Ultra-high-resolution CT vs. invasive angiography for detecting hemodynamically significant coronary artery disease: Rationale and methods of the CORE-PRECISION multicenter study.

BACKGROUND: Direct coronary arterial evaluation via computed tomography (CT) angiography is the most accurate noninvasive test for the diagnosis of coronary artery disease (CAD). However, diagnostic accuracy is limited in the setting of severe coronary calcification or stents. Ultra-high-resolution CT (UHR-CT) may overcome this limitation, but no rigorous study has tested this hypothesis. METHODS: The CORE-PRECISION is an international, multicenter, prospective diagnostic accuracy study testing the non-inferiority of UHR-CT compared to invasive coronary angiography (ICA) for identifying patients with hemodynamically significant CAD. The study will enroll 150 patients with history of CAD, defined as prior documentation of lumen obstruction, stenting, or a calcium score ≥400, who will undergo UHR-CT before clinically prompted ICA. Assessment of hemodynamically significant CAD by UHR-CT and ICA will follow clinical standards. The reference standard will be the quantitative flow ratio (QFR) with <0.8 defined as abnormal. All data will be analyzed in independent core laboratories. RESULTS: The primary outcome will be the comparative diagnostic accuracy of UHR-CT vs. ICA for detecting hemodynamically significant CAD on a patient level. Secondary analyses will focus on vessel level diagnostic accuracy, quantitative stenosis analysis, automated contour detection, in-depth plaque analysis, and others. CONCLUSION: CORE-PRECISION aims to investigate if UHR-CT is non-inferior to ICA for detecting hemodynamically significant CAD in high-risk patients, including those with severe coronary calcification or stents. We anticipate this study to provide valuable insights into the utility of UHR-CT in this challenging population and for its potential to establish a new standard for CAD assessment.

Psychosocial Factors of Women Presenting With Myocardial Infarction With or Without Obstructive Coronary Arteries.

BACKGROUND: Women with myocardial infarction (MI) are more likely to have elevated stress levels and depression than men with MI. OBJECTIVES: We investigated psychosocial factors in women with myocardial infarction with nonobstructive coronary arteries (MINOCA) and those with MI and obstructive coronary artery disease (CAD). METHODS: Women with MI enrolled in a multicenter study and completed measures of perceived stress (Perceived Stress Scale-4) and depressive symptoms (Patient Health Questionnaire-2) at the time of MI (baseline) and 2 months later. Stress, depression, and changes over time were compared between MI subtypes. RESULTS: We included 172 MINOCA and 314 MI-CAD patients. Women with MINOCA were younger (age 59.4 years vs 64.2 years; P < 0.001) and more diverse than those with MI-CAD. Women with MINOCA were less likely to have high stress (Perceived Stress Scale-4 ≥6) at the time of MI (51.0% vs 63.0%; P = 0.021) and at 2 months post-MI (32.5% vs 46.3%; P = 0.019) than women with MI-CAD. There was no difference in elevated depressive symptoms (Patient Health Questionnaire-2 ≥2) at the time of MI (36% vs 43%; P = 0.229) or at 2 months post-MI (39% vs 40%; P = 0.999). No differences in the rate of 2-month decline in stress and depression scores were observed between groups. CONCLUSIONS: Stress and depression are common among women at the time of and 2 months after MI. MINOCA patients were less likely to report high stress compared with MI-CAD patients, but the frequency of elevated depressive symptoms did not differ between the 2 groups. Stress and depressive symptoms decreased in both MI-CAD and MINOCA patients over time.

Refinements in Extended Alar Contour Grafts: Retrograde Approach in Conjunction with Alar Base Surgery.

SUMMARY: Alar contour grafts are an excellent adjunct in both primary and revision rhinoplasty for correction and prevention of alar rim irregularities. They are traditionally placed at the conclusion of a rhinoplasty through a vestibular incision along the underside of the alar rim. Alternatively, alar base resection provides an opportunity for precise retrograde placement of alar contour grafts. The purpose of this article is to describe an efficient, five-step technique for retrograde placement of alar contour grafts in the setting of concomitant alar base surgery.

