Aortic Calcification is Associated With the Difference Between Invasive Central and Cuff-Measured Brachial Blood Pressure in Chronic Kidney Disease.

BACKGROUND: Chronic kidney disease (CKD) is associated with accelerated vascular calcification and increased central systolic blood pressure when measured invasively (invCSBP) relative to cuff-based brachial systolic blood pressure (cuffSBP). The contribution of aortic wall calcification to this phenomenon has not been clarified. We, therefore, examined the effects of aortic calcification on cuffSBP and invCSBP in a cohort of patients representing all stages of CKD. METHODS: During elective coronary angiography, invCSBP was measured in the ascending aorta with a fluid-filled catheter with simultaneous recording of cuffSBP using an oscillometric device. Furthermore, participants underwent a non-contrast computed tomography scan of the entire aorta with observer-blinded calcification scoring of the aortic wall ad modum Agatston. RESULTS: We included 168 patients (mean age 67.0 ±â€…10.5, 38 females) of whom 38 had normal kidney function, while 30, 40, 28, and 32 had CKD stages 3a, 3b, 4, and 5, respectively. Agatston scores adjusted for body surface area ranged from 48 to 40,165. We found that invCSBP increased 3.6 (95% confidence interval 1.4-5.7) mm Hg relative to cuffSBP for every 10,000-increment in aortic Agatston score. This association remained significant after adjustment for age, diabetes, antihypertensive treatment, smoking, eGFR, and BP level. No such association was found for diastolic BP. CONCLUSIONS: Patients with advanced aortic calcification have relatively higher invCSBP for the same cuffSBP as compared to patients with less calcification. Advanced aortic calcification in CKD may therefore result in hidden central hypertension despite apparently well-controlled cuffSBP. ClinicalTrials.gov identifier: NCT04114695.

Computed tomographic-based three-dimensional printing of giant coronary artery fistulas to guide surgical strategy: a case series.

Background: Coronary artery fistulas (CAFs) are abnormal communications between the coronary arteries and the heart chambers, arteries, or veins, potentially leading to significant shunting, myocardial ischaemia and heart failure. Computed tomographic (CT) angiography or conventional invasive angiography is the reference standard for the diagnosis of coronary fistulas. The fistula anatomy can become very complex, which makes surgical or interventional planning challenging. Case summary: We report two cases of hugely dilated and tortuous coronary circumflex artery fistulas draining into the coronary sinus. Both patients were followed up for more than 10 years because of very complex coronary fistula anatomy and mild symptoms. From two-dimensional (2D) sliced CT images alone it, was uncertain whether surgery was feasible. However, since both patients had symptom progression (Patient 1 developed heart failure, and Patient 2 had recurrent pericardial effusions), three-dimensional (3D) heart models were printed for better understanding of the complex fistula anatomy and improved surgical planning. Both patients had successful surgery and symptomatic relief at follow-up. Discussion: The delay in surgery, until clinical deterioration, may partly be a consequence of a general reluctance in performing complex surgery in patients with CAFs. As of now, CT-based 3D printing has primarily been used in isolated cases. However, 3D printing is evolving rapidly and supplementing 2D sliced CT images with a physical 3D heart model may improve the anatomical understanding and pre-surgical planning that could lead to better surgical outcome.

Conservative treatment of type A aortic dissection: a case report with 5 years of follow-up.

Background: Acute aortic dissection causes major morbidities and mortalities. The treatment of choice for type A aortic dissection (TAAD) is emergent surgical intervention. However, surgery per se may be associated with significant risk, in part due to the general surgical challenges, and the inherent hemodynamic- and organ malperfusion effects. In particular, surgery correlates with marked perioperative mortality in octo- and nonagenarians and those with severe comorbidities. Conservative medical treatment represents an alternative approach to patients for whom surgery is deemed high-risk, but case literature in this field remains sparse. Case Description: We present a case of an 86-year-old female admitted with TAAD and deemed inoperable by the cardiothoracic surgical team due to excessive risks. The patient was treated conservatively with an extensive and aggressive antihypertensive regimen, leading to an uneventful recovery. Conclusions: Most cases of TAADs require emergent surgery. However, surgery is often contraindicated in comorbid and older patients due to excessive risks. The patient in this report is unique due to the long follow-up after conservative treatment and the close adherence to treatment protocol due to continuous therapeutic monitoring. It is important to consider factors for and against conservative therapeutic strategies, and, importantly, adherence to such should be carefully monitored to optimize patient outcomes.

