Impact of Dose Reduction Strategies on Image Quality of Coronary CTA in Real-World Clinical Practice: A Subanalysis of PROTECTION VI Registry Data.

BACKGROUND. Dose reduction strategies for coronary CTA (CCTA) have been underused in clinical practice given concern that the strategies may lower image quality. OBJECTIVE. The purpose of this study was to explore associations between dose reduction strategies and CCTA image quality in real-world clinical practice. METHODS. This subanalysis of the international Prospective Multicenter Registry on Radiation Dose Estimates of Cardiac CT Angiography in Daily Practice in 2017 (PROTECTION VI) study included 3725 patients (2109 men, 1616 women; median age, 59 years) who underwent CCTA for coronary artery evaluation performed at 55 sites in 32 countries. CCTA image sets were reviewed at a core laboratory. A range of patient and scan characteristics, including use of three dose reduction strategies (prospective ECG triggering, low tube potential, and iterative image reconstruction) and image dose, were recorded. A single core laboratory member reviewed all examinations for quantitative image quality measures, including signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR), and reviewed 50% of examinations to assign a qualitative CCTA image quality score and a semiquantitative coronary calcification measure. Multivariable logistic regression models were used to identify predictors of image quality. A second core laboratory member repeated quantitative measures for 100 examinations and the qualitative measure for 383 (approximately 20%) examinations to assess interreader agreement. RESULTS. Independent predictors (p < .05) of SNR were female sex (effect size, 2.70), lower body mass index (0.38 per 1-unit decrease), stable sinus rhythm (1.71), and scanner manufacturer (variable effect across manufacturers). These factors were also the only independent predictors of CNR. Independent predictors (p < .05) of CCTA image quality were heart rate (0.17 per 10 beats/min reduction) and coronary calcification (0.15 per coronary calcification grade). None of the three dose-saving strategies or dose-length product was an independent predictor of any image quality measure. Interreader agreement analysis showed intraclass correlation coefficients of 0.874 for SNR and 0.891 for CNR and a kappa value of 0.812 for the qualitative score. CONCLUSION. This large international multicenter study shows that three dose reduction strategies were not associated with decreased CCTA image quality. CLINICAL IMPACT. The dose reduction strategies should be routinely implemented in clinical CCTA.

Reduction in radiation exposure in cardiovascular computed tomography imaging: results from the PROspective multicenter registry on radiaTion dose Estimates of cardiac CT angIOgraphy iN daily practice in 2017 (PROTECTION VI).

Aims: Advances of cardiac computed tomography angiography (CTA) have been developed for dose reduction, but their efficacy in clinical practice is largely unknown. This study was designed to evaluate radiation dose exposure and utilization of dose-saving strategies for contrast-enhanced cardiac CTA in daily practice. Methods and results: Sixty one hospitals from 32 countries prospectively enrolled 4502 patients undergoing cardiac CTA during one calendar month in 2017. Computed tomography angiography scan data and images were analysed in a central core lab and compared with a similar dose survey performed in 2007. Linear regression analysis was performed to identify independent predictors associated with dose. The most frequent indication for cardiac CTA was the evaluation of coronary artery disease in 89% of patients. The median dose-length product (DLP) of coronary CTA was 195 mGy*cm (interquartile range 110-338 mGy*cm). When compared with 2007, the DLP was reduced by 78% (P < 0.001) without an increase in non-diagnostic coronary CTAs (1.7% in 2007 vs. 1.9% in 2017 surveys, P = 0.55). A 37-fold variability in median DLP was observed between the hospitals with lowest and highest DLP (range of median DLP 57-2090 mGy*cm). Independent predictors for radiation dose of coronary CTA were: body weight, heart rate, sinus rhythm, tube voltage, iterative image reconstruction, and the selection of scan protocols. Conclusion: This large international radiation dose survey demonstrates considerable reduction of radiation exposure in coronary CTA during the last decade. However, the large inter-site variability in radiation exposure underlines the need for further site-specific training and adaptation of contemporary cardiac scan protocols.

Mitral Valve Imaging with CT: Relationship with Transcatheter Mitral Valve Interventions.

