Prospective randomized trial of endoscopic vs open radial artery harvest for CABG: Clinical outcome, patient satisfaction, and midterm RA graft patency.

BACKGROUND AND AIM: Endoscopic radial artery (RA) harvest (ERAH) is an alternative to open RA harvest (ORAH) technique. Our aim was to ascertain clinical outcomes, patent satisfaction, and 1-year angiographic patency rates after ERAH and ORAH. PATIENTS AND METHODS: A total of 50 patients undergoing coronary artery bypass grafting were prospectively randomized to two groups. In the ERAH group (25 patients) the RA was harvested endoscopically and in the ORAH group (25 patients) openly. RESULTS: There were not differences between the groups in preoperative characteristics. Length of skin incision was shorter in ERAH (P < .001) but there were not differences in the length of RA, harvest time, blood flow, and pulsatility index after ERAH and ORAH. Wound healing was uniformly smooth in ERAH and there were two hematomas and one infection in ORAH. Postoperatively, major neuralgias were present in five patients in ORAH and none in ERAH and minor neuralgias in 11 and 3 patients (P = .02) respectively. Twenty-four patients in ERAH and four in ORAH graded their experience as excellent (P < .001). One-year angiographic RA patency was 90% without intergroup difference. Target vessel stenosis less than 90% adversely affected RA patency (P < .0001). CONCLUSIONS: In expert center, ERAH does not appear to have negative impact on the time harvest, the length, and quality of RA conduit, the wound healing, and the occurrence of hand and forearm complications. In addition, provides excellent cosmetic result and patient satisfaction. RA graft patency is gratifying when placed to a target coronary artery vessel with stenosis greater than 90%.

Coronary artery imaging with single-source rapid kilovolt peak-switching dual-energy CT.

PURPOSE: To evaluate beam-hardening (BH) artifact reduction in coronary computed tomography (CT) angiography with dual-energy CT, to define the optimal monochromatic-energy levels for coronary and myocardial signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) in dual-energy CT, and to compare these levels with single-energy CT. MATERIALS AND METHODS: The study was approved by the institutional review board and/or ethics committee at each site. Patients provided informed consent. Thirty-nine patients were prospectively enrolled to undergo dual-energy CT, and 25 also underwent single-energy CT. Myocardial and coronary SNR, CNR, and iodine concentration were measured across multiple segments at varying monochromatic energy levels (40-140 keV). BH was defined as signal decrease in basal inferior wall versus midinferior wall, and signal increase in midseptum versus midinferior wall. Generalized estimating equation was used to identify optimal monochromatic-energy levels and compare them with single-energy CT. RESULTS: BH was noted at single-energy CT with basal inferior wall mean reduction of 19.7 HU ± 29.2 (standard deviation) and midseptum increase of 46.3 HU ± 36.3. There was reduction in this artifact at 90 keV or greater (1.7 HU ± 18.4 in basal inferior wall and 20.1 HU ± 37.5 in midseptum at 90 keV; P < .05). SNR and CNR were higher in the myocardium and coronary arteries at 60-80 keV than single-energy CT (myocardium: SNR, 3.02 vs 2.39, and CNR, 6.73 vs 5.16; coronary arteries: SNR, 10.83 vs 7.75, and CNR, 13.31 vs 9.54; P < .01). Mean iodine concentration in resting myocardium was 2.19 mg/mL ± 0.57. CONCLUSION: Rapid kilovolt peak-switching dual-energy CT resulted in significant BH reduction and improvements in SNR and CNR in the myocardium and coronary arteries.

Removal of unusual multiple aortic valve fibroelastoma using right mini-thoracotomy.

Papillary Fibroelastomas are rare, primary cardiac tumors. They are typically diagnosed as an incidental finding but can also present as thrombo-embolic events. We present the case of 78-years- old man who presented to emergency room with a cerebrovascular event (CVE). Transesophageal echocardiography (TEE) revealed e presence of a mass on the aortic valve. Intra-operatively, two masses where found: one was highly mobile attached to left ventricular (LV) side of the left coronary cusp, another small size mass attached to the non-coronary cusp, and there was suspicion of a mass attached to the mitral valve. The two masses were surgically excised using a right mini-thoracotomy, and histopathological examination confirmed the diagnosis."

Computed tomography pulmonary angiography using high-pitch dual-source scanner technology.

