Non-invasive assessment of atherosclerotic coronary lesion length using multidetector computed tomography angiography: comparison to quantitative coronary angiography.

Multidetector computed tomography angiography (CTA) provides information on plaque extent and stenosis in the coronary wall. More accurate lesion assessment may be feasible with CTA as compared to invasive coronary angiography (ICA). Accordingly, lesion length assessment was compared between ICA and CTA in patients referred for CTA who underwent subsequent percutaneous coronary intervention (PCI). 89 patients clinically referred for CTA were subsequently referred for ICA and PCI. On CTA, lesion length was measured from the proximal to the distal shoulder of the plaque. Quantitative coronary angiography (QCA) was performed to analyze lesion length. Stent length was recorded for each lesion. In total, 119 lesions were retrospectively identified. Mean lesion length on CTA was 21.4 ± 8.4 mm and on QCA 12.6 ± 6.1 mm. Mean stent length deployed was 17.4 ± 5.3 mm. Lesion length on CTA was significantly longer than on QCA (difference 8.8 ± 6.7 mm, P < 0.001). Moreover, lesion length visualized on CTA was also significantly longer than mean stent length (CTA lesion length-stent length was 4.2 ± 8.7 mm, P < 0.001). Lesion length assessed by CTA is longer than that assessed by ICA. Possibly, CTA provides more accurate lesion length assessment than ICA and may facilitate improved guidance of percutaneous treatment of coronary lesions.

Multi-slice computed tomography coronary angiography: anatomic vs functional assessment in clinical practice.

Non-invasive imaging plays an increasingly important role in the diagnosis and risk stratification of coronary artery disease (CAD). Several techniques such as stress echocardiography and myocardial perfusion imaging have become available to assess cardiac function and myocardial perfusion. With the arrival of multi-slice computed tomography coronary angiography (CTA), non-invasive imaging of coronary anatomy has also become possible. Studies concerning the diagnostic accuracy have demonstrated a good agreement with conventional coronary angiography resulting in a sensitivity and specificity of approximately 86% and 96%, respectively. The high negative predictive value of 97% renders it particularly useful to rule out the presence of CAD in patients with an intermediate pretest likelihood. Moreover, comparative studies have demonstrated that anatomic imaging with CTA may provide information complementary to the traditionally used techniques for functional assessment. From these studies can be derived that only approximately 50% of significant stenoses on CTA are functionally relevant; a large proportion of significant (>50%) lesions on CTA does not result in perfusion abnormalities. Alternatively, many patients with a normal perfusion CTA show considerable atherosclerosis on CTA. Therefore, the combined use of these techniques may enhance the assessment of the presence and extent of CAD. In the future diagnostic algorithms, combining non-invasive anatomic and functional imaging need to be evaluated in large patient populations to establish their efficacy, safety, and cost effectiveness. Importantly, these investigations should result in the development of comprehensive guidelines on the use of CTA in clinical practice as well.

[Infusion of inotropic agents at home in patients with severe heart failure: an important role for the nurse practitioner]. / Thuisinfusie van inotropica bij ernstig hartfalen; een belangrijke rol voor de 'nurse practitioner'.

Patients with severe heart failure commonly require intravenous inotropic agents to stabilise their haemodynamics and improve the clinical symptoms. Continuous intravenous inotropic agents in a home-based setting under the direction of specialised nurses has been introduced in patients waiting for cardiac transplantation and also as destination therapy. Since 1982, several case reports and case series have described the use of ambulatory intravenous dobutamine, but almost none of the available studies included a control group. Moreover, most trials were small and short in duration, and thus have not been able to provide reliable information about the effect of treatment on the risk of serious cardiac events. However, these data consistently demonstrate the feasibility of home infusion as well as an improved quality of life and reduced costs. Therefore, home infusion of dobutamine guided by a specialised nurse may be desirable in patients waiting for heart transplantation or as destination therapy in the last weeks of life.

Assessment of left ventricular volumes and ejection fraction with 16-slice multi-slice computed tomography; comparison with 2D-echocardiography.