Differences in diagnostication, and revascularisation of ischaemic heart disease in Western Denmark.

INTRODUCTION: In Denmark, the incidence of and mortality from ischaemic heart disease (IHD) has been declining. In this context, it is of interest to assess any regional differences in diagnostication and invasive treatment of IHD. METHODS: We intended to describe the diagnostication and invasive treatment of IHD in Western Denmark at the regional/municipal level using the Western Denmark Heart Registry. Coronary angiography (CAG), percutaneous coronary intervention (PCI) and coronary arterial bypass grafting were registered from 2000 through 2019; cardiac multislice computed tomography (CMCT), from 2015 through 2019. RESULTS: Concerning the use of revascularisation for acute coronary syndrome (ACS), we found comparable regional activity levels but significant differences between individual municipalities. Furthermore, the use of CAG for chronic coronary syndrome (CCS) was significantly higher and the use of CMCT significantly lower in the North Denmark Region than in the Central and South Denmark Regions. CONCLUSION: We found differences in the rates of PCI for ACS at the municipal level but not between the Western Denmark regions. Furthermore, at the regional level, evaluation of chronic IHD differed regarding use of elective CAG and CMCT, and use of CMCT was not paralleled by a reduction in the number of CAG procedures. This may possibly prompt discussions on the strategy for invasive and non-invasive diagnosis of CCS and on targeted preventive measures. FUNDING: none TRIAL REGISTRATION. not relevant.

Low-Density Lipoprotein Cholesterol Is Predominantly Associated With Atherosclerotic Cardiovascular Disease Events in Patients With Evidence of Coronary Atherosclerosis: The Western Denmark Heart Registry.

BACKGROUND: Low-density lipoprotein cholesterol (LDL-C) is an important causal risk factor for atherosclerotic cardiovascular disease (ASCVD). However, a sizable proportion of middle-aged individuals with elevated LDL-C level have not developed coronary atherosclerosis as assessed by coronary artery calcification (CAC). Whether presence of CAC modifies the association of LDL-C with ASCVD risk is unknown. We evaluated the association of LDL-C with future ASCVD events in patients with and without CAC. METHODS: The study included 23 132 consecutive symptomatic patients evaluated for coronary artery disease using coronary computed tomography angiography (CTA) from the Western Denmark Heart Registry, a seminational, multicenter-based registry with longitudinal registration of patient and procedure data. We assessed the association of LDL-C level obtained before CTA with ASCVD (myocardial infarction and ischemic stroke) events occurring during follow-up stratified by CAC>0 versus CAC=0 using Cox regression models adjusted for baseline characteristics. Outcomes were identified through linkage among national registries covering all hospitals in Denmark. We replicated our results in the National Heart, Lung, and Blood Institute-funded Multi-Ethnic Study of Atherosclerosis. RESULTS: During a median follow-up of 4.3 years, 552 patients experienced a first ASCVD event. In the overall population, LDL-C (per 38.7 mg/dL increase) was associated with ASCVD events occurring during follow-up (adjusted hazard ratio [aHR], 1.14 [95% CI, 1.04-1.24]). When stratified by the presence or absence of baseline CAC, LDL-C was only associated with ASCVD in the 10 792/23 132 patients (47%) with CAC>0 (aHR, 1.18 [95% CI, 1.06-1.31]); no association was observed among the 12 340/23 132 patients (53%) with CAC=0 (aHR, 1.02 [95% CI, 0.87-1.18]). Similarly, a very high LDL-C level (>193 mg/dL) versus LDL-C <116 mg/dL was associated with ASCVD in patients with CAC>0 (aHR, 2.42 [95% CI, 1.59-3.67]) but not in those without CAC (aHR, 0.92 [0.48-1.79]). In patients with CAC=0, diabetes, current smoking, and low high-density lipoprotein cholesterol levels were associated with future ASCVD events. The principal findings were replicated in the Multi-Ethnic Study of Atherosclerosis. CONCLUSIONS: LDL-C appears to be almost exclusively associated with ASCVD events over ≈5 years of follow-up in middle-aged individuals with versus without evidence of coronary atherosclerosis. This information is valuable for individualized risk assessment among middle-aged people with or without coronary atherosclerosis.

