Non-Gated Triple Flash Coronary Computed Tomographic Angiography in Patients with Atrial Fibrillation.

BACKGROUND: Atrial fibrillation (AF) presents a potential challenge when performing coronary computed tomography angiography (CTA). To date, there is no ideal protocol for CTA in patients with AF. We sought to design a protocol for single-heartbeat coronary CTA in patients with AF. METHODS: We enrolled 32 patients with AF and a very low probability of coronary artery disease who were referred for CTA to assess pulmonary vein anatomy for catheter ablation. A 256-slice scanner was used. Twelve patients underwent CTA using non-gated triple Flash (NGTF) consisting of three prospective electrocardiogram (ECG)-triggered helical scans with a built-in ECG simulator, while retrospectively gated helical (RGH) was used in 20 patients. Radiation dose, and a 4-point scale was used to assess coronary artery image quality between CTA scan modes. RESULTS: A total of 96 vessels were analyzed. The 4-point score showed no significant differences between the RGH and NGTF scans (2.9 ± 0.6 vs. 2.8 ± 0.8, respectively; p = 0.34). The number of coronary arteries with extensive blurring did not significantly differ between the protocols, and included four vessels (6.6%) in RGH vs. three vessels (8.3%) in NGTF (p = 0.5). Radiation exposure was significantly higher with RGH scans, with a dose-length product of 835 ± 146 mGy compared with 382 ± 35 mGy for NGTF (p < 0.0001). CONCLUSIONS: Single heartbeat NGTF CTA has comparable image quality and significantly lower radiation dose compared to RGH scans in patients with AF. Whether this protocol can be used in next-generation computed tomography scanners has yet to be determined.

Very Late Patent Foramen Ovale Occluder Device Structural Dysfunction and Thrombosis.

Mechanical dysfunction of patent foramen ovale (PFO) closure device is extremely rare. We present a 58-year-old male patient who had multiple episodes of ischemic strokes 3 years after PFO closure, which was related to PFO device mechanical dysfunction and thrombosis. He was successfully treated with surgical intervention.

Prognostic value of coronary computed tomography angiography compared to radionuclide myocardial perfusion imaging in patients With coronary stents.

Objectives: The aim of this study is to compare the prognostic value of coronary computed tomography angiography (CCTA) with single-photon emission computed tomography (SPECT) in predicting cardiovascular events in patients with stents. Design: Retrospective analysis. Setting: University Hospital, London, Ontario Canada. Participants: Between January 2007 and December 2018, 119 patients post-percutaneous coronary intervention (PCI) who were referred for hybrid imaging with CTA and 2-day rest/stress SPECT were enrolled. Primary and secondary outcome measures: Patients were followed for any major adverse cardiovascular event (MACE) including: All-cause mortality, Non-fatal myocardial infarction (MI), Unplanned revascularization, Cerebrovascular accident and hospitalization for arrhythmia or heart failure. We define hard cardiac events (HCE) as: cardiac death, non-fatal MI or unplanned revascularization. We used two cut-off values to define obstructive lesions with CCTA ≥50% and ≥70% in any coronary segment. SPECT scan defined as abnormal in the presence of >5% reversible myocardial perfusion defect. Results: During the follow-up period of 7.2 ± 3.4 years. 45/119 (37.8%) patients experienced 57 MACE: Ten deaths (2 cardiac deaths and 8 of non-cardiac deaths), 29 acute coronary syndrome including non-fatal MI (25 required revascularization), 7 hospitalizations for heart failure, 6 cerebrovascular accidents and 5 new atrial fibrillation. 31 HCEs were reported. Cox regression analysis showed that obstructive coronary stenosis (≥50% and ≥70%) and abnormal SPECT were associated of MACE (p = 0.037, 0.018 and 0.026), respectively. In contrast, HCEs were significantly associated with obstructive coronary stenosis of ≥50% and ≥70% with p = 0.004 and p = 0.007, respectively. In contrast, abnormal SPECT was a nonsignificant predictor of HCEs (p = 0.062). Conclusion: Obstructive coronary artery stenosis on CCTA can predict MACE and HCE. However, abnormal SPECT can only predict MACE but not HCE in patients post-PCI with a follow-up period of approximately 7 years.