BACKGROUND: In recent years, multi-slice computed tomography (MSCT) has emerged as a rapidly expanding modality for non-invasive assessment of coronary artery disease. Simultaneously, left ventricular (LV) function can be evaluated although this is not yet a routine component of an MSCT examination. Accordingly, the purpose of the present study was to validate assessment of LV function with MSCT using 2D-echocardiography in a large cohort of patients. METHODS: In 70 patients (57 male, 13 female), 16-slice MSCT was performed (Toshiba Aquilion 16, Japan) followed by retrospective analysis of global LV function. For these measurements, 2D-echocardiography served as the standard of reference. RESULTS: For LV volumes, excellent correlations for both end-diastolic volume (EDV) (r=0.97) and end-systolic volume (ESV) (r=0.98) were obtained by linear regression analysis. At Bland-Altman analysis, mean differences (+/-standard deviations) of -1.4 ml+/-11.3 ml and -3.0 ml+/-7.7 ml were observed between MSCT and 2D-echocardiography for LV EDV and LV ESV respectively. As a result, LV EF was slightly overestimated with MSCT (1.7%+/-4.9%, P<0.05). Correlation between the two techniques was excellent (r=0.91). CONCLUSION: In a large cohort of patients, an excellent correlation was observed between 16-slice MSCT and 2D-echocardiography in the evaluation of LV volumes and EF. The addition of LV function analysis to the anatomical MSCT data may potentially enhance the diagnostic and prognostic value of the technique.

Comprehensive cardiac assessment with multislice computed tomography: evaluation of left ventricular function and perfusion in addition to coronary anatomy in patients with previous myocardial infarction.

OBJECTIVE: To evaluate a comprehensive multislice computed tomography (MSCT) protocol in patients with previous infarction, including assessment of coronary artery stenoses, left ventricular (LV) function and perfusion. PATIENTS AND METHODS: 16-slice MSCT was performed in 21 patients with previous infarction; from the MSCT data, coronary artery stenoses, (regional and global) LV function and perfusion were assessed. Invasive coronary angiography and gated single-photon emission computed tomography (SPECT) served as the reference standards for coronary artery stenoses and LV function/perfusion, respectively. RESULTS: 236 of 241 (98%) coronary artery segments were interpretable on MSCT. The sensitivity and specificity for detection of stenoses were 91% and 97%. Pearson's correlation showed excellent agreement for assessment of LV ejection fraction between MSCT and SPECT (49 (13)% v 53 (12)%, respectively, r = 0.85). Agreement for assessment of regional wall motion was excellent (92%, kappa = 0.77). In 68 of 73 (93%) segments, MSCT correctly identified a perfusion defect as compared with SPECT, whereas the absence of perfusion defects was correctly detected in 277 of 284 (98%) segments. CONCLUSIONS: MSCT permits accurate, non-invasive assessment of coronary artery stenoses, LV function and perfusion in patients with previous infarction. All parameters can be assessed from a single dataset.

Nuclear cardiac imaging for the assessment of myocardial viability.

An important aspect of the diagnostic and prognostic work-up of patients with ischaemic cardiomyopathy is the assessment of myocardial viability. Patients with left ventricular dysfunction who have viable myocardium are the patients at highest risk because of the potential for ischaemia but at the same time benefit most from revascularisation. It is important to identify viable myocardium in these patients, and radionuclide myocardial scintigraphy is an excellent tool for this. Single-photon emission computed tomography perfusion scintigraphy (SPECT), whether using 201thallium, 99mTc-sestamibi, or 99mTc- tetrofosmin, in stress and/or rest protocols, has consistently been shown to be an effective modality for identifying myocardial viability and guiding appropriate management. Metabolic and perfusion imaging with positron emission tomography radiotracers frequently adds additional information and is a powerful tool for predicting which patients will have an improved outcome from revascularisation. New techniques in the nuclear cardiology field, such as attenuation corrected SPECT, dual isotope simultaneous acquisition (DISA) SPECT and gated FDG PET are promising and will further improve the detection of myocardial viability. Also the combination of multislice computed tomography scanners with PET opens possibilities of adding coronary calcium scoring and noninvasive coronary angiography to myocardial perfusion imaging and quantification.

Magnetic resonance imaging of the main pulmonary artery: reliable assessment of dimensions in Marfan patients on a simple axial spin echo image.

