Impact of smoking in patients with suspected coronary artery disease in the randomised DISCHARGE trial.

OBJECTIVES: To investigate if the effect of cardiac computed tomography (CT) vs. invasive coronary angiography (ICA) on cardiovascular events differs based on smoking status. MATERIALS AND METHODS: This pre-specified subgroup analysis of the pragmatic, prospective, multicentre, randomised DISCHARGE trial (NCT02400229) involved 3561 patients with suspected coronary artery disease (CAD). The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, non-fatal myocardial infarction, or stroke). Secondary endpoints included an expanded MACE composite (MACE, transient ischaemic attack, or major procedure-related complications). RESULTS: Of 3445 randomised patients with smoking data (mean age 59.1 years + / - 9.7, 1151 men), at 3.5-year follow-up, the effect of CT vs. ICA on MACE was consistent across smoking groups (p for interaction = 0.98). The percutaneous coronary intervention rate was significantly lower with a CT-first strategy in smokers and former smokers (p = 0.01 for both). A CT-first strategy reduced the hazard of major procedure-related complications (HR: 0.21, 95% CI: 0.03, 0.81; p = 0.045) across smoking groups. In current smokers, the expanded MACE composite was lower in the CT- compared to the ICA-first strategy (2.3% (8) vs 6.0% (18), HR: 0.38; 95% CI: 0.17, 0.88). The rate of non-obstructive CAD was significantly higher in all three smoking groups in the CT-first strategy. CONCLUSION: For patients with stable chest pain referred for ICA, the clinical outcomes of CT were consistent across smoking status. The CT-first approach led to a higher detection rate of non-obstructive CAD and fewer major procedure-related complications in smokers. CLINICAL RELEVANCE STATEMENT: This pre-specified sub-analysis of the DISCHARGE trial confirms that a CT-first strategy in patients with stable chest pain referred for invasive coronary angiography with an intermediate pre-test probability of coronary artery disease is as effective as and safer than invasive coronary angiography, irrespective of smoking status. TRIAL REGISTRATION: ClinicalTrials.gov NCT02400229. KEY POINTS: • No randomised studies have assessed smoking status on CT effectiveness in symptomatic patients referred for invasive coronary angiography. • A CT-first strategy results in comparable adverse events, fewer complications, and increased coronary artery disease detection, irrespective of smoking status. • A CT-first strategy is safe and effective for stable chest pain patients with intermediate pre-test probability for CAD, including never smokers.

Identification of noncalcified coronary plaque characteristics using machine learning radiomic analysis of non-contrast high-resolution computed tomography.

BACKGROUND: Novel imaging and analysis techniques may offer the ability to detect noncalcified or high-risk coronary plaques on a non-contrast computer tomography (CT) scan, advancing cardiovascular diagnostics. AIMS: We aimed to explore whether machine learning (ML) radiomic analysis of low-dose high-resolution non-contrast electrocardiographically (ECG) gated cardiac CT scan allows for the identification of noncalcified coronary plaque characteristics. METHODS: We prospectively enrolled 125 patients with noncalcified plaques and adverse plaque characteristics (APC) and 25 controls without visible atherosclerosis on coronary CT angiography (CCTA). All patients underwent non-contrast CT exam before CCTA. Four hundred and nineteen radiomic features were calculated to identify the presence of any coronary artery disease (CAD), obstructive CAD (stenosis >50%), plaque with ≥2 APC, degree of calcification, and specific APCs. ML models were trained on a training set (917 segmentations) and tested (validation) on a separate set (292 segmentations). RESULTS: Among the radiomic features, 88.3% were associated with a plaque, 0.9% with obstructive CAD, and 76.4% with the presence of at least two APCs. Overall, 80.2%, 88.5%, and 36.5%, of features were associated with calcified, partially calcified, and noncalcified plaques, respectively. Regarding APCs, 61.1%, 61.8%, 84.2%, and 61.3% of features were associated with low attenuation (LAP), napkin-ring sign (NRS), spotty calcification (SC), and positive remodeling (PR), respectively. ML models outperformed conventional methods for the presence of plaque obstructive stenosis, and the presence of 2 APCs, as well as for noncalcified plaques and partially calcified plaques, but not for calcified plaques. ML models also significantly outperformed identification of LAP and PR, but neither NRS nor SC. CONCLUSION: Radiomic analysis of non-contrast cardiac CT exams may allow for the identification of specific noncalcified coronary plaque characteristics displaying the potential for future clinical applications.