The role of noninvasive imaging to help guide transcatheter aortic valvular interventions is well established and has grown with the advances in the procedure. With the rapid development of new transcatheter mitral valve interventions there is both an opportunity and a challenge for noninvasive imaging to grow understanding of mitral valve anatomy and disease, help with patient selection, and improve downstream clinical outcomes. This review will discuss the role of both echocardiography and multidetector CT in the diagnosis of mitral regurgitation, as well as grading of its severity and defining its etiology. Additionally, new concepts including measurements pertaining to mitral annular sizing, segmentation of mitral annular calcium, prediction of neo-left ventricular out flow tract obstruction, hybrid or fusion multidetector CT/echocardiographic imaging, and CT-based fluoroscopic guidance will be discussed.

Left atrial compression and right ventricular outflow tract diameter on echocardiography are independently associated with exercise capacity in patients with large hiatal hernia.

INTRODUCTION: Large hiatal hernia (HH) is often associated with left atrial (LA) compression, anteroposterior cardiac compression (manifesting as reduced right ventricular outflow tract (RVOT) diameter), and left ventricular (LV) compression (manifesting as systolic paradoxical outward motion (LV-PM) of the posterobasal LV segment). Exercise impairment, also common in this population, improves following HH surgery. We aimed to identify echocardiographic parameters independently associated with exercise impairment due to HH-mediated cardiogenic compression. METHODS: Patients with a large HH (>30% intra-thoracic stomach, n = 163) referred for cardiac evaluation were included. Echocardiographic parameters were retrospectively analyzed in relation to HH-related LA compression severity and the presence of LV-PM. Echocardiographic parameters independently associated with exercise capacity were identified by multivariable analysis. RESULTS: Mean baseline metabolic equivalents were reduced (70 ± 28% predicted). Moderate-severe LA compression and LV-PM were present in 91 of 163 (56%) and 65 of 162 (40%) patients, respectively. Patients with moderate-severe LA compression and LV-PM had decreased LA and LV dimensions. Moderate-severe LA compression was also associated with reduced RVOT diameter while LV-PM predicted a greater reduction in LV volumes. LA compression and RVOT diameter were independently associated with baseline exercise capacity and increased following HH surgery performed in a subgroup (n = 72, LA diameter: 14 ± 5 vs 20 ± 4 mm/m2 ; RVOT diameter: 17 ± 3 vs 19 ± 3 mm/m2 , P < .001 for both). Conversely, LV-PM was not independently associated with exercise capacity. CONCLUSION: Hiatal hernia-related cardiac compression reduces LA and RVOT dimensions. These parameters are independently associated with baseline exercise capacity and improve following HH surgery. LV-PM is associated with decreased LV volumes but not exercise capacity in this population.

Valsalva maneuver exacerbates left atrial compression in patients with large hiatal hernia.

INTRODUCTION: Hiatal hernia (HH) can cause left atrial (LA) compression and impair LA filling. We evaluated the cardiac effects of preload reduction and abdominal strain induced by Valsalva maneuver (VM) in large HH patients. METHODS: LA and left ventricular (LV) dimensions were measured using 2D transthoracic echocardiography at rest and during VM in HH patients (n=55, 70±10 years) and controls (n=22, 67±6 years). Biplane LV volumes (n=39) and mitral inflow pulse-wave Doppler parameters (n=27) were also evaluated. In HH patients, resting LA compression was graded qualitatively (none-mild or moderate-severe). RESULTS: In both controls and HH patients, VM significantly decreased LA (controls, 19±2 vs 16±3 mm/m2 ; HH, 16±5 vs 9±5 mm/m2 ) and LV diameters (22±3 vs 19±3 mm/m2 ; 21±3 vs 17±3 mm/m2 ) and LV volume (38±8 vs 26±10 mL/m2 ; 31±8 vs 19±9 mL/m2 ) (P<.001 for all). VM decreased LA diameter significantly more in HH patients than controls (-42% vs -16%, P<.001). HH patients with none-mild resting LA compression exhibited significantly greater LA diameter reduction than controls (-38±23% vs -16±13% P=.0003) despite similar resting LA diameters. LV volumes were similarly decreased by VM in HH patients and controls irrespective of resting LA compression severity indicating relative preservation of LV filling. LA diameter correlated inversely with early diastolic filling velocity during VM in HH patients (R=-.43, P=.03) but not controls (R=.18, P=.43). CONCLUSION: VM can markedly exacerbate LA compression in HH patients; however, LV filling is relatively less affected possibly due to augmented early diastolic filling. Conditions associated with decreased preload and increased intra-abdominal pressure may exacerbate the cardiac effects of large HH.

