Relationship between impaired myocardial blood flow by positron emission tomography and low-attenuation plaque burden and pericoronary adipose tissue attenuation from coronary computed tomography: From the prospective PACIFIC trial.

BACKGROUND: Positron emission tomography (PET) is the clinical gold standard for quantifying myocardial blood flow (MBF). Pericoronary adipose tissue (PCAT) attenuation may detect vascular inflammation indirectly. We examined the relationship between MBF by PET and plaque burden and PCAT on coronary CT angiography (CCTA). METHODS: This post hoc analysis of the PACIFIC trial included 208 patients with suspected coronary artery disease (CAD) who underwent [15O]H2O PET and CCTA. Low-attenuation plaque (LAP, < 30HU), non-calcified plaque (NCP), and PCAT attenuation were measured by CCTA. RESULTS: In 582 vessels, 211 (36.3%) had impaired per-vessel hyperemic MBF (≤ 2.30 mL/min/g). In multivariable analysis, LAP burden was independently and consistently associated with impaired hyperemic MBF (P = 0.016); over NCP burden (P = 0.997). Addition of LAP burden improved predictive performance for impaired hyperemic MBF from a model with CAD severity and calcified plaque burden (P < 0.001). There was no correlation between PCAT attenuation and hyperemic MBF (r = - 0.11), and PCAT attenuation was not associated with impaired hyperemic MBF in univariable or multivariable analysis of all vessels (P > 0.1). CONCLUSION: In patients with stable CAD, LAP burden was independently associated with impaired hyperemic MBF and a stronger predictor of impaired hyperemic MBF than NCP burden. There was no association between PCAT attenuation and hyperemic MBF.

Automated quantitative analysis of CZT SPECT stratifies cardiovascular risk in the obese population: Analysis of the REFINE SPECT registry.

BACKGROUND: Obese patients constitute a substantial proportion of patients referred for SPECT myocardial perfusion imaging (MPI), presenting a challenge of increased soft tissue attenuation. We investigated whether automated quantitative perfusion analysis can stratify risk among different obesity categories and whether two-view acquisition adds to prognostic assessment. METHODS: Participants were categorized according to body mass index (BMI). SPECT MPI was assessed visually and quantified automatically; combined total perfusion deficit (TPD) was evaluated. Kaplan-Meier and Cox proportional hazard analyses were used to assess major adverse cardiac event (MACE) risk. Prognostic accuracy for MACE was also compared. RESULTS: Patients were classified according to BMI: BMI < 30, 30 ≤ BMI < 35, BMI ≥ 35. In adjusted analysis, each category of increasing stress TPD was associated with increased MACE risk, except for 1% ≤ TPD < 5% and 5% ≤ TPD < 10% in patients with BMI ≥ 35. Compared to visual analysis, single-position stress TPD had higher prognostic accuracy in patients with BMI < 30 (AUC .652 vs .631, P < .001) and 30 ≤ BMI < 35 (AUC .660 vs .636, P = .027). Combined TPD had better discrimination than visual analysis in patients with BMI ≥ 35 (AUC .662 vs .615, P = .003). CONCLUSIONS: Automated quantitative methods for SPECT MPI interpretation provide robust risk stratification in the obese population. Combined stress TPD provides additional prognostic accuracy in patients with more significant obesity.

Soil suppressiveness to fusarium disease: shifts in root microbiome associated with reduction of pathogen root colonization.

