The performance of non-ECG gated chest CT for cardiac assessment - The cardiac pathologies in chest CT (CaPaCT) study.

PURPOSE: Evaluating the prevalence of CAD on non-ECG gated chest CTs, image quality (IQ) and the clinical performance of the CAD-RADS classification for predicting cardiovascular events (CVE). METHODS: 215 consecutive patients referred for chest CTs between May 2016 and March 2018 were included (3rd-generation DSCT) using non-ECG gated acquisitions with automated tube voltage selection (110kVqual.ref/40mAsqual.ref), pitch 2.65-3.0 and individualized contrast media injection protocols. Dedicated cardiac post-processing reconstructions (0.6 mm/0.4 mm/Kernel Bv36) were added to standard chest reconstructions. Two independent cardiac radiologists performed a 3-step analysis. In case of discrepancy, a third reader gave the final decision. Step 1: visual presence of calcifications; 2: scans with calcifications assessed for IQ using a 5-point Likert scale (poor/sufficient/moderate/good/excellent); 3: stenosis severity was analysed in detail (if Likert sufficient-excellent using CAD-RADS). Electronic patient files were checked to see if pathology was previously mentioned (incidental) and whether patients developed an CVE during follow-up. RESULTS: 1: Calcifications were present in 156/215 cases (72.6 %), 74 of these were incidental. 2: In 68/156 (43.6 %) patients with calcifications IQ was rated sufficient-excellent. 3: CAD-RADS≥3 was seen in 39/68 patients (57.4 %), 12 times (30.8 %) findings were incidental. During follow-up (median 16 [0-35] months), 7/39 (18 %) patients with CAD-RADS≥3 developed a CVE. 17 patients died during follow-up. CONCLUSION: Coronary calcification on non ECG-gated chest CTs was detected in 72.6 % of patients, cardiac assessment was feasible in nearly half of these patients. Only patients with a CAD-RADS≥3 developed CVE, therefore the CAD-RADS may help identify and guide patients at risk of future CVE.

Impact on clinical practice of updated guidelines on iodinated contrast material: CINART.

OBJECTIVE: Guidelines on safe use of iodinated contrast material recommend intravenous prophylactic hydration to prevent post-contrast adverse (renal) effects. Recently, guidelines have been updated and standard prophylaxis is no longer recommended for the majority of patients. The current study aims to evaluate the consequences for clinical practice of the updated guidelines in terms of complications, hospitalisations, and costs. METHODS: The Contrast-Induced Nephropathy After Reduction of the prophylaxis Threshold (CINART) project is a retrospective observational study. All elective procedures with intravascular iodinated contrast administration at Maastricht University Medical Centre (UMC+) in patients aged > 18 years, formerly eligible for prophylaxis (eGFR 30-44 ml/min/1.73 m2 or eGFR 45-59 ml/min/1.73 m2 in combination with diabetes or > 1 predefined risk factor), and currently eligible for prophylaxis (eGFR < 30 ml/min/1.73 m2) were included. Data were used to calculate relative reductions in complications, hospitalisations, and costs associated with standard prophylactic intravenous hydration. CINART is registered with Clinicaltrials.gov: NCT03227835. RESULTS: Between July 1, 2017, and July 1, 2018, 1992 elective procedures with intravascular iodinated contrast in patients formerly and currently eligible for prophylaxis were identified: 1808 in patients formerly eligible for prophylaxis and 184 in patients currently eligible for prophylaxis. At Maastricht UMC+, guideline updates led to large relative reductions in numbers of complications of prophylaxis (e.g. symptomatic heart failure; - 89%), extra hospitalisations (- 93%), and costs (- 91%). CONCLUSION: Guideline updates have had a demonstrable impact on daily clinical practice benefiting patient, hospital, and health care budgets. Clinical practice varies between institutions and countries; therefore, a local estimation model is provided with which local impact on costs, hospitalisations, and complications can be calculated. KEY POINTS: • Clinical practice guidelines recommend prophylactic intravenous hydration to prevent post-contrast adverse outcomes such as contrast-induced acute kidney injury. • Clinical practice guidelines have recently been updated, and standard prophylaxis is no longer recommended for the majority of patients. • The guideline updates have a large impact on daily clinical practice: relative reductions at Maastricht UMC+ were - 89% prophylaxis complications, - 93% hospitalisations, and - 91% costs, and similar reductions are expected for Dutch and adherent European medical centres.

