Transcatheter implantation of covered stents serving as extravascular conduits-Proof of a CT-based approach in three cases.

BACKGROUND: Covered stents perform similar to surgically implanted conduits, although the stents work inside of vessels. We present a computed tomography (CT)-based workflow for the implantation of covered stents as extravascular conduits. METHODS: We selected three different use cases: 1. Connecting a left-sided partially anomalous drainage of a pulmonary vein to the left atrium. 2. Bypassing an outgrown Dacron conduit in aortic recoarctation. 3. Re-directing hepatic venous blood to the left lung in a Fontan patient with heterotaxy, connecting the innominate vein to the right pulmonary artery like a right-sided cavopulmonary connection. By postprocessing and analyzing CT scans for planning and by the use of long needles under biplane fluoroscopy for the realization of the procedure, we projected and performed the exit of a long needle out of a vessel, the re-entering of a target vessel, and the bridging of the extravascular distance by implantation of covered stents. RESULTS: In all three cases, the covered stents were placed successfully, connecting vessels of 15-50 mm distance from each other with very good hemodynamic results. In one case, two stents were placed consecutively, overlapping each other to accomplish an exact fitting at the connection sites to the native vessels.

Coronary computed tomography angiography as a tool for long-term cardiovascular risk stratification in diabetic patients.

Objectives of the study were to examine the long-term prognostic power of coronary computed tomography angiography (CCTA) to predict death or myocardial infarction in patients with diabetes mellitus (DM). The prognostic value of CCTA in diabetic patients has been confirmed for short- and intermediate follow-up durations. The slowly progressing nature of coronary artery disease (CAD), however, underlines the necessity to validate CCTA for longer observation periods in this high-risk population. A total of 132 patients with DM and 1781 without DM were examined by CCTA and followed for a median duration of 9.7 (IQR 6.9, 11.2) and 9.9 (IQR 6.9, 11.1) years, respectively. Cox proportional hazards analysis was used for the composite endpoint of death and myocardial infarction. Warranty period was defined as the number of years that an individual stays in a low-risk group with a cumulative probability for the endpoint below 1% and calculated for patients with/without DM and rising degrees of CAD. The study endpoint was reached in 12 (9.1%) patients with and 87 (4.9%) patients without DM (p = 0.024). Quantification of coronary stenosis by CADRADS or CAD severity (normal/non-obstructive/obstructive) was incremental for endpoint prediction with a multivariate (+Morise) χ2 of 3.90 and 3.85, respectively. The lowest annual event rate of 0.19% was noted in non-diabetic patients with no CAD, translating to a warranty period of 5.26 years. The highest annual event rate of 1.73% was found in diabetic patients with obstructive CAD, corresponding to a warranty period of 0.58 years. Compared to patients with no DM and no CAD, the risk of death or myocardial infarction in diabetic patients increased with rising levels of coronary obstruction at multivariate hazard ratios (HR) of 3.28 [95% CI 2.32, 4.64 (p < 0.001)], 3.02 [95% CI 2.19, 4.17 (p < 0.001)] and 9.40 [95% CI 4.90, 18.03 (p < 0.001)] for normal coronary arteries, non-obstructive CAD and obstructive CAD. This study validates the long-term prognostic utility of CCTA-assessed CAD for predicting death or myocardial infarction in a population of patients with DM. The rates of death or myocardial infarction rise with CAD severity in diabetic and non-diabetic patients, identifying the highest risk group of patients with DM and obstructive CAD.

Prognostic Value of Machine Learning-based Time-to-Event Analysis Using Coronary CT Angiography in Patients with Suspected Coronary Artery Disease.

Purpose: To assess the long-term prognostic value of a machine learning (ML) approach in time-to-event analyses incorporating coronary CT angiography (CCTA)-derived and clinical parameters in patients with suspected coronary artery disease. Materials and Methods: The retrospective analysis included patients with suspected coronary artery disease who underwent CCTA between October 2004 and December 2017. Major adverse cardiovascular events were defined as the composite of all-cause death, myocardial infarction, unstable angina, or late revascularization (>90 days after index scan). Clinical and CCTA-derived parameters were assessed as predictors of major adverse cardiovascular events and incorporated into two models: a Cox proportional hazards model with recursive feature elimination and an ML model based on random survival forests. Both models were trained and validated by employing repeated nested cross-validation. Harrell concordance index (C-index) was used to assess the predictive power. Results: A total of 5457 patients (mean age, 61 years ± 11 [SD]; 3648 male patients) were evaluated. The predictive power of the ML model (C-index, 0.74; 95% CI: 0.71, 0.76) was significantly higher than the Cox model (C-index, 0.71; 95% CI: 0.68, 0.74; P = .02). The ML model also outperformed the segment stenosis score (C-index, 0.69; 95% CI: 0.66, 0.72; P < .001), which was the best performing CCTA-derived parameter, and patient age (C-index, 0.66; 95% CI: 0.63, 0.69; P < .001), the best performing clinical parameter. Conclusion: An ML model for time-to-event analysis based on random survival forests had higher performance in predicting major adverse cardiovascular events compared with established clinical or CCTA-derived metrics and a conventional Cox model.Keywords: Machine Learning, CT Angiography, Cardiac, Arteries, Heart, Arteriosclerosis, Coronary Artery DiseaseSupplemental material is available for this article.© RSNA, 2023.

