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OBJECTIVE: To assess the image quality of coronary CT angiography (CCTA) for suspected acute coronary syndrome (ACS) outside office hours. METHODS: Patients with symptoms suggestive of an ACS underwent CCTA at the emergency department 24 hours, 7 days a week. A total of 118 patients, of whom 89 (75 %) presented during office hours (weekdays between 07:00 and 17:00) and 29 (25 %) outside office hours (weekdays between 17:00 and 07:00, weekends and holidays) underwent CCTA. Image quality was evaluated per coronary segment by two experienced readers and graded on an ordinal scale ranging from 1 to 3. RESULTS: There were no significant differences in acquisition parameters, beta-blocker administration or heart rate between patients presenting during office hours and outside office hours. The median quality score per patient was 30.5 [interquartile range 26.0-33.5] for patients presenting during office hours in comparison to 27.5 [19.75-32.0] for patients presenting outside office hours (p=0.043). The number of non-evaluable segments was lower for patients presenting during office hours (0 [0-1.0] vs. 1.0 [0-4.0], p=0.009). CONCLUSION: Image quality of CCTA outside office hours in the diagnosis of suspected ACS is diminished. KEY POINTS: ⢠Quality scores were higher for coronary-CTA during office hours. ⢠There were no differences in acquisition parameters. ⢠There was a non-significant trend towards higher heart rates outside office hours. ⢠Coronary-CTA on the ED requires state-of-the-art scanner technology and sufficiently trained staff. ⢠Coronary-CTA on the ED needs preparation time and optimisation of the procedure.
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Síndrome Coronariana Aguda/diagnóstico , Angiografia por Tomografia Computadorizada/métodos , Angiografia Coronária/métodos , Unidades de Cuidados Coronarianos , Vasos Coronários/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Índice de Gravidade de DoençaRESUMO
AIMS: To compare the effectiveness and safety of a cardiac computed tomography (CT) algorithm with functional testing in patients with symptoms suggestive of coronary artery disease (CAD). METHODS AND RESULTS: Between April 2011 and July 2013, 350 patients with stable angina, referred to the outpatient clinic of four Dutch hospitals, were prospectively randomized between cardiac CT and functional testing (2 : 1 ratio). The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. By 1 year, fewer patients randomized to cardiac CT reported anginal complaints (P = 0.012). The cumulative radiation dose was slightly higher in the CT group (6.6 ± 8.7 vs. 6.1 ± 9.3 mSv; P < 0.0001). After 1.2 years, event-free survival was 96.7% for patients randomized to CT and 89.8% for patients randomized to functional testing (P = 0.011). After CT, the final diagnosis was established sooner (P < 0.0001), and additional downstream testing was required less frequently (25 vs. 53%, P < 0.0001), resulting in lower cumulative diagnostic costs (369 vs. 440; P < 0.0001). CONCLUSION: For patients with suspected stable CAD, a tiered cardiac CT protocol offers an effective and safe alternative to functional testing. Incorporating the calcium scan into the diagnostic workup was safe and lowered diagnostic expenses and radiation exposure.
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Doença da Artéria Coronariana/diagnóstico por imagem , Calcificação Vascular/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/métodos , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/terapia , Eletrocardiografia , Teste de Esforço/métodos , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/estatística & dados numéricos , Doses de Radiação , Fatores de Risco , Inquéritos e Questionários , Resultado do Tratamento , Calcificação Vascular/fisiopatologia , Calcificação Vascular/terapiaRESUMO
BACKGROUND: Prospective data on long-term survival and clinical outcome beyond 30 years after surgical correction of tetralogy of Fallot are nonexistent. METHODS AND RESULTS: This longitudinal cohort study consists of the 144 patients with tetralogy of Fallot who underwent surgical repair at <15 years of age between 1968 and 1980 in our center. They are investigated every 10 years. Cumulative survival (data available for 136 patients) was 72% after 40 years. Late mortality was due to heart failure and ventricular fibrillation. Seventy-two of 80 eligible survivors (90%) participated in the third in-hospital investigation, consisting of ECG, Holter, echocardiography, cardiopulmonary exercise testing, N-terminal pro-brain natriuretic peptide measurement, cardiac magnetic resonance (including dobutamine stress testing), and the Short Form-36 questionnaire. Median follow-up was 36 years (range, 31-43 years). Cumulative event-free survival was 25% after 40 years. Subjective health status was comparable to that in the normal Dutch population. Although systolic right and left ventricular function declined, peak exercise capacity remained stable. There was no progression of aortic root dilation. A previous shunt operation, low temperature during surgery, and early postoperative arrhythmias were found to predict late mortality (hazard ratio, 2.9, 1.1, and 2.5, respectively). An increase in QRS duration and a deterioration of exercise tolerance and ventricular dysfunction did not predict mortality. Insertion of a transannular patch was a predictor for late arrhythmias (hazard ratio, 4.0; 95% confidence interval, 1.2-13.4). CONCLUSIONS: Although many patients needed a reoperation or developed arrhythmias, late mortality was low, and the clinical condition and subjective health status of most patients remained good. Previous shunt, low temperature during surgery, and early postoperative arrhythmias were found to predict late mortality.
