Lipomatous hypertrophy of the interatrial septum: a distinct adipose tissue type in COPD?

Objective: Lipomatous hypertrophy of the interatrial septum (LHIS) is a distinct section of epicardial adipose tissue. However, its association with COPD is poorly documented. Methods: Patients undergoing coronary computed tomography angiography (CTA) for clinical indications were recruited retrospectively and screened for LHIS and COPD. LHIS density and the coronary artery disease profile were quantified by CTA: stenosis severity (coronary artery disease radiological reporting system (CADRADS)), coronary artery calcium (CAC) and high-risk plaque (HRP). COPD patients with LHIS were matched for age and sex, the major cardiovascular risk factors (CVRFs), and compared to controls. Results: The prevalence of LHIS in all 5466 patients was 5.9%. 151 (72.6%) of 208 patients with COPD had LHIS. LHIS density in COPD patients was higher (-10.93 HU versus -21.1 HU; p<0.001), despite body mass index (BMI) (28.8 versus 27.01 kg·m-2; p=0.002) being lower. LHIS density was lower in obese (BMI >30 kg·m-2) patients (20.4 versus 13.6 HU; p=0.02). BMI was inversely correlated with LHIS density (BetaR -0.031; 95% CI: -0.054- -0.008; p=0.007). LHIS density was associated with COPD, but not with BMI on multivariate models. CAC and coronary stenosis severity (CADRADS and >50% stenosis) were not different (p=0.106, p=0.156 and p=0.350, respectively). HRPs were observed more frequently in COPD patients with severe Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages ≥2 (32.3% versus 20.1%; p=0.044), but not when adding mild GOLD stages. Conclusions: The prevalence of LHIS in COPD patients is high (72.6%), and the adipose tissue density is higher, indicating a higher brown fat component. In obese, patients LHIS density is lower and declines along with BMI. Coronary stenosis severity and calcium were not different; however HRPs were more frequent in severe COPD.

The interaction of lipomatous hypertrophy of the interatrial septum with pericardial adipose tissue biomarkers by computed tomography.

OBJECTIVE: Novel pericardial adipose tissue imaging biomarkers are currently under investigation for cardiovascular risk stratification. However, a specific compartment of the epicardial adipose tissue (EAT), lipomatous hypertrophy of the interatrial septum (LHIS), is included in the pericardial fat volume (PCFV) quantification software. Our aim was to evaluate LHIS by computed tomography angiography (CTA), to elaborate differences to other pericardial adipose tissue components (EAT) and paracardial adipose tissue (PAT), and to compare CT with [18F]FDG-PET. MATERIALS AND METHODS: Of 6983 patients screened who underwent coronary CTA for clinical indications, 190 patients with LHIS were finally included (age 62.8 years ± 9.6, 31.6% females, BMI 28.5 kg/cm2 ± 4.7) in our retrospective cohort study. CT images were quantified for LHIS, EAT, and PAT density (HU), and total PCFV, with and without LHIS, was calculated. CT was compared with [18F]FDG-PET if available. RESULTS: CT-density of LHIS was higher (- 22.4 HU ± 22.8) than all other pericardial adipose tissue components: EAT right and left (97.4 HU ± 13 and - 95.1 HU ± 13) PAT right and left (- 107.5 HU ± 13.4 and - 106.3 HU ± 14.5) and PCFV density -83.3 HU ± 5.6 (p < 0.001). There was a mild association between LHIS and PAT right (Beta 0.338, p = 0.006, 95% CI: 0.098-577) and PAT left (Beta 0.249, p = 0.030; 95% CI: 0.024-0.474) but not EAT right (p = 0.325) and left (p = 0.351), and not with total PCFV density (p = 0.164). The segmented LHIS volume comprised 3.01% of the total PCFV, and 4.3% (range, 2.16-11.7%) in those with LHIS > 9 mm. [18F]FDG-PET: LHIS was tracer uptake positive in 83.3% (37.5%: mild and 45.8%: minimal) of 24 patients. CONCLUSIONS: LHIS is a distinct compartment of PCFV with higher density suggesting brown fat and has no consistent association with EAT, but rather with PAT. CLINICAL RELEVANCE STATEMENT: LHIS should be recognized as a distinct compartment of the EAT, when using EAT for cardiovascular risk stratification. KEY POINTS: LHIS is currently included in EAT quantification software. LHIS density is relatively high, it is not associated with EAT, and has a high [18F]FDG-PET positive rate suggesting brown fat. LHIS is a distinct compartment of the EAT, and it may act differently as an imaging biomarker for cardiovascular risk stratification.