Safety of returning patients immediately to their originating hospitals after primary percutaneous coronary intervention.

INTRODUCTION: The objective of this study was to evaluate the safety and feasibility of the immediate return of patients with ST-elevation myocardial infarction (STEMI) to their originating hospitals after primary percutaneous coronary intervention (PPCI). METHODS: This was a prospective study, conducted between January 2014 and December 2017. All patients with STEMI who were transferred for PPCI and returned back to their referring hospitals (RB group) were included and compared to the onsite STEMI population (OS group). Patient's demographics, PPCI data, bleeding and adverse cardiovascular events (ACEs) occurring during transfer, hospital stay, and at 1-month follow-up were recorded. RESULTS: A total of 156 patients in the OS group were compared against 350 patients in the RB group. We found that first medical contact to balloon time and onset of symptoms to balloon time were significantly longer in the RB group than in the OS group [110 ± 67 min vs. 46 ± 35 min (p < 0.0001) and 366 ± 300 min vs. 312 ± 120 min (p = 0.04)], respectively. There were no differences between the RB and OS groups in in-hospital ACEs: 0.3% versus 0% (p = 0.8) for death, 0.3% versus 0.6% (p = 0.79) for reinfarction, 0.6% versus 2% (p = 0.72) for bleeding, and no reported cases of repeat revascularization; and 30-day ACEs: 0.3% versus 0.6% (p = 0.82) for death, 0.3% versus 1.2% (p = 0.68) for reinfarction, 0.6% versus 2% (p = 0.74) for bleeding, and 1.1% versus 1.2% (p = 0.9) for repeat revascularization. CONCLUSION: The immediate return of patients with noncomplicated STEMI after PPCI to their referring hospitals is safe and feasible, and can be used as part of an effective reperfusion strategy.

Predictive and prognostic value of 256-slice computed tomography angiography in patients with suspected coronary artery diseases.

BACKGROUND: Coronary computed tomography angiography (CCTA) is commonly used to diagnose coronary artery diseases (CADs). We aimed to determine the utility of CCTA among patients suspected with CAD at the Prince Sultan Cardiac Center Qassim. MATERIALS AND METHODS: CCTA results of 425 cardiac patients, complaining of chest pain with suspected CAD, were used to classify coronary artery stenosis into two types: obstructive if the luminal stenosis was ≥50% or nonobstructive if it was <50%. Follow-ups were conducted through clinic or phone-based interviews to document any of the following endpoints: nonfatal myocardial infarctions (MIs) or cardiac deaths (CDs), representing the major cardiac events. All other cardiac cases, including hospitalization with unstable angina, and/or late coronary revascularization, were documented. RESULTS: Patients with a normal coronary artery were 278 (65.5%). The number of patients with nonobstructive and obstructive diseases was 85 (20%) and 62 (14.5%), respectively. After 19.6 ± 7 months of follow-up, 21 cardiac events occurred in twenty patients: five major adverse events (two CDs and three nonfatal MIs), ten hospitalizations due to unstable angina, and six late coronary revascularizations. Furthermore, the cumulative all-cardiac-event rates in patients with normal coronary arteries, nonobstructive CAD, and obstructive CAD were 3 (1%), 7 (8.2%), and 11 (17.7%), respectively. However, patients with normal CCTA had no major cardiac events during the follow-up. CONCLUSION: CCTA can provide valuable prognostic information on patients with suspected CAD. Patients are likely to have excellent intermediate outcomes if the coronary arteries are confirmed to be normal by CCTA.

Fat volume measurements as a predictor of image noise in coronary computed tomography angiography.

