CT-Assessment of Epicardial Fat Identifies Increased Inflammation at the Level of the Left Coronary Circulation in Patients with Atrial Fibrillation.

Background: Atrial fibrillation (AF) can often be triggered by an inflammatory substrate. Perivascular inflammation may be assessed nowadays using coronary computed tomography angiography (CCTA) imaging. The new pericoronary fat attenuation index (FAI HU) and the FAI Score have prognostic value for predicting future cardiovascular events. Our purpose was to investigate the correlation between pericoronary fat inflammation and the presence of AF among patients with coronary artery disease. Patients and methods: Eighty-one patients (mean age 64.75 ± 7.84 years) who underwent 128-slice CCTA were included in this study and divided into two groups: group 1 comprised thirty-six patients with documented AF and group 2 comprised forty-five patients without a known history of AF. Results: There were no significant differences in the absolute value of fat attenuation between the study groups (p > 0.05). However, the mean FAI Score was significantly higher in patients with AF (15.53 ± 10.29 vs. 11.09 ± 6.70, p < 0.05). Regional analysis of coronary inflammation indicated a higher level of this process, especially at the level of the left anterior descending artery (13.17 ± 7.91 in group 1 vs. 8.80 ± 4.75 in group 2, p = 0.008). Conclusions: Patients with AF present a higher level of perivascular inflammation, especially in the region of the left coronary circulation, and this seems to be associated with a higher risk of AF development.

Assessment of lesion-associated myocardial ischemia based on fusion coronary CT imaging - the FUSE-HEART study: A protocol for non-randomized clinical trial.

INTRODUCTION: Multimodality assessment of coronary artery lesions has demonstrated superior effectiveness compared to the conventional approach, for assessing both anatomical and functional significance of a coronary stenosis. Multiple imaging modalities can be integrated into a fusion imaging tool to better assess myocardial ischemia. MATERIAL AND METHODS: The FUSE-HEART trial is a single center, prospective, cohort study that will assess the impact of a coronary artery stenosis on myocardial function and viability, based on advanced fusion imaging technics derived from Cardiac Computed Tomography Angiography (CCTA). Moreover, the study will investigate the correlation between morphology and composition of the coronary plaques and myocardial ischemia in the territory irrigated by the same coronary artery. At the same time, imaging parameters will be correlated with inflammatory status of the subjects. The trial will include 100 subjects with coronary lesions found on CCTA examination. The study population will be divided into 2 groups: first group will consist of subjects with anatomically significant coronary lesions on native coronary arteries and the second one will include subjects surviving an acute myocardial infarction. The vulnerability score of the subjects will be calculated based on presence of CCTA vulnerability markers of the coronary plaques: napkin ring sign, positive remodeling, spotty calcifications, necrotic core, and low-density plaques. 3D fusion images of the coronary tree will be generated, integrating the images reflecting wall motion with the ones of coronary circulation. The fusion models will establish the correspondence between plaque composition and wall motion in the subtended myocardium of the coronary artery. The study primary outcome will be represented by the rate of major adverse cardiac events related to myocardial ischemia at 1-year post assessment, in correlation with the degree of coronary artery stenosis and myocardial ischemia or viability.The secondary outcomes are represented by the rate of re-hospitalization, rate of survival and rate of major adverse cardiovascular events (including cardiovascular death or stroke), in correlation with the morphology and composition of atheromatous plaques located in a coronary artery, and myocardial ischemia in the territory irrigated by the same coronary artery. CONCLUSION: In conclusion, FUSE-HEART will be a study based on modern imaging tools that will investigate the impact of a coronary artery stenosis on myocardial function and viability, using advanced fusion imaging technics derived from CCTA, sighting to validate plaque composition and morphology, together with inflammatory biomarkers, as predictors to myocardial viability.

From CT to artificial intelligence for complex assessment of plaque-associated risk.

The recent technological developments in the field of cardiac imaging have established coronary computed tomography angiography (CCTA) as a first-line diagnostic tool in patients with suspected coronary artery disease (CAD). CCTA offers robust information on the overall coronary circulation and luminal stenosis, also providing the ability to assess the composition, morphology, and vulnerability of atherosclerotic plaques. In addition, the perivascular adipose tissue (PVAT) has recently emerged as a marker of increased cardiovascular risk. The addition of PVAT quantification to standard CCTA imaging may provide the ability to extract information on local inflammation, for an individualized approach in coronary risk stratification. The development of image post-processing tools over the past several years allowed CCTA to provide a significant amount of data that can be incorporated into machine learning (ML) applications. ML algorithms that use radiomic features extracted from CCTA are still at an early stage. However, the recent development of artificial intelligence will probably bring major changes in the way we integrate clinical, biological, and imaging information, for a complex risk stratification and individualized therapeutic decision making in patients with CAD. This review aims to present the current evidence on the complex role of CCTA in the detection and quantification of vulnerable plaques and the associated coronary inflammation, also describing the most recent developments in the radiomics-based machine learning approach for complex assessment of plaque-associated risk.