Pressure Recovery in the Left Main Stenosis.

A 76-year-old male patient with dyspnea was referred on a suspicion of coronary artery disease. A coronary computed tomography angiography (CTA) revealed a distal left main (LM) stenosis and in the right (right coronary artery [RCA]), left circumflex (LCX) and left anterior descending (LAD) coronary arteries stenosis could not be excluded. CTA-derived fractional flow reserve (FFRct) was 0.75, 0.72, 0.74, 0.86, and 0.94 in the LM, LAD, LCX, ramus, and RCA, respectively. Invasive coronary angiography confirmed a stenosis in the LM and LAD. FFR was 0.73 and 0.85 in the LCX and ramus, respectively. The patient was referred for coronary artery bypass surgery. The FFR and FFRct values in the ramus demonstrate the phenomenon of pressure recovery. This case shows that preserved FFR and FFRct cannot always be used to exclude the hemodynamic significance of upstream coronary lesions.

Electrically vs. imaging-guided left ventricular lead placement in cardiac resynchronization therapy: a randomized controlled trial.

AIMS: To test in a double-blinded, randomized trial whether the combination of electrically guided left ventricular (LV) lead placement and post-implant interventricular pacing delay (VVd) optimization results in superior increase in LV ejection fraction (LVEF) in cardiac resynchronization therapy (CRT) recipients. METHODS AND RESULTS: Stratified according to presence of ischaemic heart disease, 122 patients were randomized 1:1 to LV lead placement targeted towards the latest electrically activated segment identified by systematic mapping of the coronary sinus tributaries during CRT implantation combined with post-implant VVd optimization (intervention group) or imaging-guided LV lead implantation by cardiac computed tomography venography, 82Rubidium myocardial perfusion imaging and speckle tracking echocardiography targeting the LV lead towards the latest mechanically activated non-scarred myocardial segment (control group). Follow-up was 6 months. Primary endpoint was absolute increase in LVEF. Additional outcome measures were changes in New York Heart Association class, 6-minute walk test, and quality of life, LV reverse remodelling, and device related complications. Analysis was intention-to-treat. A larger increase in LVEF was observed in the intervention group (11 ± 10 vs. 7 ± 11%; 95% confidence interval 0.4-7.9%, P = 0.03); when adjusting for pre-specified baseline covariates this difference did not maintain statistical significance (P = 0.09). Clinical response, LV reverse remodelling, and complication rates did not differ between treatment groups. CONCLUSION: Electrically guided CRT implantation appeared non-inferior to an imaging-guided strategy considering the outcomes of change in LVEF, LV reverse remodelling and clinical response. Larger long-term studies are warranted to investigate the effect of an electrically guided CRT strategy.

High-pressure balloon fracturing of small dysfunctional Mitroflow bioprostheses facilitates transcatheter aortic valve-in-valve implantation.

AIMS: Transcatheter valve-in-valve (VIV) implantation is usually discouraged in small surgical tissue valves. We report our first ten cases of fracturing small dysfunctional Mitroflow bioprostheses by high-pressure balloon dilatation to increase the internal diameter of the surgical valve before VIV (BF-VIV). METHODS AND RESULTS: BF-VIV was performed in 10 patients (mean age 84±4 years) with failing Mitroflow valves size 19 mm (n=3, threshold of fracture 15 atm) and 21 mm (n=7, threshold of fracture 13 atm). An Edwards SAPIEN 3 or XT 20 mm or 23 mm transcatheter valve was implanted inside the fractured Mitroflow bioprosthesis. The procedure improved aortic valve area (0.7±0.3 vs. 1.1±0.3 cm2, p=0.001), reduced peak aortic valve gradient (66±27 vs. 29±7 mmHg, p=0.002), resolved aortic regurgitation and improved patients' NYHA functional class (p=0.005). One patient had a minor stroke with complete resolution of symptoms and another patient required a pacemaker due to AV block. All patients were still alive at the end of follow-up (438±255 days). CONCLUSIONS: Initial experience with transcatheter BF-VIV suggests that this method is feasible and safe, and that it improves aortic valve haemodynamics and clinical functional capacity. BF-VIV is a promising alternative to repeat surgery in patients with small failing Mitroflow bioprostheses.