OBJECTIVE: To investigate if a simple axial spin echo (SE) image can be used for reliable assessment of pulmonary artery dimensions in patients with Marfan syndrome. METHODS: Fifty Marfan patients (mean age 33 +/- 10 years; 34 men, 16 women) and 15 normal subjects (mean age 28 +/- 4 years; nine men, six women) underwent cardiac magnetic resonance imaging (MRI). Pulmonary artery dimensions were obtained on axial SE images at two different levels: (1) the level of the pulmonary artery root, and (2) the level of the pulmonary artery bifurcation. To evaluate the accuracy of axial plane measurements 10 Marfan patients also underwent contrast-enhanced MR angiography (CE-MRA). RESULTS: In the 10 Marfan patients who also underwent CE-MRA, the mean diameter at the pulmonary bifurcation assessed with CE-MRA (31.5 +/- 3.6 mm) was almost equal to mean diameter assessed with axial SE (30.7 +/- 3.6 mm). Agreement of methodology according to Bland and Altman analysis showed a 95% confidence interval ranging from -2.6 to + 4.4 mm for all distances of the pulmonary artery root. In Marfan patients the mean right-left diameter measured on both axial SE images and CE-MRA was approximately 2.5 mm larger than the anterior-right and anterior-left diameters (p < 0.001). CONCLUSIONS: Axial SE MRI is a reliable and easy acquisition to measure pulmonary artery dimensions in patients with Marfan syndrome, and could be used for follow-up, especially in patients with severe involvement of the cardiovascular system. Not only the pulmonary artery trunk but also the asymmetric pulmonary root should be measured, although the clinical relevance of the asymmetric root is not yet known.

Assessment of quality of life in patients with angina pectoris: Progress made by the Dutch Mononitrate Quality-Of-Life (DUMQOL) Study Group.

BACKGROUND: Two major issues in quality of life (QOL) research are the patient's opinion as a contributing factor in QOL assessments, and the lack of sensitivity of QOL assessments. OBJECTIVES: To review results from recent research by the Dutch Mononitrate Quality Of Life (DUMQOL) Study Group relevant to these two issues. METHODS: Using a test battery including Stewart's Short Form (SF)-36 Questionnaire and the DUMQOL-50 questionnaire, the DUMQOL Study Group tested the hypothesis that the patient's opinion might be an independent determinant of QOL. To do this, a stepwise multiple regression analysis of data from 82 patients attending an outpatient clinic with stable angina pectoris was performed. Secondly, using an odds ratio approach to QOL scores in 1350 outpatients with stable angina pectoris who were attending a clinic, the DUMQOL Study Group assessed the question whether relative scores might provide increased precision in estimating the effects of patient characteristics on QOL data. RESULTS: Psychological distress was the most important contributor to QOL (beta 0.43, p<0.0001). Also, the patient's opinion on his/her QOL significantly contributed to QOL (beta 0.22, p=0.032). Physical health status according to the patient's judgement only made a borderline contribution (beta 0.19, p=0.71), while the physician's judgement was not associated with QOL at all (beta 0.11, p=0.87). Regarding the second issue, increased QOL difficulties were observed in New York Heart Association (NYHA) angina class III-IV patients, in patients with comorbidity, as well as in female and elderly patients. Odds ratios can be used in these categories to predict the benefit from treatments. CONCLUSIONS: Recent QOL research of the DUMQOL Study Group allows conclusions to be drawn that are relevant to clinical practice. QOL should be defined in a subjective rather than an objective method. The patient's opinion is an important independent contributor to QOL. The comparison of absolute QOL scores lacks the sensitivity to truly estimate QOL. The odds ratio approach of QOL scores provides increased precision in estimating QOL.

Quantitative assessment of dural ectasia as a marker for Marfan syndrome.

PURPOSE: To establish normal values for lumbosacral dural sac dimensions with magnetic resonance (MR) imaging and to use these values to assess the sensitivity and specificity of dural ectasia as a marker for Marfan syndrome. MATERIALS AND METHODS: MR imaging was performed to measure dural sac diameter (DSD) from L1 through S1 in 44 adult patients with Marfan syndrome and in 44 matched control subjects. DSD values were corrected for vertebral body size, yielding dural sac ratios (DSRs). The control subjects served to establish the upper limit of normal DSR values at the L1 through S1 levels. RESULTS: Cutoff values for normal DSRs for L1 through S1 were 0.64, 0.55, 0.47, 0.48, 0.48, and 0.57. Significant DSR differences were shown at all levels between patients with Marfan syndrome and control subjects (P <.001 at all levels). At L1 through S1, the sensitivity of dural ectasia as a marker for Marfan syndrome was 45%-77%, and the specificity was 95% or greater. By combining levels L3 and S1, dural ectasia as a marker for Marfan syndrome yielded a sensitivity of 95% (42 of 44 patients) and a specificity of 98% (43 of 44). The presence of dural ectasia excelled, compared with the presence of other Marfan syndrome manifestations in the patient population. CONCLUSION: Abnormal DSR values at L3 or S1 can be used to identify Marfan syndrome with 95% sensitivity and 98% specificity.