Soft Tissue Filler for Secondary Nasal Deformities.

SUMMARY: One common indication for soft tissue filler in the nose, or "liquid rhinoplasty," is the temporary treatment of secondary nasal deformities after rhinoplasty. When applied in this manner, there are multiple aspects of the patient evaluation, timing with respect to the prior rhinoplasty and planned revision, and procedural principles and steps that must be carefully considered. Ultimately, when appropriately implemented, the procedure can help avoid unnecessary patient angst and displeasure preceding a formal revision rhinoplasty. The following article reviews the principles and application of soft tissue filler for secondary nasal deformities.

Arteriovenous Malformations of the Hand: Optimizing Outcomes with Palmar Arch Reconstruction.

BACKGROUND: Arteriovenous malformations are abnormal high-flow vascular anomalies that can greatly alter the structure of surrounding tissues. Treatment of symptomatic hand arteriovenous malformations must address the functional and aesthetic considerations of the hand. Nonsurgical treatment such as embolization continues to be plagued by complications such as digital ischemia and secondary need for amputation. In this study, the authors describe their experience treating hand arteriovenous malformations with wide resection and microsurgical reconstruction of the palmar arch. This technique aims to optimize postoperative function and minimize postoperative complications and recurrence. METHODS: Retrospective review identified five patients who underwent surgical excision of hand arteriovenous malformations performed by two of the senior authors (W.C.P. and M.M.) between 2002 and 2020. Four patients underwent reconstruction of the palmar arch, whereas one patient underwent ray amputation of the involved index finger only. One patient required concurrent free flap for soft-tissue coverage following resection. RESULTS: Mean age at the time of surgery was 34.6 years. After an average follow-up of 2.7 years, there were no postoperative complications, functional deficits, or recurrences. The patient who underwent ray amputation only was postoperatively noted to have pulsatile dorsal veins concerning for a persistent high-flow state, although no recurrent mass was seen at limited 1-year follow-up. CONCLUSIONS: Meticulous surgical excision with microvascular reconstruction is an acceptable technique for management of symptomatic hand arteriovenous malformations. Potential soft-tissue loss does not preclude aggressive resection. Wide excision with palmar arch reconstruction minimizes complications, optimizes functionality, and may prevent ischemia that could otherwise trigger recurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Challenges of Upper Extremity Intramuscular Hemangioma: A Case Study and Systematic Review.

BACKGROUND: Intramuscular hemangiomas are rare, benign vascular tumors, constituting 0.8 percent of all hemangiomas. Upper extremity intramuscular hemangiomas pose diagnostic and therapeutic challenges because of their rarity, invasive nature, and potential for neurovascular involvement. The authors report a comprehensive systematic review of upper extremity intramuscular hemangioma management and a challenging case report. METHODS: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases were used to identify articles describing upper extremity intramuscular hemangiomas through 2019. Patient demographics, clinical presentation, management, complications, and outcomes were reviewed. Based on operative timing, cases were categorized as either "primary" (excision performed at initial diagnosis) or "secondary" (excision performed after failure of conservative treatment). RESULTS: Eighteen articles encompassing 25 patients were included in the authors' systematic review. Of those, 18 underwent primary excision and seven underwent secondary excision. The majority involved the forearm or antecubital region. Complete excision, evaluated by gross examination or pathology, was reported in all primary cases and 71 percent of secondary cases. Primary excisions demonstrated smaller size of mass (19.4 cm 2 versus 165.3 cm 2 ) and superior reported functional outcomes (100 percent versus 33 percent). Complications were reported in 5 percent of the primary excisions compared to 71 percent of the secondary excisions, where one complication was a fatal hematoma. CONCLUSIONS: The literature concerning upper extremity intramuscular hemangioma is limited to mostly case reports and several case series with the potential risk of bias. With careful dissection and microsurgical technique, wide local excision followed by complete reconstruction can be successfully performed at initial diagnosis for upper extremity intramuscular hemangiomas. At early stages, smaller lesion size significantly reduces the risk of functional impairment and complications.