Soil suppressiveness to Fusarium disease was induced by incubating sandy soil with debris of wild rocket (WR; Diplotaxis tenuifolia) under field conditions. We studied microbial dynamics in the roots of cucumber seedlings following transplantation into WR-amended or nonamended soil, as influenced by inoculation with Fusarium oxysporum f. sp. radicis-cucumerinum. Disease symptoms initiated in nonamended soil 6 days after inoculation, compared with 14 days in WR-amended soil. Root infection by F. oxysporum f. sp. radicis-cucumerinum was quantified using real-time polymerase chain reaction (PCR). Target numbers were similar 3 days after inoculation for both WR-amended and nonamended soils, and were significantly lower (66%) 6 days after inoculation and transplanting into the suppressive (WR-amended) soil. This decrease in root colonization was correlated with a reduction in disease (60%) 21 days after inoculation and transplanting into the suppressive soil. Fungal community composition on cucumber roots was assessed using mass sequencing of fungal internal transcribed spacer gene fragments. Sequences related to F. oxysporum, Fusarium sp. 14005, Chaetomium sp. 15003, and an unclassified Ascomycota composed 96% of the total fungal sequences in all samples. The relative abundances of these major groups were highly affected by root inoculation with F. oxysporum f. sp. radicis-cucumerinum, with a 10-fold increase in F. oxysporum sequences, but were not affected by the WR amendment. Quantitative analysis and mass-sequencing methods indicated a qualitative shift in the root's bacterial community composition in suppressive soil, rather than a change in bacterial numbers. A sharp reduction in the size and root dominance of the Massilia population in suppressive soil was accompanied by a significant increase in the relative abundance of specific populations; namely, Rhizobium, Bacillus, Paenibacillus, and Streptomyces spp. Composition of the Streptomyces community shifted significantly, as determined by PCR denaturing gradient gel electrophoresis, resulting in an increase in the dominance of a specific population in suppressive soils after only 3 days. This shift was related mainly to the increase in Streptomyces humidus, a group previously described as antagonistic to phytopathogenic fungi. Thus, suitable soil amendment resulted in a shift in the root's bacterial communities, and infection by a virulent pathogen was contained by the root microbiome, leading to a reduced disease rate.

A Novel Platform for Root Protection Applies New Root-Coating Technologies to Mitigate Soil-Borne Tomato Brown Rugose Fruit Virus Disease.

Tomato brown rugose fruit virus (ToBRFV) is a soil-borne virus showing a low percentage of ca. 3% soil-mediated infection when the soil contains root debris from a previous 30-50 day growth cycle of ToBRFV-infected tomato plants. We designed stringent conditions of soil-mediated ToBRFV infection by increasing the length of the pre-growth cycle to 90-120 days, adding a ToBRFV inoculum as well as truncating seedling roots, which increased seedling susceptibility to ToBRFV infection. These rigorous conditions were employed to challenge the efficiency of four innovative root-coating technologies in mitigating soil-mediated ToBRFV infection while avoiding any phytotoxic effect. We tested four different formulations, which were prepared with or without the addition of various virus disinfectants. We found that under conditions of 100% soil-mediated ToBRFV infection of uncoated positive control plants, root-coating with formulations based on methylcellulose (MC), polyvinyl alcohol (PVA), silica Pickering emulsion and super-absorbent polymer (SAP) that were prepared with the disinfectant chlorinated-trisodium phosphate (Cl-TSP) showed low percentages of soil-mediated ToBRFV infection of 0%, 4.3%, 5.5% and 0%, respectively. These formulations had no adverse effect on plant growth parameters when compared to negative control plants grown under non ToBRFV inoculation conditions.

Sex differences in computed tomography angiography-derived coronary plaque burden in relation to invasive fractional flow reserve.

BACKGROUND: Distinct sex-related differences exist in coronary artery plaque burden and distribution. We aimed to explore sex differences in quantitative plaque burden by coronary CT angiography (CCTA) in relation to ischemia by invasive fractional flow reserve (FFR). METHODS: This post-hoc analysis of the PACIFIC trial included 581 vessels in 203 patients (mean age 58.1 â€‹± â€‹8.7 years, 63.5% male) who underwent CCTA and per-vessel invasive FFR. Quantitative assessment of total, calcified, non-calcified, and low-density non-calcified plaque burden were performed using semiautomated software. Significant ischemia was defined as invasive FFR ≤0.8. RESULTS: The per-vessel frequency of ischemia was higher in men than women (33.5% vs. 7.5%, p â€‹< â€‹0.001). Women had a smaller burden of all plaque subtypes (all p â€‹< â€‹0.01). There was no sex difference on total, calcified, or non-calcified plaque burdens in vessels with ischemia; only low-density non-calcified plaque burden was significantly lower in women (beta: -0.183, p â€‹= â€‹0.035). The burdens of all plaque subtypes were independently associated with ischemia in both men and women (For total plaque burden (5% increase): Men, OR: 1.15, 95%CI: 1.06-1.24, p â€‹= â€‹0.001; Women, OR: 1.96, 95%CI: 1.11-3.46, p â€‹= â€‹0.02). No significant interaction existed between sex and total plaque burden for predicting ischemia (interaction p â€‹= â€‹0.108). The addition of quantitative plaque burdens to stenosis severity and adverse plaque characteristics improved the discrimination of ischemia in both men and women. CONCLUSIONS: In symptomatic patients with suspected CAD, women have a lower CCTA-derived burden of all plaque subtypes compared to men. Quantitative plaque burden provides independent and incremental predictive value for ischemia, irrespective of sex.

