Thoracic versus coronary calcification for atherosclerotic cardiovascular disease events prediction.

This study compared the prognostic value of quantified thoracic artery calcium (TAC) including aortic arch on chest CT and coronary artery calcium (CAC) score on ECG-gated cardiac CT. METHODS: A total of 2412 participants who underwent both chest CT and ECG-gated cardiac CT at the same period were included in the Multi-Ethnic Study of Atherosclerosis Exam 5. All participants were monitored for incident atherosclerotic cardiovascular disease (ASCVD) events. TAC is defined as calcification in the ascending aorta, aortic arch and descending aorta on chest CT. The quantification of TAC was measured using the Agatston method. Time-dependent receiver-operating characteristic (ROC) curves were used to compare the prognostic value of TAC and CAC scores. RESULTS: Participants were 69±9 years of age and 47% were male. The Spearman correlation between TAC and CAC scores was 0.46 (p<0.001). During the median follow-up period of 8.8 years, 234 participants (9.7%) experienced ASCVD events. In multivariable Cox regression analysis, TAC score was independently associated with increased risk of ASCVD events (HR 1.31, 95% CI 1.09 to 1.58) as well as CAC score (HR 1.82, 95% CI 1.53 to 2.17). However, the area under the time-dependent ROC curve for CAC score was greater than that for TAC score in all participants (0.698 and 0.641, p=0.031). This was particularly pronounced in participants with borderline/intermediate and high 10-year ASCVD risk scores. CONCLUSION: Our study demonstrated a significant association between TAC and CAC scores but a superior prognostic value of CAC score for ASCVD events. These findings suggest TAC on chest CT provides supplementary data to estimate ASCVD risk but does not replace CAC on ECG-gated cardiac CT.

Hirsutella sinensis fungus improves cardiac function in mouse model of heart failure.

Cordyceps sinensis, including Hirsutella sinensis, is a highly valuable traditional Chinese medicine and is used to treat patients with pulmonary heart disease in clinical practice. However, the underlying mechanisms of its effects remain unclear. In this study, a mouse model of heart failure established by non-thoracic, transverse aortic constriction (TAC) was developed to determine the underlying mechanisms of therapeutic effects of Hirsutella sinensis fungus (HSF) powder. The results showed that HSF treatment remarkably ameliorated myocardial hypertrophy, collagen fiber hyperplasia, and cardiac function in mice with heart failure. Using transcriptional and epigenetic analyses, we found that the mechanism of HSF mainly involved a variety of signaling pathways related to myocardial fibrosis and determined that HSF could reduce the levels of TGF-ß1 proteins in heart tissue, as well as type I and III collagen levels. These data suggest that HSF alleviates heart failure, inhibits irreversible ventricular remodeling, and improves cardiac function through the regulation of myocardial fibrosis-related signaling pathways, which can provide novel opportunities to improve heart failure therapy.

Chimney reconstruction provides a wider subaortic space and reduces the risk of pulmonary artery compression in the Norwood-type aortic arch reconstruction without patch supplementation.

OBJECTIVES: Pulmonary artery (PA) compression by the neoaorta is a serious complication after the Norwood-type palliation (NP) for hypoplastic left heart syndrome. Either excess patch tailoring or limited use of autologous tissue may cause narrowing of the subaortic space. The chimney technique could theoretically provide a wide subaortic space. METHODS: Twenty-nine patients with both pre- and post-NP computed tomography data available of the 37 consecutive patients who underwent NP in our institution were reviewed. Arch height, arch width, sinus of Valsalva diameter, area under the neoaortic arch and arch angle were measured. These patients were divided according to the neo-arch reconstruction technique, chimney reconstruction technique (CR) or conventional direct reconstruction technique (DR). RESULTS: Median age and weight at NP were 2.1 months and 3.5 kg, respectively. Twenty-two patients underwent previous bilateral PA banding. During NP, 17 CR and 12 DR were performed. Four patients in the DR group developed PA compression. No neoaortic arch dilatation was found in either group. Post-NP arch width, area under the neo-arch and the arch angle were significantly larger in the CR group. Pre-NP arch height was significantly smaller in DR patients with PA compression than in those without. CONCLUSIONS: The chimney technique decreased the risk of PA compression and provided a wider subaortic space and a less acute arch angle. This technique had no short-term effect on the neoaortic root. Small preoperative arch height is a potential risk factor for PA compression in DR, and the chimney technique could be an effective solution.