Left atrial size and function as assessed by computed tomography in cardiac resynchronization therapy: Association to echocardiographic and clinical outcome.

To evaluate whether baseline left atrial (LA) volume and function were associated with clinical or echocardiographic response to cardiac resynchronization therapy (CRT), and to determine LA reverse remodeling as assessed by computed tomography (CT). We prospectively included patients receiving a CRT system who underwent dynamic cardiac CT with measurement of LA size and function before and 6 months after implantation. Patients alive not hospitalized for heart failure, and improving ≥1 NYHA class or ≥10% in 6-min walk test after 6 months follow-up were classified as clinical responders. Echocardiographic response was defined as ≥15% reduction in left ventricular (LV) end-systolic volume. We included 138 patients, of whom 95 (69%) were clinical responders and 114 (83%) were echocardiographic responders. We found no association between baseline measures of LA volume or function and clinical or echocardiographic response. Mean reduction in LA maximum and minimum volumes at 6 months were 3.3 ± 12.7 ml/m2 (p = 0.004) and 2.6 ± 11.4 ml/m2 (p = 0.01) corresponding to a relative reduction of 4.1 and 5.0%, respectively. LV end-systolic relative volume reduction was 35.2 ± 22.4% (p < 0.001). No measures of LA function changed significantly. Cardiac CT measures of baseline LA volume and function are not associated with clinical or echocardiographic response to CRT. Change in LA volume and function is marginal after 6 months despite pronounced LV reverse remodeling.

Transcatheter aortic valve implantation in a young heart transplant recipient crossing the traditional boundaries.

Transcatheter aortic valve implantation (TAVI) is an established therapeutic alternative to surgical aortic valve replacement (SAVR) in high-risk or inoperable patients with symptomatic aortic valve stenosis. Hitherto, TAVI is not recommended in young and low-intermediate risk patients. However, TAVI may also serve as an alternative to SAVR in selected young patients, e.g., patients who have previously undergone multiple cardiac surgery procedures. We report a case of trans-femoral TAVI in a 25-year-old heart transplant (HTx) recipient with prior surgery for congenital heart disease.

Potential impact of clinical use of noninvasive FFRCT on radiation dose exposure and downstream clinical event rate.

OBJECTIVE: This study aims to determine the potential impact of introducing noninvasive fractional flow reserve based on coronary computed tomography angiography (CTA) into clinical practice, with respect to radiation dose exposure and downstream event rate. METHODS: We modeled a population of 1000 stable, symptomatic patients with suspected coronary artery disease, using the disease prevalence from the CONFIRM registry to estimate the pretest likelihood. Four potential clinical pathways were modeled based on the first noninvasive diagnostic test performed: (1) dobutamine echo; (2) single-photon emission computerized tomography (SPECT); (3) coronary CTA; and (4) CTA+FFRCT and leading to possible invasive coronary angiography. The posttest likelihood of testing positive/negative by each test was based on the presenting disease burden and diagnostic accuracy of each test. RESULTS: The dobutamine echo pathway resulted in the lowest radiation dose of 5.4 mSv, with 4.0 mSv from angiography and 1.4 mSv from percutaneous coronary intervention (PCI). The highest dose was with SPECT, with 26.5 mSv. The coronary computed tomography angiography (cCTA) pathway demonstrated a dose of 14.2 mSv, 3.7 mSv from cCTA, 7.7 mSv from angiography, and 2.8 mSv from PCI. The CTA+FFRCT pathway exhibited a radiation dose of 9.7 mSv, 3.7 mSv for cCTA, 4.2 mSv for angiography, and 1.8 mSv for PCI. Radiation dose exposure for CTA+FFRCT was lower than for SPECT (P<.001). The CTA+FFRCT pathway resulted in the lowest projected death/myocardial infarction rate at 1 year (2.44%) while the dobutamine stress pathway had the highest 1-year event rate (2.84%). CONCLUSION: Our analysis suggests that integrating FFRCT into the CTA clinical pathway may result in reduced cumulative radiation exposure, while promoting favorable clinical outcomes.