Detection of small coronary calcifications in patients with Agatston coronary artery calcium score of zero.

BACKGROUND: A coronary artery calcium score (CACS) of 0 is associated with a very low risk of cardiac event. However, the Agatston CACS may fail to detect very small or less dense calcifications. We investigated if an alteration of the Agatston criteria would affect the ability to detect such plaques. METHODS: We evaluated 322 patients, 161 who had a baseline scan with CACS â€‹= â€‹0 and a follow-up scan with CACS>0 and 161 with two serial CACS â€‹= â€‹0 scans (control group), to identify subtle calcification not detected in the baseline scan because it was not meeting the Agatston size and HU thresholds (≥1 â€‹mm2 and ≥130HU). Size threshold was set to <1 â€‹mm2 and the HU threshold modified in a stepwise manner to 120, 110, 100 and 90. New lesions were classified as true positive or false positive(noise) using the follow-up scan. RESULTS: We identified 69 visually suspected subtle calcified lesions in 65/322 (20.2%) patients with CAC â€‹= â€‹0 by the Agatston criteria. When size threshold was set as <1 â€‹mm2 and HU â€‹≥ â€‹130, 36 lesions scored CACS>0, 34 (94.4%) true positive and 2 (5.6%) false positive. When decrease in HU (120HU, 110HU, 100HU, and 90HU) threshold was added to the reduced size threshold, the number of lesions scoring>0 increased (46, 55, 59, and 69, respectively) at a cost of increased false positive rate (8.7%, 20%, 22%, and 30.4% respectively). Eliminating size or both size and HU threshold to ≥120HU correctly reclassified 9.6% and 12.1% of patients respectively. CONCLUSION: Eliminating size and reducing HU thresholds to ≥120HU improved the detection of subtle calcification when compared to the Agatston CACS method.

Value of semiquantitative assessment of high-risk plaque features on coronary CT angiography over stenosis in selection of studies for FFRct.

INTRODUCTION: The degree of stenosis on coronary CT angiography (CCTA) guides referral for CT-derived flow reserve (FFRct). We sought to assess whether semiquantitative assessment of high-risk plaque (HRP) features on CCTA improves selection of studies for FFRct over stenosis assessment alone. METHODS: Per-vessel FFRct was computed in 1,395 vessels of 836 patients undergoing CCTA with 25-99% maximal stenosis. By consensus analysis, stenosis severity was graded as 25-49%, 50-69%, 70-89%, and 90-99%. HRPs including low attenuation plaque (LAP), positive remodeling (PR), and spotty calcification (SC) were assessed in lesions with maximal stenosis. Lesion FFRct was measured distal to the lesion with maximal stenosis, and FFRct<0.80 was defined as abnormal. Association of HRP and abnormal lesion FFRct was evaluated by univariable and multivariable logistic regression models. RESULTS: The frequency of abnormal lesion FFRct increased with increase of stenosis severity across each stenosis category (25-49%:6%; 50-69%:30%; 70-89%:54%; 90-99%:91%, p â€‹< â€‹0.001). Univariable analysis demonstrated that stenosis severity, LAP, and PR were predictive of abnormal lesion FFRct, while SC was not. In multivariable analyses considering stenosis severity, presence of PR, LAP, and PR and/or LAP were independently associated with abnormal FFRct: Odds ratio 1.58, 1.68, and 1.53, respectively (p â€‹< â€‹0.02 for all). The presence of PR and/or LAP increased the frequency of abnormal FFRct with mild stenosis (p â€‹< â€‹0.05) with a similar trend with 70-89% stenosis. The combination of 2 HRP (LAP and PR) identified more lesions with FFR < 0.80 than only 1 HRP. CONCLUSIONS: Semiquantitative visual assessment of high-risk plaque features may improve the selection of studies for FFRct.

Machine Learning From Quantitative Coronary Computed Tomography Angiography Predicts Fractional Flow Reserve-Defined Ischemia and Impaired Myocardial Blood Flow.