Rapid Access to Contrast-Enhanced spectral mammogRaphy in women recalled from breast cancer screening: the RACER trial study design.

BACKGROUND: In the Dutch breast cancer screening program, women recalled with a BI-RADS 0 score are referred for additional imaging, while those with BI-RADS 4/5 scores are also directed to an outpatient breast clinic. Approximately six out of ten women are recalled without being diagnosed with a malignancy. However, these recalls require additional imaging and doctor visits, which result in patient anxiety and increased health care costs. Conventional types of imaging used for additional imaging are full-field digital mammography and tomosynthesis. Contrast-enhanced spectral mammography has proved to have higher sensitivity and specificity than conventional imaging in women recalled from screening. Therefore, the aim is to study if CESM instead of conventional imaging is a more accurate, patient-friendly, and cost-effective strategy in the work-up of women recalled from breast cancer screening. METHODS: This prospective, multicenter, randomized controlled trial will be conducted at four centers and will include 528 patients recalled for suspicious breast lesions from the Dutch breast cancer screening program. Participants are randomized in two groups: (1) standard care using conventional breast imaging techniques as initial imaging after recall versus (2) work-up primarily based on CESM. Written informed consent will be collected prior to study inclusion. The primary outcome is the diagnostic accuracy for detection of breast cancer. Secondary outcomes are numbers of additional diagnostic exams, days until final diagnosis, health care costs, and experienced patient anxiety. DISCUSSION: Based on previously published retrospective studies, we expect to demonstrate in this prospective multicenter randomized controlled trial, that using CESM as a primary work-up tool in women recalled from breast cancer screening is a more accurate, cost-effective, and patient-friendly strategy. TRIAL REGISTRATION: Netherlands Trial Register, NL6413/NTR6589. Registered on 6 July, 2017.

[Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial]. / Preventieve intraveneuze hydratie ter voorkoming van contrastnefropathie helpt niet.

BACKGROUND: Intravenous saline is recommended in clinical practice guidelines as the cornerstone for preventing contrast-induced nephropathy in patients with compromised renal function. However, clinical-effectiveness and cost-effectiveness of this prophylactic hydration treatment in protecting renal function has not been adequately studied in the population targeted by the guidelines, against a group receiving no prophylaxis. This was the aim of the AMACING trial. METHODS: AMACING is a prospective, randomised, phase 3, parallel-group, open-label, non-inferiority trial of patients at risk of contrast-induced nephropathy according to current guidelines. High-risk patients (with an estimated glomerular filtration rate [eGFR] of 30-59 mL per min/1·73 m²) aged 18 years and older, undergoing an elective procedure requiring iodinated contrast material administration at Maastricht University Medical Centre, the Netherlands, were randomly assigned (1:1) to receive intravenous 0·9% NaCl or no prophylaxis. We excluded patients with eGFR lower than 30 mL per min/1·73 m², previous dialysis, or no referral for intravenous hydration. Randomisation was stratified by predefined risk factors. The primary outcome was incidence of contrast-induced nephropathy, defined as an increase in serum creatinine from baseline of more than 25% or 44 µmol/L within 2-6 days of contrast exposure, and cost-effectiveness of no prophylaxis compared with intravenous hydration in the prevention of contrast-induced nephropathy. We measured serum creatinine immediately before, 2-6 days, and 26-35 days after contrast-material exposure. Laboratory personnel were masked to treatment allocation. Adverse events and use of resources were systematically recorded. The non-inferiority margin was set at 2·1%. Both intention-to-treat and per-protocol analyses were done. This trial is registered with ClinicalTrials.gov, number NCT02106234. FINDINGS: Between June 17, 2014, and July 17, 2016, 660 consecutive patients were randomly assigned to receive no prophylaxis (n=332) or intravenous hydration (n=328). 2-6 day serum creatinine was available for 307 (92%) of 332 patients in the no prophylaxis group and 296 (90%) of 328 patients in the intravenous hydration group. Contrast-induced nephropathy was recorded in eight (2·6%) of 307 non-hydrated patients and in eight (2·7%) of 296 hydrated patients. The absolute difference (no hydration vs hydration) was -0·10% (one-sided 95% CI -2·25 to 2·06; one-tailed p=0·4710). No hydration was cost-saving relative to hydration. No haemodialysis or related deaths occurred within 35 days. 18 (5·5%) of 328 patients had complications associated with intravenous hydration. INTERPRETATION: We found no prophylaxis to be non-inferior and cost-saving in preventing contrast-induced nephropathy compared with intravenous hydration according to current clinical practice guidelines.