Role of Cardiac Magnetic Resonance Imaging and Troponin T in Definitive Diagnosis of Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA).

BACKGROUND: It is unknown whether the degree of high-sensitivity troponin T (hsTropT) elevation in patients with suspected myocardial infarction without obstructive coronary arteries (MINOCA) presentations can help predict the likelihood of an abnormal cardiac magnetic resonance (CMR) scan. In this study we describe the diagnostic utility of CMR in patients with MINOCA and assesses the effect of peak hsTropT levels at presentation on CMR diagnostic yield. METHODS: Records of consecutive patients (n = 1407) referred for CMR at a tertiary referral hospital between January 2016 and September 2021 were reviewed. A total of 70 patients met the criteria of MINOCA including ischemic chest pain, elevated peak hsTropT, and nonobstructive coronary artery disease (< 50% stenosis). The peak hsTropT levels within 72 hours of admission were identified. CMR images were generated using a 3.0 T Siemens scanner. Predictors of having an abnormal CMR were evaluated. RESULTS: CMR established a diagnosis in 71% (n = 50) of patients, with the most common CMR diagnosis being myopericarditis (n = 27; 39%). Time to CMR was an independent predictor of a normal CMR scan (odds ratio, 0.98; 95% confidence interval, 0.97-0.999). Peak hsTropT had a high diagnostic accuracy for identifying patients with an abnormal CMR scan (area under the receiver operator characteristic curve, 0.81; P < 0.001). The optimal hsTropT cutoff was 166 ng/L, with 72% sensitivity and specificity. A troponin value ≥ 166 ng/L was independently predictive of an abnormal CMR scan (odds ratio, 4.76; 95% confidence interval, 1.32-17.11). CONCLUSIONS: HsTropT and early CMR imaging are independently predictive of an abnormal CMR scan in patients with MINOCA. Additionally, the use of a hsTropT cutoff provides incremental predictive value to clinical parameters and time to CMR scanning in determining an abnormal scan.

Multivessel Giant Coronary Artery Aneurysms Incidentally Demonstrated During Angiography for Acute Myocardial Infarction.

Giant coronary artery aneurysms are a rare manifestation of coronary artery disease and are defined by an aneurysmal diameter of >20 mm. Multimodal invasive and noninvasive imaging is required for accurate assessment We describe a case of multivessel giant coronary artery aneurysms noted during angiography for myocardial infarction. (Level of Difficulty: Intermediate.).

Cardiac manifestations of IgG4-related disease: a case series.

Background: IgG4-related disease (IgG4-RD) is an autoimmune condition affecting almost every organ system, with an early inflammatory phase and later fibrotic consequences. Vascular manifestations, particularly, large-vessel involvement in IgG4-RD, are well described. However, important IgG4-related effects on medium-sized arteries and the pericardium are less well recognized. These less frequently reported cardiovascular effects of IgG4-RD include coronary artery stenosis, pericardial disease, cardiac masses, and valvular heart disease. Case summary: This case series focuses on three patients that demonstrate the cardiovascular effects of IgG4-RD and the pitfalls and importance of early diagnosis. Cases 1 and 2 presented with cardiac manifestations prior to more typical organ systems being affected which led to a delay in diagnosis. Case 1 presented with an acute myocardial infarction secondary to IgG4-RD of the coronary arteries and Case 2 presented with pericarditis which progressed to pericardial constriction due to IgG4-RD. Case 3 already had a diagnosis of IgG4-RD from a prior renal biopsy which raised the index of suspicion that his pericardial disease and thoracic mass were also related to IgG4-RD. Discussion: Cardiac manifestations of IgG4-RD remain under-recognized and include coronary artery and pericardial disease. These manifestations often precede more typical manifestations in other organ systems. Recognizing cardiac manifestations of IgG4-RD on cardiac imaging can raise clinical suspicion and act as a catalyst to ascertain a confirmatory diagnosis. Early diagnosis and treatment are crucial to prevent potentially fatal outcomes and irreversible fibrosis.

Geometric differences of the mitral valve apparatus in atrial and ventricular functional mitral regurgitation.