Atherosclerotic cardiovascular disease burden in patients with familial hypercholesterolemia: interpretation of data on involvement of different vascular beds.

Familial hypercholesterolemia (FH) is a monogenic, autosomal dominant disorder that results in a rise of low­density lipoprotein cholesterol (LDL­C) and markedly increased risk of premature atherosclerotic cardiovascular disease. FH is relatively common, treatable, and its clinical course can be improved through early detection and timely initiation of lipid­lowering medications. The clinical picture of FH is highly variable, with a heterogeneous phenotype even within a single family, ranging from patients with very early onset of major cardiovascular events to those who do not develop overt cardiovascular disease even at an old age. We summarized studies indicating that atherosclerotic involvement in the coronary arteries and lower extremities is higher in FH patients than in the general population. There is a paucity of data regarding the relationship between FH and the incidence of atherosclerosis in other vascular beds. There are no studies systematically evaluating several vascular beds in asymptomatic patients with FH. Providing a systematic characteristic of patients with FH with respect to the presence and extent of atherosclerotic lesions in different vascular beds may have implications for daily practice not only for patients with FH but also for a larger number of patients with very high plasma LDL­C concentrations.

Dynamic Myocardial Perfusion CT for the Detection of Hemodynamically Significant Coronary Artery Disease.

OBJECTIVES: In this international, multicenter study, using third-generation dual-source computed tomography (CT), we investigated the diagnostic performance of dynamic stress CT myocardial perfusion imaging (CT-MPI) in addition to coronary CT angiography (CTA) compared to invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR). BACKGROUND: CT-MPI combined with coronary CTA integrates coronary artery anatomy with inducible myocardial ischemia, showing promising results for the diagnosis of hemodynamically significant coronary artery disease in single-center studies. METHODS: At 9 centers in Europe, Japan, and the United States, 132 patients scheduled for ICA were enrolled; 114 patients successfully completed coronary CTA, adenosine-stress dynamic CT-MPI, and ICA. Invasive FFR was performed in vessels with 25% to 90% stenosis. Data were analyzed by independent core laboratories. For the primary analysis, for each coronary artery the presence of hemodynamically significant obstruction was interpreted by coronary CTA with CT-MPI compared to coronary CTA alone, using an FFR of ≤0.80 and angiographic severity as reference. Territorial absolute myocardial blood flow (MBF) and relative MBF were compared using C-statistics. RESULTS: ICA and FFR identified hemodynamically significant stenoses in 74 of 289 coronary vessels (26%). Coronary CTA with ≥50% stenosis demonstrated a per-vessel sensitivity, specificity, and accuracy for the detection of hemodynamically significant stenosis of 96% (95% CI: 91%-100%), 72% (95% CI: 66%-78%), and 78% (95% CI: 73%-83%), respectively. Coronary CTA with CT-MPI showed a lower sensitivity (84%; 95% CI: 75%-92%) but higher specificity (89%; 95% CI: 85%-93%) and accuracy (88%; 95% CI: 84%-92%). The areas under the receiver-operating characteristic curve of absolute MBF and relative MBF were 0.79 (95% CI: 0.71-0.86) and 0.82 (95% CI: 0.74-0.88), respectively. The median dose-length product of CT-MPI and coronary CTA were 313 mGy·cm and 138 mGy·cm, respectively. CONCLUSIONS: Dynamic CT-MPI offers incremental diagnostic value over coronary CTA alone for the identification of hemodynamically significant coronary artery disease. Generalized results from this multicenter study encourage broader consideration of dynamic CT-MPI in clinical practice. (Dynamic Stress Perfusion CT for Detection of Inducible Myocardial Ischemia [SPECIFIC]; NCT02810795).

Imaging risk features for device related pulmonary artery injury after left atrial appendage closure with Amplatzer™ Amulet™ device.

