Image quality and radiation dose of coronary CT angiography performed with whole-heart coverage CT scanner with intra-cycle motion correction algorithm in patients with atrial fibrillation.

OBJECTIVES: To evaluate image quality, coronary evaluability and radiation exposure of coronary CT angiography (CCTA) performed with whole-heart coverage cardiac-CT in patients with atrial fibrillation (AF). MATERIALS AND METHODS: We prospectively enrolled 164 patients with AF who underwent a clinically indicated CCTA with a 16-cm z-axis coverage scanner. In all patients CCTA was performed using prospective ECG-triggering with targeted RR interval. We evaluated image quality, coronary evaluability and effective dose (ED). Patients were divided in two subgroups based on heart rate (HR) during imaging. Group 1: 64 patients with low HR (<75 bpm), group 2: 100 patients with high HR (≥75 bpm). Written informed consent was obtained from all patients and the institutional ethics committee approved the study protocol. RESULTS: In a segment-based analysis, coronary evaluability was 98.4 % (2,577/2,620 segments) in the whole population, without significant differences between groups (1,013/1,024 (98.9 %) and 1,565/1,596 (98.1 %), for groups 1 and 2, respectively, p=0.15). Mean ED was similar in both groups (3.8±1.9 mSv and 3.9±2.1 mSv in groups 1 and 2, respectively, p=0.75) CONCLUSIONS: The whole-heart-coverage scanner could evaluate coronary arteries with high image quality and without increase in radiation exposure in AF patients, even in the high HR group. KEY POINTS: • Last-generation CT scanner improves coronary artery assessment in AF patients. • The new CT scanner enables low radiation exposure in AF patients. • Diagnostic ICA maybe avoided in AF patients with suspected CAD. • Whole-heart coverage CT scanner enables low radiation exposure in AF patients.

Endomyocardial biopsy guided by intracardiac echocardiography as a key step in intracardiac mass diagnosis.

BACKGROUND: Based on a plenty of different applications, intracardiac echocardiography (ICE) is now a well-established technology in complex electrophysiological procedures. Recently, ICE has become the most widely used ultrasound-based imaging tool to guide diagnostic endomyocardial biopsy (EMB). EMB of cardiac mass guided by ICE is an interesting application of ICE. Allowing a correct positioning of the bioptome, ICE reduce the procedure-related risks and the need of a diagnostic open-chest procedure reserving the more invasive approach to selected cases. CASE PRESENTATION: Hereby we report a case series of right ventricular masses in which the EMB was safely and effectively performed under ICE guidance giving essential information for planning the therapeutic strategy. CONCLUSIONS: The diagnosis of both metastatic and primary cardiac tumors relies on the histopathological analyses. The endomyocardial biopsy is a valuable tool for preoperative diagnosis and surgical planning of intracardiac masses suspected for tumors. In our experience, the use of ICE for right ventricle EMB of an intracardiac mass is an attractive modality thanks to the precise localization of the cardiac structures and the ability to guide bioptic withdrawal in the target area.

Atrial Fibrillation: Diagnostic Accuracy of Coronary CT Angiography Performed with a Whole-Heart 230-µm Spatial Resolution CT Scanner.

Purpose To assess image quality, interpretability, diagnostic accuracy, and radiation exposure of a computed tomography (CT) scanner with 16-cm coverage and 230-µm spatial resolution at coronary artery evaluation in patients with atrial fibrillation (AF) by using invasive coronary angiography (ICA) as the reference method and to compare the results with those obtained in patients with sinus rhythm (SR). Materials and Methods Written informed consent and institutional ethics committee approval were obtained. Between March 2015 and February 2016, 166 consecutive patients were prospectively enrolled (83 with AF, 83 with SR). They underwent ICA and coronary CT angiography performed with a whole-heart CT scanner. Image quality, coronary segment interpretability, effective dose (ED), and diagnostic accuracy were assessed at CT angiography and were compared with those attained with ICA. Diagnostic performance of the groups was compared with the pairwise McNemar test. Results Mean heart rate during scanning was 83 beats per minute ± 21 (standard deviation) in the AF group and 63 beats per minute ± 14 in the SR group (P < .01). Coronary interpretability was 98.5% in the AF group and 98.4% in the SR group (P = .96). In a segment-based analysis, sensitivity and specificity in the detection of coronary stenosis of more than 50% compared with detection of ICA were 96.4% and 98.7%, respectively, in the chronic AF group (P = .98) and 95.6% and 98.1%, respectively, in the SR group (P = .32). In a patient-based analysis, sensitivity and specificity were 95.2% and 97.6%, respectively, in the chronic AF group (P = .95) and 97.8% and 94.7%, respectively, in the SR group (P = .93). Conclusion Whole-heart CT enables evaluation of coronary arteries with high image quality, low radiation exposure, and high diagnostic accuracy in patients with chronic AF, with a diagnostic performance similar to that in patients with SR. © RSNA, 2017 Online supplemental material is available for this article.