INTRODUCTION: Image noise can negatively affect the overall quality of coronary computed tomography angiography (CCTA). OBJECTIVES: The purpose of this study was to evaluate the relationship between image noise and fat volumes in the chest wall. We also aimed to compare these with other patient-specific predictors of image noise, such as body weight (BW) and body mass index (BMI). METHODS: We undertook a cross-sectional, single-center study. A tube voltage of 100 kV was used for patients with BW <85 kg and 120 kV for BW ≥85 kg. The image noise in the aortic root, single-slice fat volume (SFV) at the level of the left main coronary artery and the total fat volume of the chest (TFV) were analyzed. RESULTS: A total of 132 consecutive patients were enrolled (mean age ±â€¯standard deviation, 51 ±â€¯11 years; 64% male). The mean image noise was 30.5 ±â€¯11 Hounsfield units (HU). We found that patients with image noise >30 HU had significantly higher SFV (75 ±â€¯33 vs. 51 ±â€¯24, p < 0.0001) and TFV (2206 ±â€¯927 vs. 1815 ±â€¯737, p < 0.01) compared with patients having noise ≤30 HU, whereas BW and BMI showed no significant difference (78 ±â€¯13 vs. 81 ±â€¯14, p < 0.34) and (28.7 ±â€¯4.7 vs. 26.8 ±â€¯3.8, p < 0.19), respectively. Linear regression analysis showed that image noise has better correlation with SFV (R = 0.399; p < 0.0001); and TFV (R = 0, p < 0.009) than BMI (R = 0.154, p < 0.039) and BW (R = -0.102, p = 0.12). CONCLUSIONS: Fat volume measurements of the chest wall can predict CCTA image noise better than other patient-specific predictors, such as BW and BMI.

Awareness of fitness to drive among cardiologists in Saudi Arabia.

OBJECTIVES: To assess the perception and awareness of cardiologists in Saudi Arabia about medical fitness to drive in different cardiovascular diseases. Methods: The study is a cross-sectional survey-based study between June 2018 and July 2018. Cardiologists were asked to complete a self-administered questionnaire inquiring about awareness of driving fitness and educating patients regarding driving risks in specific cardiovascular conditions. Results: A total of 194 cardiologists completed the study survey; there were 30.4% consultants, 59.3% specialists, and 10.3% residents. Out of 195, 72% were aware of the existence of particular international driving regulations for cardiovascular diseases, whereas 28% were not aware. Although, no Saudi guidelines assessing fitness-to-drive are available, 11% of the participants claimed awareness of such regulations. Interestingly, we found that cardiologists had never or rarely educated their patients regarding the potential risks of driving: 49% in symptomatic angina, 47% when ejection fraction is ≤35%, 39% in symptomatic valvular diseases, 26% after cardioverter defibrillators implantation, and 23% after non-elective percutaneous coronary interventions. Conclusion: There is a lack of awareness among cardiologists in Saudi Arabia about international guidelines regarding medical driving fitness. This study highlights the necessity of formulating appropriate national driving regulations for cardiovascular diseases.

Are cardiac patients in Saudi Arabia provided adequate instructions when they should not drive?

OBJECTIVE: Driving capability can be significantly affected by different heath disorders; cardiovascular diseases (CVDs) should be considered when assessing patients for medical fitness to drive (MFTD). The aim of this study was to evaluate the awareness of Saudi patients about driving recommendations and to assess the incidence of motor vehicle accidents (MVAs) among cardiac patients. MATERIALS AND METHODS: We conducted a cross-sectional survey-based study. Male patients diagnosed with CVDs and who were visiting outpatient departments were invited to complete a questionnaire regarding their awareness of driving recommendations. Patients' demographics, clinical diagnosis, echocardiography parameters, and time-to-CVD diagnosis were all obtained from the patients' medical records. Women were excluded because it was illegal for women to drive in Saudi Arabia during the study period. RESULTS: In total, 800 men were included, with a mean age of 54 ± 12 years. Driving counseling had been provided to 241 participants (30%). Of these, 207 (25%) were advised not to drive for a period of between one week and six months. Five percent of the patients had a history of MVAs during the follow-up period of 6.2 ± 4 years. We found that the presence of a dyspnea ≥2, according to the New York Heart Association (NYHA), and a history of loss of consciousness (syncope/pre-syncope) were significantly associated with accidents (46% vs. 20%, P < 0.0001 and 41% vs. 10%, P < 0.0001, respectively). CONCLUSION: Patient-physician discussion about MFTD was only performed with 30% of the patients with CVDs in Saudi Arabia. Dyspnea NYHA class ≥2 or a prior history of syncope were significantly associated with the incidence of MVAs.