OBJECTIVES: This study aimed to find imaging risk features for device related-pulmonary artery (PA) injury (DR-PAI) in patients after left atrial appendage closure (LAAC). BACKGROUND: Cardiac tamponade resulting from DR-PAI is a rare but life-threatening complication of LAAC. METHODS: In vitro analysis of Amplatzer™ Amulet™ (Abbott, MN) device was done. Measurements of the distance between PA and Amplatzer lobe at its middle part, distal part, and along the stabilizing wires' trajectory (wires-to-PA distance) were taken in 100 consecutive patients on post-LAAC computed tomography (CT) studies. Clinical outcomes were collected. RESULTS: In vitro analysis indicated that both middle and distal lobe had to be in close PA proximity (<1.5 mm) for the stabilizing wires to cause risk for DR-PAI, configuration called ''cuddling lobe orientation''. On CT measurements middle lobe-PA distance was 4.7 mm (IQR = 2.7-9.5), with close proximity in 4 (4%) patients, and distal lobe-PA distance was 3.2 mm (IQR = 1.8-7.2 mm), with close proximity in 17 (17%) patients. Stabilizing wires were pointing toward PA in 47 patients (47%) with median wire-to-PA distance 5.7 mm (IQR = 3.6-8.5 mm). ''Cuddling'' was found in 2 (2%) patients and resulted in shorter wires-to-PA distance vs no ''cuddling'' group (2.3 vs 5.8 mm p <.01). At 2.9 ± 1.0 yrs of follow-up, the two patients with ''cuddling lobe orientation'' on post-LAAC CT scan developed late cardiac tamponades (p <.001). One of those required surgery, which confirmed DR-PAI. CONCLUSIONS: ''Cuddling lobe orientation'' of Amulet device with the PA was associated with short wires-to-PA distance and late pericardial effusions, including DR-PAI. Hence, such device-to-PA configuration should be avoided.

Giant Intrapericardial Myxoma Adjacent to the Left Main Coronary Artery.

A 62-years-old woman was admitted to the hospital because of chronic cough, expectoration of thick mucus, hoarseness and tightness in the precordial area. Computed Tomography (CT) examination revealed the presence of a giant intrapericardial tumor with the dimensions of 80 × 38 × 32 mm. It was located anteriorly and laterally to the left atrium, posteriorly to the pulmonary trunk and the ascending aorta. This hypodense change modeled the left atrium without evidence of invasion. CT coronary angiography and 3-dimensional reconstruction were applied to enable precise planning of cardiac surgery. CT evaluation confirmed that it is possible to remove the tumor without damage to the adjacent left main coronary artery. The patient underwent cardiac surgery with sternotomy and cardiopulmonary bypass. A cohesive, smooth, vascularized tumor pedunculated to the left atrial epicardium was visualized. The location and dimensions corresponded to those determined by CT scan examination. The entire tumor was successfully dissected together with adjacent adipose and fibrous tissue. Histological evaluation revealed the presence of myxoid cells, blood vessels, degenerative changes, and microcalcifications embedded in profuse hyalinized stroma. Those histological features enabled identification of the intrapericardial tumor as a myxoma. Follow-up CT examination did not demonstrate any signs of recurrence of the myxoma. According to our knowledge, a myxoma located inside the pericardial sac has never been described before.

Increased prevalence of subclinical coronary atherosclerosis in young patients with ankylosing spondylitis.