Early detection of anthracycline cardiotoxicity and improvement with heart failure therapy.

BACKGROUND: Three types of anthracycline-induced cardiotoxicities are currently recognized: acute, early-onset chronic, and late-onset chronic. However, data supporting this classification are lacking. We prospectively evaluated incidence, time of occurrence, clinical correlates, and response to heart failure therapy of cardiotoxicity. METHODS AND RESULTS: We assessed left ventricular ejection fraction (LVEF), at baseline, every 3 months during chemotherapy and for the following year, every 6 months over the following 4 years, and yearly afterward in a heterogeneous cohort of 2625 patients receiving anthracycline-containing therapy. In case of cardiotoxicity (LVEF decrease >10 absolute points, and <50%), heart failure therapy was initiated. Recovery from cardiotoxicity was defined as partial (LVEF increase >5 absolute points and >50%) or full (LVEF increase to the baseline value). The median follow-up was 5.2 (quartile 1 to quartile 3, 2.6-8.0) years. The overall incidence of cardiotoxicity was 9% (n=226). The median time elapsed between the end of chemotherapy and cardiotoxicity development was 3.5 (quartile 1 to quartile 3, 3-6) months. In 98% of cases (n=221), cardiotoxicity occurred within the first year. Twenty-five (11%) patients had full recovery, and 160 (71%) patients had partial recovery. At multivariable analysis, end-chemotherapy LVEF (hazard ratio, 1.37; 95% confidence interval, 1.33-1.42 for each percent unit decrement) and cumulative doxorubicin dose (hazard ratio, 1.09; 95% confidence interval, 1.04-1.15 for each 50 mg/m(2) increment) were independent correlates of cardiotoxicity. CONCLUSIONS: Most cardiotoxicity after anthracycline-containing therapy occurs within the first year and is associated with anthracycline dose and LVEF at the end of treatment. Early detection and prompt therapy of cardiotoxicity appear crucial for substantial recovery of cardiac function.

ACE-Inhibition Benefit on Lung Function in Heart Failure is Modulated by ACE Insertion/Deletion Polymorphism.

PURPOSE: The benefit of angiotensin converting enzyme (ACE) inhibition in chronic heart failure (HF) is partially due to its effects on pulmonary function and particularly on lung diffusion, the latter being counteracted by acetylsalicylic acid (ASA). Tissue ACE activity is largely determined by an insertion/deletion (I/D) polymorphism resulting in three possible genotypes (DD, ID and II). It is not clear if ACE inhibitor therapy could exert different effects in these genotypes. The aim of the study was to understand whether I/D polymorphism interferes with ACE inhibitor's protection of the lungs in HF during acute fluid overload. METHODS: 100 HF patients (left ventricular ejection fraction ≤40 %) in stable clinical conditions, treated with enalapril but without ASA performed pulmonary function tests including lung diffusion (DLco) and its subcomponents, membrane diffusion (Dm) and capillary volume (Vcap), and a cardiopulmonary exercise test before and immediately after rapid infusion of 500 cc saline. RESULTS: ACE I/D genotype prevalence was: DD = 28, ID =55 and II = 17 cases. No significant differences in major pulmonary function and exercise parameters were observed before saline infusion among ACE genotypes. After fluid challenge, DD patients presented a higher DLco and Dm reduction than ID and II (DLco -2.3 ± 1.3 vs. -0.8 ± 1.9 and -0.6 ± 1 mL/mmHg/min, p < 0.0001 and p < 0.01; Dm -7 ± 5 vs. -3.2 ± 7.4 and -1.3 ± 5 mL/mmHg/min, p < 0.05, respectively) and a higher increase in VE/VCO2 slope than II (1.8 ± 1.9 vs. -0.8 ± 2.3, p = 0.01). CONCLUSIONS: ACE DD genotype is associated with higher vulnerability of the alveolar-capillary membrane to acute fluid overload in HF patients treated with ACE inhibitors.