BACKGROUND: A pathophysiological interplay exists between plaque morphology and coronary physiology. Machine learning (ML) is increasingly being applied to coronary computed tomography angiography (CCTA) for cardiovascular risk stratification. We sought to assess the performance of a ML score integrating CCTA-based quantitative plaque features for predicting vessel-specific ischemia by invasive fractional flow reserve (FFR) and impaired myocardial blood flow (MBF) by positron emission tomography (PET). METHODS: This post-hoc analysis of the PACIFIC trial (Prospective Comparison of Cardiac Positron Emission Tomography/Computed Tomography [CT]' Single Photon Emission Computed Tomography/CT Perfusion Imaging and CT Coronary Angiography with Invasive Coronary Angiography) included 208 patients with suspected coronary artery disease who prospectively underwent CCTA' [15O]H2O PET, and invasive FFR. Plaque quantification from CCTA was performed using semiautomated software. An ML algorithm trained on the prospective NXT trial (484 vessels) was used to develop a ML score for the prediction of ischemia (FFR≤0.80), which was then evaluated in 581 vessels from the PACIFIC trial. Thereafter, the ML score was applied for predicting impaired hyperemic MBF (≤2.30 mL/min per g) from corresponding PET scans. The performance of the ML score was compared with CCTA reads and noninvasive FFR derived from CCTA (FFRCT). RESULTS: One hundred thirty-nine (23.9%) vessels had FFR-defined ischemia, and 195 (33.6%) vessels had impaired hyperemic MBF. For the prediction of FFR-defined ischemia, the ML score yielded an area under the receiver-operating characteristic curve of 0.92, which was significantly higher than that of visual stenosis grade (0.84; P<0.001) and comparable with that of FFRCT (0.93; P=0.34). Quantitative percent diameter stenosis and low-density noncalcified plaque volume had the greatest ML feature importance for predicting FFR-defined ischemia. When applied for impaired MBF prediction, the ML score exhibited an area under the receiver-operating characteristic curve of 0.80; significantly higher than visual stenosis grade (area under the receiver-operating characteristic curve 0.74; P=0.02) and comparable with FFRCT (area under the receiver-operating characteristic curve 0.77; P=0.16). CONCLUSIONS: An externally validated ML score integrating CCTA-based quantitative plaque features accurately predicts FFR-defined ischemia and impaired MBF by PET, performing superiorly to standard CCTA stenosis evaluation and comparably to FFRCT.

Association of Plaque Location and Vessel Geometry Determined by Coronary Computed Tomographic Angiography With Future Acute Coronary Syndrome-Causing Culprit Lesions.

IMPORTANCE: Distinct plaque locations and vessel geometric features predispose to altered coronary flow hemodynamics. The association between these lesion-level characteristics assessed by coronary computed tomographic angiography (CCTA) and risk of future acute coronary syndrome (ACS) is unknown. OBJECTIVE: To examine whether CCTA-derived adverse geometric characteristics (AGCs) of coronary lesions describing location and vessel geometry add to plaque morphology and burden for identifying culprit lesion precursors associated with future ACS. DESIGN, SETTING, AND PARTICIPANTS: This substudy of ICONIC (Incident Coronary Syndromes Identified by Computed Tomography), a multicenter nested case-control cohort study, included patients with ACS and a culprit lesion precursor identified on baseline CCTA (n = 116) and propensity score-matched non-ACS controls (n = 116). Data were collected from July 20, 2012, to April 30, 2017, and analyzed from October 1, 2020, to October 31, 2021. EXPOSURES: Coronary lesions were evaluated for the following 3 AGCs: (1) distance from the coronary ostium to lesion; (2) location at vessel bifurcations; and (3) vessel tortuosity, defined as the presence of 1 bend of greater than 90° or 3 curves of 45° to 90° using a 3-point angle within the lesion. MAIN OUTCOMES AND MEASURES: Association between lesion-level AGCs and risk of future ACS-causing culprit lesions. RESULTS: Of 548 lesions, 116 culprit lesion precursors were identified in 116 patients (80 [69.0%] men; mean [SD], age 62.7 [11.5] years). Compared with nonculprit lesions, culprit lesion precursors had a shorter distance from the ostium (median, 35.1 [IQR, 23.6-48.4] mm vs 44.5 [IQR, 28.2-70.8] mm), more frequently localized to bifurcations (85 [73.3%] vs 168 [38.9%]), and had more tortuous vessel segments (5 [4.3%] vs 6 [1.4%]; all P < .05). In multivariable Cox regression analysis, an increasing number of AGCs was associated with a greater risk of future culprit lesions (hazard ratio [HR] for 1 AGC, 2.90 [95% CI, 1.38-6.08]; P = .005; HR for ≥2 AGCs, 6.84 [95% CI, 3.33-14.04]; P < .001). Adverse geometric characteristics provided incremental discriminatory value for culprit lesion precursors when added to a model containing stenosis severity, adverse morphological plaque characteristics, and quantitative plaque characteristics (area under the curve, 0.766 [95% CI, 0.718-0.814] vs 0.733 [95% CI, 0.685-0.782]). In per-patient comparison, patients with ACS had a higher frequency of lesions with adverse plaque characteristics, AGCs, or both compared with control patients (≥2 adverse plaque characteristics, 70 [60.3%] vs 50 [43.1%]; ≥2 AGCs, 92 [79.3%] vs 60 [51.7%]; ≥2 of both, 37 [31.9%] vs 20 [17.2%]; all P < .05). CONCLUSIONS AND RELEVANCE: These findings support the concept that CCTA-derived AGCs capturing lesion location and vessel geometry are associated with risk of future ACS-causing culprit lesions. Adverse geometric characteristics may provide additive prognostic information beyond plaque assessment in CCTA.