BACKGROUND: Functional mitral regurgitation (FMR) occurs in patients with annular dilation (atrial, aFMR) or patients with left ventricular (LV) disease (ventricular, vFMR). Meticulous understanding of the mechanisms underpinning regurgitation is crucial to optimize therapeutic strategies. METHODS: Patients with moderate-severe FMR were identified from a registry of patients referred for transcatheter mitral valve intervention. In addition, controls without cardiovascular disease were identified. Differences in the geometry of the LV and mitral valve apparatus (including leaflet and tenting geometry, papillary muscle displacement and movement, annular dimensions, and dynamism) between atrial and ventricular FMR, and control subjects, were assessed using multiphasic cardiac CT. RESULTS: Of 183 FMR patients, 18 patients (10%) were found to have aFMR. The remaining patients had either ischemic or non-ischemic ventricular FMR. In aFMR, both increasing LV end-systolic volume (rho 0.701, p â€‹< â€‹0.01) and left atrial volume (rho 0.909, p â€‹< â€‹0.01) were associated with larger annular area. By contrast, in vFMR larger annular area was most strongly associated with larger left atrial volume (rho 0.63, p â€‹< â€‹0.01). In controls, increased annular area was associated with larger LVEDV (rho 0.78, p â€‹< â€‹0.01) and LVESV (rho 0.824, p â€‹< â€‹0.01), but not left atrial size (rho 0.16, p â€‹= â€‹0.45). Ventricular FMR comprised apicolaterally displaced, akinetic posteromedial papillary muscles, resulting in pronounced leaflet tethering, leaflet elongation compared to controls, and only modest relative LA dilatation. Compared to vFMR, aFMR was characterised by marked relative annular dilation, smaller but discernible mitral valve tenting, shorter leaflet lengths when related to annular size, but normal papillary geometry. CONCLUSION: FMR is characterised by multiple changes within the mitral valve complex. Atrial and ventricular FMR differ significantly in terms of the drivers of annular size, and geometry and function of the subvalvular apparatus. This highlights the need to consider these as separate disease entities.

Aspirin and Statin Therapy for Nonobstructive Coronary Artery Disease: Five-year Outcomes from the CONFIRM Registry.

Purpose: In this cohort study, 5-year data from the Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry (ie, CONFIRM) were examined to identify associations of baseline aspirin and statin use with mortality, major adverse cardiovascular events (MACE), and myocardial infarction (MI) in individuals without substantial (≥50%) stenosis. Materials and Methods: In this prospective cohort study, all participants in the registry underwent coronary CT angiography and were classified as having no detectable coronary plaque or having nonobstructive coronary artery disease (CAD) (1%-49% stenosis). Participants with obstructive (≥50%) stenosis were excluded from analysis. The study commenced in June 2003 and was completed in March 2016. All unadjusted and risk-adjusted analyses utilized the Cox proportional hazard model with hospital sites modeled using shared frailty. Results: A total of 6386 participants with no detectable plaque or with nonobstructive CAD were included (mean age, 56.0 years ± 13.3 [SD], 52% men). The mean follow-up period was 5.66 years ± 1.10. Nonobstructive CAD (n = 2815, 44% of all participants included in the study) was associated with a greater risk of all-cause mortality (10.6% [298 of 2815] vs 4.8% [170 of 3571], P < .001) compared to those without CAD (n = 3571, 56%). Baseline aspirin and statin use was documented for 1415 and 1429 participants, respectively, with nonobstructive CAD, and for 1560 and 1565 participants without detectable plaque, respectively. In individuals with nonobstructive CAD, baseline aspirin use was not associated with a reduction in MACE (10.9% [102 of 936] vs 14.7% [52 of 355], P = .06), all-cause mortality (9.6% [95 of 991] vs 10.9% [46 of 424], P = .468), or MI (4.4% [41 of 936] vs 6.2% [22 of 355], P = .18). On multivariate risk-adjusted analysis, baseline statin use was associated with a lower rate of MACE (hazard ratio, 0.59; 95% CI: 0.40, 0.87; P = .007). Neither therapy improved clinical outcomes for participants with no detectable plaque. Conclusion: In participants with nonobstructive CAD, baseline use of statins, but not of aspirin, was associated with improved clinical outcomes. Neither therapy was associated with benefit in participants without plaque.Keywords: Aspirin, Statin, Coronary Artery Disease, CT Angiography, Nonobstructive Coronary Artery DiseaseClinical trial registration no. NCT01443637 Supplemental material is available for this article. © RSNA, 2022See also the commentary by Canan and Navar in this issue.

Incidentally identified coronary artery calcium on non-contrast CT scan of the chest predicts major adverse cardiac events among hospital inpatients.