64-slice computed tomography assessment of coronary artery stents: a phantom study.

PURPOSE: To compare the use of a new 64-slice computed tomography (CT) scanner with 16-slice CT in the visualization of coronary artery stent lumen. MATERIAL AND METHODS: Eight different coronary artery stents, each with a diameter of 3 mm, were placed in a static chest phantom. The phantom was positioned in the CT gantry at an angle of 0 degrees and 45 degrees towards the z-axis and examined with both a 64-slice and a 16-slice CT scanner. Effective slice thickness was 0.6 mm with 64-slice CT and 1 mm with 16-slice CT. A reconstruction increment of 0.3 mm was applied in both scanners. Image quality was assessed visually using a 5-point grading scale. Stent diameters were measured and compared using paired Wilcoxon tests. RESULTS: Artificial lumen reduction was significantly less with 64-slice than with 16-slice CT. Average visible stent lumen was 53.4% using 64-slice CT and 47.5% with 16-slice MSCT. Most severe artifacts were seen in stents with radiopaque markers. Using 64-slice CT, image noise increased by approximately 30% due to thinner slice thickness. CONCLUSION: Improved spatial resolution of 64-slice CT resulted in superior assessment of coronary artery stent lumen compared to 16-slice CT. However, a relevant part of the stent lumen is still not assessable with multi-slice CT.

[Value of cardiac multislice spiral CT for the assessment of degenerative aortic stenosis: comparison with echocardiography]. / Wertigkeit der kardialen Mehrschicht-Spiral-CT zur Beurteilung der degenerativen Aortenklappenstenose: Vergleich zur Echokardiographie.

OBJECTIVE: To non-invasively assess the severity of aortic valve stenosis (AS) by the determination of aortic valve calcification (AVC) using multislice spiral computed tomography (MSCT). MATERIALS AND METHODS: Forty-one consecutive patients (17 male, 24 female, mean age 71.0 +/- 7.9 years) with a history of AS and an aortic valve area < or = 2 cm (2) underwent retrospectively ECG-gated 4-slice MSCT and echocardiography. The AVCs were quantitatively assessed using the score described by Agatston as well as by calculating the calcium mass. The echocardiographically determined aortic valve area (AVA) and the severity of AS according to the ACC/AHA guidelines were compared to the degree of aortic valve calcifications. Pearson's correlation coefficient, cut-off values, kappa test and F-test with post hoc Bonferroni t-tests were calculated. RESULTS: Calcium scores were significantly higher in patients with severe AS, when compared to mild or moderate AS (p < 0.001). In patients suffering from severe AS, the mean Agatston score was 4125.5 +/- 1168.9 (calcium mass 904.1 +/- 263.3) while in patients with moderate and mild AS the corresponding values were 1596.3 +/- 987.0 (319.1 +/- 208.3) and 785.9 +/- 390.1 (149.1 +/- 90.2), respectively. Pearson's correlation coefficients were r = - 0.75 for the Agatston score and r = - 0.72 for the calcium mass. There was a moderate agreement between severity of AS according to the ACC/AHA guidelines and the degree of AS determined from AVC scores with kappa = 0.6091 and kappa = 0.6985, respectively. CONCLUSION: Severe AS may be differentiated from moderate or mild AS using cardiac MSCT. Extensive calcifications of the aortic valve presenting with an Agatston-Score > or = 2824 (calcium mass > or = 611) indicate a severe AS and should be taken as an indication for further diagnostic workup.