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Tetralogia de Fallot/diagnóstico , Tetralogia de Fallot/cirurgia , Adolescente , Adulto , Estudos de Coortes , Feminino , Seguimentos , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Tetralogia de Fallot/fisiopatologia , Fatores de Tempo , Adulto JovemRESUMO
PURPOSE: To validate an on-site algorithm for computation of fractional flow reserve (FFR) from coronary computed tomographic (CT) angiography data against invasively measured FFR and to test its diagnostic performance as compared with that of coronary CT angiography. MATERIALS AND METHODS: The institutional review board provided a waiver for this retrospective study. From coronary CT angiography data in 106 patients, FFR was computed at a local workstation by using a computational fluid dynamics algorithm. Invasive FFR measurement was performed in 189 vessels (80 of which had an FFR ≤ 0.80); these measurements were regarded as the reference standard. The diagnostic characteristics of coronary CT angiography-derived computational FFR, coronary CT angiography, and quantitative coronary angiography were evaluated against those of invasively measured FFR by using C statistics. Sensitivity and specificity were compared by using a two-sided McNemar test. RESULTS: For computational FFR, sensitivity was 87.5% (95% confidence interval [CI]: 78.2%, 93.8%), specificity was 65.1% (95% CI: 55.4%, 74.0%), and accuracy was 74.6% (95% CI: 68.4%, 80.8%), as compared with the finding of lumen stenosis of 50% or greater at coronary CT angiography, for which sensitivity was 81.3% (95% CI: 71.0%, 89.1%), specificity was 37.6% (95% CI: 28.5%, 47.4%), and accuracy was 56.1% (95% CI: 49.0%, 63.2%). C statistics revealed a larger area under the receiver operating characteristic curve (AUC) for computational FFR (AUC, 0.83) than for coronary CT angiography (AUC, 0.64). For vessels with intermediate (25%-69%) stenosis, the sensitivity of computational FFR was 87.3% (95% CI: 76.5%, 94.3%) and the specificity was 59.3% (95% CI: 47.8%, 70.1%). CONCLUSION: With use of a reduced-order algorithm, computation of the FFR from coronary CT angiography data can be performed locally, at a regular workstation. The diagnostic accuracy of coronary CT angiography-derived computational FFR for the detection of functionally important coronary artery disease (CAD) was good and was incremental to that of coronary CT angiography within a population with a high prevalence of CAD.
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Algoritmos , Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Reserva Fracionada de Fluxo Miocárdico , Tomografia Computadorizada por Raios X , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
MRI is an important additional tool in the diagnostic work-up of children with congenital heart disease. This review aims to summarise the role MRI has in this patient population. Echocardiography remains the main diagnostic tool in congenital heart disease. In specific situations, MRI is used for anatomical imaging of congenital heart disease. This includes detailed assessment of intracardiac anatomy with 2-D and 3-D sequences. MRI is particularly useful for assessment of retrosternal structures in the heart and for imaging large vessel anatomy. Functional assessment includes assessment of ventricular function using 2-D cine techniques. Of particular interest in congenital heart disease is assessment of right and single ventricular function. Two-dimensional and newer 3-D techniques to quantify flow in these patients are or will soon become an integral part of quantification of shunt size, valve function and complex flow patterns in large vessels. More advanced uses of MRI include imaging of cardiovascular function during stress and tissue characterisation of the myocardium. Techniques used for this purpose need further validation before they can become part of the daily routine of MRI assessment of congenital heart disease.