Diagnostic accuracy of multidetector computed tomography coronary angiography in 325 consecutive patients referred for transcatheter aortic valve replacement.

BACKGROUND: Multidetector computed tomography (MDCT) provides detailed assessment of valve annulus and iliofemoral vessels in transcatheter aortic valve replacement (TAVR) patients. However, data on diagnostic performance of MDCT coronary angiography (MDCT-CA) are scarce. The aim of the study is to assess diagnostic performance of MDCT for coronary artery evaluation before TAVR. METHODS: A total of 325 consecutive patients (234 without previous myocardial revascularization, 49 with previous coronary stenting, and 42 with previous coronary artery bypass graft [CABG]) underwent invasive coronary angiography and MDCT before TAVR. MDCT-CA was performed using the same data set dedicated to standard MDCT aortic annulus evaluation. Multidetector computed tomography-CA evaluability and diagnostic accuracy in comparison with invasive coronary angiography as criterion standard were assessed. RESULTS: The MDCT-CA evaluability of native coronaries was 95.6%. The leading cause of unevaluability was beam-hardening artifact due to coronary calcifications. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for detecting ≥50% stenosis of 91%, 99.2%, 83.4%, 99.6% and 98.8%, respectively. The MDCT-CA evaluability of coronary stents was 82.1%. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy for detecting ≥50% in-stent restenosis of 94.1%, 86.7%, 66.7%, 98.1%, and 88.3%, respectively. All CABGs were correctly assessed by MDCT-CA. In a patient-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy of 89.7%, 90.8%, 80.6%, 95.4%, and 90.5%, respectively. CONCLUSIONS: Multidetector computed tomography-CA allows to correctly rule out the presence of significant native coronary artery stenosis, significant in-stent restenosis, and CABG disease in patients referred for TAVR.

Coronary in-stent restenosis: assessment with CT coronary angiography.

PURPOSE: To compare accuracy and radiation exposure of a new computed tomographic (CT) scanner with improved spatial resolution (scanner A) with those of a CT scanner with standard spatial resolution (scanner B) for evaluation of coronary in-stent restenosis (ISR) by using invasive coronary angiography (ICA) and intravascular ultrasonography (US) as reference methods. MATERIALS AND METHODS: Written informed consent was obtained and study protocol was approved by institutional ethics committee. A total of 180 consecutive patients (154 men [mean age ± standard deviation, 66 years±12; range, 51-79 years] and 36 women [mean age, 70 years±12; range, 55-83 years]) scheduled to undergo ICA for suspected ISR were enrolled. Ninety patients were studied with scanner A (group 1: 72 men [mean age, 65 years±11; range, 52-79], 18 women [mean age, 68 years±12; range, 55-83 years]) and 90 with scanner B (group 2: 74 men [mean age, 64 years±10; range, 51-77 years], 16 women [mean age, 68 years±11; range, 55-82 years). Examination with the two scanners was compared with ICA and intravascular US. Radiation dose exposure was estimated. To compare stent evaluability between the two groups, χ2 test was used. RESULTS: Stent evaluability was higher in group 1 than in group 2 (99% vs 92%, P=.0021). A significantly lower rate of beam-hardening artifact was observed in group 1 (two cases) than group 2 (12 cases, P<.05). For stent-based analysis, sensitivity, specificity, and accuracy of multidetector CT for ISR identification were 96%, 95%, and 96% in group 1 and 90%, 91%, and 91% in group 2, respectively, without statistically significant differences. The correlation between percent ISR evaluated at multidetector CT versus intravascular US was higher in group 1 than in group 2 (r=0.89 vs r=0.58; P=.019). The correlations of diameter and area measurements at reference site and stent maximal lumen narrowing site between multidetector CT and intravascular US were higher in group 1 than in group 2. Radiation dose was low in both multidetector CT groups (1.9 mSv±0.2). CONCLUSION: Scanner A, with improved spatial resolution, allowed reliable detection and quantification of coronary ISR with low radiation exposure.