Quantitative and qualitative assessment of left ventricular volume with ECG-gated multislice spiral CT: value of different image reconstruction algorithms in comparison to MRI.

PURPOSE: To assess the value of different image reconstruction algorithms for assessment of the left ventricular function using retrospectively ECG-gated multislice spiral computed tomography (MSCT) of the heart. MATERIAL AND METHODS: MSCT and cine magnetic resonance (MR) imaging of the heart were performed in 15 patients. For MSCT, standard and multisegmental image reconstruction with improved temporal resolution were used. Standardized multiplanar reformats in the short axis and long axis views were reconstructed from MSCT data. End-systolic (ESV) and end-diastolic volume (EDV), stroke volume (SV), ejection fraction (EF) and myocardial mass (MM) were calculated. Left ventricular wall motion was assessed qualitatively. RESULTS: MSCT was in acceptable agreement with MR imaging for quantification of the ventricular function. According to the Bland-Altman approach the mean differences for the left ventricular volumes (ESV, EDV, SV) ranged from -9.6 ml to 3.1 ml with standard image reconstruction and from -0.6 ml to 1.9 ml utilizing multisegmental image reconstruction with limits of agreement ranging from -26.6 ml to 12.5 ml and -15.6 ml to 15.0 ml, respectively. Applying the multisegmental image reconstruction algorithm, a significantly improved agreement with the MR data was found for EDV, SV and EF. For wall motion analysis, standard image reconstruction showed a significant difference to MR imaging with a correspondence in 83.75% of the 240 assessed segments, while multisegmental image reconstruction agreed with MR imaging in 92.5% of the segments. CONCLUSION: Multisegmental image reconstruction improves the quantitative assessment of left ventricular function when compared to standard image reconstruction. Multisegmental image reconstruction allows qualitative wall motion analysis.

Value of 3D-volume rendering in the assessment of coronary arteries with retrospectively ECG-gated multislice spiral CT.

PURPOSE: To assess the diagnostic value and measurement precision of 3D volume rendering technique (3D-VRT) from retrospectively ECG-gated multislice spiral CT (MSCT) data sets for imaging of the coronary arteries. MATERIAL AND METHODS: In 35 patients, retrospectively ECG-gated MSCT of the heart using a four detector row MSCT scanner with a standardized examination protocol was performed as well as quantitative X-ray coronary angiography (QCA). The MSCT data was assessed on segmental basis using 3D-VRT exclusively. The coronary artery diameters were measured at the origin of each main coronary branch and 1 cm, 3 cm and 5 cm distally. The minimum, maximum and mean diameters were determined from MSCT angiography and compared to QCA. RESULTS: A total of 353 of 525 (67.2%) coronary artery segments were assessable by MSCT angiography. The proximal segments were more often assessable when compared to the distal segments. Stenoses were detected with a sensitivity of 82.6% and a specificity of 92.8%. According to the Bland-Altman method the mean differences between QCA and MSCT ranged from -0.55 to 1.07 mm with limits of agreement from -2.2 mm to -2.7 mm. CONCLUSION: When compared to QCA, the ability of 3D-VRT to quantitatively assess coronary artery diameters and coronary artery stenoses is insufficient for clinical purposes.

[New TIPS placement in pregnancy in recurrent esophageal varices hemorrhage--assessment of fetal radiation exposure]. / TIPS-Neuanlage in der Schwangerschaft bei rezidivierender Osophagusvarizenblutung--Abschätzung der fetalen Strahlenexposition.

Recurrent variceal bleeding due to liver cirrhosis led to treatment with a transjugular intrahepatic portosystemic shunt (TIPS) in a pregnant woman at 20 weeks' gestation. Fetal radiation exposure was estimated to be less than 10 mSv. The use of a graduated catheter allowed measurement of field size and reliable determination of the patient's entrance dose. Radiation exposure of an approximated fetal dosage of 5.2 mSv did not justify abortion for medical reasons. Therefore, TIPS procedure is not generally contraindicated during pregnancy itself. TIPS placement may be a therapeutic option related to the severity of the underlying maternal disease, after radiation exposure of the fetus has been estimated.