Soil Suppressiveness to Fusarium Disease Following Organic Amendments and Solarization.

Soil suppressiveness to soilborne pathogens can evolve following the incorporation of plant residues in the soil and solarization. We studied its occurrence by assessing disease incidence and severity in sandy soil which was infested after the disinfestation treatment. Disease incidence and severity of crown and root rot in cucumber plants inoculated with Fusarium oxysporum f. sp. radicis-cucumerinum macroconidia were reduced by 20 to 80% when seedlings were planted in the tested soils 2 to 34 months after soil amendment. Residues of Diplotaxis tenuifolia (wild rocket [WR]), Artemisia dracunculus (tarragon), Salvia officinalis (sage), and Brassica oleracea var. italica (broccoli) were most effective for inducing soil suppressiveness. Effective soil suppressiveness continued to be evident after repeated inoculations and plantings in the same soil without additional treatment between inoculations. Moreover, residues of WR induced soil suppressiveness in two additional tested soils differing in their physical and chemical properties. Residues of Rosmarinus officinalis (rosemary), Coriandrum sativum (coriander), Mentha piperita (peppermint), and B. oleraceae var. botrytis (cauliflower) induced disease suppression at the first inoculated planting but not upon repeated inoculation and planting. The contribution of soil solarization to the evolution of soil suppressiveness, albeit evident, was inconsistent. Soil suppressiveness to Fusarium crown and root rot was also observed when cucumber seed were sown in soils which were initially amended with WR residues and later infested with F. oxysporum f. sp. radicis-cucumerinum chlamydospores. There is a potential for the use of plant residues for inducing soil suppressiveness and further contributing to the control of diseases caused by soilborne pathogens.

Temporal trends in management and outcomes of patients with acute coronary syndrome according to body mass index.

BACKGROUND: Obesity is a major public health concern. We sought to investigate temporal trends in characteristics and outcomes of acute coronary syndrome patients according to body mass index. METHODS: The study population consisted of patients who were included in the Acute Coronary Syndromes Israeli Surveys during 2000-2016. Patients were categorised into three groups according to body mass index: below 25 kg/m2, 25-30 kg/m2 (overweight) and above 30 kg/m2 (obese). Among each body mass index group the outcomes of two time frames were compared - early (2000-2006) versus late (2008-2016). RESULTS: Overall 12,167 patients were included. Between the years 2000 and 2016, the percentage of obese patients increased from 20% to 30%. Obese patients were more frequently selected for an invasive approach, and had the lowest all-cause mortality rates. A significant reduction in 1-year mortality in recent compared to early surveys among patients with body mass index less than 25 kg/m2 and in obese patients but not for overweight patients was shown. Multivariable analysis showed that body mass index greater than 25 kg/m2 was associated with 30% lower 1-year mortality (hazard ratio 0.70, 95% confidence interval 0.55-0.90, P=0.005). CONCLUSION: The prevalence of obesity among acute coronary syndrome patients has increased over the past two decades. A reduction of all-cause mortality was mainly seen in lean and obese patients.

The accuracy of coronary CT angiography in patients with coronary calcium score above 1000 Agatston Units: Comparison with quantitative coronary angiography.