Aortic annulus area assessment by multidetector computed tomography for predicting paravalvular regurgitation in patients undergoing balloon-expandable transcatheter aortic valve implantation: a comparison with transthoracic and transesophageal echocardiography.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a valid alternative to surgery in high-risk patients with severe aortic stenosis. Aortic annulus (AoA) sizing is crucial for TAVI success. The aim of the study was to compare AoA dimensions measured by multidetector computed tomography (MDCT) vs those obtained with transthoracic (TTE) and transesophageal echocardiography (TEE) for predicting paravalvular aortic regurgitation (PVR) after TAVI. METHODS: Aortic annulus maximum diameter, minimum diameter, and area were assessed using MDCT and compared with TTE and TEE diameter and area for predicting PVR after TAVI in 151 patients (45 men, age 81.2 ± 6.4 years). RESULTS: Aortic annulus maximum, minimum diameter, and area detected by MDCT were 25.04 ± 2.39 mm, 21.27 ± 2.10 mm, and 420.87 ± 76.10 mm(2), respectively. Aortic annulus diameter and area measured by TTE and TEE were 21.14 ± 1.94 mm and 353.82 ± 64.57 mm(2) and 22.04 ± 1.94 mm and 384.33 ± 67.30 mm(2), respectively. A good correlation was found between AoA diameters and area evaluated by MDCT vs TTE and TEE (0.61, 0.65, and 0.69 and 0.61, 0.65, and 0.70, respectively), with a mean difference of 3.90 ± 1.98 mm, 0.13 ± 1.67 mm, and 67.05 ± 55.87 mm(2) and 3.0 ± 2.0 mm, 0.77 ± 1.70 mm, and 36.54 ± 56.43 mm(2), respectively. Grade ≥2 PVR occurred in 46 patients and was related to male gender, higher body mass index, preprocedural aortic regurgitation, and lower mismatch between the nominal area of the implanted prosthesis and AoA area detected by MDCT. CONCLUSIONS: Mismatch between prosthesis area and AoA area detected by MDCT is a better predictor of PVR as compared with echocardiography mismatch. Specific MDCT-based sizing recommendations should be developed.

Rationale and design of the NO-PARTY trial: near-zero fluoroscopic exposure during catheter ablation of supraventricular arrhythmias in young patients.

INTRODUCTION: Radiofrequency catheter ablation is the mainstay of therapy for supraventricular tachyarrhythmias. Conventional radiofrequency catheter ablation requires the use of fluoroscopy, thus exposing patients to ionising radiation. The feasibility and safety of non-fluoroscopic radiofrequency catheter ablation has been recently reported in a wide range of supraventricular tachyarrhythmias using the EnSite NavX™ mapping system. The NO-PARTY is a multi-centre, randomised controlled trial designed to test the hypothesis that catheter ablation of supraventricular tachyarrhythmias guided by the EnSite NavX™ mapping system results in a clinically significant reduction in exposure to ionising radiation compared with conventional catheter ablation. METHODS: The study will randomise 210 patients undergoing catheter ablation of supraventricular tachyarrhythmias to either a conventional ablation technique or one guided by the EnSite NavX™ mapping system. The primary end-point is the reduction of the radiation dose to the patient. Secondary end-points include procedural success, reduction of the radiation dose to the operator, and a cost-effectiveness analysis. In a subgroup of patients, we will also evaluate the radiobiological effectiveness of dose reduction by assessing acute chromosomal DNA damage in peripheral blood lymphocytes. CONCLUSIONS: NO-PARTY will determine whether radiofrequency catheter ablation of supraventricular tachyarrhythmias guided by the EnSite NavX™ mapping system is a suitable and cost-effective approach to achieve a clinically significant reduction in ionising radiation exposure for both patient and operator.

Ventricular arrhythmias in athletes: Role of a comprehensive diagnostic workup.