Ultra-fast, low dose high-pitch (FLASH) versus prospectively-gated coronary computed tomography angiography: Comparison of image quality and patient radiation exposure.

BACKGROUND: Coronary computed tomography angiography (CCTA) is increasingly being used for the evaluation of coronary artery disease; however, radiation exposure remains a major limitation of its use. OBJECTIVE: To compare image quality and radiation exposure in two groups of patients undergoing CCTA using a 256-slice dual-source helical computed tomography scanner with high-pitch (FLASH) or prospective [step-and-shoot (SAS)] gating protocols. METHODS: A prospective, single-center study was performed in our cardiac center. In total, 162 patients underwent CCTA with either FLASH or SAS scanning protocols. Subjective image quality was graded on the basis of a four-point grading system (1, non-diagnostic; 2, adequate; 3, good; 4, excellent). Objective image quality was assessed using image signal, noise, and signal-to-noise ratio (SNR). The effective radiation dose was also estimated. RESULTS: The clinical and demographic characteristics of the patients in both groups were similar. The median age of the patients in both groups was 48.43 years, and males accounted for 63% and 68.7% of the FLASH and SAS groups, respectively. We found that the subjective image quality obtained with the FLASH protocol was superior to that obtained with the SAS protocol (3.35 ±â€¯0.6 mSv vs. 2.82 ±â€¯0.61 mSv; p < 0.001). Image noise was higher in the FLASH group but was not statistically significant (25.0 ±â€¯6.13 vs. 24.0 ±â€¯6.8; p = 0.10), whereas the signal and SNR was significantly higher with the FLASH protocol than with the SAS protocol [(469 ±â€¯116 vs. 397 ±â€¯106; p > 0.001) and (21.6 ±â€¯8.7 mSv vs. 16.6 ±â€¯7.7 mSv; p < 0.001), respectively]. Radiation exposure was 62% lower in the FLASH protocol than in the SAS protocol, (1.9 ±â€¯0.4 mSv vs. 5.12 ±â€¯1.8 mSv; p < 0.001). CONCLUSION: The use of 256-slice CCTA performed with the FLASH protocol has a better objective and subjective image quality as well as lower radiation exposure when compared with the use of prospective electrocardiography gating.

The Role of Computed Tomographic Angiography in Predicting Left Anterior Descending Artery Graftability When Catheter Angiography is Inconclusive.

PURPOSE: Graftability of the left anterior descending artery (LAD) has important prognostic value for coronary artery bypass graft (CABG) surgery. However, with a chronic total occlusion (CTO) of the LAD, invasive coronary angiography (ICA) may be insufficient to determine its graftability. We evaluated the role of coronary computed tomographic angiography (CTA) in the assessment of CTO and LAD graftability when the distal vessel segment was incompletely visualized by ICA. MATERIALS AND METHODS: We enrolled 31 patients with equivocal eligibility for CABG due to CTO of the LAD with poor distal flow defined by ICA. Patients with LAD diameters ≥1.5 mm by CTA underwent CABG surgery, and the vessel diameter was reassessed intraoperatively. RESULTS: The mean age was 54±14 years. Seven patients (23%) had suitable LAD targets on CTA and underwent successful CABG. Another 24 patients (77%) had nongraftable LADs. Patients with a graftable LAD showed no significant difference between mean LAD diameter measured by CTA and during surgery (1.6±0.3 vs. 1.5±0.3 mm, P=0.21). The preoperative left ventricular ejection fraction was not significantly different between groups (35%±8% vs. 35%±7%, P=0.2). However, after a mean follow-up of 21±7 months, left ventricular ejection fraction was significantly higher in vascularized patients (41%±5.8% vs. 34%±8%, P=0.01, respectively). Six of 7 patients had patent LAD grafts on CTA at 1-year follow-up. CONCLUSION: CTA may provide valuable information about chronically occluded LAD size and graftability when ICA is inconclusive.

Visual versus fully automated assessment of left ventricular ejection fraction.

