, respectively), with a mean difference of 3.90 ± 1.98 mm, 0.13 ± 1.67 mm, and 67.05 ± 55.87 mm(2) and 3.0 ± 2.0 mm, 0.77 ± 1.70 mm, and 36.54 ± 56.43 mm(2), respectively. Grade ≥2 PVR occurred in 46 patients and was related to male gender, higher body mass index, preprocedural aortic regurgitation, and lower mismatch between the nominal area of the implanted prosthesis and AoA area detected by MDCT. CONCLUSIONS: Mismatch between prosthesis area and AoA area detected by MDCT is a better predictor of PVR as compared with echocardiography mismatch. Specific MDCT-based sizing recommendations should be developed.

Prevalence and clinical significance of collateral findings detected by chest computed tomography in patients undergoing atrial fibrillation ablation.

AIMS: Chest computed tomography (CT) scanning is increasingly used as an imaging technique in patients undergoing atrial fibrillation (AF) catheter ablation. Chest CT scans visualize organs other than the heart and collateral findings may be identified incidentally. Our study aims to assess the prevalence and clinical relevance of such collateral findings in patients undergoing AF ablation. METHODS AND RESULTS: One hundred and seventy-three patients (127 males, age 59 ± 10 years) underwent chest CT scan for image integration in AF ablation. Collateral findings from visualized thoracic and upper abdominal organs were collected. Findings that required further investigations or treatment according to current guidelines were considered as clinically significant. A total of 164 collateral findings were identified in 97 (56%) patients, and most patients showed abnormalities of the lungs (67 patients, 39%). Forty-nine (28%) patients had clinically significant findings needing further investigation and 17 (10%) of them required specific treatments, including three cases (1.7 %) of lung malignancy. CONCLUSIONS: Chest CT images acquired for integration in AF ablation should be read thoroughly as they may serve as a screening tool for otherwise unrecognized clinically significant conditions of the heart, lungs, or other visualized organs.

Feasibility and accuracy of a comprehensive multidetector computed tomography acquisition for patients referred for balloon-expandable transcatheter aortic valve implantation.

BACKGROUND: The aim of this study was to assess the accuracy of a comprehensive multidetector computed tomography (MDCT) evaluation of the aortic annulus (AoA), coronary artery disease (CAD), and peripheral vessels in patients referred for transcatheter aortic valve implantation (TAVI). METHODS: In 60 patients referred for TAVI, the following parameters were assessed with 64-slices MDCT and compared with transesophageal echocardiography (TEE), invasive coronary angiography (ICA), and peripheral angiography: AoA maximum diameter (Max-AoA-D(MDCT)), minimum diameter (Min-AoA-D(MDCT)), and area; lumen morphology index ([Max-AoA-D(MDCT)/Min-AoA-D(MDCT)]); length of the left, right, and non-coronary aortic leaflets; degree (grades 1-4) of aortic leaflet calcifications; distance between AoA and left main coronary ostium and between AoA and right coronary ostium CAD and peripheral vessel disease. RESULTS: The Max-AoA-D(MDCT) and Min-AoA-D(MDCT) were 25.1 ± 2.8 and 21.2 ± 2.2 mm, respectively, with high correlation versus AoA diameter measured with TEE (r = 0.82 and 0.86, respectively). The area of AoA, systolic and diastolic lumen morphology index were 410 ± 81.5 mm(2), 1.19 ± 0.1 and 1.22 ± 0.11, respectively. Aortic leaflet calcification score was 3.3 ± 0.5. The lengths of left, right, and non-coronary aortic leaflets were 14.2 ± 2.4, 13.7.1 ± 2.1, and 14.5 ± 2.6 mm, whereas distances between AoA and the left main coronary ostium and between AoA, and the right coronary ostium were 13.7 ± 2.9 and 15.8 ± 3.5 mm, respectively. Feasibility, negative predictive value, and accuracy for CAD detection versus ICA were 87%, 100% (CI 100-100), and 96% (95% CI 94-100), respectively. All patients (N = 17) who were ineligible for TAVI were correctly detected by MDCT. CONCLUSIONS: A comprehensive MDCT evaluation of patients referred for TAVI is feasible, provides more accurate assessment than TEE of AoA morphology, and may replace peripheral angiography in all patients and ICA in patients without significant CAD.