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Cardiopatias Congênitas/patologia , Imageamento Tridimensional/métodos , Imageamento por Ressonância Magnética/métodos , Imagem de Perfusão do Miocárdio/métodos , Disfunção Ventricular Esquerda/patologia , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/complicações , Humanos , Lactente , Recém-Nascido , Masculino , Disfunção Ventricular Esquerda/etiologiaRESUMO
AIMS: To describe long-term survival, clinical outcome and ventricular systolic function in a longitudinally followed cohort of patients after Mustard repair for transposition of the great arteries (TGA). There is serious concern about the long-term outcome after Mustard repair. METHODS AND RESULTS: This longitudinal single-centre study consisted of 91 consecutive patients, who underwent Mustard repair before 1980, at age <15 years, and were evaluated in-hospital every 10 years. Survival status was obtained of 86 patients. Median follow-up was 35 (IQR 34-38) years. Cumulative survival was 84% after 10 years, 80% after 20 years, 77% after 30 years, and 68% after 39 years. Cumulative survival free of events (i.e. heart transplantation, arrhythmias, reintervention, and heart failure) was 19% after 39 years. Reinterventions were mainly required for baffle-related problems. Supraventricular and ventricular arrhythmias occurred in 28 and 6% of the patients, respectively. Pacemaker and/or ICD implantation was performed in 39%. Fifty survivors participated in the current in-hospital investigation including electrocardiography, 2D-echocardiography, cardiopulmonary-exercise testing, NT-proBNP measurement, Holter monitoring, and cardiac magnetic resonance. Right ventricular systolic function was impaired in all but one patient at last follow-up, and 14% developed heart failure in the last decade. NT-proBNP levels [median 31.6 (IQR 22.3-53.2) pmol/L] were elevated in 92% of the patients. Early postoperative arrhythmias were a predictor for late arrhythmias [HR 3.8 (95% CI 1.5-9.5)], and development of heart failure [HR 8.1 (95% CI 2.2-30.7)]. Also older age at operation was a predictor for heart failure [HR 1.26 (95% CI 1.0-1.6)]. CONCLUSION: Long-term survival after Mustard repair is clearly diminished and morbidity is substantial. Early postoperative arrhythmias are a predictor for heart failure and late arrhythmias.
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Procedimentos Cirúrgicos Cardíacos/métodos , Transposição dos Grandes Vasos/cirurgia , Adulto , Arritmias Cardíacas/etiologia , Biomarcadores/metabolismo , Procedimentos Cirúrgicos Cardíacos/mortalidade , Pré-Escolar , Ecocardiografia , Eletrocardiografia , Eletrocardiografia Ambulatorial , Métodos Epidemiológicos , Teste de Esforço/métodos , Feminino , Insuficiência Cardíaca/etiologia , Humanos , Lactente , Angiografia por Ressonância Magnética , Masculino , Peptídeo Natriurético Encefálico/metabolismo , Fragmentos de Peptídeos/metabolismo , Complicações Pós-Operatórias/etiologia , Reoperação , Transposição dos Grandes Vasos/mortalidade , Disfunção Ventricular Direita/etiologiaRESUMO
INTRODUCTION AND IMPORTANCE: Blunt abdominal trauma is one of the most common reasons for emergency department visits, and spleen and splenic vasculature is involved variably in those cases. Splenic artery pseudoaneurysm formation is one complication with potentially devastating consequences. Early detection and management are of paramount importance given its potential fatality. Management includes open repair with or without splenectomy, and endovascular approach. The minimally invasive endovascular treatment offers earlier recovery, preserved splenic function, and positive outcomes. We report a case of delayed presentation of a large splenic artery pseudoaneurysm after blunt abdominal trauma, managed using endovascular intervention. CASE PRESENTATION: A 45-year-old male presented 10 days after being involved in a pedestrian accident with blunt abdominal trauma resulting in a large splenic artery pseudoaneurysm. After multidisciplinary discussion, the decision was to take him for endovascular treatment. The patient recovered very well and was discharged two days later and followed up in an outpatient setting. Over a year, he became symptom free, and demonstrated radiological finding of shrinking pseudoaneurysm. CLINICAL DISCUSSION: Pseudoaneurysms of visceral arteries are repaired regardless of their size per society of vascular surgery guidelines. Larger ones are at higher risk of rupture and are associated with high mortality. When discovered, treatment plans should be readily discussed, and undertaken. In our case, the patient had a 6.5 cm splenic artery pseudoaneurysm, and a multidisciplinary meeting was conducted and concluded that endovascular treatment would be the best modality to start with, with surgical option as a backup in a hybrid room setting. CONCLUSION: Blunt abdominal trauma can present with overt symptoms of internal organ injury; however, some might be missed and need high index of suspicion and therefore further testing and imaging. Splenic artery pseudoaneurysms can expand and rupture in delayed presentation, early detection and management is of paramount importance. Endovascular treatment represents an excellent modality, with minimal invasive nature, faster recovery, and early return to daily activity with preserved splenic function.