Intracoronary Imaging for Assessment of Vascular Healing and Stent Follow-up in Bioresorbable Vascular Scaffolds.

Bioresorbable Vascular Scaffolds (BVS) are polymer-based materials implanted in the coronary arteries in order to treat atherosclerotic lesions, based on the concept that once the lesion has been treated, the material of the implanted stent will undergo a process of gradual resorption that will leave, in several years, the vessel wall smooth, free of any foreign material and with its vasomotion restored. However, after the first enthusiastic reports on the efficacy of BVSs, the recently published trials demonstrated disappointing results regarding long-term patency following BVS implantation, which were mainly attributed to technical deficiencies during the stenting procedure. Intracoronary imaging could play a crucial role for helping the operator to correctly implant a BVS into the coronary artery, as well as providing relevant information in the follow-up period. This review aims to summarize the role of intracoronary imaging in the follow-up of coronary stents, with a particular emphasis on the role of intravascular ultrasound and optical coherence tomography for procedural guidance during stent implantation and also for follow-up of bioabsorbable scaffolds.

Computed tomography versus invasive coronary angiography: design and methods of the pragmatic randomised multicentre DISCHARGE trial.

OBJECTIVES: More than 3.5 million invasive coronary angiographies (ICA) are performed in Europe annually. Approximately 2 million of these invasive procedures might be reduced by noninvasive tests because no coronary intervention is performed. Computed tomography (CT) is the most accurate noninvasive test for detection and exclusion of coronary artery disease (CAD). To investigate the comparative effectiveness of CT and ICA, we designed the European pragmatic multicentre DISCHARGE trial funded by the 7th Framework Programme of the European Union (EC-GA 603266). METHODS: In this trial, patients with a low-to-intermediate pretest probability (10-60 %) of suspected CAD and a clinical indication for ICA because of stable chest pain will be randomised in a 1-to-1 ratio to CT or ICA. CT and ICA findings guide subsequent management decisions by the local heart teams according to current evidence and European guidelines. RESULTS: Major adverse cardiovascular events (MACE) defined as cardiovascular death, myocardial infarction and stroke as a composite endpoint will be the primary outcome measure. Secondary and other outcomes include cost-effectiveness, radiation exposure, health-related quality of life (HRQoL), socioeconomic status, lifestyle, adverse events related to CT/ICA, and gender differences. CONCLUSIONS: The DISCHARGE trial will assess the comparative effectiveness of CT and ICA. KEY POINTS: • Coronary artery disease (CAD) is a major cause of morbidity and mortality. • Invasive coronary angiography (ICA) is the reference standard for detection of CAD. • Noninvasive computed tomography angiography excludes CAD with high sensitivity. • CT may effectively reduce the approximately 2 million negative ICAs in Europe. • DISCHARGE addresses this hypothesis in patients with low-to-intermediate pretest probability for CAD.

Multislice computed tomographic coronary angiography for quantitative assessment of culprit lesions in acute coronary syndromes.

BACKGROUND: We studied the characteristics of low-density plaque (LDP) burden in patients with acute coronary syndrome (ACS), using 64-slice computed tomography (CT) assessment. Though several CT plaque features such as positive remodelling, adjacent spotty calcification or the presence of LDP have been demonstrated to be associated with unstable plaques, it is still unknown whether their severity and extent present any differences between different types of ACS. METHODS: In 45 subjects with ACS (22 unstable angina and 23 non-ST-elevation myocardial infarction [NSTEMI]), 118 coronary plaques were evaluated using a CT multislice 64 assessment including the burden with atheroma having a CT density below 30, 60, or 100 Hounsfield units (HU), remodelling index and spotty calcification. RESULTS: Culprit lesions tend to be larger in volume (111.11 mm(3) vs 62.25 mm(3); P < 0.0001), have a higher remodelling index (1.27 vs 1.01; P < 0.0001), and present a significantly larger LDP with a density < 30 HU (23.3 mm(3) vs 7.6 mm(3); P < 0.0001) or < 60 HU (33.4 mm(3) vs 16.9 mm(3); P < 0.0001) than nonculprit lesions. The presence of a plaque more than 20 mm(3) in volume with a CT density < 30 HU (P = 0.0009) and the presence of all 3 markers of plaque vulnerability (LDP, spotty calcifications or positive remodelling) (P = 0.01) significantly correlated with the presence of an NSTEMI. CONCLUSIONS: Culprit lesions demonstrated larger plaque volumes, a higher burden with low-density cores, and more intense remodelling than nonculprit lesions, whereas culprit lesions associated with NSTEMI showed a higher burden with lower density cores than those associated with unstable angina.