OBJECTIVES: To compare use of ultra-fast high-pitch dual-source free-breathing computed tomography pulmonary angiogram (CTPA) with conventional standard-pitch single-source breath-hold CTPA. Methods: This retrospective comparative study was conducted in Radiology Department at King Fahad Military Medical Complex Dhahran, Saudi Arabia from July 2016 to December 2017. Patients (N=130) were divided into 2 groups, each having 65 consecutive patients; Group-1 (single-source CT) and Group-2 (dual-source CT). Previously treated pulmonary embolism cases, pregnant patients and those with incomplete data were excluded. Image quality was subjectively assessed by 2 readers for adequacy of contrast opacification and pulmonary vessel outline, and presence of artifacts (breathing motion, cardiac pulsation, and contrast related). Scan acquisition times and radiation doses were also compared. Chi-square and t-test were used to determine association. Results: Improved image quality (optimal studies without artifacts 91%) was seen in Group-2 compared to Group-1 (optimal studies without artifacts 75.4%). Also, reduced scan time (1-2 sec.) and radiation dose (mean dose length product (DLP)-248 mGy-cm) were observed in Group-2 compared to Group-1 (scan time- 6.5 sec, mean DLP-375). Results were found significant (p less than 0.05). Conclusion: High-pitch dual-source CT with free-breathing yields better image quality, reduces image acquisition time and radiation doses.

Three-dimensional assessment of left atrial appendage orifice geometry and potential implications for device closure.

Transcatheter placement of left atrial closure device is an attractive therapy for patients with atrial fibrillation (AF), to avoid anticoagulation and reduce cerebrovascular events; however peri-device leaks occur. The geometry of the left atrial appendage (LAA) is not well understood, largely owing to limitations of 2-dimensional imaging techniques. We sought to better define the LAA orifice geometry, by performing 3-dimensional multi-detector computed tomography measurements. We prospectively recruited 105 consecutive patients referred for pulmonary vein ablation (PVA) and age-matched controls. Area, short and long-axis measurements were performed. Eccentricity was calculated as 1-(short axis/long axis). Multiple clinical variables were tested for their ability to predict appendage orifice eccentricity using univariate linear regression models. The PVA cohort demographics included; 25 (24%) females, mean age 59 years (SD = 10), median height (1.55-2.03), weight 89 (56-139) kg and body surface area 2.1 (1.61-2.58). In the PVA cohort, there was a significant difference between the long and short-axis; median short-axis dimension was 20.5 (12.9-35.4) mm, versus long-axis median 30.4 (17.7-43.8) (p < 0.001). Mean eccentricity score was 0.4. When compared with controls, there was a significant difference in the short and long-axis measurements (p < 0.001) as well as eccentricity (p = 0.04). All clinical variables tested showed limited ability to predict appendage eccentricity (p = NS). LAA ostium is an elliptical structure in the setting of AF with a high eccentricity index and uniformly significant differences between short and long-axis. There were significant differences between these parameters when compared with controls. A deeper appreciation of LAA geometry and eccentricity may allow for reduction in peri-closure leaks.

Noninvasive fractional flow reserve derived from coronary computed tomography angiography: integrated anatomical and functional assessment.

Coronary computed tomographic angiography (CCTA) provides anatomic detail of lumen stenosis and information on plaque burden, plaque extent and plaque characteristics. CCTA does not, however, provide insight into the hemodynamic significance of a stenosis, which is essential to allow appropriate revascularization decision-making. This could reduce downstream invasive coronary angiography and nonbeneficial coronary revascularization, particularly with intermediate coronary stenosis. Invasive fractional flow reserve (FFR) is the gold standard for the determination of lesion-specific ischemia and the need for revascularization. Advances in computational technology now permit calculation of FFR using resting CCTA image data, without the need for additional radiation or medication. Early data demonstrate improved accuracy and a discriminatory ability of FFR computed tomography to identify ischemia-producing lesions compared with CCTA alone. This new, combined anatomic-functional assessment has the potential to simplify the noninvasive diagnosis of coronary artery disease with a single study to identify patients with ischemia-causing stenosis who may benefit from revascularization.

Caseous calcification of the mitral annulus.

A 61-year-old asymptomatic woman was referred for echocardiography to evaluate recently detected systolic murmur. Transthoracic echocardiography revealed an echodense obstructive mass in the left ventricular outflow tract of unclear origin. Subsequent transesophageal echo suggested an intracardiac calcified tumor and recommended surgical excision. Contrast-enhanced cardiac computed tomography (CT) confirmed a well-defined lobulated mass adherent to the anterior mitral valve leaflet, the non-enhanced scout view revealed marked hyper-attenuation confirming diffuse calcification. Caseous calcification was diagnosed and surgery was deferred. Caseous calcification is typically benign and most commonly involves the posterior mitral annulus. Our patient displayed an atypical location of exuberant mitral annular calcification.