Introduction There is substantial evidence that spondyloarthropathies, such as ankylosing spondylitis (AS) and psoriatic arthritis (PsA), may increase cardiovascular risk. Objectives The study aimed to compare development of atherosclerotic lesions in coronary arteries between patients with AS and individuals without rheumatic dise ases. Patients and methods A total of 37 adult patients with AS (mean [SD] age, 40.4 [9.6] years; men, 26 [70.3%]), with disease duration of less than 10 years were enrolled. The control group consisted of 76 participants without rheumatic diseases. Controls were matched for age, sex, history of hypertension, dyslipidemia, and smoking status. Coronary computed tomography angiography was performed in both groups. Results Atherosclerotic lesions in the coronary arteries were present in 18 patients (48.7%) with AS compared with 20 controls (26.3%) (P = 0.02). Univariate analysis performed in the AS group demonstrated an association between the presence of lesions and age (P = 0.02), hypertension (P = 0.003), and dyslipidemia (P = 0.001). The multivariable logistic regression analysis showed a significant association between coronary atherosclerosis and hypertension (P = 0.008) and with dyslipidemia (P = 0.001). The average plaque burden was higher in patients with AS than in controls (mean [SD], 42.2% [4.7%] vs 36.5% [3.1%], P <0.0001). Conclusions Atherosclerotic plaques in the coronary arteries were significantly more prevalent in patients with AS. A strong association was demonstrated between atherosclerotic lesions and age, hypertension, and dyslipidemia. Our results confirm the need for cardiovascular risk assessment in patients with AS and cardiovascular prevention, if indicated.

Feasibility and safety of augmented-reality glass for computed tomography-assisted percutaneous revascularization of coronary chronic total occlusion: A single center prospective pilot study.

BACKGROUND: Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) may be facilitated by projection of coronary computed tomography angiography (CTA) datasets in the catheterization laboratory. There is no data on the feasibility and safety outcomes of CTA-assisted CTO PCI using a wearable augmented-reality glass. METHODS: A total of 15 patients scheduled for elective antegrade CTO intervention were prospectively enrolled and underwent preprocedural coronary CTA. Three-dimensional and curved multiplanar CT reconstructions were transmitted to a head-mounted hands-free computer worn by interventional cardiologists during CTO PCI to provide additional information on CTO tortuosity and calcification. The results of CTO PCI using a wearable computer were compared with a time-matched prospective angiographic registry of 59 patients undergoing antegrade CTO PCI without a wearable computer. Operators' satisfaction was assessed by a 5-point Likert scale. RESULTS: Mean age was 64 ± 8 years and the mean J-CTO score was 2.1 ± 0.9 in the CTA-assisted group. The voice-activated co-registration and review of CTA images in a wearable computer during CTO PCI were feasible and highly rated by PCI operators (4.7/5 points). There were no major adverse cardiovascular events. Compared with standard CTO PCI, CTA-assisted recanalization of CTO using a wearable computer showed more frequent selection of the first-choice stiff wire (0% vs 40%, p < 0.001) and lower contrast exposure (166 ± 52 vs 134 ± 43 ml, p = 0.03). Overall CTO success rates and safety outcomes remained similar between both groups. CONCLUSIONS: CTA-assisted CTO PCI using an augmented-reality glass is feasible and safe, and might reduce the resources required for the interventional treatment of CTO.

CT Angiography for the Detection of Coronary Artery Stenoses in Patients Referred for Cardiac Valve Surgery: Systematic Review and Meta-Analysis.

OBJECTIVES: This study aimed to evaluate the diagnostic accuracy of coronary computed tomography angiography (CTA) for detecting coronary artery stenoses in patients with valvular heart disease undergoing valve surgery. BACKGROUND: Coronary CTA is currently not routinely recommended for detecting coronary artery stenoses before cardiac valve surgery. However, recent improvements in computed tomography technology may enable the identification of the most appropriate candidates for coronary CTA before valve surgery. METHODS: A systematic review was performed of PubMed, EMBASE, and the Cochrane databases for all studies that used ≥16-detector row computed tomography scanning to perform coronary CTA in patients with valvular heart disease scheduled for valve surgery and validated the results against invasive angiography. Summary diagnostic accuracies were calculated by using a bivariate random effects model, and a generalized linear mixed model was applied for heterogeneity analysis. RESULTS: Seventeen studies analyzing 1,107 patients and 12,851 coronary segments were included. Patient-based analysis revealed a pooled sensitivity of 93% (95% confidence interval [CI]: 86 to 97), specificity of 89% (95% CI: 86 to 91), a negative likelihood ratio (LR) of 0.07 (95% CI: 0.04 to 0.16), and a positive LR of 8.44 (95% CI: 6.49 to 10.99) for coronary CTA to identify individuals with stenosis ≥50%. Specificity and positive LR were higher in patients without aortic stenosis (AS) versus those with AS (96% vs. 87% and 21.2 vs. 7.4, respectively), as well as with ≥64 detectors versus <64 detectors (90% vs. 86% and 9.5 vs. 6.9). Heterogeneity analysis revealed a significant impact of AS and the number of detectors on specificity of CTA. CONCLUSIONS: Coronary CTA using currently available technology is a reliable imaging alternative to invasive angiography with excellent sensitivity and negative LR for the detection of significant coronary stenoses in patients undergoing cardiac valve surgery. The specificity of coronary CTA may be decreased against the background of AS (Computed Tomography Angiography for the Detection of Coronary Artery Disease in Patients Referred for Cardiac Valve Surgery: A Meta-Analysis; CRD42015016213).