Allyl Methyl Sulfide Preserved Pressure Overload-Induced Heart Failure Via Modulation of Mitochondrial Function.

BACKGROUND: Cardiovascular diseases are the leading cause of death globally, and they are causing enormous socio-economic burden to the developed and developing countries. Allyl Methyl Sulfide (AMS) is a novel cardioprotective metabolite identified in the serum of rats after raw garlic administration. The present study explored the cardioprotective effect of AMS on thoracic aortic constriction (TAC)-induced cardiac hypertrophy and heart failure model in rats. METHODS: Thoracic aortic constriction (TAC) by titanium ligating clips resulted in the development of pressure overload-induced cardiac hypertrophy and heart failure model. Four weeks prior to TAC and for 8 weeks after TAC, Sprague Dawley (SD) rats were administered with AMS (25 and 50 mg/kg/day) or Enalapril (10 mg/kg/day). RESULTS: We have observed AMS (25 and 50 mg/kg/day) intervention significantly improved structural and functional parameters of the heart. mRNA expression of fetal genes i.e., atrial natriuretic peptide (ANP), alpha skeletal actin (α-SA) and beta myosin heavy chain (ß-MHC) were reduced in AMS treated TAC hearts along with decrease in perivascular and interstitial fibrosis. AMS attenuated lipid peroxidation and improved protein expression of endogenous antioxidant enzymes i.e., catalase and manganese superoxide dismutase (MnSOD) along with electron transport chain (ETC) complex activity. AMS increased mitochondrial fusion proteins i.e., mitofusin 1 (MFN1), mitofusin 2 (MFN2) and optic atrophy protein (OPA1), and reduced fission protein i.e., dynamin-related protein 1 (DRP1). Preliminary study suggests that AMS intervention upregulated genes involved in mitochondrial bioenergetics in normal rats. Further, in-vitro studies suggest that AMS reduced mitochondrial reactive oxygen species (ROS), preserved mitochondrial membrane potential and oxygen consumption rate (OCR) in isoproterenol-treated cardiomyoblast. CONCLUSION: This study demonstrated that AMS protected cardiac remodelling, LV dysfunction and fibrosis in pressure overload-induced cardiac hypertrophy and heart failure model by improving endogenous antioxidants and mitochondrial function.

Stenting Coarctation of the "Fifth Aortic Arch": A Safe and Attractive Therapeutic Alternative to Surgery.

"Persistence of the fifth aortic arch" is a rare congenital cardiovascular anomaly that consists of an abnormal vessel arising from the distal ascending aorta connecting with the systemic or pulmonary circulation. We report a case of a type A interruption of the aortic arch and a coarctation of the fifth aortic arch, which connected the ascending with the descending aorta. No cardiac surgery was required because a covered stent was successfully implanted in the fifth aortic arch when the patient was 4 years old. A chromosome 9 q arm duplication of uncertain significance was also found, an anomaly never described before in this clinical context.

Minimally Invasive Endovascular Repair of Ascending Thoracic Aortic Aneurysm with Use of Local Anesthesia and Conscious Sedation.

Ascending thoracic aortic aneurysm (ATAA) is typically treated surgically. No commercially available device has been specifically designed for endovascular ATAA repair, and currently, multiple anatomic and technical challenges affect its feasibility. Previously, such repairs have been performed with the patients under general anesthesia. We describe a novel, minimally invasive approach to endovascular repair of ATAA, involving local anesthesia, conscious sedation, and 24-hour hospitalization. Two consecutive male patients (ages, 79 and 54 yr) who had comorbidities underwent percutaneous transfemoral endovascular ATAA repair with use of commercially available endografts. Patient 1 had a saccular aneurysm, and Patient 2 had a pseudoaneurysm consequent to recent surgical ATAA repair. The patients were discharged from the hospital 24 hours after technically successful, uncomplicated procedures. At 2 months, computed tomograms showed no endoleak or stent-graft migration. Our experience shows that minimally invasive endovascular ATAA repair is feasible for selected high-risk patients. We describe the procedure, access and closure devices, and challenges associated with this approach.