A Neuronal Network-Based Score Predicting Survival in Patients Undergoing Aortic Valve Intervention: The ABC-AS Score.

Background: Despite being the most commonly performed valvular intervention, risk prediction for aortic valve replacement in patients with severe aortic stenosis by currently used risk scores remains challenging. The study aim was to develop a biomarker-based risk score by means of a neuronal network. Methods: In this multicenter study, 3595 patients were divided into test and validation cohorts (70% to 30%) by random allocation. Input variables to develop the ABC-AS score were age, the cardiac biomarker high-sensitivity troponin T, and a patient history of cardiac decompensation. The validation cohort was used to verify the scores' value and for comparison with the Society of Thoracic Surgery Predictive Risk of Operative Mortality score. Results: Receiver operating curves demonstrated an improvement in prediction by using the ABC-AS score compared to the Society of Thoracic Surgery Predictive Risk of Operative Mortality (STS prom) score. Although the difference in predicting cardiovascular mortality was most notable at 30-day follow-up (area under the curve of 0.922 versus 0.678), ABC-AS also performed better in overall follow-up (0.839 versus 0.699). Furthermore, univariate analysis of ABC-AS tertiles yielded highly significant differences for all-cause (p < 0.0001) and cardiovascular mortality (p < 0.0001). Head-to-head comparison between both risk scores in a multivariable cox regression model underlined the potential of the ABC-AS score (HR per z-unit 2.633 (95% CI 2.156-3.216), p < 0.0001), while the STS prom score failed to reach statistical significance (p = 0.226). Conclusions: The newly developed ABC-AS score is an improved risk stratification tool to predict cardiovascular outcomes for patients undergoing aortic valve intervention.

Ongoing substrate-driven atrial fibrillation "boxed" in the left atrial posterior wall with ablation: a case report.

Patients undergoing valve surgery for rheumatic heart disease are expected to develop significant atrial arrhythmogenic substrates outside of the pulmonary veins, which sometimes require complex ablation techniques for the treatment of symptomatic arrhythmias. We describe, herein, the case of a 76-year-old male undergoing endocardial ablation for the treatment of symptomatic persistent atrial fibrillation which developed after aortic and mitral valve replacement with a simultaneous tricuspid ring annuloplasty. Following pulmonary vein isolation, the patient's atrial fibrillation was converted into cavotricuspid isthmus-dependent atrial flutter. After a successful cavotricuspid isthmus ablation, the arrhythmia reverted back to a left atrial tachyarrhythmia originating from the posterior wall. A linear left atrial lesion led to the electrical isolation of a large area, which included the posterior wall, as well as the containment of the ongoing fibrillatory activity, while sinus rhythm was restored in the rest of the atria. In conclusion, successful left atrial posterior wall isolation can be achieved in the setting of severe scarring due to previous atriotomy by creating a linear lesion on the atrial roof, in conjunction with pulmonary vein isolation, sparing the patient from requiring bottom-line ablation, and avoiding possible esophageal injury. Such compartmentalization of the left atrium may effectively contain local fibrillatory activity, while allowing for the restoration of sinus rhythm.

The Effect of Vitamin D on Coronary Atherosclerosis: A Propensity Score Matched Case-Control Coronary CTA Study.