Computed tomography angiography for prediction of atrial fibrillation after coronary artery bypass grafting: proof of concept.

BACKGROUND: Postoperative atrial fibrillation (AF) is a serious complication of coronary artery bypass grafting (CABG). There are scant data on the application of coronary computed tomography angiography (CCTA) for prediction of postoperative AF. METHODS: A total of 102 patients (77 male, mean age: 64±10 years) with pre-procedural CCTA undergoing isolated CABG were enrolled. Clinical risk factors were collected. Qualitative and quantitative CCTA analysis of the atria, pulmonary veins (PV), and epicardial adipose tissue (EAT) along the left atrium (LA) was performed to determine the predictors for postoperative AF. The primary endpoint was defined as any in-hospital AF requiring treatment. RESULTS: Postoperative AF occurred in 24% of patients. Patients with AF had higher body mass index (29.7±4.8kg/m(2) vs 27.3±3.9kg/m(2), p=0.013), larger right atrial area (25.4±5.3cm(2) vs 22.3±6.4cm(2), p=0.035), LA systolic volume (114.7±32.8ml vs 96.8±30.4ml, p=0.015), LA EAT volume (5.6±3ml vs 4±2.5ml, p=0.009), and right superior PV ostium area (3.8±1.3cm(2) vs 3±1cm(2), p=0.021) compared to non-AF patients. By multivariable analysis, only LA EAT volume [odds ratio (OR): 1.21, 95% confidence interval (CI): 1.01-1.44, p=0.036] and right superior PV ostium area (OR: 1.63, 95% CI: 1.06-2.50, p=0.026) were independent predictors of AF. The optimal cut-offs for LA EAT volume and right superior PV ostium were >3.4ml and >4.1cm(2), respectively (max. sensitivity: 83%, max. specificity: 86%). CONCLUSIONS: Increased LA EAT and right superior PV ostial size are independently associated with AF after CABG. CCTA might be used as a noninvasive prediction tool for AF in patients undergoing CABG.

The clinical significance and management of patients with incomplete coronary angiography and the value of additional computed tomography coronary angiography.

To assess the anatomical background and significance of incomplete invasive coronary angiography (ICA) and to evaluate the value of coronary computed tomography angiography (CTA) in this scenario. The current study is an analysis of high volume center experience with prospective registry of coronary CTA and ICA. The target population was identified through a review of the electronic database. We included consecutive patients referred for coronary CTA after ICA, which did not visualize at least one native coronary artery or by-pass graft. Between January 2009 and April 2013, 13,603 diagnostic ICA were performed. There were 45 (0.3 %) patients referred for coronary CTA after incomplete ICA. Patients were divided into 3 groups: angina symptoms without previous coronary artery by-pass grafting (CABG) (n = 11,212), angina symptoms with previous CABG (n = 986), and patients prior to valvular surgery (n = 925). ICA did not identify by-pass grafts in 21 (2.2 %) patients and in 24 (0.2 %) cases of native arteries. The explanations for an incomplete ICA included: 11 ostium anomalies, 2 left main spasms, 5 access site problems, 5 ascending aorta aneurysms, and 2 tortuous take-off of a subclavian artery. However, in 20 (44 %) patients no specific reason for the incomplete ICA was identified. After coronary CTA revascularization was performed in 11 (24 %) patients: 6 successful repeat ICA and percutaneous intervention and 5 CABG. Incomplete ICA constitutes rare, but a significant clinical problem. Coronary CTA provides adequate clinical information in these patients.