BACKGROUND: High amounts of coronary artery calcium (CAC) pose challenges in interpretation of coronary CT angiography (CCTA). The accuracy of stenosis assessment by CCTA in patients with very extensive CAC is uncertain. METHODS: Retrospective study was performed including patients who underwent clinically directed CCTA with CAC score >1000 and invasive coronary angiography within 90 days. Segmental stenosis on CCTA was graded by visual inspection with two-observer consensus using categories of 0%, 1-24%, 25-49%, 50-69%, 70-99%, 100% stenosis, or uninterpretable. Blinded quantitative coronary angiography (QCA) was performed on all segments with stenosis ≥25% by CCTA. The primary outcome was vessel-based agreement between CCTA and QCA, using significant stenosis defined by diameter stenosis ≥70%. Secondary analyses on a per-patient basis and inclusive of uninterpretable segments were performed. RESULTS: 726 segments with stenosis ≥25% in 346 vessels within 119 patients were analyzed. Median coronary calcium score was 1616 (1221-2118). CCTA identification of QCA-based stenosis resulted in a per-vessel sensitivity of 79%, specificity of 75%, positive predictive value (PPV) of 45%, negative predictive value (NPV) of 93%, and accuracy 76% (68 false positive and 15 false negative). Per-patient analysis had sensitivity 94%, specificity 55%, PPV 63%, NPV 92%, and accuracy 72% (30 false-positive and 3 false-negative). Inclusion of uninterpretable segments had variable effect on sensitivity and specificity, depending on whether they are considered as significant or non-significant stenosis. CONCLUSIONS: In patients with very extensive CAC (>1000 Agatston units), CCTA retained a negative predictive value â€‹> â€‹90% to identify lack of significant stenosis on a per-vessel and per-patient level, but frequently overestimated stenosis.

Computed tomography angiography-derived extracellular volume fraction predicts early recovery of left ventricular systolic function after transcatheter aortic valve replacement.

AIMS: Recovery of left ventricular ejection fraction (LVEF) after aortic valve replacement has prognostic importance in patients with aortic stenosis (AS). The mechanism by which myocardial fibrosis impacts LVEF recovery in AS is not well characterized. We sought to evaluate the predictive value of extracellular volume fraction (ECV) quantified by cardiac CT angiography (CTA) for LVEF recovery in patients with AS after transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS: In 109 pre-TAVR patients with LVEF <50% at baseline echocardiography, CTA-derived ECV was calculated as the ratio of change in CT attenuation of the myocardium and the left ventricular (LV) blood pool before and after contrast administration. Early LVEF recovery was defined as an absolute increase of ≥10% in LVEF measured by post-TAVR follow-up echocardiography within 6 months of the procedure. Early LVEF recovery was observed in 39 (36%) patients. The absolute increase in LVEF was 17.6 ± 8.8% in the LVEF recovery group and 0.9 ± 5.9% in the no LVEF recovery group (P < 0.001). ECV was significantly lower in patients with LVEF recovery compared with those without LVEF recovery (29.4 ± 6.1% vs. 33.2 ± 7.7%, respectively, P = 0.009). In multivariable analysis, mean pressure gradient across the aortic valve [odds ratio (OR): 1.07, 95% confidence interval (CI): 1.03-1.11, P: 0.001], LV end-diastolic volume (OR: 0.99, 95% CI: 0.98-0.99, P: 0.035), and ECV (OR: 0.92, 95% CI: 0.86-0.99, P: 0.018) were independent predictors of early LVEF recovery. CONCLUSION: Increased myocardial ECV on CTA is associated with impaired LVEF recovery post-TAVR in severe AS patients with impaired LV systolic function.

Short membranous septum length in bicuspid aortic valve stenosis increases the risk of conduction disturbances.

BACKGROUND: Distinct anatomical features predispose bicuspid AS patients to conduction disturbances after TAVR. This study sought to evaluate whether the incidence of permanent pacemaker implantation (PPMI) and left bundle branch block (LBBB) in patients with bicuspid aortic stenosis (AS) following transcatheter aortic valve replacement (TAVR) is related to an anatomical association between bicuspid AS and short membranous septal (MS) length. METHODS: Sixty-seven consecutive patients with bicuspid AS from a Bicuspid AS TAVR multicenter registry and 67 propensity-matched patients with tricuspid AS underwent computed tomography before TAVR. RESULTS: MS length was significantly shorter in bicuspid AS compared with tricuspid AS (6.2 ± 2.5 mm vs. 8.4 ± 2.7 mm, respectively; p < 0.001). In patients with bicuspid AS, MS length and aortic valve calcification were the most powerful pre-procedural independent predictors of PPMI or LBBB (odds ratio [OR]: 1.38, 95% confidence interval [CI]: 1.15 to 1.55, p = 0.003 and OR: 1.92, 95% CI: 1.1 to 3.34, p = 0.022, respectively). When taking into account pre- and post-procedural parameters, aortic valve calcification and the difference between MS length and implantation depth were the most powerful independent predictors of PPMI or LBBB in patients with bicuspid AS (OR: 1.82, 95%: 1.1 to 3.1, p = 0.027; OR: 1.25, 95% CI: 1.10 to 1.38, p = 0.003). CONCLUSION: MS length, which was significantly shorter in bicuspid AS compared with tricuspid AS, aortic valve calcification, and device implantation deeper than MS length predict PPMI or LBBB in bicuspid AS after TAVR.