BACKGROUND: Coronary artery calcium (CAC) identified on non-gated CT scan of the chest is predictive of major adverse cardiac events (MACE) in multiple studies with guidelines therefore recommending the routine reporting of incidental CAC. These studies have been limited however to the outpatient setting. We aimed to determine the prognostic utility of incidentally identified CAC on CT scan of the chest among hospital inpatients. METHODS AND RESULTS: Consecutive patients (n=740) referred for inpatient non-contrast CT scan of the chest at a tertiary referral hospital (January 2011 to March 2017) were included (n=280) if they had no known history of coronary artery disease, active malignancy or died within 30 days of admission. Scans were assessed for the presence of CAC by visual assessment and quantified by Agatston scoring. Median age was 69 years (IQR: 54-82) and 51% were male with a median CAC score of 7 (IQR 0-205). MACE occurred in 140 (50%) patients at 3.5 years median follow-up including 98 deaths. Half of all events occurred within 18 months. Visible CAC was associated with increased MACE (HR) 6.0 (95% CI: 3.7 to 9.7) compared with patients with no visible CAC. This finding persisted after adjusting for cardiovascular risk factors HR 2.4 (95% CI: 1.3 to 4.3) and with both absolute CAC score and CAC score ≥50th percentile. CONCLUSION: Incidental CAC identified on CT scan of the chest among hospital inpatients provides prognostic information that is independent of cardiovascular risk factors. These patients may benefit from aggressive risk factor modification given the high event rate in the short term.

Novel Pressure-Regulated Deployment Strategy for Improving the Safety and Efficacy of Balloon-Expandable Transcatheter Aortic Valves.

OBJECTIVES: The authors propose a novel pressure-regulated method for balloon-expandable transcatheter heart valve (THV) deployment, aimed at optimizing prosthesis-annulus apposition while preventing significant tissue injury. BACKGROUND: The optimal method for balloon-expandable THV deployment remains debated. Current protocols are volume dependent, relying on under- and overfilling of the deployment apparatus. During deployment, the annular wall tension exerted by the expanding prosthesis is determined by maximal THV diameter and balloon pressure (Laplace's law). METHODS: Three hundred thirty consecutive patients with severe native aortic stenosis who underwent TAVR with SAPIEN 3 THVs were included. One hundred and six patients were considered at high risk for annular rupture. THVs were deployed until reaching a predetermined balloon pressure. Postdilatation was performed to reduce mild or greater angiographic paravalvular regurgitation (PVR). Using a biomechanical model, annular wall stress was estimated for each case and assessed against rates of postdilatation, mild or greater PVR on transthoracic echocardiography, new permanent pacemaker placement or left bundle branch block, and annular rupture. RESULTS: Patients with wall stress >3 MPa had reduced postdilatation rate (P < 0.001) and reduced final PVR (P = 0.014). Annular rupture occurred in 2 of 3 high-risk patients with wall stress >3.5 MPa (3.69 and 3.84 MPa); no rupture occurred in 95 high-risk patients with wall stress ≤3.5 MPa. We defined a single target deployment pressure per THV size to ensure deployment within target wall stress levels of 3 to 3.5 MPa: 6.25 atm for 23-mm THVs, 5.5 atm for 26-mm THVs, and 5 atm for 29-mm THVs. Patients within this target range (n = 136) had a 10.0% postdilatation rate, 12.7% mild PVR, and no moderate to severe PVR. The relationship between balloon filling volume and associated pressure and wall stress was inconsistent. CONCLUSIONS: Pressure-regulated THV deployment is a simple, reproducible, safe, and effective method, regardless of high-risk anatomical complexities.

Feeding Induces Left Atrial Compression and Impedes Cardiac Filling in Patients With Large Hiatal Hernia.

