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Purpose: Recent guidelines provide broader support for the use of less invasive imaging modalities for the evaluation of patients with stable chest pain. Coronary CT angiography (CCTA) uses increasingly sophisticated techniques to improve evaluation of coronary lesions. The purpose of this study is to describe one center's experience implementing AI-assisted advanced imaging techniques to diagnose coronary artery disease. Materials & methods: Retrospective study of patients who had AI-assisted CCTA interpretation, including a subgroup who underwent fractional flow reserve CT (FFR-CT) and invasive coronary angiography. Descriptive statistics summarized baseline characteristics and univariate statistics compared findings between groups of patients with and without anatomically and hemodynamically significant lesions based on FFR-CT. For patients who underwent invasive coronary angiography, concordance between CCTA and angiography was evaluated. Results: Of 532 included patients, AI-assisted CCTA identified statistically significant difference in calcification scores, plaque types and total plaque volume between lesions <50% and ≥50% stenosis. CCTA results were mostly concordant with invasive coronary angiography. Importantly, we identified a subset of patients with less than 50% anatomical stenosis that demonstrated physiologically significant stenosis on FFR-CT and invasive coronary angiography. Conclusions: AI-assisted CCTA and other advanced techniques are a tool to support high quality diagnostic assessment of coronary lesions in a clinical environment. Combined CCTA with FFRCT in mild to moderate coronary stenosis identifies patients with hemodynamically significant stenosis even when quantitative stenosis is <50%. Implementation of AI-assisted coronary CT angiography is feasible in a community hospital setting, but these technologies do not replace the need for expert review and clinical correlation.
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BACKGROUND: Bicuspid aortic valve (BAV) comprises a broad spectrum of phenotypes. The importance of BAV in thoracic aortic aneurysm management has been debated. A subtle phenotype of BAV has been identified recently that could impact this debate. METHODS AND RESULTS: 101 consecutive patients with intact aortic valves operated in the setting of ascending aneurysm between January 2011-January 2014 were retrospectively identified. 20 were excluded because of valve calcification. 79 of 81 remaining had aortic valve phenotype described in operative reports, including tri-leaflet, bicuspid, and difficult-to-classify valves with small degrees of non-calcific fusion (raphe) at the commissures. Photographs of some three-leaflet valves with very small raphes were obtained. 18/79 (22.8%) had obvious BAVs and 61/79 (77.2%) were initially considered tri-leaflet valves. 18/61 (29.5%) of these had distinct but very small raphes and 12/18 (66.7%) involved the right/left commissure. Moderate or greater aortic insufficiency was found in 13/43 (30%) of patients with tri-leaflet valves, 8/18 (44.4%) with obvious BAVs, and in 9/18 (50%) three-leaflet valves with very small raphes. Retrospective review of computed tomography, magnetic resonance imaging and trans-esophageal (but not trans-thoracic) echocardiography sometimes identified very small raphes. CONCLUSIONS: Three-leaflet aortic valves exhibiting very small raphes occur in the setting of thoracic aneurysm and aortic insufficiency and may represent forme fruste BAVs. They are sometimes identifiable with high-resolution valve imaging. Without accounting for forme fruste BAVs, the true prevalence and impact of BAV on aortic complications may have been historically underestimated. This entity warrants further study in a prospective multi-center registry.