Prognostic significance of previous myocardial infarction and previous revascularization in patients undergoing SPECT MPI.

BACKGROUND: Accurate risk stratification in patients with known coronary artery disease (CAD) is critical for patient management. Prior myocardial infarction (MI) or revascularization without MI are often equated as known CAD. We compared the prognostic significance of prior MI and previous revascularization in patients undergoing single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI). METHODS: Consecutive patients undergoing SPECT MPI at Cedars-Sinai Medical Center between 1992 and 2012 were included. Medical history, including history of MI or revascularization, was collected prospectively. Association with all-cause mortality was assessed with multivariable Cox analysis, adjusted for patient demographics, medical history, medications, and SPECT MPI results. RESULTS: In total, 50,121 patients were identified including 7428 (14.8%) with a history of previous MI and 3608 (7.2%) with a history of revascularization without prior MI. During a median follow-up of 8.0 years, 19,696 (39.3%) patients died including 4467 (60.1%) with a history of MI and 1880 (52.1%) with a history of revascularization. Prior MI (adjusted HR 1.12, p=0.001) and prior revascularization without MI (adjusted HR 1.15, p<0.001) were independently associated with increased all-cause mortality. Previous MI (adjusted HR 1.27, p<0.001) and previous revascularization without MI (adjusted HR 1.21, p<0.001) were significantly associated with increased all-cause mortality only in patients without ischemia. CONCLUSIONS: In this large cohort of patients undergoing SPECT MPI, previous MI and previous revascularization without MI were independent predictors of all-cause mortality, with no significant difference in associated risk. History of CAD may be particularly important for risk stratification in patients without ischemia.

Prognostic significance of subtle coronary calcification in patients with zero coronary artery calcium score: From the CONFIRM registry.

BACKGROUND AND AIMS: The Agatston coronary artery calcium score (CACS) may fail to identify small or less dense coronary calcification that can be detected on coronary CT angiography (CCTA). We investigated the prevalence and prognostic importance of subtle calcified plaques on CCTA among individuals with CACS 0. METHODS: From the prospective multicenter CONFIRM registry, we evaluated patients without known CAD who underwent CAC scan and CCTA. CACS was categorized as 0, 1-10, 11-100, 101-400, and >400. Patients with CACS 0 were stratified according to the visual presence of coronary plaques on CCTA. Plaque composition was categorized as non-calcified (NCP), mixed (MP) and calcified (CP). The primary outcome was a major adverse cardiac event (MACE) which was defined as death and myocardial infarction. RESULTS: Of 4049 patients, 1741 (43%) had a CACS 0. NCP and plaques that contained calcium (MP or CP) were detected by CCTA in 110 patients (6% of CACS 0) and 64 patients (4% of CACS 0), respectively. During a 5.6 years median follow-up (IQR 5.1-6.2 years), 413 MACE events occurred (13%). Patients with CACS 0 and MP/CP detected by CCTA had similar MACE risk compared to patients with CACS 1-10 (p = 0.868). In patients with CACS 0, after adjustment for risk factors and symptom, MP/CP was associated with an increased MACE risk compared to those with entirely normal CCTA (HR 2.39, 95% CI [1.09-5.24], p = 0.030). CONCLUSIONS: A small but non-negligible proportion of patients with CACS 0 had identifiable coronary calcification, which was associated with increased MACE risk. Modifying CAC image acquisition and/or scoring methods could improve the detection of subtle coronary calcification.

Value of Adding the CHA2DS2-VASc Score to the GRACE Score for Mortality Risk Prediction in Patients With Acute Coronary Syndrome.