High diagnostic accuracy of prospective ECG-gating 64-slice computed tomography coronary angiography for the detection of in-stent restenosis: in-stent restenosis assessment by low-dose MDCT.

OBJECTIVES: The accuracy of computed tomography (CT) for assessment of coronary stents is as yet unproven and radiation exposure has been a concern. The aim of our study is to compare radiation dose and diagnostic performance of CT with prospective ECG-triggering versus retrospective ECG-triggering for the detection of in-stent restenosis (ISR). METHODS: We enrolled 168 consecutive patients with suspected ISR, 83 studied using CT with prospective ECG-triggering (group 1) and 85 using retrospective ECG-triggering (group 2). RESULTS: Prevalence of ISR according to catheter angiography was 24% in both groups. The overall evaluability was similar (93% in group 1 vs 95% in group 2). Artefact sub-analysis showed a significantly lower number of blooming and higher number of slice misalignment in group 1 vs group 2. In the stent-based analysis using only evaluable stents, specificity, positive predictive value and accuracy were significantly higher in group 1 (100%, 100% and 99%, respectively) than in group 2 (97%, 91% and 95%, respectively, p < 0.05). Group 1 was exposed to a lower radiation dose compared with group 2 (4.3 ± 1.4 mSv vs 18.5 ± 5.5 mSv, p < 00.1). CONCLUSIONS: CT with prospective ECG-triggering can improve diagnostic accuracy of non-invasive imaging of coronary stents with a significant reduction in radiation exposure.

Comparison of the diagnostic performance of 64-slice computed tomography coronary angiography in diabetic and non-diabetic patients with suspected coronary artery disease.

BACKGROUND: Diabetics have high prevalence of subclinical coronary artery disease (CAD) with typical characteristics (diffuse disease, large calcifications). Although 64-slice multidetector computed tomography (MDCT) coronary angiography has high diagnostic accuracy to detect CAD, its diagnostic performance in diabetics with suspected CAD is unknown. To compare the diagnostic performance of 64-slice MDCT between diabetics and non-diabetics with suspected CAD scheduled for invasive coronary angiography (ICA). METHODS: We enrolled one hundred and five diabetic patients (92 men, age 65 +/- 9 years, Group 1) and 105 non-diabetic patients (63 men, age 63+/-5 years, Group 2) with indication to ICA for suspected CAD undergoing coronary 64-slice MDCT before ICA. RESULTS: In Group 1, the overall feasibility of coronary artery visualization was 93.8%. The most frequent artifact was blooming due to large coronary calcifications (54 artifacts, 67%). In Group 2, the overall feasibility was significantly higher vs. Group 1 (97%, p < 0.0001). In Group 1, the segment-based analysis showed a MDCT sensibility, specificity, positive predictive value, negative predictive value and accuracy for the detection of ≥50% luminal narrowing of 77%, 90%, 70%, 93% and 87%, respectively. In Group 2, all these parameters were significantly higher vs. Group 1. In the patient-based analysis, specificity, negative predictive value and accuracy were significantly lower in Group 1 vs. Group 2. CONCLUSIONS: Although MDCT has high sensitivity for early identification of significant CAD in diabetics, its diagnostic performance is significantly reduced in these patients as compared to non-diabetics with similar clinical characteristics.

Image integration-guided catheter ablation of atrial fibrillation: a prospective randomized study.

BACKGROUND: Several studies have provided details of left atrial anatomy by means of the image integration techniques, particularly focusing on the atypical patterns of the pulmonary veins. OBJECTIVE: To compare, in a prospective, randomized fashion, the conventional method of pulmonary vein disconnection and the image integration-guided approach. METHODS: Two hundred and ninety consecutive patients (290 patients, mean age 55 +/- 11 years) with drug-refractory paroxysmal or persistent atrial fibrillation were enrolled in the study and were divided into two treatment groups: group 1 (145 patients) undergoing an imaging integration-guided (CartoMerge TM) ablation; group 2 (145 patients) treated by a conventional radiofrequency catheter ablation procedure. The arrhythmia was refractory to at least two antiarrhythmic drugs (IC, amiodarone). RESULTS: Electrical disconnection of all identified pulmonary veins was obtained in all patients of both groups. Bidirectional block of the cavotricuspid isthmus was achieved in 34 group 1 patients and in 40 group 2 patients. Left mitral isthmus ablation was attempted in 52 group 1 patients and in 56 group 2 patients. At a mean follow-up of 14 +/- 12 months, the atrial fibrillation-free survival rate was significantly higher in group 1 patients compared with group 2 patients (88% vs 69%, P = 0.017). The analysis for the subset of patients with previously ineffective ablation (98 patients: 52 group 1 patients and 46 group 2 patients) showed a significantly lower recurrence rate in group 1 versus group 2 (19% vs 48%, P < 0.01). CONCLUSIONS: Our data indicate a superior efficacy of the image-integration guided catheter ablation of atrial fibrillation over the long term.