BACKGROUND: Ventricular arrhythmias (VAs) represent a critical issue with regard to sports eligibility assessment in athletes. The ideal diagnostic evaluation of competitive and leisure-time athletes with complex VAs has not been clearly defined. OBJECTIVE: The purpose of this study was to assess the clinical implications of invasive electrophysiological assessments and endomyocardial biopsy (EMB) among athletes with VAs. METHODS: We evaluated 227 consecutive athletes who presented to our institutions after being disqualified from participating in sports because of VAs. After noninvasive tests, electrophysiological study (EPS), electroanatomic mapping (EAM), and EAM- or cardiac magnetic resonance imaging-guided EMB was performed, following a prespecified protocol. Sports eligibility status was redefined at 6-month follow-up. RESULTS: From our sample, 188 athletes (82.8%) underwent EAM and EPS, and 42 (15.2%) underwent EMB. A diagnosis of heart disease could be formulated in 30% of the study population (67/227; 95% confidence interval [CI] 0.24-0.36) after noninvasive tests; in 37% (83/227; 95% CI 31%-43%) after EPS and EAM; and in 45% (102/227; 95% CI 39%-51%) after EMB. In the subset of athletes undergoing EMB, invasive diagnostic workup allowed diagnostic reclassification of half of the athletes (n = 21 [50%]). Reclassification was particularly common among subjects without definitive findings after noninvasive evaluation (n = 23; 87% reclassified). History of syncope, abnormal echocardiogram, presence of late gadolinium enhancement, and abnormal EAM were linked to sports ineligibility at 6-month follow-up. CONCLUSION: A comprehensive invasive workup provided additional diagnostic elements and could improve the sports eligibility assessment of athletes presenting with VAs. The extensive invasive evaluation presented could be especially helpful when noninvasive tests show unclear findings.

Feasibility and accuracy of a comprehensive multidetector computed tomography acquisition for patients referred for balloon-expandable transcatheter aortic valve implantation.

BACKGROUND: The aim of this study was to assess the accuracy of a comprehensive multidetector computed tomography (MDCT) evaluation of the aortic annulus (AoA), coronary artery disease (CAD), and peripheral vessels in patients referred for transcatheter aortic valve implantation (TAVI). METHODS: In 60 patients referred for TAVI, the following parameters were assessed with 64-slices MDCT and compared with transesophageal echocardiography (TEE), invasive coronary angiography (ICA), and peripheral angiography: AoA maximum diameter (Max-AoA-D(MDCT)), minimum diameter (Min-AoA-D(MDCT)), and area; lumen morphology index ([Max-AoA-D(MDCT)/Min-AoA-D(MDCT)]); length of the left, right, and non-coronary aortic leaflets; degree (grades 1-4) of aortic leaflet calcifications; distance between AoA and left main coronary ostium and between AoA and right coronary ostium CAD and peripheral vessel disease. RESULTS: The Max-AoA-D(MDCT) and Min-AoA-D(MDCT) were 25.1 ± 2.8 and 21.2 ± 2.2 mm, respectively, with high correlation versus AoA diameter measured with TEE (r = 0.82 and 0.86, respectively). The area of AoA, systolic and diastolic lumen morphology index were 410 ± 81.5 mm(2), 1.19 ± 0.1 and 1.22 ± 0.11, respectively. Aortic leaflet calcification score was 3.3 ± 0.5. The lengths of left, right, and non-coronary aortic leaflets were 14.2 ± 2.4, 13.7.1 ± 2.1, and 14.5 ± 2.6 mm, whereas distances between AoA and the left main coronary ostium and between AoA, and the right coronary ostium were 13.7 ± 2.9 and 15.8 ± 3.5 mm, respectively. Feasibility, negative predictive value, and accuracy for CAD detection versus ICA were 87%, 100% (CI 100-100), and 96% (95% CI 94-100), respectively. All patients (N = 17) who were ineligible for TAVI were correctly detected by MDCT. CONCLUSIONS: A comprehensive MDCT evaluation of patients referred for TAVI is feasible, provides more accurate assessment than TEE of AoA morphology, and may replace peripheral angiography in all patients and ICA in patients without significant CAD.

High diagnostic accuracy of prospective ECG-gating 64-slice computed tomography coronary angiography for the detection of in-stent restenosis: in-stent restenosis assessment by low-dose MDCT.

OBJECTIVES: The accuracy of computed tomography (CT) for assessment of coronary stents is as yet unproven and radiation exposure has been a concern. The aim of our study is to compare radiation dose and diagnostic performance of CT with prospective ECG-triggering versus retrospective ECG-triggering for the detection of in-stent restenosis (ISR). METHODS: We enrolled 168 consecutive patients with suspected ISR, 83 studied using CT with prospective ECG-triggering (group 1) and 85 using retrospective ECG-triggering (group 2). RESULTS: Prevalence of ISR according to catheter angiography was 24% in both groups. The overall evaluability was similar (93% in group 1 vs 95% in group 2). Artefact sub-analysis showed a significantly lower number of blooming and higher number of slice misalignment in group 1 vs group 2. In the stent-based analysis using only evaluable stents, specificity, positive predictive value and accuracy were significantly higher in group 1 (100%, 100% and 99%, respectively) than in group 2 (97%, 91% and 95%, respectively, p < 0.05). Group 1 was exposed to a lower radiation dose compared with group 2 (4.3 ± 1.4 mSv vs 18.5 ± 5.5 mSv, p < 00.1). CONCLUSIONS: CT with prospective ECG-triggering can improve diagnostic accuracy of non-invasive imaging of coronary stents with a significant reduction in radiation exposure.