BACKGROUND: Patients with large hiatal hernias (HH) frequently experience postprandial dyspnea. The aim of this study was to evaluate whether feeding induced cardiac compression in these patients using echocardiography. METHODS: Transthoracic echocardiography was performed during fasting and 30 min after feeding (300 g rice pudding) in patients with HHs (n = 32; mean age, 72 ± 9 years). A subset of patients (n = 15; mean age, 76 ± 6 years) were evaluated postoperatively. RESULTS: Preoperatively, feeding decreased left atrial (LA) volumes (maximal 27.4 ± 11.3 vs 19.2 ± 9.7 mL/m2, P < .001; minimal 13.1 ± 7.0 vs 6.9 ± 5.1 mL/m2, P < .001), and increased LA inflow velocities (systolic wave 0.62 ± 0.14 vs 0.77 ± 0.17 m/sec, P < .01; diastolic wave 0.46 ± 0.13 vs 0.59 ± 0.13 m/sec, P < .01), mitral inflow velocities (E wave 0.79 ± 0.17 vs 0.94 ± 0.19 m/sec, P < .01; A wave 0.93 ± 0.20 vs 1.05 ± 0.22 m/sec, P < .01), and E/E' ratio (12.1 ± 2.7 vs 13.7 ± 3.9, P < .01). Cardiac output (6.3 ± 1.6 vs 7.24 ± 2.0 L, P < .01) increased postprandially by marked heart rate augmentation (68.8 ± 7.0 vs 84.2 ± 8.4 beats/min, P < .01), with modest stroke volume increase (88.5 ± 16.7 vs 94.3 ± 19.5 mL, P = .03). After HH surgery, feeding did not change LA volumes (maximal 52.9 ± 13.6 vs 53.4 ± 12.5 mL, P = .89; minimal 28.6 ± 12.2 vs 27.4 ± 8.7 mL, P = .59) or E/E' ratio (10.9 ± 2.1 vs 11.3 ± 2.3) and induced more modest alterations in LA inflow (systolic wave 0.58 ± 0.17 vs 0.68 ± 0.16 m/sec, P = .01; diastolic wave 0.41 ± 0.12 vs 0.47 ± 0.13 m/sec, P = .01) and mitral inflow (E wave 0.69 ± 0.15 vs 0.80 ± 0.13 m/sec, P < .01; A wave 0.92 ± 0.13 vs 1.01 ± 0.18 m/sec, P = .02). Postoperatively, feeding increased cardiac output by substantial stroke volume augmentation (81.9 ± 16.5 vs 90.8 ± 16.0 mL, P = .01), with only modest increase in heart rate (69.8 ± 9.1 vs 75.9 ± 10.5 beats/min, P < .01). CONCLUSIONS: Feeding produces marked LA compression in patients with HHs, inducing compensatory exaggerated responses in cardiac inflow and hemodynamic status. These compensatory mechanisms improve postoperatively following resolution of LA compression, likely explaining the debility noted preoperatively.

Long-term prognostic utility of computed tomography coronary angiography in older populations.

AIMS: The long-term prognostic value of coronary computed tomography angiography (CCTA)-identified coronary artery disease (CAD) has not been evaluated in elderly patients (≥70 years). We compared the ability of coronary CCTA to predict 5-year mortality in older vs. younger populations. METHODS AND RESULTS: From the prospective CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) registry, we analysed CCTA results according to age <70 years (n = 7198) vs. ≥70 years (n = 1786). The severity of CAD was classified according to: (i) maximal stenosis degree per vessel: none, non-obstructive (1-49%), or obstructive (>50%); (ii) segment involvement score (SIS): number of segments with plaque. Cox-proportional hazard models assessed the relationship between CCTA findings and time to mortality. At a mean 5.6 ± 1.1 year follow-up, CCTA-identified CAD predicted increased mortality compared with patients with a normal CCTA in both <70 years [non-obstructive hazard ratio (HR) confidence interval (CI): 1.70 (1.19-2.41); one-vessel: 1.65 (1.03-2.67); two-vessel: 2.24 (1.21-4.15); three-vessel/left main: 4.12 (2.27-7.46), P < 0.001] and ≥70 years [non-obstructive: 1.84 (1.15-2.95); one-vessel: HR (CI): 2.28 (1.37-3.81); two-vessel: 2.36 (1.33-4.19); three-vessel/left main: 2.41 (1.33-4.36), P = 0.014]. Similarly, SIS was predictive of mortality in both <70 years [SIS 1-3: 1.57 (1.10-2.24); SIS ≥4: 2.42 (1.65-3.57), P < 0.001] and ≥70 years [SIS 1-3: 1.73 (1.07-2.79); SIS ≥4: 2.45 (1.52-3.93), P < 0.001]. CCTA findings similarly predicted long-term major adverse cardiovascular outcomes (MACE) (all-cause mortality, myocardial infarction, and late revascularization) in both groups compared with patients with no CAD. CONCLUSION: The presence and extent of CAD is a meaningful stratifier of long-term mortality and MACE in patients aged <70 years and ≥70 years old. The presence of obstructive and non-obstructive disease and the burden of atherosclerosis determined by SIS remain important predictors of prognosis in older populations.