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OBJECTIVE: To determine the diagnostic accuracy of copeptin in patients with suspected acute coronary syndrome (ACS) and its correlation with obstructive coronary artery disease (CAD) on coronary CT angiography (CTA). METHODS: Copeptin was measured at arrival in 65 consecutive patients (56 ± 10 years, 45 men) suspected of ACS and no indication for immediate invasive angiography. All patients underwent coronary CTA without disclosure of the results to the treating physician, and outcomes were classified as obstructive CAD (>50% stenosis) or no obstructive CAD (≤ 50%) in one or more vessel. RESULTS: The final diagnosis of ACS was established in 10 (15%) patients, 6 myocardial infarctions and 4 unstable angina pectoris. Coronary CTA detected obstructive CAD in all patients with ACS and in 10 (15%) patients with no ACS. Copeptin concentrations were higher in patients with ACS (median 7.42 pmol/l (IQR 3.71-18.72)) vs patients with no ACS (3.40 pmol/l (1.13-6.27), p=0.02). Copeptin was not higher in patients with obstructive CAD on coronary CTA (4.87 pmol/l (2.90-8.51) vs 3.60 pmol/l (1.21-6.23), p=0.20) compared with patients with no obstructive CAD. CONCLUSIONS: Copeptin seems to be elevated in patients with ACS while there is no strong correlation with obstructive coronary disease on CTA.
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Síndrome Coronariana Aguda/diagnóstico , Dor no Peito/diagnóstico , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Glicopeptídeos/sangue , Tomografia Computadorizada por Raios X , Síndrome Coronariana Aguda/sangue , Idoso , Análise de Variância , Biomarcadores/sangue , Dor no Peito/sangue , Doença da Artéria Coronariana/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sensibilidade e EspecificidadeRESUMO
Arterial access is therapeutically and diagnostically useful. Its clinical utility is vast, and associated complications are infrequent. However, some unfortunate patients progress to disastrous outcomes. Luckily, ischemic hand complications are rare. Hand ischemia threatens independence and quality of life, thus warranting vigilance. We present a case of index digit necrosis as a complication of arterial cannulation in a 30-year-old patient with end-stage renal disease admitted to an intensive care unit.
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Insuficiência da Valva Aórtica/etiologia , Valva Aórtica/anormalidades , Transtornos Cromossômicos/patologia , Seio Coronário/anormalidades , Veias Cavas/anormalidades , Adulto , Aneuploidia , Aneurisma/etiologia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/cirurgia , Transtornos Cromossômicos/diagnóstico , Cromossomos Humanos Par 22 , Diagnóstico Tardio , Dispneia/etiologia , Anormalidades do Olho , Feminino , Implante de Prótese de Valva Cardíaca , Humanos , Polimorfismo de Nucleotídeo Único , Fístula Retovaginal/genética , Síndrome , Tomografia Computadorizada por Raios X , Ultrassonografia , Veias Cavas/diagnóstico por imagemRESUMO
OBJECTIVE: In a previous in vitro study we have demonstrated that atherosclerotic plaque components can be characterized with multidetector computed tomography (MDCT) based on differences in Hounsfield values (HV). Now we evaluated the use of MDCT in vivo to characterize and quantify atherosclerotic carotid plaque components compared with histology as reference standard. METHODS AND RESULTS: Fifteen symptomatic patients with carotid stenosis (>70%) underwent MDCT angiography before carotid endarterectomy (CEA). From each CEA specimen 3 histological sections and corresponding MDCT images were selected. The HV of the major plaque components were assessed. The measured HV were: 657+/-416HU, 88+/-18HU, and 25+/-19HU for calcifications, fibrous tissue, and lipid core, respectively. The cut-off value to differentiate lipid core from fibrous tissue and fibrous tissue from calcifications was based on these measurements and set at 60 HU and 130 HU, respectively. Regression plots showed good correlations (R2>0.73) between MDCT and histology except for lipid core areas, which had a good correlation (R2=0.77) only in mildly calcified (0% to 10%) plaques. CONCLUSIONS: MDCT is able to quantify total plaque area, calcifications, and fibrous tissue in atherosclerotic carotid plaques in good correlation with histology. Lipid core can only be adequately quantified in mildly calcified plaques.