INTRODUCTION: The aim of this study is to compare three different echocardiographic methods commonly used in the assessment of left ventricle (LV) ejection fraction (EF). METHODS: All patients underwent full echocardiography including LVEF assessed using M-mode, automated EF (Auto-EF), and visual estimation by two readers. RESULTS: We enrolled 268 patients. Auto-EF measurement was feasible in 240 (89.5%) patients. The averaged LVEF was (52% ± 12) with the visual assessment, (51% ± 11) with Auto-EF and (57% ± 13) with M-mode. Using Bland-Altman analysis, we found that the difference between the mean visual and the Auto-EF was not significant (-0.3% [-0.5803-0.0053], P = 0.054). However, the mean EF was significantly different when comparing visual versus M-mode and Auto-EF versus M-mode with the mean differences: (-2.4365 [-2.9946--1.8783], P < 0.0001) and (-2.1490 [-2.7348--1.5631], P < 0.0001) respectively. Inter-observer variability analysis of the visual EF assessment between the two readers showed that intraclass correlation coefficient was 0.953, (95% confidence interval: 0.939-0.965, P < 0.0001), with excellent correlation between the two readers: R = 0.911, P < 0.0001). CONCLUSION: The two-dimensional echocardiographic methods using Biplane Auto-EF or visual assessment were significantly comparable, whereas M-mode results in an overestimation of the LVEF.

Effects of Ramadan fasting on the symptoms of chronic heart failure.

OBJECTIVES: To investigate the effect of Ramadan fasting on the symptoms of chronic heart failure with a reduced ejection fraction (HFrEF). Globally, more than one billion Muslims fast during Ramadan. Data regarding the effect of fasting in heart failure patients with a reduced ejection fraction are limited. METHODS: We prospectively studied 249 outpatients with HFrEF who undertook Ramadan fasting at tertiary care cardiac center in Saudi Arabia in 2017. We obtained information regarding the clinical assessment, diagnosis, emergency department visits, and hospitalization during and in the month preceding Ramadan. RESULTS: We enrolled 249 patients, 227 (91%) undertook the fast for the entire month. During Ramadan, 209 (92%) patients remained hemodynamically stable, whereas 18 (8%) developed instability. The mean New York Heart Association (NYHA) functional class was significantly lower in the stable than in the unstable group (1.46±0.7 vs. 3.22±0.55, p less than 0.0001), although no intergroup differences were observed before Ramadan. Patients from the unstable vs. the stable group showed significantly less adherence to medications (67% vs. 94%, p less than 0.0001) and to diet (39% vs. 79%, p less than 0.0001), and a lower likelihood of demonstrating ischemic cardiomyopathy as an underlying etiology of HFrEF (33% vs. 57%, p=0.046). Dependent t-test analysis including all patients showed that the NYHA classification before Ramadan was significantly higher than during Ramadan (2.19±0.9 vs. 1.6±0.8, t-value 8.5, p less than 0.0001). CONCLUSION: In most patients with chronic HFrEF, Ramadan fasting is considered safe. Non-adherence to medication and diet are significantly associated with decompensated heart failure during Ramadan.

Analysis of three risk stratification systems in a Saudi population.

INTRODUCTION: Coronary artery disease is the leading cause of death worldwide. Although there are a number of algorithms in use for determining the risk of coronary artery disease and thus predicting future cardiovascular events, the data available regarding their validity among the Saudi population are insufficient. OBJECTIVE: We studied the validity of three clinical score systems in predicting a high risk population defined as having excessive coronary calcification: the American College of Cardiology/American Heart Association (ACC/AHA) Pooled Cohort Risk Equation, the Framingham Risk Score, and the European Systematic Coronary Risk Evaluation. METHODS: We analyzed data from 462 patients aged ⩾40 years. High-risk features were if the Coronary Calcium Score was either >400 or in the ⩾75th percentile using Multi-Ethnic Study of Atherosclerosis (MESA) score. The scores for the three algorithms were then calculated using the participants' clinical data. RESULTS: A total of 87 (18.8%) patients were positive for coronary calcification. Among them, 60 (13%) were classified as being at high risk according to the MESA score. Analyzing these patients by the ACC/AHA Pooled Cohort Risk Equation resulted in nine (15%) as being at low risk, 12 (20%) at intermediate risk, and 39 (65%) at high risk. The Framingham Risk classification resulted in 14 (23%) being at low risk, 13 (22%) at intermediate risk, and 33 (55%) at high risk. The European Systematic Coronary Risk Evaluation risk classification showed 24 (40%) at low risk, 12 (20%) at intermediate risk, and 24 (40%) at high risk, with p < 0.0001. CONCLUSION: The ACC/AHA Pooled Cohort Risk Equation has superior risk ​ calibration compared to the other two risk-score algorithms in a Saudi population.