BACKGROUND: Vitamin D supplementation may be associated with lower cardiovascular (CV) events, but the data are controversial. It remains speculative whether vitamin D supplementation has a direct effect on coronary atherosclerosis. We therefore set out to assess the influence of vitamin D supplementation on the coronary atherosclerosis profile quantified by coronary computed tomography angiography (CTA) in a retrospective case-control cohort study. METHODS: 176 patients (age: 62.4 ± 10.4) referred to coronary CTA for clinical indications were included. A total of 88 patients receiving vitamin D supplementation (mean duration 65.3 ± 81 months) were 1:1 propensity score matched with 88 controls for age, gender, smoking, arterial hypertension, positive family history, dyslipidemia, and diabetes. Coronary stenosis severity (CAD-RADSTM), mixed plaque burden (weighted for non-calcified), high-risk-plaque (HRP) features, and plaque density (HU) were quantified by CTA. Serum 25-hydroxyvitamin D (OH)-levels were measured in 138 patients and categorized into four groups (0: <20 ng/mL; 1: 20-40 ng/mL; 2: 40-60 ng/mL; and 3: >60 ng/mL) and compared with CTA. RESULTS: The prevalence of atherosclerosis by CTA was similar in both groups (75.6% versus 74.3%, p = 0.999), >50% coronary stenosis was slightly higher in controls (p = 0.046), but stenosis severity score (CAD-RADS) was not different (p = 0.106). Mixed plaque burden (weighted for non-calcified) was lower in patients receiving vitamin D supplementation (p = 0.002) and high-risk-plaque prevalence was markedly lower (3.8% versus 32%, p < 0.001). CT plaque density (HU) was higher (p < 0.001) in the vitamin D group. Patients with serum vitamin D (OH) levels >60 ng/mL had higher plaque density (p = 0.04), indicating more calcified and less vulnerable plaque. CONCLUSIONS: In this retrospective case-control cohort study, vitamin D supplementation was associated with less high-risk plaque, less non-calcified plaque burden, and a higher calcified plaque independent of CV risk factors.

Bicuspid Aortic Valve Is Associated with Less Coronary Calcium and Coronary Artery Disease Burden.

(1) Background. Bicuspid aortic valve (BAV) is associated with genetic defects (NOTCH 1, GATA 5) and aortopathy. Differences in the flow patterns and a genetic predisposition could also affect coronary arteries. The objective was to assess the coronary artery calcium score (CACS) and coronary artery disease (CAD) burden by coronary computed tomography angiography (CTA) in patients with BAV stenosis, as compared to stenotic tricuspid aortic valves (TAV). (2) Methods. A retrospective case-control study. A total of 47 patients with BAV stenosis (68.9 years ± 12.9, 38.3% females) who underwent CTA were matched with 47 TAV stenosis patients for age, gender, smoking, arterial hypertension, dyslipidemia, diabetes, body-mass-index and chronic kidney disease. (3) Results. The coronary artery calcium score (CACS) was lower in BAV (237.4 vs. 1013.3AU; p < 0.001) than in TAV, and stenosis severity was less (CAD-RADTM: p < 0.001). More patients with BAV had CACS zero (27.7% vs. 0%; p < 0.001). The majority (68.1%) of patients with BAV had no or non-obstructive CAD but only 25.5% of TAV (p < 0.001). Obstructive CAD (>50% stenosis) by CTA was more frequently observed in patients with TAV (68.1%; p < 0.001). (4) Conclusions and Relevance. Patients with BAV stenosis have markedly less coronary calcium and less severe coronary stenosis. CTA succeeds to rule out obstructive CAD in the majority of BAV, with adherent implications for TAVR planning.

Smoking and obesity predict high-risk plaque by coronary CTA in low coronary artery calcium score (CACS).

BACKGROUND: The AHA recommends statins in patients with CACS>100 AU. However in patients with low CACS (1-99 AU), no clear statement is provided, leaving the clinician in a grey-zone. High-risk plaque (HRP) criteria by coronary CTA are novel imaging biomarkers indicating a higher a-priori cardiovascular (CV) risk, which could help for decision-making. Therefore the objective of our study was to identify which CV-risk factors predict HRP in patients with low CACS 1-99. METHODS: 1003 symptomatic patients with low-to-intermediate risk, a clinical indication for coronary computed tomography angiography (CCTA) and who had a coronary artery calcium score (CACS) between 1 and 99 AU, were enrolled. CCTA analysis included: stenosis severity and HRP-criteria: low-attenuation plaque (LAP <30HU, <60HU and <90HU) napkin-ring-sign, spotty calcification and positive remodeling. Multivariate regression models were created for predicting HRP-criteria by the major 5 cardiovascular risk factors (CVRF) (smoking, arterial hypertension, positive family history, dyslipidemia, diabetes) and obesity (BMI>25 â€‹kg/m2). RESULTS: 304 (33.5%) were smokers. 20.4% of smokers had HRP compared with only 14.9% of non-smokers (p â€‹= â€‹0.045). Male gender was associated with HRP (p â€‹< â€‹0.001). Smoking but not the other 5 CVRF had the most associations with HRP-criteria (LAP<60HU/≥2 criteria:OR 1.59; 95%CI:1.07-2.35), LAP<90HU (OR 1.57; 95%CI:1.01-2.43), Napkin-Ring-Sign (OR 1.78; 95%CI:1.02-3.1) and positive remodelling (OR 1.54; 95%CI:1.09-2.19). Smoking predicted fibrofatty LAP<90HU in males only. Obesity predicted LAP<60HU in both females and males. CONCLUSIONS: In patients with low CACS 1-99AU, male gender, smoking and obesity, but not the other CVRF predict HRP. These patients would rather benefit from intensification of primary CV-prevention measures such as statins.