White Matter Lesions, Carotid and Coronary Atherosclerosis in Late-Onset Depression and Healthy Controls.

BACKGROUND: Cerebral white matter lesions (WMLs) are more common in individuals with late-onset or late-life depression. It has been proposed that carotid atherosclerosis may predispose to WMLs by inducing cerebral hypoperfusion. This hemodynamic effect of carotid atherosclerosis could be important for the formation of WMLs in depression. METHODS: The case-control study included 29 patients with late-onset major depressive disorder and 27 controls matched for sex, age, and tobacco use. WML volume, carotid intima-media thickness, and coronary plaque volume were assessed using magnetic resonance imaging, ultrasound scan, and coronary computed tomography (CT) angiography, respectively. RESULTS: The mean age for the total sample was 59.7 ± 4.7 years. There was no difference in carotid intima-media thickness between patients and controls (p = 0.164), whereas a higher WML volume in the patients was found (p = 0.051). In both patients and controls, WML volume was associated with carotid but not with coronary atherosclerosis. In adjusted multiple linear regression, a 0.1mm increase in averaged carotid intima-media thickness was associated with a 52% (95% CI: 8.4-112, p = 0.032) increase in WML volume. The association between carotid intima-media thickness and WML volume was, however, similar in patients and controls. CONCLUSIONS: In older persons aged between 50 and 70 years, WMLs do not seem to be a part of generalized atherosclerotic disease, but seem to be dependent on atherosclerosis in the carotid arteries. Carotid atherosclerosis, however, could not explain the higher WML load observed in the depressed patients, and thus, studies are needed to establish the mechanisms linking depression and WMLs.

Multimodality imaging-guided left ventricular lead placement in cardiac resynchronization therapy: a randomized controlled trial.

AIM: Left ventricular (LV) lead position at the latest mechanically activated non-scarred myocardial LV region confers improved response to cardiac resynchronization therapy (CRT). We conducted a double-blind, randomized controlled trial to evaluate the clinical benefit of multimodality imaging-guided LV lead placement in CRT. METHODS AND RESULTS: Patients were allocated (1:1) to imaging-guided LV lead placement using cardiac computed tomography (CT) venography, 99m Technetium myocardial perfusion imaging, and speckle-tracking echocardiography radial strain to target the optimal coronary sinus (CS) branch closest to the non-scarred myocardial segment with latest mechanical activation (imaging group, n = 89) or to routine LV lead implantation in a posterolateral region with late electrical activation (control group, n = 93). The primary endpoint was clinical non-response to CRT [≥1 of the following after 6 months: (1) death, (2) heart failure hospitalization, or (3) no improvement in New York Heart Association class and <10% increase in 6-min walk distance]. Secondary outcomes included LV remodelling and the combination of all-cause mortality and hospitalization owing to heart failure during 1.8 ± 0.9 years. Analysis was intention-to-treat. In the imaging group, fewer patients reached the primary endpoint (26% vs. 42%, P = 0.02). More patients in the imaging group had the LV lead placed in the optimal CS branch (83% vs. 65%, P = 0.01). There were no between-group differences in reverse LV remodelling or the combined endpoint of death or hospitalizations for heart failure. CONCLUSIONS: Multimodality imaging-guided LV lead placement towards the CS branch closest to latest mechanically activated non-scarred myocardial LV segment reduces the proportion of clinical non-responders to CRT. Larger long-term multicentre studies are needed.

Reproducibility of semi-automatic coronary plaque quantification in coronary CT angiography with sub-mSv radiation dose.