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Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/patologia , Arteriosclerose Intracraniana/diagnóstico por imagem , Arteriosclerose Intracraniana/patologia , Tomografia Computadorizada por Raios X , Idoso , Idoso de 80 Anos ou mais , Calcinose/diagnóstico por imagem , Calcinose/patologia , Estenose das Carótidas/metabolismo , Feminino , Fibrose , Humanos , Arteriosclerose Intracraniana/metabolismo , Metabolismo dos Lipídeos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND: Cardiac computed tomography (CT) represents an alternative diagnostic strategy for women with suspected coronary artery disease, with potential benefits in terms of effectiveness and cost-efficiency. METHODS AND RESULTS: The CRESCENT trial (Calcium Imaging and Selective CT Angiography in Comparison to Functional Testing for Suspected Coronary Artery Disease) prospectively randomized 350 patients with stable angina (55% women; aged 55±10 years), mostly with an intermediate coronary artery disease probability, between cardiac CT and functional testing. The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. Sex differences were studied as a prespecified subanalysis. Enrolled women presented more frequently with atypical chest pain and had a lower pretest probability of coronary artery disease compared with men. Independently of these differences, cardiac CT led in both sexes to a fast final diagnosis when compared with functional testing, although the effect was larger in women (P interaction=0.01). The reduced need for further testing after CT, compared with functional testing, was most evident in women (P interaction=0.009). However, no sex interaction was observed with respect to changes in angina and quality of life, cumulative diagnostic costs, and applied radiation dose (all P interactions≥0.097). CONCLUSIONS: Cardiac CT is more efficient in women than in men in terms of time to reach the final diagnosis and downstream testing. However, overall clinical outcome showed no significant difference between women and men after 1 year. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01393028.
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Angina Estável/etiologia , Angiografia por Tomografia Computadorizada/estatística & dados numéricos , Angiografia Coronária/estatística & dados numéricos , Doença da Artéria Coronariana/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Disparidades em Assistência à Saúde , Calcificação Vascular/diagnóstico por imagem , Idoso , Angiografia Coronária/métodos , Doença da Artéria Coronariana/complicações , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Países Baixos , Valor Preditivo dos Testes , Estudos Prospectivos , Doses de Radiação , Exposição à Radiação , Reprodutibilidade dos Testes , Índice de Gravidade de Doença , Fatores Sexuais , Fatores de Tempo , Calcificação Vascular/complicaçõesRESUMO
PURPOSE: This study aims to compare image quality, radiation dose, and the influence of the heart rate on image quality of high-pitch spiral coronary computed tomography angiography (CCTA) using 128-slice (second generation) dual-source CT (DSCT) and a 192-slice DSCT (third generation) scanner. MATERIALS AND METHODS: Two consecutive cohorts of fifty patients underwent CCTA by high-pitch spiral scan mode using 128 or 192-slice DSCT. The 192-slice DSCT system has a more powerful roentgen tube (2 × 120 kW) that allows CCTA acquisition at lower tube voltages, wider longitudinal coverage for faster table speed (732 m/s), and the use of iterative reconstruction. Objective image quality was measured as the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). Subjective image quality was evaluated using a Likert scale. RESULTS: While the effective dose was lower with 192-slice DSCT (1.2 ± 0.5 vs. 0.6 ± 0.3 mSv; P < 0.001), the SNR (18.9 ± 4.3 vs. 11.0 ± 2.9; P < 0.001) and CNR (23.5 ± 4.8 vs. 14.3 ± 4.1; P < 0.001) were superior to 128-slice DSCT. Although patients scanned with 192-slice DSCT had a faster heart rate (59 ± 7 vs. 56 ± 6; P = 0.045), subjective image quality was scored higher (4.2 ± 0.8 vs. 3.0 ± 0.7; P < 0.001) compared to 128-slice DSCT. CONCLUSIONS: High-pitch spiral CCTA by 192-slice DSCT provides better image quality, despite a higher average heart rate, at lower radiation doses compared to 128-slice DSCT.