Effects of beta-blockers on ventilation efficiency in heart failure.

BACKGROUND: Hyperventilation and consequent reduction of ventilation (VE) efficiency are frequently observed during exercise in heart failure (HF) patients, resulting in an increased slope of VE/carbon dioxide (VE/Vco(2)) relationship. The latter is an independent predictor of HF prognosis. beta-Blockers improve the prognosis of HF patients. We evaluated the effect on the efficiency of VE of a beta(1)-beta(2) unselective (carvedilol) versus a beta(1) selective (bisoprolol) beta-blocker. METHODS: We analyzed consecutive maximal cardiopulmonary exercise tests performed on 572 clinically stable HF patients (New York Heart Association class I-III, left ventricle ejection fraction < or =50%) categorized in 3 groups: 81 were not treated with beta-blocker, 304 were treated with carvedilol, and 187 were treated with bisoprolol. Clinical conditions were similar. RESULTS: The VE/Vco(2) slope was lower in carvedilol- compared with bisoprolol-treated patients (29.7 +/- 0.4 vs 31.6 +/- 0.5, P = .023, peak oxygen consumption adjusted) and with patients not receiving beta-blockers (31.6 +/- 0.7, P = .036). Maximum end-tidal CO(2) pressure during the isocapnic buffering period was higher in patients treated with carvedilol (39.0 +/- 0.3 mm Hg) than with bisoprolol (37.2 +/- 0.4 mm Hg, P < .001) and in patients not receiving beta-blockers (37.2 +/- 0.5 mm Hg, P = .001). CONCLUSIONS: Reduction of hyperventilation, with improvement of VE efficiency during exercise (reduction of VE/Vco(2) slope and increase of maximum end-tidal CO(2) pressure), is specific to carvedilol (beta(1)-beta(2) unselective blocker) and not to bisoprolol (beta(1)-selective blocker).

Comparison of the diagnostic performance of 64-slice computed tomography coronary angiography in diabetic and non-diabetic patients with suspected coronary artery disease.

BACKGROUND: Diabetics have high prevalence of subclinical coronary artery disease (CAD) with typical characteristics (diffuse disease, large calcifications). Although 64-slice multidetector computed tomography (MDCT) coronary angiography has high diagnostic accuracy to detect CAD, its diagnostic performance in diabetics with suspected CAD is unknown. To compare the diagnostic performance of 64-slice MDCT between diabetics and non-diabetics with suspected CAD scheduled for invasive coronary angiography (ICA). METHODS: We enrolled one hundred and five diabetic patients (92 men, age 65 +/- 9 years, Group 1) and 105 non-diabetic patients (63 men, age 63+/-5 years, Group 2) with indication to ICA for suspected CAD undergoing coronary 64-slice MDCT before ICA. RESULTS: In Group 1, the overall feasibility of coronary artery visualization was 93.8%. The most frequent artifact was blooming due to large coronary calcifications (54 artifacts, 67%). In Group 2, the overall feasibility was significantly higher vs. Group 1 (97%, p < 0.0001). In Group 1, the segment-based analysis showed a MDCT sensibility, specificity, positive predictive value, negative predictive value and accuracy for the detection of ≥50% luminal narrowing of 77%, 90%, 70%, 93% and 87%, respectively. In Group 2, all these parameters were significantly higher vs. Group 1. In the patient-based analysis, specificity, negative predictive value and accuracy were significantly lower in Group 1 vs. Group 2. CONCLUSIONS: Although MDCT has high sensitivity for early identification of significant CAD in diabetics, its diagnostic performance is significantly reduced in these patients as compared to non-diabetics with similar clinical characteristics.

Relationship of resting hemoglobin concentration to peak oxygen uptake in heart failure patients.