One-year experience of a regional service model of teleconsultation for planning and treatment of complex thoracoabdominal aortic disease.

OBJECTIVE: The objective of this study was to report the methodology and 1-year experience of a regional service model of teleconsultation for planning and treatment of complex thoracoabdominal aortic disease (TAAD). METHODS: Complex TAADs without a feasible conventional surgical repair were prospectively evaluated by vascular surgeons of the same public health service (National Health System) located in a huge area of 22,994 km2 with 3.7 million inhabitants and 11 tertiary hospitals. Surgeons evaluated computed tomography scans and clinical details that were placed on a web platform (Google Drive; Google, Mountain View, Calif) and shared by all surgeons. Patients gave informed consent for the teleconsultation. The surgeon who submits a case discusses in detail his or her case and proposes a possible therapeutic strategy. The other surgeons suggest other solutions and options in terms of grafts, techniques, or access to be used. Computed tomography angiography, angiography, and clinical outcomes of cases are then presented at the following telemeetings, and a final agreement of the operative strategy is evaluated. Teleconsultation is performed using a web conference service (WebConference.com; Avaya Inc, Basking Ridge, NJ) every month. An inter-rater agreement statistic was calculated, and the κ value was interpreted according to Altman's criteria for computed tomography angiography measurements. RESULTS: The rate of participation was constant (mean number of surgeons, 11; range, 9-15). Twenty-four complex TAAD cases were discussed for planning and operation during the study period. The interobserver reliability recorded was moderate (κ = 0.41-0.60) to good (κ = 0.61-0.80) for measurements of proximal and distal sealing and very good (κ = 0.81-1) for detection of any target vessel angulation >60 degrees, significant calcification (circumferential), and thrombus presence (>50%). The concordance for planning and therapeutic strategy among all participants was complete in 16 cases. In one case, the consultation was decisive for creating an innovative therapeutic strategy; in the remaining seven cases, the strategy proposed by the patient's surgeon was changed completely after the discussion. Technical success was the same (100%) if concordance in planning was present initially or not. Overall 6-month mortality was 4%, 0% for those patients with initial concordance in planning vs 12% for those without initial concordance (P = .33). Surgery was always performed in a tertiary hospital by local surgeons, and in two cases (8%) external surgeons joined the local surgical team. CONCLUSIONS: Such a regional service of teleconsultation may be of value in standardizing the treatment and derived costs of complex TAADs in a huge region under the same health provider. The shared decision-making strategy may be of medical-legal value as well.

Effects of Shenlian extract on experimental atherosclerosis in ApoE-deficient mice based on ultrasound biomicroscopy.

BACKGROUND: This study directly and dynamically investigated the effects of SL extract (i.e., a combination of Radix Salviae miltiorrhizae and Andrographis paniculata extract) on plaque progression in vivo by high resolution ultrasound biomicroscopy (UBM). METHODS: An atherosclerosis model was established by placing a perivascular collar on the right common carotid artery in apolipoprotein E-deficient (ApoE-/-) mice. Thickness, plaque area and local blood flow were observed by UBM, pathological changes were observed by histochemical staining, and lipid levels were measured by respective commercially available kits. RESULTS: Compared with the model group, the SL extract groups showed reduced wall thickness of the aortic arch (GC: P = 0.001, P = 0.002, and P < 0.001; LC: P < 0.001, P < 0.001, and P < 0.001; BC: P = 0.027, P = 0.017, and P = 0.003; respectively), which presented with retarded plaque progression of the cartoid artery with concordantly increased blood flow (P = 0.002 and P < 0.001) as visualized in vivo by UBM. Histological analysis confirmed the reduction of carotid atherosclerosis. CONCLUSIONS: The SL extract inhibited the formation of atherosclerotic plaques in an ApoE-/- mice model by UBM analysis, and did so by effects that ameliorated local blood flow and improved blood lipid levels.

Near Infrared Fluorescence (NIRF) Molecular Imaging of Oxidized LDL with an Autoantibody in Experimental Atherosclerosis.