Impact of coronary artery calcium characteristics on accuracy of CT angiography.

OBJECTIVES: This study sought to evaluate which specific calcium characteristics impact diagnostic accuracy of coronary computed tomography angiography (CTA). BACKGROUND: Coronary calcifications comprise one of the most significant factors interfering with diagnostic accuracy of coronary CTA. Despite this fact, there is paucity of data regarding this phenomenon. METHODS: A total of 525 coronary lesions (252 calcified and 273 reference [noncalcified] lesions) within 97 arteries of 60 patients (19 women, age 63 ± 10 years) underwent assessment with both 2 × 64-slice computed tomography and intravascular ultrasound (IVUS). Nineteen calcium characteristics were determined. The main outcome was coronary CTA inaccuracy defined as the deviation of minimum lumen area within the calcification measured with coronary CTA from that measured with IVUS, in both absolute (mm(2)) and relative (%) terms. RESULTS: Presence of calcification was found to be independently correlated to coronary CTA inaccuracy in both absolute and relative terms (p < 0.001 for both). The relative (%) inaccuracy of coronary CTA was independently correlated to total calcium length (p = 0.004), total calcium volume (p = 0.008), cross section calcium thickness (p = 0.023), cross section calcium area (p = 0.023), and cross section lumen area (p = 0.001). The absolute inaccuracy of CTA was correlated to calcium length (p = 0.010), calcium volume (p = 0.017), and cross section calcium area (p < 0.001). The presence of both total calcium arc ≥47° and mean lumen diameter of ≤2.8 mm provided the best predictive accuracy for detection of excessive lumen underestimation by CTA. The best accuracy for prediction of excessive lumen overestimation provided combination of 2 of 3 features: maximum calcium density <869 HU, OR whole calcium length <2.4 mm, OR total calcium volume <6.4 mm(3). CONCLUSIONS: Our results indicate which specific calcium characteristics impact accuracy of coronary CTA in lumen assessment within calcified lesions. This may provide practical assistance in predicting coronary lumen underestimation or overestimation by coronary CTA, therefore mitigating risk of diagnostic errors in clinical practice.

Prevalence and characteristics of coronary anomalies originating from the opposite sinus of Valsalva in 8,522 patients referred for coronary computed tomography angiography.

Although coronary computed tomographic angiography has the ability to depict potentially malignant features of anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS), there are limited data on the significance of ACAOS in the computed tomography population. The aims of this study were to assess the prevalence of ACAOS and to correlate its anatomic features with patients' symptoms among 8,522 consecutive subjects who underwent coronary computed tomographic angiography from February 2008 to May 2012. The ACAOS proximal course was classified into anterior, interarterial, septal, and retroaortic subtypes. Malignant ACAOS was recorded if a slitlike ostium, an acute angle of takeoff, an intramural course, and significant compression between the aorta and pulmonary trunk were present simultaneously. The prevalence of ACAOS was 0.84% (72 of 8,522), including right-sided origins of the left main coronary artery (n = 11), left anterior descending coronary artery (n = 9), and left circumflex coronary artery (n = 33) and left-sided origin of the right coronary artery (n = 20). Of the 24 ACAOS (0.28%) with an interarterial course, 12 (0.14%) showed significant vessel compression, of which 6 (0.07%) were classified as malignant. The presence of significant interarterial compression and malignant ACAOS type were observed in left-sided right coronary arteries only, and interarterial compression correlated with patients' symptoms at a median of 15-month follow-up. In conclusion, the computed tomographic prevalence of ACAOS seems to be comparable with that of previous angiographic studies. The malignant features of ACAOS in the adult computed tomography population might be exclusively associated with left-sided right coronary arteries.

May dual-source computed tomography angiography replace invasive coronary angiography in the evaluation of patients referred for valvular disease surgery?