Convolutional neural networks on risk stratification of patients with suspected coronary artery disease undergoing coronary computed tomography angiography.

To assess the prognostic value of convolutional neural networks (CNN) on coronary computed tomography angiography (CCTA) in comparison to conventional computed tomography (CT) reporting and clinical risk scores. 5468 patients who underwent CCTA with suspected coronary artery disease (CAD) were included. Primary endpoint was defined as a composite of all-cause death, myocardial infarction, unstable angina or late revascularization (> 90 days after CCTA). Early revascularization was additionally included as a training endpoint for the CNN algorithm. Cardiovascular risk stratification was based on Morise score and the extent of CAD (eoCAD) as assessed on CCTA. Semiautomatic post-processing was performed for vessel delineation and annotation of calcified and non-calcified plaque areas. Using a two-step training of a DenseNet-121 CNN the entire network was trained with the training endpoint, followed by training the feature layer with the primary endpoint. During a median follow-up of 7.2 years, the primary endpoint occurred in 334 patients. CNN showed an AUC of 0.631 ± 0.015 for prediction of the combined primary endpoint, while combining it with conventional CT and clinical risk scores showed an improvement of AUC from 0.646 ± 0.014 (based on eoCAD only) to 0.680 ± 0.015 (p < 0.0001) and from 0.619 ± 0.0149 (based on Morise Score only) to 0.6812 ± 0.0145 (p < 0.0001), respectively. In a stepwise model including all prediction methods, it was found an AUC of 0.680 ± 0.0148. CNN analysis showed to improve conventional CCTA-derived and clinical risk stratification when evaluating CCTA of patients with suspected CAD.

Delayed right-ventricular perforation of a pacemaker lead.

We present a case of a migrated ventricular pacing lead after 1 month of implantation. Enhanced computed tomography allowed for the exact diagnosis. Defibrillator lead perforations are widely described. Although most pacemaker lead perforations are usually recognized during or shortly after implantation, late perforations can occur.

Sex- and age-specific differences in the long-term prognostic value of morphological plaque features detected by coronary computed tomography angiography.

BACKGROUND: Although sex- and age-specific differences in coronary plaque features detected by coronary computed tomography angiography (CCTA) are known, insufficient information regarding the long-term prognostic value of these findings exists. METHODS: A total of 1615 patients with suspected but not previously diagnosed coronary artery disease (CAD) were examined by CCTA and coronary plaque features were assessed. The median follow-up period was 10.5 (IQR 9.2-11.4) years. Cox proportional-hazards analysis was used for the combined endpoint of cardiac death or nonfatal myocardial infarction. RESULTS: The endpoint occurred more often in patients older than 65 years (5.66% vs. 2.05%; p = 0.00029) but similarly between female (3.34%) and male (3.07%) patients (p = 0.76). Both sexes displayed a similar prevalence for noncalcified (female vs. male: 0.77 ± 1.38 vs. 0.89 ± 1.41; p = 0.098) and low-attenuation (female vs. male: 2.6% vs. 4.37%; p = 0.096) plaques. As assessed by p for interaction CADRADS (p for interaction = 0.013), noncalcified plaques (p for interaction = 0.022) and low-attenuation plaques (p for interaction = 0.045) had a better primary endpoint association in women than in men. Concerning age, no difference in outcome association was apparent as evaluated by p for interaction. CONCLUSION: CCTA demonstrates excellent long-term prognostic value irrespective of sex and age and independent from the higher prevalence of atherosclerotic plaques in men and patients older than 65 years. Although similarly prevalent in both sexes, noncalcified and low-attenuation plaques exhibit a better prognostic value in women.