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Cardiovascular CT acquisition protocol optimization in pediatric patients, including newborns is often challenging. This might be due to non-cooperative patients, the complexity and variety of diseases and the need for stringent dose minimization. Motion artifacts caused by voluntary and involuntary motion are most frequently seen in cardiac imaging with high heart and respiratory rates. Dual source scanners of the second and third generation are particularly well suited to respond to these challenges. This can be accomplished with advanced scan options, such as high pitch scanning, short rotation times, automated tube voltage selection, tube current modulation and iterative reconstruction.
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Algoritmos , Técnicas de Imagem de Sincronização Cardíaca/métodos , Cardiopatias Congênitas/diagnóstico por imagem , Interpretação de Imagem Radiográfica Assistida por Computador/métodos , Imagem Radiográfica a Partir de Emissão de Duplo Fóton/métodos , Tomografia Computadorizada por Raios X/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Intensificação de Imagem Radiográfica/métodos , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: It is uncertain whether a diagnostic strategy supplemented by early coronary computed tomography angiography (CCTA) is superior to contemporary standard optimal care (SOC) encompassing high-sensitivity troponin assays (hs-troponins) for patients suspected of acute coronary syndrome (ACS) in the emergency department (ED). OBJECTIVES: This study assessed whether a diagnostic strategy supplemented by early CCTA improves clinical effectiveness compared with contemporary SOC. METHODS: In a prospective, open-label, multicenter, randomized trial, we enrolled patients presenting with symptoms suggestive of an ACS at the ED of 5 community and 2 university hospitals in the Netherlands. Exclusion criteria included the need for urgent cardiac catheterization and history of ACS or coronary revascularization. The primary endpoint was the number of patients identified with significant coronary artery disease requiring revascularization within 30 days. RESULTS: The study population consisted of 500 patients, of whom 236 (47%) were women (mean age 54 ± 10 years). There was no difference in the primary endpoint (22 [9%] patients underwent coronary revascularization within 30 days in the CCTA group and 17 [7%] in the SOC group [p = 0.40]). Discharge from the ED was not more frequent after CCTA (65% vs. 59%, p = 0.16), and length of stay was similar (6.3 h in both groups; p = 0.80). The CCTA group had lower direct medical costs (337 vs. 511, p < 0.01) and less outpatient testing after the index ED visit (10 [4%] vs. 26 [10%], p < 0.01). There was no difference in incidence of undetected ACS. CONCLUSIONS: CCTA, applied early in the work-up of suspected ACS, is safe and associated with less outpatient testing and lower costs. However, in the era of hs-troponins, CCTA does not identify more patients with significant CAD requiring coronary revascularization, shorten hospital stay, or allow for more direct discharge from the ED. (Better Evaluation of Acute Chest Pain with Computed Tomography Angiography [BEACON]; NCT01413282).
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Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/diagnóstico por imagem , Angiografia Coronária , Serviço Hospitalar de Emergência , Tomografia Computadorizada por Raios X , Troponina/sangue , Síndrome Coronariana Aguda/terapia , Idoso , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica , Países Baixos , Estudos ProspectivosRESUMO
Over the past 10 years there has been intense research in the development of volumetric visualization of intracardiac flow by cardiac magnetic resonance (CMR).This volumetric time resolved technique called CMR 4D flow imaging has several advantages over standard CMR. It offers anatomical, functional and flow information in a single free-breathing, ten-minute acquisition. However, the data obtained is large and its processing requires dedicated software. We evaluated a cloud-based application package that combines volumetric data correction and visualization of CMR 4D flow data, and assessed its accuracy for the detection and grading of aortic valve regurgitation using transthoracic echocardiography as reference. Between June 2014 and January 2015, patients planned for clinical CMR were consecutively approached to undergo the supplementary CMR 4D flow acquisition. Fifty four patients(median age 39 years, 32 males) were included. Detection and grading of the aortic valve regurgitation using CMR4D flow imaging were evaluated against transthoracic echocardiography. The agreement between 4D flow CMR and transthoracic echocardiography for grading of aortic valve regurgitation was good (j = 0.73). To identify relevant,more than mild aortic valve regurgitation, CMR 4D flow imaging had a sensitivity of 100 % and specificity of 98 %. Aortic regurgitation can be well visualized, in a similar manner as transthoracic echocardiography, when using CMR 4D flow imaging.