Carotid stenting through the right brachial approach for left internal carotid artery stenosis and bovine aortic arch configuration.

Unfavorable complex anatomy or congenital anomalies of supra-aortic vessel take-off may increase carotid artery stenting (CAS) procedural difficulties and complications through the femoral route. We assessed the feasibility, safety, and efficacy of CAS through the right brachial approach in patients in whom left internal carotid artery stenosis and bovine aortic arch configuration were identified with computed tomography (CT) angiography. Bovine configuration of the aortic arch and left carotid artery stenosis were easily identified by CT angiography and successfully treated through the right brachial approach technique.

Diagnostic work-up of unselected patients with suspected coronary artery disease: complementary role of multidetector computed tomography, symptoms and electrocardiogram stress test.

AIM: We evaluated the accuracy of multidetector computed tomography in detecting coronary artery disease and how it could change the indication to coronary angiography in patients with suspected cardiac chest pain. METHODS AND RESULTS: We enrolled 142 consecutive patients who had already performed an exercise electrocardiogram test referred to our hospital and scheduled for coronary angiography for chest pain. According to the characteristics of chest pain and the results of exercise electrocardiogram, patients were divided into four groups: atypical chest pain and negative exercise electrocardiogram (group 1); typical chest pain and negative exercise electrocardiogram (group 2); atypical chest pain and positive exercise electrocardiogram (group 3); and typical chest pain with positive exercise electrocardiogram (group 4). We evaluated the accuracy of multidetector computed tomography and whether it could reduce the number of unnecessary coronary angiography in the study groups. Of 1801 segments larger than 1.5 mm, 1696 (94%) were assessable. In a segment based-model, sensitivity, specificity, negative predictive value, positive predictive value and accuracy were 81% (95% confidence interval 75-89%), 94% (95% confidence interval 90-98%), 96% (95% confidence interval 93-98%), 75% (95% confidence interval 69-82%) and 91% (95% confidence interval 89-93%), respectively. In a patient-based model, sensitivity, specificity, negative predictive value, positive predictive value and accuracy were 95% (95% confidence interval 91-99%), 78% (95% confidence interval 67-89%), 88% (95% confidence interval 79-97%), 89% (95% confidence interval 83-95%) and 89% (95% confidence interval 84-94%). Unnecessary coronary angiography may be avoided by multidetector computed tomography results particularly in group 2 (16%) and group 3 (24%), whereas in groups 1 and 4 the role of multidetector computed tomography in facilitating the correct indication to coronary angiography was less relevant. CONCLUSIONS: Multidetector computed tomography is a particularly helpful technique in patients with discordance between the clinical features of chest pain and stress-test results. This technique may be introduced in the diagnostic work-up of patients with suspected coronary artery disease and may potentially reduce the number of unnecessary coronary angiography.

Comparison of feasibility and accuracy of transthoracic echocardiography versus computed tomography in patients with known ascending aortic aneurysm.

Aortic valve diseases, hypertension, and connective tissue disorders may be causes of ascending aortic aneurysms. Aortic enlargement monitoring is essential for surgical timing and for operative design. In this regard, several imaging techniques may have limitations: magnetic resonance is not widespread and is expensive, computed tomography uses radiation, and transesophageal echocardiography is a semi-invasive method. The aim of this study was to analyze the feasibility of transthoracic echocardiography in the evaluation of aortic dimensions and its accuracy in comparison with multidetector computed tomography. In 44 patients with known ascending aortic aneurysms, transthoracic echocardiographic and computed tomographic measurements were obtained and compared at different levels: the annulus, sinuses of Valsalva, sinotubular junction, ascending aorta, and aortic arch. Transthoracic echocardiographic diameters were obtained in all patients, apart from the aortic arch, which was measured in 40 cases. Transthoracic echocardiographic and computed tomographic diameters correlated significantly (p <0.001), with very small SEEs: for the annulus, r = 0.846 (SEE 0.37); for the sinuses of Valsalva, r = 0.967 (SEE 0.35); for the sinotubular junction, r = 0.965 (SEE 0.33); for the ascending aorta, r = 0.976 (SEE 0.41); and for the aortic arch, r = 0.87 (SEE 0.50). In conclusion, transthoracic echocardiography is a feasible and accurate technique for the assessment and follow-up of thoracic aortic diameters in patients with ascending aortic aneurysms.