We aimed to develop a quantitative antibody-based near infrared fluorescence (NIRF) approach for the imaging of oxidized LDL in atherosclerosis. LO1, a well- characterized monoclonal autoantibody that reacts with malondialdehyde-conjugated LDL, was labeled with a NIRF dye to yield LO1-750. LO1-750 specifically identified necrotic core in ex vivo human coronary lesions. Injection of LO1-750 into high fat (HF) fed atherosclerotic Ldlr(-/-) mice led to specific focal localization within the aortic arch and its branches, as detected by fluorescence molecular tomography (FMT) combined with micro-computed tomography (CT). Ex vivo confocal microscopy confirmed LO1-750 subendothelial localization of LO1-750 at sites of atherosclerosis, in the vicinity of macrophages. When compared with a NIRF reporter of MMP activity (MMPSense-645-FAST), both probes produced statistically significant increases in NIRF signal in the Ldlr(-/-) model in relation to duration of HF diet. Upon withdrawing the HF diet, the reduction in oxLDL accumulation, as demonstrated with LO1-750, was less marked than the effect seen on MMP activity. In the rabbit, in vivo injected LO1-750 localization was successfully imaged ex vivo in aortic lesions with a customised intra-arterial NIRF detection catheter. A partially humanized chimeric LO1-Fab-Cys localized similarly to the parent antibody in murine atheroma showing promise for future translation.

Association of thoracic aorta calcium and non cardiac vascular events in cardiac disease-free individuals.

OBJECTIVE: Thoracic aorta calcium (TAC) is measurable on the same computed tomography (CT) scan as coronary artery calcium (CAC) but has still unclear clinical value. We assessed TAC and CAC relations with non-cardiac vascular events history in a cohort of subjects at risk for cardiovascular disease. METHODS: We analyzed retrospectively 1000 consecutive subjects having undergone CAC detection by non-contrast multi-slice CT with measurement field longer than usual in order to measure total TAC including aortic arch calcium. We also determined partial TAC restricted to ascending and descending thoracic aorta sites by removing arch calcium from total TAC. Calcium deposits were measured with a custom made software using Agatston score. RESULTS: Compared with the rest of the cohort, the 30 subjects with non-cardiac vascular event history had higher median values [95% CI] of total TAC (282 [28-1809] vs 39 [0-333], p < 0.01) and partial TAC (4 [0-284] vs 0 [0-5], p < 0.01) but no different value of CAC (73 [0-284] vs 16 [0-148]). Odds ratio [95% CI] of having non-cardiac vascular event per 1-SD increase in log-transformed calcium value was significant for total TAC but not for CAC, if total TAC and CAC were entered separately (1.56 [1.12-2.24], p < 0.01 and 1.13 [0.86-1.50], respectively) or together (1.57 [1.10-2.32], p < 0.01 and 0.98 [0.73-1.32], respectively) in the logistic adjusted model. CONCLUSION: TAC assessment simultaneous with CAC detection provides complementary information on the extra coronary component of cardiovascular risk beyond CAC's coronary risk prediction. Further studies are required to prospectively confirm this result.

Identifying the principal modes of variation in human thoracic aorta morphology.

PURPOSE: Diagnosis and management of thoracic aorta (TA) disease demand the assessment of accurate quantitative information of the aortic anatomy. We investigated the principal modes of variation in aortic 3-dimensional geometry paying particular attention to the curvilinear portion. MATERIALS AND METHODS: Images were obtained from extended noncontrast multislice computed tomography scans, originally intended for coronary calcium assessment. The ascending, arch, and descending aortas of 500 asymptomatic patients (57 ± 9 y, 81% male) were segmented using a semiautomated algorithm that sequentially inscribed circles inside the vessel cross-section. Axial planes were used for the descending aorta, whereas oblique reconstructions through a toroid path were required for the arch. Vessel centerline coordinates and the corresponding diameter values were obtained. Twelve size and shape geometric parameters were calculated to perform a principal component analysis. RESULTS: Statistics revealed that the geometric variability of the TA was successfully explained using 3 factors that account for ∼80% of total variability. Averaged aortas were reconstructed varying each factor in 5 intervals. Analyzing the parameter loadings for each principal component, the dominant contributors were interpreted as vessel size (46%), arch unfolding (22%), and arch symmetry (12%). Variables such as age, body size, and risk factors did not substantially modify the correlation coefficients, although some particular differences were observed with sex. CONCLUSIONS: We conclude that vessel size, arch unfolding, and symmetry form the basis for characterizing the variability of TA morphology. The numerical data provided in this study as supplementary material can be exploited to accurately reconstruct the curvilinear shape of normal TAs.