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Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/patologia , Imageamento Tridimensional/métodos , Imageamento por Ressonância Magnética/métodos , Adulto , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/patologia , Feminino , Humanos , Masculino , Projetos Piloto , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Índice de Gravidade de DoençaRESUMO
At present, traditional risk factors are used to guide cardiovascular management of asymptomatic subjects. Intensified surveillance may be warranted in those identified as high risk of developing cardiovascular disease (CVD). This study aims to determine the prognostic value of coronary computed tomography (CT) angiography (CCTA) next to the coronary artery calcium score (CACS) in patients at high CVD risk without symptoms suspect for coronary artery disease (CAD). A total of 665 patients at high risk (mean age 56 ± 9 years, 417 men), having at least one important CVD risk factor (diabetes mellitus, familial hypercholesterolemia, peripheral artery disease, or severe hypertension) or a calculated European systematic coronary risk evaluation of >10% were included from outpatient clinics at 2 academic centers. Follow-up was performed for the occurrence of adverse events including all-cause mortality, nonfatal myocardial infarction, unstable angina, or coronary revascularization. During a median follow-up of 3.0 (interquartile range 1.3 to 4.1) years, adverse events occurred in 40 subjects (6.0%). By multivariate analysis, adjusted for age, gender, and CACS, obstructive CAD on CCTA (≥50% luminal stenosis) was a significant predictor of adverse events (hazard ratio 5.9 [CI 1.3 to 26.1]). Addition of CCTA to age, gender, plus CACS, increased the C statistic from 0.81 to 0.84 and resulted in a total net reclassification index of 0.19 (p <0.01). In conclusion, CCTA has incremental prognostic value and risk reclassification benefit beyond CACS in patients without CAD symptoms but with high risk of developing CVD.
Assuntos
Angiografia Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Medição de Risco , Tomografia Computadorizada por Raios X/métodos , Idoso , Doença da Artéria Coronariana/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendênciasRESUMO
BACKGROUND AND PURPOSE: Besides the severity of carotid artery stenosis, atherosclerotic plaque composition is an important determinant of cerebral symptoms. We analyzed the relationship between the composition of the atherosclerotic plaque at the carotid artery bifurcation and ipsilateral ischemic cerebral lesions on MR imaging. METHODS: Forty-one patients with symptomatic carotid artery stenosis (>70%) underwent black-blood, fast spin-echo imaging of the carotid artery and turbo fluid-attenuated inversion recovery (t-FLAIR) imaging of the brain. Plaque regions with a relative decrease in signal intensity in the plaque from proton density-weighted (TE = 14 ms) to T2-weighted (TE = 50 ms) imaging were considered to be lipid cores. We assessed the number and location of infarcts in the ipsilateral cortex, basal ganglia, and centrum semiovale, and hyperintense white matter lesions on t-FLAIR images. RESULTS: Lipid in the atherosclerotic plaque at the carotid bifurcation was seen in 25 patients. Ipsilateral infarctions were seen in 22 (54%); most often, it involved the centrum semiovale. Patients with a lipid core had an ipsilateral infarct more often than patients without a lipid core (68% vs. 31%; P = .03). Centrum semiovale infarcts were more frequent (56% vs. 25%, P = .06) and the median number of centrum semiovale infarcts was higher P = .04) in patients with a lipid core than in patients without a lipid core. CONCLUSION: Ischemic cerebral lesions were common in patients with symptomatic carotid artery disease. Plaque composition, as assessed with MR imaging, is related to the presence and extent of ischemic cerebral lesions.