BACKGROUND: Coronary computed tomography (CT) angiography is currently the only alternative to invasive angiography in the evaluation of coronary anatomy. In patients referred for valvular or thoracic aortic disease surgery, invasive coronary angiography remains the gold standard required by cardiac surgeons during the preoperative evaluation. According to the current European Society of Cardiology guidelines, evaluation of coronary anatomy is recommended in all patients above 40 years of age, with a history of coronary artery disease (CAD), in postmenopausal women, patients with left ventricular systolic dysfunction, with suspected ischaemic aetiology of mitral regurgitation, and in patients with one or more risk factors for CAD. The possibility to perform coronary CT angiography to exclude CAD before planned non-coronary cardiac surgery was first allowed in the 2010 Report of the American College of Cardiology Foundation Task Force on Expert Consensus. AIM: To evaluate the usefulness of dual-source CT for the evaluation of coronary anatomy in patients before planned cardiac valvular surgery. METHODS: We studied 98 consecutive patients with a haemodynamically significant valvular heart disease and guideline-based indications for coronary angiography to exclude CAD before planned valvular surgery. Exclusion criteria included cardiac arrhythmia (atrial fibrillation, frequent ventricular and supraventricular premature beats), estimated glomerular filtration rate < 60 mL/min/1.73 m(2), allergy to iodine contrast agents, and lack of patient consent. Mean patient age was 58.8 (range 30-78) years. Coronary artery calcium score (CACS) was first determined in all patients. Coronary CT angiography was not performed if CACS was > 1000. In the remaining patients, complete CT evaluation was performed with the administration of a contrast agent. Conventional invasive coronary angiography was subsequently performed in patients with at least one > 50% stenosis, artifacts due to calcifications, or motion artifacts. RESULTS: In 79 (80.6%) patients, CT angiography excluded the presence of a significant coronary artery stenosis without the need for invasive angiography. Conventional coronary angiography was required in 19 (19.4%) patients, including 13 (13.3%) patients with a > 50% stenosis in CT angiography, 2 (2%) patients with calcification artifacts, 1 (1%) patient with motion artifacts, 2 (2%) patients with CACS > 1000 in whom CT angiography was nor performed, and 1 (1%) patient with allergic symptoms during administration of a test dose of the contrast agent. Ultimately, significant CAD was diagnosed in 9 (9.2%) patients in whom coronary artery bypass surgery was also performed. In addition, vascular anomalies were diagnosed with cardiac CT angiography in 5 (5.1%) patients. In 14 patients, CT angiography was also used for previously planned evaluation of a coexisting aortic aneurysm. CONCLUSIONS: Coronary CT angiography may be useful to exclude significant CAD in patients referred for valvular disease surgery.

Coronary computed tomographic angiography for prediction of procedural and intermediate outcome of bypass grafting to left anterior descending artery occlusion with failed visualization on conventional angiography.

Conventional coronary angiography (CCA) has considerable limitations regarding visualization of distal vessel segments in chronic total occlusion. We assessed the ability of coronary computed tomographic angiography (CCTA) to predict the success of coronary artery bypass grafting (CABG) to the chronically occluded left anterior descending coronary artery (LAD) incompletely visualized on CCA. Thirty symptomatic patients rejected for CABG on the basis of the CCA findings underwent preoperative CCTA before intended transmyocardial laser revascularization. The LAD was explored operatively in all patients, and CABG to the LAD was attempted if the distal vessel was suitable for anastomosis. The procedural outcome of CABG and the 6-month patency of the left internal mammary artery graft at follow-up CCTA were defined as the primary and secondary end point, respectively. The primary and secondary end points were achieved in 80% and 77% of patients, respectively. We found a significant correlation between the intraoperative and computed tomographic measurement of distal LAD diameter (R = 0.428, p = 0.037). On multivariate analysis, the maximum diameter of the distal LAD by CCTA (odds ratio 8.16, p = 0.043) was the only independent correlate of procedural success of CABG. A cutoff value of 1.5 mm for the mean distal LAD diameter predicted left internal mammary artery graft patency with 100% specificity and 83% sensitivity. Successful CABG resulted in significant improvements in angina class and left ventricular function in LAD segments at 6 months of follow-up. In conclusion, CCTA predicted both the procedural and the intermediate outcome of CABG to chronic LAD occlusion with failed visualization on CCA.