Coronary stent evaluation with coronary computed tomographic angiography: comparison between low-osmolar, high-iodine concentration iomeprol-400 and iso-osmolar, lower-iodine concentration iodixanol-320.

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

Pre-operative CT coronary angiography in patients with mitral valve prolapse referred for surgical repair: comparison of accuracy, radiation dose and cost versus invasive coronary angiography.

BACKGROUND: The aims of this study are to evaluate the accuracy of low dose multidetector computed tomography coronary angiography (MDCT) versus invasive coronary angiography (ICA) in ruling out CAD in patients with mitral valve prolapse and severe mitral regurgitation (MVP) before cardiac surgery and to compare the overall effective radiation dose (ED) and cost of a diagnostic approach in which conventional ICA should be performed only in patients with significant CAD as detected by MDCT. METHODS: Eighty patients with MVP and without history of CAD were randomized to MDCT (Group 1) or ICA (Group 2) to rule out CAD before surgery. However, ICA was also performed as gold standard reference in Group 1 to test the diagnostic accuracy of MDCT. A diagnostic work-up A in whom all patients underwent low-dose MDCT as initial diagnostic test and those with positive findings were referred for ICA was compared with work-up B in which all patients were referred for ICA according to the standard of care in terms of ED and cost. RESULTS: The two groups were homogeneous in terms of gender, age and body mass index. The overall feasibility and accuracy in a patient-based model were 99% and 93%, respectively. The overall ED and costs were significantly lower in diagnostic work-up A compared to diagnostic work-up B. CONCLUSIONS: The accuracy of low dose MDCT for ruling out the presence of significant CAD in patients undergoing elective valve surgery for mitral valve prolapse is excellent with a reduction of overall radiation dose exposure and costs.

Prognostic value of multidetector computed tomography coronary angiography in diabetes: excellent long-term prognosis in patients with normal coronary arteries.

OBJECTIVE: To assess the prognostic role of multidetector computed tomography coronary angiography (MDCT-CA) in patients with diabetes with suspected coronary artery disease (CAD). Use of MDCT-CA is increasing in patients with suspected CAD. However, data supporting its prognostic value in patients with diabetes are limited. RESEARCH DESIGN AND METHODS: Between January 2006 and September 2007, 429 consecutive diabetic patients were prospectively studied with MDCT-CA for detecting the presence and assessing the extent of CAD (disease extension and coronary plaque scores). Patients were classified according to the presence of normal coronary arteries and nonobstructive (<50%) and obstructive (≥50%) coronary lesions. The composite rates of hard cardiac events (cardiac death, nonfatal myocardial infarction, unstable angina) and all cardiac events (including revascularization) were the end points of the study. RESULTS: Twenty-four patients were excluded because MDCT-CA data were not able to be interpreted. Of the remaining 405 patients, clinical follow-up (mean 62 ± 9 months) was obtained in 390 (98%). Multivariate analysis showed that predictors of hard and all events were obstructive CAD, three-vessel CAD, and left main coronary artery (LMCA) disease. Cumulative event-free survival was 100% for hard and all events in patients with normal coronary arteries, 78% for hard events and 56% for all events in patients with nonobstructive CAD, and 60% for hard events and 16% for all events in patients with obstructive CAD. Three-vessel CAD and LMCA disease were associated with a higher rate of hard cardiac events. CONCLUSIONS: MDCT-CA provides long-term prognostic information for patients with diabetes with suspected CAD, showing excellent prognosis when there is no evidence of atherosclerosis and allowing risk stratification when CAD is present.

Comparison of accuracy of aortic root annulus assessment with cardiac magnetic resonance versus echocardiography and multidetector computed tomography in patients referred for transcatheter aortic valve implantation.