Role of Multimodality Imaging in the Assessment of Myocardial Infarction With Nonobstructive Coronary Arteries: Beyond Conventional Coronary Angiography.

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a heterogeneous clinical entity, encompassing multiple different causes, and a cause of substantial morbidity and mortality. Current guidelines suggest a multimodality imaging approach in establishing the underlying cause for MINOCA, which is considered a working diagnosis. Recent studies have suggested that an initial workup consisting of cardiac magnetic resonance and invasive coronary imaging can yield the diagnosis in most patients. Cardiac magnetic resonance is particularly helpful in excluding nonischemic causes that can mimic MINOCA including myocarditis and Takotsubo cardiomyopathy, as well as for long-term prognostication. Additionally, intracoronary imaging with intravascular ultrasound or optical coherence tomography may be warranted to evaluate plaque composition, or evaluate for plaque disruption or spontaneous coronary dissection. The role of noninvasive imaging modalities such as coronary computed tomography angiography is currently being investigated in the diagnostic approach and follow-up of MINOCA and may be appropriate in lieu of invasive coronary angiography in select patients. In recent years, many strides have been made in the workup of MINOCA; however, significant knowledge gaps remain in the field, particularly in terms of treatment strategies. In this review, we summarize recent society guideline recommendations and consensus statements on the initial evaluation of MINOCA, review contemporary multimodality imaging approaches, and discuss treatment strategies including an ongoing clinical trial.

Nonvascularized Toe Joint Transfers to the Hand in Young Children: Technique Revisited.

BACKGROUND: Small joint reconstruction of the hand poses a significant challenge, especially in children where both functional motion and preservation of the epiphysis are desired. Auto-transplantation of whole joints is the only way to reconstruct a functional joint that maintains growth potential. Historically, nonvascularized toe-to-finger joint transfer has been criticized for high rates of avascular necrosis and joint dissolution, while vascularized transfers seemingly resulted in increased durability of the joint space and epiphysis. However, certain populations remain poor candidates for microvascular reconstruction, such as those with congenital deformities or sequelae from trauma or infection. In our case series, we demonstrate that a simplified nonvascularized surgical technique and careful patient selection can produce stable, functional joints. METHODS: Nonvascularized toe-to-finger joint transfer was performed in 3 children between the ages of 4 and 6. Reconstructed joints included 2 proximal interphalangeal (PIP) joints and 1 metacarpophalangeal (MCP) joint. Donor grafts consisted of second toe PIP joints harvested en bloc to include the epiphysis of the middle phalanx, collateral ligaments, volar plate, and a diamond-shaped island of extensor tendon with its central slip attachment. RESULTS: Follow-up ranged from 7 to 29 months. Each patient demonstrated functional improvements in joint motion and stability. Postoperative radiographs confirmed adequate joint alignment and persistence of the joint spaces. Epiphyseal closure was observed in 1 patient as early as 25 months postoperatively. CONCLUSIONS: Nonvascularized joint transfer should remain a practical consideration for small joint reconstruction of the hand in certain pediatric patients.

Update on Thumb Basal Joint Arthritis Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Comprehend anatomy and biomechanics of the normal and arthritic trapeziometacarpal joint. 2. Evaluate best evidence for diagnosis and for operative and nonoperative treatment of thumb osteoarthritis. 3. Understand treatment pitfalls of basilar joint arthritis and complication avoidance. SUMMARY: Articular and ligamentous anatomy of the trapeziometacarpal joint enables complex motions. Disability from arthritis, common at the trapeziometacarpal joint, is debilitating. Furthering the understanding of how trapeziometacarpal arthritis develops can improve treatment. The authors provide current best evidence for diagnosis and treatment of basilar joint arthritis. Pitfalls in treatment are discussed.