The effect of omega-3 fatty acids on coronary atherosclerosis quantified by coronary computed tomography angiography.

BACKGROUND & AIMS: Data on the effects omega-3 fatty acids on coronary artery disease (CAD) are contradictory. While a recent metanalysis could not show improved cardiovascular outcomes, anti-atherogenic mechanisms are well known. OBJECTIVE: Aim was to assess the influence of Omega-3 polyunsaturated long-chain fatty acids (PUFA) supplementation on coronary atherosclerosis quantified by coronary computed tomography angiography (CTA). METHODS: 106 patients (59.4y± 10.7; 50% females) with low-to-intermediate risk referred to CTA were included. 53 patients under omega 3-PUFA (docosahexaenoic acid, DHA and eicosapentaenoic acid, EPA) supplementation were retrospectively matched with 53 controls (CR) for age, gender and coronary risk profile (smoking, arterial hypertension, family history, dyslipidemia, c-LDL, Cholesterol, TG, diabetes) (1:1, propensity score) and lifestyle habits (exercise, alcohol consumption and nutrition). CTA analysis included 1) stenosis severity score >70%severe, 50-70% moderate, 25-50%mild, <25% minimal), 2) total plaque burden (segment involvement score (SIS) and mixed non-calcified plaque burden (G-score) and 3) high-risk-plaque features (Napkin-Ring-Sign, low attenuation plaque (LAP), spotty calcification<3 mm, RI>1.1). CT-Density (Hounsfield Units, HU) of plaque was quantified by CTA. RESULTS: Prevalence of coronary atherosclerosis (any plaque: 83% vs. 90.6%, p = 0.252), >50% stenosis and stenosis severity score (p = 0.134) were not different between groups. Total and non-calcified plaque burden scores were lower in the omega-3 group (2.7 vs. 3.5, p = 0.08 and 4.5 vs. 7.4, p = 0.027 for SIS and G-score, resp.). Coronary artery calcium score (CACS) was similar (84.7 vs. 87.1AU). High-risk-plaque prevalence was lower in the Omega-3 group (3.8% vs. 32%, p < 0.001); the number of high-risk-plaques (p < 0.001) and Napkin-Ring-Sign prevalence was lower (3.8% vs. 20.9%) (p < 0.001), resp. CT-density (HU) of plaque was higher in the Omega-3 group (131.6 ± 2 vs. 62.1 ± 27, p = 0.02) indicating more fibrous-dense plaque component rather than lipid-rich atheroma. Mean duration of Omega-3 intake was 38.6 ± 52 months (range, 2-240). CONCLUSIONS: Omega-3-PUFA supplementation is associated with less coronary atherosclerotic "high-risk" plaque (lipid-rich) and lower total non-calcified plaque burden independent on cardiovascular risk factors. Our study supports direct anti-atherogenic effects of Omega-3-PUFA.

Clinical Features and Outcomes of Patients With Malignancy and Takotsubo Syndrome: Observations From the International Takotsubo Registry.

Background Clinical characteristics and outcomes of takotsubo syndrome (TTS) patients with malignancy have not been fully elucidated. This study sought to explore differences in clinical characteristics and to investigate short- and long-term outcomes in TTS patients with or without malignancy. Methods and Results TTS patients were enrolled from the International Takotsubo Registry. The TTS cohort was divided into patients with and without malignancy to investigate differences in clinical characteristics and to assess short- and long-term mortality. A subanalysis was performed comparing long-term mortality between a subset of TTS patients with or without malignancy and acute coronary syndrome (ACS) patients with or without malignancy. Malignancy was observed in 16.6% of 1604 TTS patients. Patients with malignancy were older and more likely to have physical triggers, but less likely to have emotional triggers compared with those without malignancy. Long-term mortality was higher in patients with malignancy (P<0.001), while short-term outcome was comparable (P=0.17). In a subanalysis, long-term mortality was comparable between TTS patients with malignancies and ACS patients with malignancies (P=0.13). Malignancy emerged as an independent predictor of long-term mortality. Conclusions A substantial number of TTS patients show an association with malignancy. History of malignancy might increase the risk for TTS, and therefore, appropriate screening for malignancy should be considered in these patients. Clinical Trial Registration URL: http://www.clinicaltrial.gov. Unique identifier: NCT01947621.