Intensification of statin therapy results in a rapid reduction in atherosclerotic inflammation: results of a multicenter fluorodeoxyglucose-positron emission tomography/computed tomography feasibility study.

OBJECTIVES: The study sought to test whether high-dose statin treatment would result in greater reductions in plaque inflammation than low-dose statins, using fluorodeoxyglucose-positron emission tomography/computed tomographic imaging (FDG-PET/CT). BACKGROUND: Intensification of statin therapy reduces major cardiovascular events. METHODS: Adults with risk factors or with established atherosclerosis, who were not taking high-dose statins (n = 83), were randomized to atorvastatin 10 versus 80 mg in a double-blind, multicenter trial. FDG-PET/CT imaging of the ascending thoracic aorta and carotid arteries was performed at baseline, 4, and 12 weeks after randomization and target-to-background ratio (TBR) of FDG uptake within the artery wall was assessed while blinded to time points and treatment. RESULTS: Sixty-seven subjects completed the study, providing imaging data for analysis. At 12 weeks, inflammation (TBR) in the index vessel was significantly reduced from baseline with atorvastatin 80 mg (% reduction [95% confidence interval]: 14.42% [8.7% to 19.8%]; p < 0.001), but not atorvastatin 10 mg (% reduction: 4.2% [-2.3% to 10.4%]; p > 0.1). Atorvastatin 80 mg resulted in significant additional relative reductions in TBR versus atorvastatin 10 mg (10.6% [2.2% to 18.3%]; p = 0.01) at week 12. Reductions from baseline in TBR were seen as early as 4 weeks after randomization with atorvastatin 10 mg (6.4% reduction, p < 0.05) and 80 mg (12.5% reduction, p < 0.001). Changes in TBR did not correlate with lipid profile changes. CONCLUSIONS: Statin therapy produced significant rapid dose-dependent reductions in FDG uptake that may represent changes in atherosclerotic plaque inflammation. FDG-PET imaging may be useful in detecting early treatment effects in patients at risk or with established atherosclerosis.

Thoracic aortic calcification and coronary heart disease events: the multi-ethnic study of atherosclerosis (MESA).

BACKGROUND: The presence and extent of coronary artery calcium (CAC) is an independent predictor of coronary heart disease (CHD) morbidity and mortality. Few studies have evaluated interactions or independent incremental risk for coronary and thoracic aortic calcification (TAC). The independent predictive value of TAC for CHD events is not well-established. METHODS: This study used risk factor and computed tomography scan data from 6807 participants in the multi-ethnic study of atherosclerosis (MESA). Using the same images for each participant, TAC and CAC were each computed using the Agatston method. The study subjects were free of incident CHD at entry into the study. RESULTS: The mean age of the study population (n=6807) was 62±10 years (47% males). At baseline, the prevalence of TAC and CAC was 28% (1904/6809) and 50% (3393/6809), respectively. Over 4.5±0.9 years, a total of 232 participants (3.41%) had CHD events, of which 132 (1.94%) had a hard event (myocardial infarction, resuscitated cardiac arrest, or CHD death). There was a significant interaction between gender and TAC for CHD events (p<0.05). Specifically, in women, the risk of all CHD event was nearly 3-fold greater among those with any TAC (hazard ratio: 3.04, 95% CI: 1.60-5.76). After further adjustment for increasing CAC score, this risk was attenuated but remained robust (HR: 2.15, 95% CI: 1.10-4.17). Conversely, there was no significant association between TAC and incident CHD in men. In women, the likelihood ratio chi square statistics indicate that the addition of TAC contributed significantly to predicting incident CHD event above that provided by traditional risk factors alone (chi square=12.44, p=0.0004) as well as risk factors+CAC scores (chi square=5.33, p=0.02). On the other hand, addition of TAC only contributed in the prediction of hard CHD events to traditional risk factors (chi-square=4.33, p=0.04) in women, without contributing to the model containing both risk factors and CAC scores (chi square=1.55, p=0.21). CONCLUSION: Our study indicates that TAC is a significant predictor of future coronary events only in women, independent of CAC. On studies obtained for either cardiac or lung applications, determination of TAC may provide modest supplementary prognostic information in women with no extra cost or radiation.