The prevalence of coronary artery anomalies in Qassim Province detected by cardiac computed tomography angiography.

BACKGROUND: Coronary artery anomalies (CAAs) affect about 1% of the general population based on invasive coronary angiography (ICA) data, computed tomography angiography (CTA) enables better visualization of the origin, course, relation to the adjacent structures, and termination of CAAs compared to ICA. OBJECTIVE: The aim of our work is to estimate the frequency of CAAs in Qassim province among patients underwent cardiac CTA at Prince Sultan Cardiac Center. METHODS: Retrospective analysis of the CTA data of 2235 patients between 2009 and 2015. RESULTS: The prevalence of CAAs in our study was 1.029%. Among the 2235 patients, 241 (10.78%) had CAAs or coronary variants, 198 (8.85%) had myocardial bridging, 34 (1.52%) had a variable location of the Coronary Ostia, Twenty two (0.98%) had a separate origin of left anterior descending (LAD) and left circumflex coronary (LCX) arteries, ten (0.447%) had a separate origin of the RCA and the Conus artery. Seventeen (0.76%) had an anomalous origin of the coronaries. Six (0.268%) had a coronary artery fistula, which is connected mainly to the right heart chambers, one of these fistulas was complicated by acute myocardial infarction. CONCLUSIONS: The incidence of CAAs in our patient population was similar to the former studies, CTA is an excellent tool for diagnosis and guiding the management of the CAAs.

Impact of coronary artery calcification on percutaneous coronary intervention and postprocedural complications.

BACKGROUND: Excessive coronary calcification can lead to adverse outcomes after percutaneous coronary intervention (PCI). We therefore evaluated the impact of coronary calcium score (CCS) measured by multidetector computed tomography (MDCT) on immediate complications of PCI and rate of restenosis. METHODS: We performed a single-center retrospective analysis of 84 patients with coronary stenosis diagnosed by MDCT who underwent PCI. The Agatston method was used to measure total, target-vessel, and segmental (stent deployment site) CCS. RESULTS: In 108 PCI procedures, 32 lesions (29.5%) were American College of Cardiology/American Heart Association type A, 60 (55.5%) were type B, and 16 (15%) were type C. ANOVA showed significantly higher segmental CCS in type C than in type A lesions (29 ± 51 vs. 214 ± 162; p = 0.03). Six patients (7.1%) had periprocedural complications and seven (8.3%) had in-stent restenosis and angina. Mean total, target-vessel, and segmental CCS was significantly higher in complicated than in successful PCI (199 ± 325 vs. 816 ± 624, p = 0.001; 92 ± 207 vs. 337 ± 157, p = 0.001; and 79 ± 158 vs. 256 ± 142, p = 0.003, respectively), but there was no significant difference in CCS between successful PCI and PCI complicated by late restenosis. CONCLUSIONS: CCS measured by MDCT has an important role in predicting early, but not late, complications from PCI.

Radial artery ultrasound predicts the success of transradial coronary angiography.

BACKGROUND: The transradial approach has become the preferred vascular access during conventional coronary angiography (CCA). Hereby, we evaluated the impact of pre-procedural radial artery diameter (RAD), the cross-sectional area (CSA), and the perimeter on vascular complications (VACs). METHODS: We conducted a single-center prospective analysis of 513 patients who underwent CCA. Radial artery ultrasonography was performed before and after CCA to measure the RAD, CSA, and perimeter. RESULTS: The average RAD, CSA, and perimeter were 2.60 ± 0.48 mm, 6.2 ± 3.0 mm2, and 8.9 ± 1.7 mm, respectively. Vascular complications were reported in 56 (11%) patients. The RAD, CSA, and perimeter were significantly smaller in patients in whom procedure-related VACs were observed than in those with no complications: 2.3 ± 0.5 vs. 2.70 ± 0.54 mm (p = 0.0001), 4.9 ± 2.1 vs. 6.4 ± 3 mm2 (p = 0.001), and 7.6 ± 2.1 vs. 9.2 ± 1.6 mm (p = 0.0001), respectively. Univariate logistic regression showed that RAD, CSA and perimeter can independently predict VACs (OR 0.833, 95% CI 0.777-0.894, p < 0.0001; OR 0.647, 95% CI 0.541-0.773, p < 0.0001; OR 0.545, 95% CI 0.446-0.665, p < 0.0001, respectively). CONCLUSIONS: Ultrasonographic study of the radial artery before CCA can provide valuable information regarding vascular access.