Quantification of aortic regurgitant fraction and volume with multi-detector computed tomography comparison with echocardiography.

RATIONALE AND OBJECTIVES: Evaluate quantification of the aortic regurgitant fraction and volume with computed tomography (CT). MATERIALS AND METHODS: Fifty-three patients with aortic regurgitation (AR) and 29 controls were examined with 64-multi-detector CT coronary angiography and transthoracic echocardiography (TTE). A dedicated software algorithm employing three-dimensional segmentation of left ventricle (LV) and right ventricle (RV) volumes and LV mass was applied. AR volume and fraction was calculated based on RV and LV stroke volumes (SV) and compared with echocardiography. The aortic regurgitant orifice area (ROA) was measured by CT. RESULTS: A good correlation of the AR fraction and AR volume determined by CT compared to echocardiography was found for mild, moderate, and severe AR with 14.2% ± 9, 28.8% ± 8, and 57.9% ± 9 (r = 0.95, P < .001) for AR fraction, and 15.7 mL ± 11.33 mL ± 14, and 98.9 mL ± 36 for AR volume (r = 0.92, P < .0001), respectively. CT correctly classified severity of AR in 93% of patients based of AR-fraction, and in 89% based on AR volume. The sensitivity and specificity of CT were 98% and specificity 90.3%. The specificity improved to 97%, if the ROA by CT was added as diagnostic criterion. CONCLUSION: Aortic regurgitation fraction and volume can be accurately quantified from CT coronary angiography datasets. These parameters can assist clinical management, e.g. in case of pending cardiac surgery decision.

Multislice computed tomography in infective endocarditis: comparison with transesophageal echocardiography and intraoperative findings.

OBJECTIVES: The aim of this study was to assess the value of multislice computed tomography (CT) for the assessment of valvular abnormalities in patients with infective endocarditis (IE) in comparison with transesophageal echocardiography (TEE) and intraoperative findings. BACKGROUND: Multislice CT has recently shown promising data regarding valvular imaging in a 4-dimensional fashion. METHODS: Thirty-seven consecutive patients with clinically suspected IE were examined with TEE and 64-slice CT or dual-source CT. Twenty-nine patients had definite IE and underwent surgery. RESULTS: The diagnostic performance of CT for the detection of evident valvular abnormalities for IE compared with TEE was: sensitivity 97%, specificity 88%, positive predictive value (PPV) 97%, and negative predictive value (NPV) 88% on a per-patient basis (n = 37; excellent intermodality agreement kappa = 0.84). CT correctly identified 26 of 27 (96%) patients with valvular vegetations and 9 of 9 (100%) patients with abscesses/pseudoaneurysms compared with the intraoperative specimen. On a per-valve-based analysis, diagnostic accuracy for the detection of vegetations and abscesses/pseudoaneurysms compared with surgery was: sensitivity 96%, specificity 97%, PPV 96%, NPV 97%, and sensitivity 100%, specificity 100%, PPV 100%, NPV 100%, respectively, without significant differences as compared with TEE. Vegetation size measurements by CT correlated (r = 0.95; p <0.001) with TEE (mean 7.6 +/- 5.6 mm). The mobility of vegetations was accurately diagnosed in 21 of 22 (96%) patients with CT, but all of 4 leaflet perforations (

Neopterin, CD4+CD28- lymphocytes and the extent and severity of coronary artery disease.