Ultra-High-Resolution Coronary CT Angiography for Assessment of Patients with Severe Coronary Artery Calcification: Initial Experience.

PURPOSE: Conventional CT technology yields only modest accuracy of coronary artery stenosis assessment in severely calcified lesions. Reported herein are this study's initial observations on the potential of ultra-high-resolution CT (UHR-CT) for evaluating severely calcified coronary arterial lesions. MATERIALS AND METHODS: Fifteen patients 45 years of age or older, with history of coronary artery disease, referred for invasive coronary angiography, were prospectively enrolled. Patients underwent UHR-CT within 30 days prior to cardiac catheterization. Image noise levels and diagnostic confidence (level 1-5) using UHR-CT were compared with reconstructed images simulating conventional CT technology. Stenosis assessment for the major coronary arteries and the left main coronary artery with UHR-CT and invasive angiography were compared. Results from clinically driven coronary CT using conventional technology were considered for comparison when available. RESULTS: Mean patient age was 67 years (range, 53-79 years). Thirteen patients were men, nine had obesity. Radiation dose was 9.3 mSv owing to expanded x-ray exposure to accommodate research software application (70%-99% of R-R cycle). Overall image noise was considerably greater for UHR-CT (50.9 ± 7.8 [standard deviation]) versus conventional CT image reconstruction (19.5 ± 8.3, P < .01), yet diagnostic confidence scores for UHR-CT were high (4.3 ± 0.9). Average calcium score in patients without stents (n = 6) was 1205, and of 86 vessels evaluated, 22 had 70% or greater stenosis depicted with invasive angiography (26%). Stenosis comparison with invasive angiography yielded 86% (19 of 22) sensitivity and 88% (56 of 64) specificity (95% CI: 65%, 97%; and 77%, 95%, respectively). CONCLUSION: Initial observations suggest UHR-CT may be effective in overcoming the limitation of conventional CT for accurately evaluating coronary artery stenoses in severely calcified vessels.Keywords: CT-Angiography, Coronary Arteries, ArteriosclerosisClinical trial registration no. NCT04272060See also commentary by Shanbhag and Chen in this issue.© RSNA, 2021.

Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women.

BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 6% to 15% of myocardial infarctions (MIs) and disproportionately affects women. Scientific statements recommend multimodality imaging in MINOCA to define the underlying cause. We performed coronary optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) imaging to assess mechanisms of MINOCA. METHODS: In this prospective, multicenter, international, observational study, we enrolled women with a clinical diagnosis of myocardial infarction. If invasive coronary angiography revealed <50% stenosis in all major arteries, multivessel OCT was performed, followed by CMR (cine imaging, late gadolinium enhancement, and T2-weighted imaging and T1 mapping). Angiography, OCT, and CMR were evaluated at blinded, independent core laboratories. Culprit lesions identified by OCT were classified as definite or possible. The CMR core laboratory identified ischemia-related and nonischemic myocardial injury. Imaging results were combined to determine the mechanism of MINOCA, when possible. RESULTS: Among 301 women enrolled at 16 sites, 170 were diagnosed with MINOCA, of whom 145 had adequate OCT image quality for analysis; 116 of these underwent CMR. A definite or possible culprit lesion was identified by OCT in 46.2% (67/145) of participants, most commonly plaque rupture, intraplaque cavity, or layered plaque. CMR was abnormal in 74.1% (86/116) of participants. An ischemic pattern of CMR abnormalities (infarction or myocardial edema in a coronary territory) was present in 53.4% (62/116) of participants undergoing CMR. A nonischemic pattern of CMR abnormalities (myocarditis, takotsubo syndrome, or nonischemic cardiomyopathy) was present in 20.7% (24/116). A cause of MINOCA was identified in 84.5% (98/116) of the women with multimodality imaging, higher than with OCT alone (P<0.001) or CMR alone (P=0.001). An ischemic cause was identified in 63.8% of women with MINOCA (74/116), a nonischemic cause was identified in 20.7% (24/116) of the women, and no mechanism was identified in 15.5% (18/116). CONCLUSIONS: Multimodality imaging with coronary OCT and CMR identified potential mechanisms in 84.5% of women with a diagnosis of MINOCA, 75.5% of which were ischemic and 24.5% of which were nonischemic, alternate diagnoses to myocardial infarction. Identification of the cause of MINOCA is feasible and has the potential to guide medical therapy for secondary prevention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02905357.