INTRODUCTION: Coronary computed tomographic angiography (CTA) can characterize coronary atherosclerotic plaque components as calcified and non-calcified. Quantitative measurements of coronary plaque burden by coronary CTA may play a role in serial studies to determine disease progression or response to medical therapies. The reproducibility from repeated assessment of such quantitative measurements from low-radiation dose coronary CTA has not been previously assessed. PURPOSE: To evaluate the interscan, interobserver and intraobserver reproducibility for coronary plaque volume assessment using semi-automatic plaque analyses algorithm in low radiation dose coronary CTA. METHODS: In 50 consecutive patients undergoing two 128-slice dual source CT scans within 12 days with a mean radiation dose of 0.7 mSv per coronary CTA, the interscan, interobserver and intraobserver reproducibility of coronary plaque assessment using validated software (AutoPlaq) were evaluated. RESULTS: Interscan, interobserver and intraobserver agreement for non-calcified and calcified plaque volumes were excellent (Spearman rho 0.87-0.99). Interscan mean percentage difference in non-calcified and calcified plaque volumes were 0.1% (p = 0.8) and 1.9% (p = 0.19) with limits of agreement of ±11% and ±48.5%; per inter- and intraobserver mean percentage differences were 0.1% (p = 0.25) and 0.3% (p = 0.001), and 0.3% (p = 0.33) and 0.4% (p = 0.59) with limits of agreement of ±7% and ±32.9%, and ±6.6% and ±32.1%, respectively. CONCLUSION: A semi-automatic plaque assessment algorithm in repeated low radiation dose coronary CTA allows for high reproducibility of coronary plaque characterization and quantification measures.

Social factors and coping status in asymptomatic middle-aged Danes: association to coronary artery calcification.

AIMS: Understanding the determinants of social and coping inequalities in subclinical cardiovascular disease is an important prerequisite in developing and implementing preventive strategies. The aim of this study was to investigate the association between social factors and coping status, respectively, and subclinical coronary artery disease (CAD) in middle-aged Danes. METHODS: This is a DanRisk screening substudy, thus including healthy Danish males and females aged 50 or 60 years. Social measures included grade of education, employment and co-habiting status. The coping status was estimated by the general self-efficacy (GES) scale. Coronary artery calcification (CAC) was assessed by computed tomography using the Agatston score (AS). Conventional clinical risk factors included sex, family history of CAD, BMI > 25, smoking, hypercholesterolaemia and hypertension. RESULTS: In 568 individuals the prevalence of subjects with CAC was 267 (45%). Independent predictors of CAC in males were age (OR = 1.10, 95% CI = 1.04-1.16, p < 0.001), smoking (OR = 1.75, 95% CI = 1.03-2.99, p = 0.038), and low co-habiting status (OR = 3.66, 95% CI = 1.19-11.25, p = 0.023). Independent predictors in females were age (OR = 1.67, 95% CI = 1.02-1.12, p = 0.006), and smoking (OR = 1.71, 95% CI = 1.06-2.78, p = 0.029). Higher AS was associated to lower employment level in females (p = 0.001) but not in males (p = 0.833). CONCLUSIONS: Social factors are associated to the prevalence and severity of CAC in asymptomatic middle-aged individuals with gender differences. The relative value of gender specific social versus conventional clinical risk factors in the risk assessment of subclinical CAC in middle-aged individuals needs further investigation in future prospective studies.

Coronary artery calcification and ECG pattern of left ventricular hypertrophy or strain identify different healthy individuals at risk.

PURPOSE: To improve risk stratification for development of ischaemic heart disease, several markers have been proposed. Both the presence of coronary artery calcification (CAC) and ECG pattern of left ventricular hypertrophy/strain have been shown to provide independent prognostic information. In this study, we investigated the association between established risk factors, ECG measurements and the presence of coronary artery calcification. METHOD: A random sample of healthy men and women aged 50 or 60 years were invited to the screening study. Established risk factors were measured. A noncontrast computed tomographic (CT) scan was performed to assess the CAC score. ECG analysis included left ventricular hypertrophy (LVH) using the Sokolow-Lyon criteria and the Cornell voltage × QRS duration product, and strain pattern based on ST segment depression and T-wave abnormalities. The association between the presence of CAC, clinical variables and ECG findings was evaluated by means of multivariate logistic regression. RESULTS: Of 1825 invited individuals, 1226 accepted the screening. The prevalence of hypertension was 50%. Hypertensive patients frequently had LVH and/or strain when compared with nonhypertensive individuals (21 vs. 14%, P < 0.0001) as well as CAC (52 vs. 38%, P < 0.0001). In multiple logistic regressions analyses, there was no association between the ECG abnormalities and the presence of CAC. CONCLUSION: There appears to be no relationship between CAC and ECG-suspected LVH and/or strain. We propose that these markers identify different individuals at risk and together may have additive prognostic value.