Emergency treatment of the thoracic aorta: results in 113 consecutive acute patients (the Talent Thoracic Retrospective Registry).

BACKGROUND: Elective thoracic endovascular aortic repair in selected patients with suitable aortic anatomy is associated with low morbidity and mortality, and is gaining widespread acceptance. Its benefit in acute thoracic aorta diseases, however, has not yet been demonstrated in high-numbered studies. This report presents data of the Talent Thoracic Retrospective Registry (TTR) of all patients who underwent endovascular stent grafting for acute thoracic aorta pathology. METHODS: Between December 1996 and July 2004 data were collected regarding 113 consecutive patients who underwent emergent endovascular stent grafting of the thoracic aorta using the Talent thoracic stent graft (Medtronic, Inc., Santa Rosa, California) in 7 European referral centers. Acute thoracic aorta pathology consisted of 41 (36.3 %) traumatic aortic injuries, 37 (32.7 %) Stanford type B dissections, 5 (4.4 %) intramural hematomas, 18 (15.9 %) thoracic aorta aneurysms, 4 (3.5 %) pseudoaneurysms and 8 (7.1 %) penetrating ulcers. RESULTS: In all patients the stent graft system could be introduced via the common femoral artery. Conversion to open surgical repair was necessary in 2 patients, one in the early phase due to persistent bleeding via backflow in the false lumen from a distal entry tear, and another patient in a late phase due to retrograde dissection. Intraoperative mortality was 1.8%, one patient suffered a massive myocardial infarction, and another died of tamponade secondary to retrograde dissection. Overall hospital mortality was 8.0% (9 patients). In only 2 of them, it was considered a stent graft procedure related death. New neurological symptoms were seen in 6.2% (7 patients), with complete recovery in 5 patients. Mean follow-up was 15 months (range 1-69 months). Late mortality was 8.7% (9 patients). Only one late death was considered aorta related. Overall re-intervention rate was 8.9% (n=10) and was mainly for type I endoleak or persistent false lumen perfusion. CONCLUSION: Sub-analysis of the Talent Thoracic Retrospective Registry for endovascular stent grafting of acute thoracic aorta pathology in over 100 consecutive patients demonstrated its feasibility, with low morbidity and acceptable low mortality rates.

Electrophysiological study and catheter ablation of a Mahaim fibre located at the mitral annulus-aorta junction.

Accessory pathways with slow and anterograde decremental conduction (Mahaim fibres) are responsible for a minority of atrioventricular reentrant tachycardias. While usually located along the tricuspid annulus, left-sided Mahaim fibres have been occasionally reported. We here report on a unique case of radiofrequency catheter ablation of a Mahaim pathway located at the supero-septal aspect of the mitral annulus, in a region known as mitral annulus-aorta junction, between the right and left fibrous trigons. Electrophysiological properties and embryological implications of this unusual accessory pathway are discussed.

Coronary and aortic calcifications inter-relationship in stable angina pectoris: A Coronary Disease Trial Investigating Outcome with Nifedipine GITS (ACTION)--Israeli spiral computed tomography substudy.