Myocardial Injury in Severe COVID-19 Compared With Non-COVID-19 Acute Respiratory Distress Syndrome.

BACKGROUND: Knowledge gaps remain in the epidemiology and clinical implications of myocardial injury in coronavirus disease 2019 (COVID-19). We aimed to determine the prevalence and outcomes of myocardial injury in severe COVID-19 compared with acute respiratory distress syndrome (ARDS) unrelated to COVID-19. METHODS: We included intubated patients with COVID-19 from 5 hospitals between March 15 and June 11, 2020, with troponin levels assessed. We compared them with patients from a cohort study of myocardial injury in ARDS and performed survival analysis with primary outcome of in-hospital death associated with myocardial injury. In addition, we performed linear regression to identify clinical factors associated with myocardial injury in COVID-19. RESULTS: Of 243 intubated patients with COVID-19, 51% had troponin levels above the upper limit of normal. Chronic kidney disease, lactate, ferritin, and fibrinogen were associated with myocardial injury. Mortality was 22.7% among patients with COVID-19 with troponin under the upper limit of normal and 61.5% for those with troponin levels >10 times the upper limit of normal (P<0.001). The association of myocardial injury with mortality was not statistically significant after adjusting for age, sex, and multisystem organ dysfunction. Compared with patients with ARDS without COVID-19, patients with COVID-19 were older and had higher creatinine levels and less favorable vital signs. After adjustment, COVID-19-related ARDS was associated with lower odds of myocardial injury compared with non-COVID-19-related ARDS (odds ratio, 0.55 [95% CI, 0.36-0.84]; P=0.005). CONCLUSIONS: Myocardial injury in severe COVID-19 is a function of baseline comorbidities, advanced age, and multisystem organ dysfunction, similar to traditional ARDS. The adverse prognosis of myocardial injury in COVID-19 relates largely to multisystem organ involvement and critical illness.

Extremity anomalies associated with Robinow syndrome.

Robinow syndrome, a rare genetic disorder, is characterized by skeletal dysplasia with, among other anomalies, extremity and hand anomalies. There is locus heterogeneity and both dominant and recessive inheritance. A detailed description of associated extremity and hand anomalies does not currently exist due to the rarity of this syndrome. This study seeks to document the hand anomalies present in Robinow syndrome to allow for improved rates of timely and accurate diagnosis. A focused assessment of the extremities and stature was performed using clinical examination and standard photographic images. A total of 13 patients with clinical and molecular diagnosis consistent with dominant Robinow syndrome or recessive Robinow syndrome were evaluated. All patients had limb shortening, the most common of which was mesomelia; however, rhizomelia and micromelia were also seen. These findings are relevant to clinical characterization, particularly as Robinow syndrome has classically been defined as a "mesomelic disorder." A total of eight distinct hand anomalies were identified in 12 patients with both autosomal recessive and dominant forms of Robinow syndrome. One patient did not present with any hand differences. The most common hand findings included brachydactyly, broad thumbs, and clinodactyly. A thorough understanding of the breadth of Robinow syndrome-associated extremity and hand anomalies can aid in early patient identification, improving rates of timely diagnosis and allowing for proactive management of sequelae.