Anemia is frequent in chronic heart failure (HF). To calculate what change in peak oxygen uptake ( VO(2)) should be expected in the event of changes in hemoglobin concentration, we studied the correlation between peak VO(2) and hemoglobin concentration in a large HF population. We carried out retrospective analysis of all cardiopulmonary exercise tests (CPET) performed in our HF Clinic between June 2001 and March 2009 in HF patients who had a resting hemoglobin concentration measurement taken within 7 days of the CPET. We collected 967 CPETs, 704 tests were considered maximal and analyzed. We identified 181 patients (26%) as anemic. Peak VO(2) was lower (P < 0.001) in anemic patients (971 +/- 23 ml/min) compared with nonanemic (1243 +/- 18 ml/min). The slope of the VO(2) vs. hemoglobin ratio was 109 ml/min/g/dl at peak exercise. This correlation remained significant also when several confounding variables were analyzed by multivariate analysis. As an average, each gram of hemoglobin accounts, at peak exercise, for 109 ml/min change in VO(2) which is equivalent to 0.97 ml/min/kg. Therefore, in HF patients anemia treatment should increase VO(2) by 109 ml/min for each g/dl of hemoglobin increase.

Pre-operative transthoracic real-time three-dimensional echocardiography in patients undergoing mitral valve repair: accuracy in cases with simple vs. complex prolapse lesions.

AIMS: The aim of this study, undertaken in patients who underwent mitral valve (MV) repair surgery, was to evaluate the accuracy of pre-operative three-dimensional (3D) transthoracic echocardiography (TTE) in the evaluation of MV pathology in cases with simple or complex lesions. METHODS AND RESULTS: Two hundred consecutive patients with severe mitral regurgitation due to degenerative MV prolapse underwent a complete 3DTTE the day before surgery. Three-dimensional TTE data were compared with MV surgical inspection. Three-dimensional echocardiography was feasible in a relatively short time (5 ± 3 min) with good (67%) and optimal (21%) imaging quality in the majority of cases. Three-dimensional TTE allowed an accurate identification (95% accuracy) of all MV lesions. Seventy-three (36.5%) patients had simple lesions at 3DTTE and 71 of them (97.2%) underwent a simple surgical procedure; 127 (63.5%) had complex lesions at 3DTTE and, in these cases, surgeons performed either simple procedures (48%) or complex procedures (47.2%) or valve replacement in 4.7% (after a first attempt for repair). CONCLUSION: Three-dimensional TTE is feasible, not time-consuming, and accurate in identifying cases with simple vs. complex MV lesions.

Rationale and design of the EPLURIBUS Study (Evidence for a comPrehensive evaLUation of left ventRicle dysfnctIon By a whole-heart coverage cardiac compUted tomography Scanner).

BACKGROUND: Cardiac magnetic resonance (CMR) is the standard of reference for myocardial fibrosis detection by late gadolinium enhancement. Cardiac computed tomography (CCT) is emerging as a promising alternative. The Evidence for a comPrehensive evaLUation of left ventRicle dysfnctIon By a whole-heart coverage cardiac compUted tomography Scanner study will assess the feasibility and diagnostic accuracy of a comprehensive functional and anatomical cardiac evaluation with CCT as compared with CMR and invasive coronary angiography as standard of reference. METHODS: Consecutive patients with a newly diagnosed left ventricle (LV) dysfunction (left ventricular ejection fraction <50%) and a clinical indication to CMR will be screened. Exclusion criteria will be contraindications to contrast agents and impaired renal function. CCT will be performed per protocol within 10 days from CMR. A total of 100 patients will be enrolled within 24 months. We will evaluate with CCT volume and ejection fraction of the LV and right ventricle, presence, extent and pattern of delayed enhancement and cardiac venous system. Moreover, presence and degree of coronary stenoses will be evaluated among patients undergoing invasive coronary angiography in the 6 months following CCT. RESULTS: The primary study endpoints will be: first, to assess the diagnostic performance of CCT vs. CMR to detect the delayed enhancement in a territory-based and patient-based analysis; second, to assess the agreement between CCT and CMR in the discrimination between ischemic vs. nonischemic delayed enhancement patters in a territory-based analysis; third, to assess the correlation between CCT and CMR for LV and right ventricle end-diastolic and end-systolic volumes and ejection fraction measurements. CONCLUSION: The Evidence for a comPrehensive evaLUation of left ventRicle dysfnctIon By a whole-heart coverage cardiac compUted tomography Scanner study will assess the diagnostic performance of CCT using the latest scanner generation for a comprehensive evaluation of patients with new-onset LV dysfunction.