BACKGROUND: Coronary heart disease and ischemic stroke are among the leading causes of morbidity and mortality in adults, and cerebrovascular disease is associated with the presence of symptomatic and asymptomatic CHD. Several studies noted an association between coronary calcification and thoracic aorta calcification by several imaging techniques, but this association has not yet been examined in stable angina pectoris patients with the use of spiral computed tomography. OBJECTIVES: To examine by spiral CT the association between the presence and severity of CC and thoracic aorta calcification in patients with stable angina pectoris. METHODS: The patients were enrolled in ACTION (A Coronary Disease Trial Investigating Outcome with Nifedipine GITS) in Israel. The 432 patients (371 men and 61 women aged 40-89 years) underwent chest CT and were evaluated for CC and aortic calcification. RESULTS: CC was documented in 90% of the patients (n = 392) and aortic calcification in 70% (n = 303). A significant association (P < 0.05) was found between severity of CC and severity of aortic calcification (as measured by area, volume and slices of calcification). We also found an association between the number of coronary vessels calcified and the presence of aortic calcification: 90% of patients with triple-vessel disease (n = 157) were also positive for aortic calcification (P < 0.05). Age also had an effect: 87% of patients > 65 years (n=219) were positive for both coronary and aortic calcification (P = 0.005) while only 57% < or = 65 (n = 209) were positive for both (P = 0.081). CONCLUSIONS: Our study demonstrates a strong association between the presence and severity of CC and the presence and severity of calcification of thoracic aorta in patients with stable angina pectoris as detected by spiral CT.

On the accuracy of CartoMerge for guiding posterior left atrial ablation in man.

BACKGROUND: Recent reports suggest that the CartoMerge system is useful for guiding human posterior left atrial (PLA) endocardial ablation. OBJECTIVE: To assess the accuracy of the CartoMerge system during PLA ablation. METHODS: Sixteen patients undergoing PLA catheter ablation were studied. In each patient, registration of preoperative computed tomographic (CT) and intraoperative electroanatomic left atrial images was performed to create CartoMerge images. Encircling of right and left pulmonary venous vestibules with ablation points was then performed guided solely by intracardiac echocardiography, with point locations saved on a CartoMerge image to which the operator was blinded. The accuracy of the CartoMerge image was then assessed by measuring the distance from the location of each ablation point on the image to its actual anatomic location. In five patients, accuracy of registration of each of three left atrial CT images (just prior to mitral valve opening, at end-diastasis, at end-atrial contraction) with the electroanatomic image was compared. In two patients, accuracy of registration using left atrial image data alone was compared with that which used both left atrial and thoracic aorta image data. RESULTS: In each patient, inaccuracy of the CartoMerge image was apparent, the magnitude of which was similar for right- and left-vestibule ablation points. Accuracy was significantly improved when the end-atrial contraction CT image was used for registration. The inclusion of thoracic aorta image data did not improve accuracy. CONCLUSIONS: The CartoMerge system is inaccurate. Inaccuracy may be reduced by using CT and electroanatomic images obtained at the same point in the atrial mechanical cycle.

Optimization of cardiac preload during laparoscopic donor nephrectomy: a preliminary study of central venous pressure versus esophageal Doppler monitoring.

BACKGROUND: While the popularity of laparoscopic donor nephrectomy (LDN) has increased, concern persists about the potential deleterious effects of pneumoperitoneum on renal function. Thus, preload optimization with vigorous intravenous hydration has been recommended. The purpose of this study was to compare central venous pressure (CVP) monitoring with a noninvasive measure of cardiac preload (esophageal Doppler) during LDN. METHODS: Thirteen patients were studied. Following induction of general anesthesia, a Doppler probe was inserted in the lower third of the esophagus to measure flow time corrected for heart rate (FTc), which is an index of preload. In 10 patients, a catheter was placed in the right internal jugular vein and CVP measured. CVP and FTc were measured at baseline in the supine and right lateral decubitus positions, then 15 and 60 min after the establishment of CO(2) pneumoperitoneum (12-15 mmHg). IV fluids were increased if the FTc fell below 300 msec. Results are expressed as means (+/-SD). Data were analyzed using repeated measures ANOVA. RESULTS: Lateral positioning and pneumoperitoneum significantly increased CVP from baseline ( p < 0.01), while the FTc did not change ( p = 0.57). After 60 min of pneumoperitoneum, the FTc was <300 msec in only one patient. CONCLUSION: CVP is not an accurate guide for administration of IV fluids during LDN. Esophageal Doppler monitoring can be used to noninvasively follow changes in preload during LDN and is worthy of further study.