Assuntos
Estenose das Carótidas/complicações , Estenose das Carótidas/patologia , Infarto Cerebral/etiologia , Imageamento por Ressonância Magnética , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: The aim of this study was to identify variables associated with tissue fragment embolization during transcatheter aortic valve replacement (TAVR). BACKGROUND: Brain magnetic resonance imaging and transcranial Doppler studies have revealed that cerebrovascular embolization occurs frequently during TAVR. Embolized material may be r thrombotic, tissue derived, or catheter (foreign material) fragments. METHODS: A total of 81 patients underwent TAVR with a dual filter-based embolic protection device (Montage Dual Filter System, Claret Medical, Inc., Santa Rosa, California) deployed in the brachiocephalic trunk and left common carotid artery. Both balloon-expandable and self-expanding transcatheter heart valves (THVs) were used. Filters were retrieved after TAVR and sent for histopathological analysis. RESULTS: Overall, debris was captured in 86% of patients. Captured material varied in size from 0.1 to 9.0 mm. Thrombotic material was found in 74% of patients and tissue-derived debris in 63%. Tissue fragments were found more often with balloon-expandable THVs (79% vs. 56%; p = 0.05). The embolized tissue originated from the native aortic valve leaflets, aortic wall, or left ventricular myocardium. On multivariable logistic regression analysis, balloon-expandable THVs (odds ratio: 7.315; 95% confidence interval: 1.398 to 38.289; p = 0.018) and cover index (odds ratio: 1.141; 95% confidence interval: 1.014 to 1.283; p = 0.028) were independent predictors of tissue embolization. CONCLUSIONS: Debris is captured with filter-based embolic protection in the vast majority of patients undergoing TAVR. Tissue-derived material is found in 63% of cases and is more frequent with the use of balloon-expandable systems and more oversizing.
Assuntos
Valva Aórtica , Cateterismo Cardíaco/efeitos adversos , Migração de Corpo Estranho/epidemiologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Embolia Intracraniana/epidemiologia , Trombose/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Valvuloplastia com Balão/efeitos adversos , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/métodos , Distribuição de Qui-Quadrado , Dispositivos de Proteção Embólica , Feminino , Migração de Corpo Estranho/diagnóstico , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Incidência , Embolia Intracraniana/diagnóstico , Modelos Logísticos , Imageamento por Ressonância Magnética , Masculino , Análise Multivariada , Países Baixos/epidemiologia , Razão de Chances , Desenho de Prótese , Fatores de Risco , Trombose/diagnóstico , Ultrassonografia Doppler TranscranianaRESUMO
BACKGROUND: Renal denervation is a new treatment considered for several possible indications. As new systems are introduced, the incidence of acute renal artery wall injury with relation to the denervation method is unknown. We investigated the acute repercussion of renal denervation on the renal arteries of patients treated with balloon-based and nonballoon-based denervation systems by quantitative angiography, intravascular ultrasound, and optical coherence tomography (OCT). METHODS AND RESULTS: Twenty-five patients (50 renal arteries) underwent bilateral renal denervation with 5 different systems, 3 of which balloon-based (Paradise [n=5], Oneshot [n=6], and Vessix V2 [n=5)]) and 2 nonballoon-based (Symplicity [n=6] and EnligHTN [n=3]). Analysis included quantitative angiography and morphometric intravascular ultrasound measurements pre and post procedure and assessment of vascular trauma (dissection, edema, or thrombus) by OCT after denervation. A significant reduction in lumen size by quantitative angiography and intravascular ultrasound was observed in nonballoon denervation but not in balloon denervation. By postdenervation OCT, dissection was seen in 14 arteries (32.6%). The percentage of frames with dissection was higher in balloon-based denervation catheters. Thrombus and edema were detected in 35 (81.4%) and 32 (74.4%) arteries, respectively. In arteries treated with balloon-based denervation that had dissection by OCT, the balloon/artery ratio was higher (1.24 [1.17-1.32] versus 1.10 [1.04-1.18]; P<0.01). CONCLUSIONS: A varying extent of vascular injury was observed after renal denervation in all systems; however, different patterns were identified in balloon-based and in nonballoon-based denervation systems. In balloon denervation, the presence of dissections by OCT was associated with a higher balloon/artery ratio.