Relation Between Epicardial Fat and Subclinical Atherosclerosis in Asymptomatic Individuals.

PURPOSE: Excessive quantity of epicardial adipose tissue (EAT) is considered a risk factor for coronary artery disease (CAD). There are limited data, however, on the relationship between the quality of EAT and CAD. We investigated the association between the density and volume of EAT and subclinical CAD defined by positive coronary artery calcification (CAC), using computed tomography (CT). MATERIALS AND METHODS: We reviewed 609 consecutive CT scans of patients with a mild to moderate risk for CAD to assess the EAT volume, which was measured manually by tracing the parietal pericardial sac on axial images. Fat density was recorded in mean Hounsfield units (HU), and CAC was measured using the Agatston method. RESULTS: The mean patients' age was 50±11 years, and 393 (64.5%) were men. Overall, CAC was present in 135 (22%) patients, of whom 97 (72%) were men and 38 (28%) were women. The mean EAT volume and density were 65±27 cm and -87.0±3.4 HU, respectively. Patients with CAC had significantly higher EAT volume (74±27 vs. 62±26 cm, P<0.001) and lower EAT density (-88±3 vs. -87±3.4 HU, P<0.001) compared with patients without CAC. Multivariate regression analysis showed that both EAT density (hazard ratio, 0.879; 95% confidence interval, 0.817-0.946; P=0.001) and EAT volume >100 cm (hazard ratio, 1.693; 95% confidence interval, 1.256-2.999; P=0.029) predicted the presence of CAC. CONCLUSIONS: Both the quality and quantity of EAT derived from noncontrast CT scan predict subclinical CAD, with lower density and higher volume of epicardial fat associated with higher CACs.

Interrupted aortic arch with isolated persistent left superior vena cava in patient with Turners syndrome.

We present a case of 13-year-old female with Turner syndrome (TS), who presented with unexplained lower limbs swelling and ejection systolic murmur at the left second intercostal space. Suspicion of mild aortic coarctation was made by echocardiography. Computed tomography angiography (CTA) showed a complete interruption of the aortic arch (IAA) below the left subclavian artery with persistent left superior vena cava (PLSVC) and absent right SVC, defined as an isolated PLSVC. The patient underwent successful surgical correction after unsuccessful trial of transcatheter stent placement. We present this case of asymptomatic IAA to draw attention to the importance of CTA in diagnosing such rare anomalies and ruling out asymptomatic major cardiovascular abnormalities in patient with TS.

A rare case of coronary artery fistula presented with acute myocardial infarction.

Coronary artery fistulas (CAFs): Are anomalous connections of the coronary arteries (CA) with major vascular structures or heart chambers. Most of CAFs are incidental findings during invasive coronary angiography (ICA) or computed tomography angiography (CTA). Many patients with CAFs are asymptomatic; only a minority has been associated with various clinical features and outcomes. We have reported a rare CAF complicated with acute myocardial infarction (AMI) in 43 years old female Patient who was admitted to our institution with a Diagnosis of Acute Infero-Posterior Myocardial Infarction (AMI). ICA and CTA showed a thrombosed CAF between left main coronary artery and right atrium with totally occluded left circumflex artery by a thrombus extended from the fistula. As there was a high risk associated with immediate intervention, the patient was kept on conservative management with a future plan of catheter-assisted or surgical closure. We have shown a rare case of CAF presenting with AMI that is unusual for such an anomaly, and have highlighted the role of CTA in the diagnosis and management of such rare disorder.