Assessment of regional myocardial wall motion and thickening by gated 99Tcm-tetrofosmin SPECT: a comparison with magnetic resonance imaging.

Gated single photon emission computed tomography (SPECT) imaging allows the simultaneous assessment of both perfusion and function by using one single study. The assessment of regional wall motion and thickening pattern with gated SPECT allows viability studies to be performed. Magnetic resonance imaging (MRI) is well validated for the assessment of myocardial wall motion and thickening in patients with normal and impaired ventricular function. The aim of the study was to analyse the concordance between wall motion and thickening scores derived by gated SPECT and MRI imaging. Furthermore, the agreement for myocardial wall motion and thickening according to myocardial perfusion was analysed with both techniques. We studied a group of 21 patients, including 13 with a previous myocardial infarction (all more than 4 months before the study), using both gated SPECT 99Tcm-tetrofosmin myocardial perfusion imaging and MRI. A 13-segment model was used for both gated SPECT and MRI and each segment was visually scored using a scale of 1-3 for wall motion and thickening. There was a high agreement between gated SPECT and MRI for both wall motion (229/273, 84%; k = 0.72, P<0.001) and wall thickening (236/273, 86%; k = 0.77, P<0.001). The agreement for wall motion and thickening was 80% (k = 0.66) and 83% (k = 0.70), respectively, for patients with myocardial infarction; and 90% (k = 0.81) and 92% (k = 0.86), respectively (P = NS), for patients without myocardial infarction. Agreement in segmental wall motion and thickening scores between gated SPECT and MRI was 90% (k = 0.80) and 91% (k = 0.84), respectively, for segments with normal or mild to moderate hypoperfusion; and 71% (k = 0.45) and 77% (k = 0.57), respectively, for segments with severe hypoperfusion or no perfusion. Of the 70 (41%) segments that had severely diminished or no perfusion in post-myocardial infarction patients, 22 (31%) showed preserved wall motion and 17 (24%) showed preserved wall thickening both by gated SPECT and MRI, suggesting residual myocardial viability in malperfused segments. Our results suggest that gated SPECT imaging is a reliable tool for the assessment of regional wall motion and thickening in patients with known or suspected coronary artery disease. In patients with a previous myocardial infarction gated SPECT imaging has the potential to detect preserved wall motion and thickening in regions with fixed perfusion defects indicating the potential presence of residual myocardial viability.

Prognostic value and quality of life in patients with normal rest thallium-201/stress technetium 99m-tetrofosmin dual-isotope myocardial SPECT.

BACKGROUND: The prognostic value of normal dual-isotope single photon emission computed tomography (SPECT), with technetium 99m-tetrofosmin for the stress images, is not well known. Furthermore, thallium-201 cross talk in the Tc-99m window may reduce the defect severity of the Tc-99m images. METHODS AND RESULTS: In a consecutive series of 610 patients, 246 patients with normal rest and stress SPECT images by means of visual semiquantitative analysis were included. The patients' pre-test likelihood of coronary artery disease was determined, based on age, sex, symptoms, and the results of stress electrocardiography. Quality of life was assessed by using a mailed self-administered general quality-of-life questionnaire. We compared the mean scores (8 dimensions) of our study population with the scores of 1063 control subjects, sampled randomly out of the inhabitant register of a Dutch city. The mean follow-up period was 25+/-3 months. Compared with the control group, patients in our study scored lower (less perceived health) for all dimensions of the SF-36 (P<.05), suggesting a selection of symptomatic or otherwise diseased patients. The primary cardiac event rate was 0.4% per year. The cardiac events occurred in patients with an intermediate-to-high pre-test likelihood of disease and negative or nondiagnostic exercise electrocardiographic results. In a subset of patients with a high pre-test likelihood of coronary artery disease (more than 85%), the primary cardiac event rate was 0.7% per year. CONCLUSIONS: Patients with normal results on dual-isotope myocardial perfusion scintigraphy, performed with Tc-99m-tetrofosmin for the stress images, have an excellent prognosis. Furthermore, our results suggest that Tl-201 cross talk in the Tc-99m window may be low and functionally and clinically unimportant.