Hypereosinophilic Syndrome Leading to Severe Right-Sided Heart Failure in a Patient with Ebstein's Anomaly.

A 36-year-old male with mild Ebstein's anomaly developed severe right-sided heart failure, following a 5-year-long course of hypereosinophilic syndrome. No regular followups had been done, during the years of antineoplastic therapy. A year after being cured from the hypereosinophilic syndrome, the patient developed right-sided heart failure symptoms and was found to have excessive fibrosis of the right ventricular endocardium and free tricuspid regurgitation. The findings were compatible with substantial scarring of the endocardium caused by the hypereosinophilic syndrome. Over a few years, the patient deteriorated significantly and was finally offered a heart transplant. Examination of the explanted heart revealed severe fibrosis of the right ventricle and almost complete sparing of the left.

Reproducibility of coronary plaque detection and characterization using low radiation dose coronary computed tomographic angiography in patients with intermediate likelihood of coronary artery disease (ReSCAN study).

The purpose of this study is to evaluate the interscan, interobserver and intraobserver agreement for coronary plaque detection, and characterization using low radiation dose high-pitch spiral acquisition coronary CT angiography (CTA). Two experienced observers independently evaluated coronary CTA datasets from 50 consecutive patients undergoing two 128-slice dual source CT scans within 12 days. Mean (±SD) estimated radiation exposure was 1.5 ± 0.2 mSv per scan. Observers recorded the presence and characterization of coronary plaques as non-calcified or calcified. A "segment involvement score" (SIS) was computed by summing the numbers of segments with any coronary plaque per patient. Reproducibility was assessed using kappa (κ) statistics, paired t test and Bland-Altman analyses. Interscan, interobserver, and intraobserver agreement (κ-values) for detection of any or calcified plaques were 83-94% (κ-values 0.57-0.85), and 67-84% (0.31-0.67) for non-calcified plaques on a patient level. No significant difference was observed in mean interscan or interobserver SIS. Mean (95% CI) intraobserver SIS difference was -0.88 (-1.25; -0.51), P < 0.001, with limits of agreement from -4.7 to 2.9. Low radiation dose high-pitch coronary CTA permits detection of any or calcified plaques with high interscan, interobserver, intraobserver agreement. However, variability for the detection of non-calcified plaque is substantial.

How to set up an effective national primary angioplasty network: lessons learned from five European countries.

AIMS: Percutaneous coronary interventions (PCI) are used to treat acute and chronic forms of coronary artery disease. While in chronic forms the main goal of PCI is to improve the quality of life, in acute coronary syndromes (ACS) timely PCI is a life-saving procedure - especially in the setting of ST-elevation myocardial infarction (STEMI). The aim of this study was to describe the experience of countries with successful nationwide implementation of PCI in STEMI, and to provide general recommendations for other countries. METHODS AND RESULTS: The European Association of Percutaneous Cardiovascular Interventions (EAPCI) recenty launched the Stent For Life Initiative (SFLI). The initial phase of this pan-European project was focused on the positive experience of five countries to provide the best practice examples. The Netherlands, the Czech Republic, Sweden, Denmark and Austria were visited and the logistics of ACS treatment was studied. Public campaigns improved patient access to acute PCI. Regional networks involving emergency medical services (EMS), non-PCI hospitals and PCI centres are useful in providing access to acute PCI for most patients. Direct transfer from the first medical contact site to the cathlab is essential to minimise the time delays. Cathlab staff work is organised to provide acute PCI services 24 hours a day / seven days a week (24/7). Even in those regions where thrombolysis is still used due to long transfer distances to PCI, patients should still be transferred to a PCI centre (after thrombolysis). The highest risk non-ST elevation acute myocardial infarction patients should undergo emergency coronary angiography within two hours of hospital admission, i.e. similar to STEMI patients. CONCLUSIONS: Three realistic goals for other countries were defined based on these experiences: 1) primary PCI should be used for >70% of all STEMI patients, 2) primary PCI rates should reach >600 per million inhabitants per year and 3) existing PCI centres should treat all their STEMI patients by primary PCI, i.e. should offer a 24/7 service.