Global Registry of Acute Coronary Events (GRACE) risk score has been routinely used for risk stratification of acute coronary syndrome (ACS) patients. We aimed to examine whether the addition of the CHA2DS2-VASc score to the GRACE score improves risk stratification. Included were patients with ACS who were divided into high (>140), intermediate (110< GRACE score ≤140) and low (<110) GRACE score. Each group was further divided into 3 subgroups categorized according to their CHA2DS2-VASc score: 0-1, 2-3, and ≥4. Management and Outcomes were compared for each GRACE score group and CHA2DS2-VASc score subgroups. Included 6,854 ACS patients, of them 3596 (52.5%) were classified as low risk, 1,937 (28.3%) were at intermediate risk and 1,321 (19.3%) were high-risk patients. In the intermediate risk group, patients with a higher CHA2DS2-VASc score more frequently underwent percutaneous coronary revascularization. For low risk patients, 30-day mortality rates were 0.8%, 1.5%, and 1.3% (p = 0.02), and 1-year all-cause mortality rates were 1.3%, 3%, and 2.6% (p = 0.002) for CHA2DS2-VASc score 0-1, 2-3, ≥4, respectively. For intermediate risk patients, 30-day mortality rates were 2.9%, 3.4%, and 3.8% (p = 0.8), and 1-year all-cause mortality rates were 6.4%, 7.8%, and 11.2% (p = 0.01) for CHA2DS2-VASc score 0-1, 2-3, ≥4, respectively. Among patients with a GRACE score <140, each 1 point increase in the CHA2DS2-VASc score was associated with a 57% increase in 1-year mortality rates. In conclusion, the addition of the CHA2DS2-VASc score to the GRACE risk score in ACS patients improves risk stratification of patients with low and intermediate risk.

Accuracy of the Global Registry of Acute Coronary Events (GRACE) Risk Score in Contemporary Treatment of Patients With Acute Coronary Syndrome.

BACKGROUND: Global Registry of Acute Coronary Events (GRACE) score has been routinely used for risk stratification in acute coronary syndromes (ACS). We aimed to investigate whether the GRACE score has remained relevant with contemporary treatment of patients with ACS. METHODS: Included were patients with ACS in the Acute Coronary Syndrome Israeli Survey (ACSIS). Patients were divided into high (> 140) and low-intermediate (≤ 140) GRACE score. Outcomes were compared for each GRACE score group among patients enrolled in early (2000 to 2006), mid (2008 to 2010) and late (2013 to 2016) surveys. RESULTS: Included were 4931 patients. For patients with GRACE scores > 140, temporal improvements in therapy were associated with reduced 7-day all-cause mortality (5.7%, 4.1%, and 2.0% for patients in early, mid-, and late surveys, respectively, P = 0.01) and 1-year mortality rates (27.8%, 25.3%, and 21.8% for patients in early, mid-, and late surveys, respectively, P = 0.07). Among patients with GRACE scores ≤ 140, all-cause mortality rates at 1 year were lower among participants enrolled in recent surveys (5.3%, 3.5%, and 3.1% for patients in early, mid-, and late surveys, respectively, P = 0.01). No significant differences in the accuracy of the GRACE score in predicting 7-day mortality were observed, (area under the curve [AUC] = 0.83, 0.87, and 0.75 for early, mid-, and late surveys, respectively, P = NS). Similarly, for 1-year all-cause mortality, the accuracy of the GRACE score remained comparable (AUC = 0.79, 0.84, and 0.82 for early, mid-, and late surveys, respectively, P = NS). CONCLUSIONS: Our results validated the accuracy of the GRACE score for risk stratification in ACS. The discrimination of the score has not been influenced by the better outcome with latest treatment.

Controlled laboratory system to study soil solarization and organic amendment effects on plant pathogens.

ABSTRACT A controlled laboratory system for simulating soil solarization, with and without organic amendment, was developed and validated using physical, chemical, and biological parameters. The system consists of soil containers that are exposed to controlled and constant aeration, and to temperature fluctuations that resemble those occurring during solarization at various depths. This system enables a separate analysis of volatiles and other components. We recorded a sharp decrease in oxygen concentration in the soil atmosphere followed by a gradual increase to the original concentration during solarization in the field and heating in the simulation system of soil amended with wild rocket (Diplotaxis tenuifolia) or thyme (Thymus vulgaris). The combined treatment of organic amendment and solarization (or heating in the controlled system) was highly effective at controlling populations of Fusarium oxysporum f. sp. radicis-lycopersici. Changes in soil pH, enzymatic activities, and microbial populations followed, in most cases, trends which were similar under both solarization and the heating system, when exposed to controlled aerobic conditions. The reliability and validity of the system in simulating physical, chemical, and biological processes taking place during solarization is demonstrated.