OBJECTIVES: Macrophages and pro-inflammatory CD3+CD4+CD28- T lymphocytes are involved in atherosclerotic plaque destabilization. Whether neopterin, a macrophage-specific activation-marker, and circulating CD3+CD4+CD28- cells are also related to the severity and extent of coronary artery disease (CAD) in stable patients is still unclear. METHODS: Coronary angiograms of 30 patients with stable angina pectoris were graded using the Gensini severity and an extent score. Patients were grouped according to the median of each score. Lymphocyte subsets were determined by FACS analysis and neopterin by radioimmunoassay. Peripheral endothelial function of the brachial artery (FMD) shown to correlate with cardiovascular risk factors was evaluated using high-resolution ultrasound. RESULTS: More extensive CAD was associated with increased neopterin levels (8.3 +/- 3.3 vs. 5.5 +/- 1.2 nmol/L, p < 0.001) and increased CD3+CD4+CD28- cells (3.1 +/- 1.6 vs. 2.0 +/- 1.2%, p < 0.05). A high Gensini severity score was associated with increased neopterin levels (7.8 +/- 2.7 vs. 6.3 +/- 1.7 nmol/L, p < 0.05), but not with CD3+CD4+CD28- cells. Neopterin correlated with both the extent (r = 0.59, p < 0.001) and the Gensini score (r = 0.57, p < 0.003). FMD was not correlated with both scores. CONCLUSIONS: Neopterin and CD3+CD4+CD28- lymphocytes are associated with CAD extent in stable patients, thereby emphasizing the inherent role of inflammation in atherogenesis itself beyond plaque destabilization. Neopterin's correlation with CAD severity might be additionally useful in identifying patients eligible for revascularization procedures.

Evaluation of aortic root and valve calcifications by multi-detector computed tomography.

BACKGROUND AND AIM OF THE STUDY: In percutaneous aortic valve replacement (AVR), whilst calcifications are used as landmarks in fluoroscopic placement of the stent, they may also complicate stent placement. In response to this problem, the study aim was to examine severe aortic root calcification by using multi-detector computed tomography (MDCT), to better understand the pathology complicating percutaneous valve placement. METHODS: In 33 patients with severe aortic stenosis and scheduled for surgery, the 'inner orifice' and 'outer fibrous' annulus diameter and area (with and without calcification) were measured, in addition to the distances of the calcifications and coronary ostia from the annulus, using by ECG-gated 64-slice MDCT. Aortic root calcification was evaluated as minimal (< 25% of total circumference), mild (25-50%), moderate (50-75%), and severe (75-100%). RESULTS: The inner orifice annulus area was 5.9 +/- 1.9 cm2 (range: 1.4-10.1 cm2), while the outer fibrous area was 7.5 +/- 1.8 cm2 (range: 4.7-11.5 cm2). The proximal-to-distal extent of valve calcification from the annulus in the mid-center of leaflets was 0.8 +/- 0.26 cm. In 36% of patients, valvular calcification extended +/- 3 mm within the coronary-ostium level. The distance of the coronary ostia from the annulus was variable, with a mean of 1.3 +/- 0.35 cm (range: 0.6-2.4 cm) for the left coronary artery. In 42% of patients, a 'low coronary ostium' (< or = 1.1 cm), and in 6% a 'critical-low-coronary ostium' (< or = 8 mm) was identified. Annulus calcification was present in 100% of cases, but the severity varied widely (severe 50%, moderate 35%, mild 15%). In 36% of cases, the aortic annulus calcification extended caudally into the membranous part of the interventricular septum (and thus into the left ventricular outflow tract), and in 42% of cases (n = 14) into the anterior mitral valve leaflet. CONCLUSION: The present results indicated that cardiac MDCT may qualify as a primary pre-procedural imaging modality to select patients for percutaneous AVR, based on the measurement and characterization of the aortic root and valve calcification. In comparison to echocardiography, CT will reduce--if not eliminate--difficulties in visualizing the aortic orifice area in heavily calcified valves. Furthermore, knowledge of the exact location of calcific deposits provides a distinct advantage to the fluroscopist for precise placement of the percutaneous aortic valve. Likewise, knowledge of the coronary arteries orifice in relation to the valve plane is critical to prevent inadvertent coronary artery occlusion, and would clearly be beneficial when planning future valve designs.

Diagnostic accuracy of cardiac 64-slice computed tomography in detecting atrial thrombi. Comparative study with transesophageal echocardiography and cardiac surgery.