Evaluation and Management of Patients With Stable Angina: Beyond the Ischemia Paradigm: JACC State-of-the-Art Review.

Coronary heart disease is a chronic, systemic disease with a wide range of associated symptoms, clinical outcomes, and health care expenditure. Adverse events from coronary heart disease can be mitigated or avoided with lifestyle and risk factor modifications, and medical therapy. These measures are effective in slowing the progression of atherosclerotic disease and in reducing the risk of thrombosis in the setting of plaque disruptions. With increasing effectiveness of prevention and medical therapy, the role of coronary artery revascularization has decreased and is largely confined to subgroups of patients with unacceptable angina, severe left ventricular systolic dysfunction, or high-risk coronary anatomy. There is a compelling need to allocate resources appropriately to improve prevention. Herein, we review the scientific evidence in support of medical therapy and revascularization for the management of patients with stable coronary heart disease and discuss implications for the evaluation of patients with stable angina and public policy.

A Case of an Aggressive Intraosseous Arteriovenous Malformation in the Lower Extremity: Special Considerations for Diagnosis and Management.

BACKGROUND: Arteriovenous malformations (AVMs) are rare, congenital vascular anomalies. Intraosseous AVMS most frequently arise in the head and neck, with only a small fraction occurring in the extremities. Herein, we report the findings of a combined soft tissue and intraosseous AVM involving the lower extremity of a 13-year-old child. This case highlights the necessity of an interdisciplinary approach for the effective treatment and management of these rare vascular anomalies. CASE DESCRIPTION: A 13-year-old female presented with a 4-year history of intermittent pain and swelling over her right lateral malleolus. The patient was evaluated with radiologic imaging revealing an AVM involving the right distal leg, ankle, and hindfoot with intraosseous involvement of the distal tibia and talus. She was then referred to Vascular and Plastic Surgery and an angiogram was performed demonstrating shunting from the anterior tibial, peroneal, and posterior tibial arteries to the AVM. Venous drainage was to the anterior tibial and greater saphenous veins. Three embolizations were performed over the course of 6 months. Following the third embolization, the patient was taken to the operating room where Plastic and Orthopedic Surgery performed total resection of the nidus and involved bone which was then grafted with injectable synthetic bone graft. RESULTS: Successful resection of the nidus was achieved, and the patient had an uncomplicated recovery. Within 6 months postoperatively, the patient demonstrated full range of lower extremity motion and was able to participate in age appropriate gross motor activities. Radiologic evaluation 7 months postoperatively showed no evidence of nidus recurrence. CONCLUSION: Intraosseous involvement of AVMS is rare and presents a therapeutic challenge due to its invasive potential and high incidence of recurrence. Wide local excision with bone grafting and interdisciplinary management are paramount for complete resection.

The correlation between intensive care unit attending physician continuity of care with financial and clinical outcomes.

PURPOSE: "Attending rotations" on intensive care unit (ICU) services have been in place in most teaching hospitals for decades. However, the ideal frequency of patient care handoffs is unknown. Frequent attending physician handoffs could result in delays in care and other complications, while too few handoffs can lead to provider burnout and exhaustion. Therefore, we sought to determine the correlation between frequency of attending shifts with ICU charges, 30-day readmission rates, and mortality rates. METHODS: We performed a retrospective cohort study at a large, urban, academic community hospital in Baltimore, MD. We included patients admitted into the cardiac or medical ICUs between September 1, 2012, and December 10, 2015. We tracked the number of attending shifts for each patient and correlated shifts with financial outcomes as a primary measure. RESULTS: For any given ICU length of stay, we found no distinct association between handoff frequency and charges, 30-day readmission rates, or mortality rates. CONCLUSIONS: Despite frequent handoffs in care, there was no objective evidence of care compromise or differences in cost. Further validation of these observations in a larger cohort is justified.