The evaluation of the aortic root in patients referred for transcatheter aortic valve implantation is crucial. The aim of the present study was to compare the accuracy of cardiac magnetic resonance (CMR) evaluation of the aortic annulus (AoA) with transthoracic and transesophageal echocardiography and multidetector computed tomography (MDCT) in patients referred for transcatheter aortic valve implantation. In 50 patients, maximum diameter, minimum diameter and AoA, length of the left coronary, right coronary, and noncoronary aortic leaflets, degree (grades 1 to 4) of aortic leaflet calcification, and distance between AoA and coronary artery ostia were assessed. AoA maximum diameter, minimum diameter, and area by CMR were 26.4 ± 2.8 mm, 20.6 ± 2.3 mm, 449.8 ± 86.2 mm(2), respectively. The length of left coronary, right coronary, and noncoronary leaflets by CMR were 13.9 ± 2.2, 13.3 ± 2.1, and 13.4 ± 1.8 mm, respectively, whereas the score of aortic leaflet calcifications was 2.9 ± 0.8. Finally, the distances between AoA and left main and right coronary artery ostia were 16.1 ± 2.8 and 16.1 ± 4.4 mm, respectively. Regarding AoA area, transthoracic and transesophageal echocardiography showed an underestimation (p <0.01), with a moderate agreement (r: 0.5 and 0.6, respectively, p <0.01) compared with CMR. No differences and excellent correlation were observed between CMR and MDCT for all parameters (r: 0.9, p <0.01), except for aortic leaflet calcifications that were underestimated by CMR. In conclusion, aortic root assessment with CMR including AoA size, aortic leaflet length, and coronary artery ostia height is accurate compared with MDCT. CMR may be a valid imaging alternative in patients unsuitable for MDCT.

A long-term prognostic value of CT angiography and exercise ECG in patients with suspected CAD.

OBJECTIVES: The aim of the study was to perform a comparison of the prognostic performance of computed tomography coronary angiography (CTA) and exercise electrocardiography (ex-ECG) in patients with suspected coronary artery disease (CAD). BACKGROUND: CAD is a major cause of mortality and morbidity, and its management consumes a large proportion of the health care budget. Therefore, identification of patients at high risk of adverse events is crucial. Despite its limited accuracy, ex-ECG is the most commonly used noninvasive test in CAD evaluation. CTA was recently introduced as alternative test. METHODS: We enrolled 681 patients (age 61.3 ± 10.4 years, 461 men) with atypical or typical angina and no history of CAD. All patients underwent ex-ECG and CTA and were followed for 44 ±12 months. The endpoints were all cardiac events, defined as nonfatal myocardial infarction, cardiac death, and revascularization, and hard cardiac events, defined as all cardiac events excluding revascularization. RESULTS: ex-ECG and CTA were rated as positive in 419 (61%) and 274 (40%) of 681 patients, respectively. In univariate analysis, both ex-ECG and CTA were predictors of all cardiac events (hazard ratio [HR]: 2.09, 95% confidence interval [CI]: 1.5 to 2.8; p < 0.0001 and HR: 21.1, 95% CI: 14.6 to 30.5; p < 0.0001, respectively) and hard cardiac events (HR: 1.9, 95% CI: 1.1 to 3.2; p = 0.02 and HR: 6.8, 95% CI: 3.9 to 11.0; p < 0.0001, respectively), whereas in a multivariate analysis, CAD with ≥50% stenoses detected by CTA was the only independent predictor of hard cardiac events. Stratifying our population by ex-ECG and CTA findings, Kaplan-Meier curves showed that ex-ECG provides only a further risk stratification in the subset of patients with positive findings on CTA and a low to intermediate likelihood of CAD. Moreover, positive findings on CTA identify a shorter event-free period, regardless the ex-ECG findings for both all cardiac events and hard cardiac events, respectively. CONCLUSIONS: CTA may have a higher prognostic value compared with ex-ECG in patients with suspected CAD, mainly in those with a low to intermediate pre-test likelihood of CAD.

An unusual case of coronary fistula diagnosed by multidetector computed tomography.

We present a case of a 82-year-old hypertensive woman who underwent multidetector computed tomography angiography because of chest pain, with detection of a large coronary fistula that originated from the anastomosis between left anterior descending coronary artery and posterior descending artery, in correspondence with the left ventricular apex, and drained into the right atrium and the proximal portion of the right coronary artery.