OBJECTIVES: Atrial thrombi are a potential source for cerebral and peripheral emboli. Objective of this study was to evaluate the diagnostic accuracy of 64-slice cardiac computed tomography (CT) for detection of atrial thrombi in comparison with transesophageal echocardiography (TEE) and cardiac surgery. MATERIAL AND METHODS: Sixty-four patients were examined with ECG-gated multidetector CT coronary or pulmonary vein angiography. All patients underwent TEE. Cardiac surgery was performed in 31 patients. The Hounsfield units (HU) of atrial lesions were measured. RESULTS: The diagnostic accuracy of 64-slice CT for the detection of atrial thrombi was 77%: sensitivity 100% (9/9), specificity 73% (40/55), positive predictive value (PPV) 38% (9/24), and negative predictive value (NPV) 100% (40/40). All 15 false positive (FP) findings by CT were located in the left atrial appendage (LAA). Four characteristic imaging features suggesting incomplete filling of the LAA were noted in FP: "hypostatic layering," 5/15 (33%); "flow phenomenon," 9/15 (60%); "HU-run-off," 8/15 (53%); higher intralesional HU in FP when compared with thrombi (153.8 HU +/- 71 vs. 46.6 HU +/- 10; P < 0.0001). The diagnostic accuracy of CT in detecting atrial thrombi improved significantly (P = 0.03) to 86% after defining "typical filling defects" as "flow phenomenon/>180 HU" (sensitivity 100%; specificity 84%; PPV 50%; NPV 100%). On receiver operating curve (ROC) analysis, a threshold of 60.7 HU showed a specificity of 100% and a sensitivity of 86.7% to distinguish between FP and thrombi. CONCLUSIONS: Cardiac ECG-gated 64-slice CT is accurate to exclude atrial thrombi, which can be applied eg, in patients before radiofrequency (RF) ablation. Left atrial appendage "filling defects" cause a high number of false positive findings, and there are radiologic features, which are helpful to differentiate them from true thrombi.

Prognosis and risk factors in patients with asymptomatic aortic stenosis and their modulation by atorvastatin (20 mg).

The aim of the prospective, randomized, placebo-controlled Tyrolean Aortic Stenosis Study (TASS) was to characterize the natural history and risk factors and their possible modulation by new-onset atorvastatin treatment (20 mg/day vs placebo) in patients with asymptomatic calcified aortic stenosis. Forty-seven patients without previous lipid-lowering therapy or indications for it according to guidelines at study entry were randomized to atorvastatin treatment or placebo and prospectively followed for a mean study period of 2.3 +/- 1.2 years. Patients' prognoses were worse than expected, with 24 (51%) experiencing major adverse clinical events, in most cases the new onset of symptoms followed by aortic valve replacement. In multivariate regression analysis, independent risk factors for worse clinical outcomes were aortic valve calcification, as assessed by multidetector computed tomography, and plasma levels of C-reactive protein. In univariate analysis, mean systolic pressure gradient or an increased N-terminal-pro-B-type natriuretic peptide plasma level allowed the prediction of major adverse clinical events as well, whereas concomitant coronary calcification, age, and the initiation of atorvastatin treatment had no significant prognostic implication. As shown in a subgroup of 35 patients (19 randomly assigned to atorvastatin and 16 to placebo), annular progression in aortic valve calcification and hemodynamic deterioration were similar in both treatment groups. In conclusion, TASS could demonstrate a poor clinical outcome in patients with asymptomatic calcified aortic stenosis which can be predicted by new risk factors such as strong AVC or increased plasma levels of CRP or NT-proBNP. The study does not support the concept that treatment with a HMG-CoA reductase inhibitor (20 mg atorvastatin once daily) halts the progression of calcified aortic stenosis.

Fusion of multislice computed tomography and electroanatomical mapping data for 3D navigation of left and right atrial catheter ablation.