Update on the clinical utility of coronary computed tomographic angiography in stable angina pectoris.

Over the last decade, coronary computed tomographic angiography (CCTA) has emerged as a valuable non-invasive imaging modality with excellent diagnostic performance compared to invasive coronary angiography (ICA) for identifying patients with coronary artery disease (CAD). Beyond the diagnosis of CAD, CCTA also provides valuable prognostic information. While patients with normal CCTA have excellent long-term prognosis, among those with CAD, increasing CAD extent and severity is associated with increased cardiovascular event risk over both medium- and long-term follow-up in both men and women. The ability to image non-obstructive CAD is a particularly unique attribute of CCTA. Moreover, the ability to assess plaque features on CCTA has further enhanced our understanding of coronary plaque dynamics and the prediction of future cardiovascular events. The clinical impact of CCTA has been recently evaluated in two landmark prospective multicenter trials, which have provided insights into the influence of CCTA on the clinical management of symptomatic patients with suspected CAD. We review the value of CCTA in the evaluation of patients with stable chest pain including its diagnostic performance, prognostic utility and real-world clinical application.

Cardiac Computed Tomography and Magnetic Resonance Imaging in the Evaluation of Mitral and Tricuspid Valve Disease: Implications for Transcatheter Interventions.

Transcatheter interventions to treat mitral and tricuspid valve disease are becoming increasingly available because of the growing number of elderly patients with significant comorbidities or high operative risk. Thorough clinical and imaging evaluation in these patients is essential. The latter involves both characterization of the mechanism and severity of valvular disease as well as determining the hemodynamic consequences and extent of ventricular remodeling, which is an important predictor of future outcomes. Moreover, an assessment of the suitability and risk of complications associated with device-specific therapies is also an important component of the preprocedural evaluation in this cohort. Although echocardiography including 2-dimensional and 3-dimensional methods has an important role in the initial assessment and procedural guidance, cross-sectional imaging, including both computed tomographic imagning and cardiac magnetic resonance imaging, is increasingly being integrated into the evaluation of mitral and tricuspid valve disease. In this review, we discuss the role of cross-sectional imaging in mitral and tricuspid valve disease, primarily valvular regurgitation assessment, with an emphasis on the preprocedural evaluation and implications for transcatheter interventions.

Changes in lung volumes and gas trapping in patients with large hiatal hernia.

BACKGROUND AND AIMS: Studies assessing hiatal hernia (HH)-related effects on lung volumes derived by body plethysmography are limited. We aimed to evaluate the effect of hernia size on lung volumes (including assessment by body plethysmography) and the relationship to functional capacity, as well as the impact of corrective surgery. METHODS: Seventy-three patients (70 ± 10 years; 54 female) with large HH [mean ± standard deviation, intra-thoracic stomach (ITS) (%): 63 ± 20%; type III in 65/73] had respiratory function data (spirometry, 73/73; body plethysmography, 64/73; diffusing capacity, 71/73) and underwent HH surgery. Respiratory function was analysed in relation to hernia size (groups I, II and III: ≤50, 50%-75% and ≥75% ITS, respectively) and functional capacity. Post-operative changes were quantified in a subgroup. RESULTS: Total lung capacity (TLC) and vital capacity (VC) correlated inversely with hernia size (TLC: 97 ± 11%, 96 ± 13%, 88 ± 10% predicted in groups I, II and III, respectively, P = 0.01; VC: 110 ± 17%, 111 ± 14%, 98 ± 14% predicted, P = 0.02); however, mean values were normal and only 14% had abnormal lung volumes. Surgery increased TLC (93 ± 11% vs 97 ± 10% predicted) and VC (105 ± 15% vs 116 ± 18%), and decreased residual volume/total lung capacity (RV/TLC) ratio (39 ± 7% vs 37 ± 6%) (P < 0.01 for all). Respiratory changes were modest relative to the marked functional class improvement. Among parameters that improved following HH surgery, decreased TLC and forced expiratory volume in 1 s and increased RV/TLC ratio correlated with poorer functional class pre-operatively. CONCLUSIONS: Increasing HH size correlates with reduced TLC and VC. Surgery improves lung volumes and gas trapping; however, the changes are mild and within the normal range.