Interpretability of coronary CT angiography performed with a novel whole-heart coverage high-definition CT scanner in 300 consecutive patients with coronary artery bypass grafts.

AIMS: Coronary CT angiography (CCTA) is an accurate non-invasive tool for the evaluation of coronary artery bypass graft (CABG). However, inability to sustain a long breath-hold, high heart rate (HR) and atrial fibrillation may affect image quality. Moreover, radiation exposure is still a matter of some concern. A scanner combining 0.23-mm spatial resolution, new iterative reconstruction and fast gantry rotation time has been recently introduced in the clinical field. The aims of our study were to evaluate interpretability, radiation exposure and diagnostic accuracy of CCTA performed with the latest generation of cardiac-CT scanners compared to invasive coronary angiography (ICA) in the assessment of bypass grafts, and non-grafted and post-anastomotic native coronary arteries. METHODS AND RESULTS: We prospectively enrolled 300 patients undergoing clinically indicated CCTA with a 16-cm z-axis coverage, 256-detector rows, and 0.28-sec gantry rotation time scanner. Coronary artery and graft interpretability, image quality and effective dose (ED) were assessed in all patients and diagnostic accuracy was evaluated in a subgroup of 100 patients who underwent ICA. Mean HR during the scan was 69.6 ±â€¯10.8. Sinus rhythm was present in 118 patients with HR < 75 bpm and in 112 patients with HR ≥ 75 bpm, while 70 patients had atrial fibrillation. CABG interpretability was 100%. Compared to ICA, CCTA was able to correctly detecting occlusions or significant stenoses of all CABG segments. Overall interpretability of native coronary segments was 95.6%. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of coronary arteries were 98.3%, 97.4%, 93.1%, 99.3% and 96.5%, respectively. The diagnostic accuracy in a patient based analysis was 95.2%. Mean ED was 3.14 ±â€¯1.7 mSv. CONCLUSIONS: The novel whole-heart coverage CT scanner allows to evaluating CABG and native coronary arteries with excellent interpretability and low radiation exposure even in the presence of unfavorable heart rhythm.

CMR for Identifying the Substrate of Ventricular Arrhythmia in Patients With Normal Echocardiography.

OBJECTIVES: This study sought to determine whether cardiac magnetic resonance (CMR) may identify structural heart disease (SHD) in patients with ventricular arrhythmia who had echocardiography ruled out pathological findings. BACKGROUND: Approximately one-half of sudden cardiac deaths are attributable to malignant VA. Echocardiography is commonly used to identify SHD that is the most frequent substrate of VA. METHODS: A single-center prospective study was conducted in consecutive patients with significant VA, categorized as >1,000 but <10,000 ventricular ectopic beats [VEBs]/24 h; ≥10,000 VEBs/24 h; nonsustained ventricular tachycardia, sustained ventricular tachycardia, or a history of resuscitated cardiac arrest, and no pathological findings at echocardiography, requiring a clinically indicated CMR. Primary endpoint was CMR detection of SHD. Secondary endpoints were a composite of CMR detection of SHD and abnormal findings not specific for a definite SHD diagnosis. RESULTS: A total of 946 patients were enrolled (mean 41 ± 16 years of age; 64% men). CMR studies were used to diagnose SHD in 241 patients (25.5%) and abnormal findings not specific for a definite SHD diagnosis in 187 patients (19.7%). Myocarditis (n = 91) was the more frequent disease, followed by arrhythmogenic cardiomyopathy (n = 55), dilated cardiomyopathy (n = 39), ischemic heart disease (n = 22), hypertrophic cardiomyopathy (n = 13), congenital cardiac disease (n = 10), left ventricle noncompaction (n = 5), and pericarditis (n = 5). The strongest univariate and multivariate predictors of SHD on CMR images were chest pain (odds ratios [OR]: 2.52 and 2.38, respectively) and sustained ventricular tachycardia (ORs: 2.67 and 2.23, respectively). CONCLUSIONS: SHD was able to be identified on CMR imaging in a sizable number of patients with significant VA and completely normal echocardiography. Chest pain and sustained ventricular tachycardia were the strongest predictors of positive CMR imaging results.