PURPOSE: To assess whether fusion of multislice computed tomography (CT) images with electroanatomical (EA)-mapping data using a new image integration module (CartoMerge) is feasible and accurate to navigate ablation catheters in right and left atrial catheter ablation. MATERIAL AND METHODS: Twenty-four patients were examined with ECG-gated cardiac multislice CT (64 mm x 0.6mm, 0.33 s) 1 day before left atrial (LA) (15 patients) radiofrequency or right atrial cavotricuspid isthmus ablation (9 patients). CT data were fused with the non-fluoroscopic EA-mapping data by using dedicated software (CartoMerge) and the value of CT was analysed. RESULTS: In 23/24 (96%) patients, CT images could be fused with the EA-map. The alignment error was 2.16+/-0.35 mm. In 15/15 (100%) patients, CT added relevant anatomical information regarding the course of the esophagus or the pulmonary veins before LA-ablation. CT added useful information in only 3/8 (37.5%) of patients undergoing right atrial cavotricuspid isthmus ablation. CONCLUSION: 3D-navigation of RF-ablation catheters in the atria assisted by image fusion of multislice CT with EA-mapping data is feasible and accurate. CT added relevant anatomical information about the left atrium and the pulmonary veins before LA-ablation, CT also provided information about the course of the esophagus which might help to avoid thermal injury. CT image fusion might be of minor value before right atrial cavotricuspid isthmus catheter ablation.

Is there a relation between non-calcifying coronary plaques and acute coronary syndromes? A retrospective study using multislice computed tomography.

OBJECTIVES: The purpose of this study was to assess whether different coronary plaque types as classified by multislice computed tomography (CT) are retrospectively correlated with acute coronary syndromes (ACS) in an unselected study population. METHODS: Sixty-three consecutive patients were examined with 16-slice CT coronary angiography. Coronary plaque types were classified as calcifying type 1, mixed (calcifying > non-calcifying) type 2, mixed (non-calcifying > calcifying) type 3, and non-calcifying type 4. Patients who had an ACS within 17 days were included. All patients underwent invasive coronary angiography. RESULTS: Fifty-eight patients (92%) had coronary plaques evaluated by CT: 18 type 1 (31%), 10 type 2 (17%), 16 type 3 (28%) and 14 type 4 (24%). The presence of a non-calcifying plaque component (types 2-4; 40 of 63 patients, 63%) was correlated with ACS (n = 15; 24%) (p < 0.001). Only type 3 was significantly correlated with ACS (p = 0.01), but plaque types 2 and 4 were not. The diagnostic accuracy of CT for detection of stenosis >50% in proximal segments was: sensitivity 98%, specificity 90%, negative predictive value 97%, positive predictive value 97% per patient. CONCLUSIONS: Mixed calcifying/non-calcifying plaques with a predominantly non-calcifying component (type 3) as classified by multislice CT are retrospectively correlated with ACS.

Aortic valve calcification as quantified with multislice computed tomography predicts short-term clinical outcome in patients with asymptomatic aortic stenosis.

BACKGROUND AND AIM OF THE STUDY: Aortic valve calcification may be an independent risk factor for adverse clinical outcome. The study aim was to assess the predictive value of possible risk factors, including the severity of aortic valve calcification as quantified with 16-multislice computed tomography (MSCT) for adverse short-term clinical outcome in patients with asymptomatic, degenerative aortic stenosis (AS). METHODS: Possible risk factors for adverse short-term clinical outcome were prospectively tested in 34 consecutive patients with asymptomatic AS as follows: (i) aortic valve calcium (AVC) score as quantified with MSCT; (ii) echocardiographic parameters--aortic valve area (AVA) calculated with continuity equation, mean and maximal transvalvular pressure gradients, end-diastolic septal wall diameter; and (iii) laboratory tests (brain natriuretic peptide (BNP), C-reactive protein (CRP)). RESULTS: Within 18-24 months of follow up, 11 of 34 patients developed a major adverse clinical outcome. Ten patients suffered from onset of symptoms accompanied by hemodynamic progression, and one patient died from sudden cardiac death. Six of these 10 patients underwent aortic valve replacement, one patient declined surgery, and three patients were not accepted for surgery (one of these died suddenly shortly afterwards). The aortic valve calcium score was the strongest predictor of a major adverse clinical event (p < 0.001) among all parameters assessed (1,928 +/- 789 versus 5,111 +/- 2,409 Agatston units). The plasma level of BNP (p = 0.003), mean transvalvular pressure gradient (p = 0.002) and AVA (p = 0.003) were also risk factors for adverse clinical outcome. CONCLUSION: The AVC score as quantified with MSCT predicted adverse short-term clinical outcome in patients with asymptomatic AS. In patients with severe aortic valve calcification, close follow up examinations are mandatory, and early elective surgery may be considered even in the absence of symptoms. MSCT provides a comprehensive non-invasive imaging approach for risk stratification in patients with asymptomatic AS.