Radiation Dose and Image Quality of a High-Pitch Prospective Spiral First Approach in Coronary Computed Tomography Angiography (CCTA).

Objective: To investigate a high-pitch spiral first (HPSF) approach for coronary computed tomography angiography (CCTA) in an unselected patient cohort and compare diagnostic yield and radiation exposure to CCTAs acquired via conventional, non-high-pitch spiral first (NHPSF) scan regimes. Materials and Methods: All consecutive patients from 1 January 2015 to 31 December 2017 were included. Two investigation protocols (HPSF/NHPSF) were used with the aim to achieve diagnostic image quality of all coronary segments. Low-pitch secondary scans followed the initial examination if image quality was unsatisfactory. Dosage and image quality were compared between both regimes. Results: 1410 patients were subject to a HPSF and 236 patients to a NHPSF approach. While the HPSF approach led to a higher fraction of re-scans (35% vs. 11%, p < 0.001), the fraction of aggregate scans that remained non-diagnostic after considering the initial and secondary scan was comparably low for the HPSF and NHPSF approach (0.78 vs. 0%, p = 0.18). Aggregate radiation exposure in the HPSF protocol was significantly lower (1.12 mSv (IQR: 0.73, 2.10) vs. 3.96 mSv (IQR: 2.23, 8.33) p < 0.001). Conclusions: In spite of a higher number of re-scans, a HPSF approach leads to a reduction in overall radiation exposure with diagnostic yields similar to a NHPSF approach.

Aortic annulus evaluation in transcatheter aortic valve implantation.

OBJECTIVES: We compared the annulus diameters measured by transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and dual-source computed tomography (DSCT) before transcatheter aortic valve implantation (TAVI). BACKGROUND: In TAVI correct evaluation of the aortic annulus is mandatory to choose the correct prosthesis type and size and to prevent complications. There is no gold standard for the assessment of aortic annulus diameters. METHODS: Preoperative assessment of the aortic annulus with TTE, TEE, and DSCT was performed in 187 consecutive patients referred for TAVI between June 2007 and May 2009. RESULTS: The mean aortic annuli were 22.6 ± 2.0 mm measured with DSCT, 22.3 ± 2.5 mm with TTE, and 22.9 ± 2.2 mm with TEE. Despite a strong correlation between the measurement techniques, relevant statistical spread occurred with differences up to 3 mm in all measurement methods. Inter- and intraobserver variability was good for TEE and less satisfactory for DSCT measurements. TEE measurements taken as decisive parameter for the implantation changed the implantation strategy in 15.5% of patients and did not show an increased rate of procedural complications. CONCLUSION: Despite a strong correlation, the measurement techniques for the aortic annulus show relevant statistical spread, consequently one measurement technique cannot definitely predict another. TEE measurements show a more satisfactory intra- and interobserver variability than DSCT. Taking TEE annulus measurements as decisive parameter for the implantation has an impact on the implantation strategy and is safe with a low rate of procedural complications.

Long-term prognostic value of morphological plaque features on coronary computed tomography angiography.

AIMS: To investigate the incremental prognostic value of morphological plaque features beyond clinical risk and coronary stenosis levels. Although associated with the degree of coronary stenosis, most cardiac events occur on the basis of ruptured non-obstructive plaques and consecutive vessel thrombosis. As such, identification of vulnerable plaques is paramount for cardiovascular risk prediction and treatment decisions. METHODS AND RESULTS: A total of 1615 patients with suspected but not previously diagnosed coronary artery disease (CAD) were examined by coronary computed tomography angiography and morphological plaque features were assessed. Mean follow-up was 10.5 (interquartile range 9.2-11.4) years. Cox proportional hazards analysis was used for the composite endpoint of cardiac death and non-fatal myocardial infarction. The study endpoint was reached in 51 patients (36 cardiac deaths, 15 non-fatal myocardial infarctions). In addition to quantitative parameters (presence of any calcified/non-calcified plaque or elevated plaque load), morphologic plaque features such as a spotty or gross calcification pattern and napkin-ring sign (NRS) were predictive for events. However, only spotty calcified plaques and NRS could confer additive prognostic value beyond clinical risk and coronary stenosis level. In a stepwise approach, endpoint prediction beyond clinical risk (Morise score) could be improved by inclusion of CAD severity (χ2 of 27.5, P < 0.001) and further discrimination for spotty calcified plaques (χ2 of 3.89, P = 0.049). CONCLUSION: Improved cardiovascular risk prediction beyond clinical risk and coronary stenosis levels can be made by discriminating for the presence of spotty calcified plaques. Thus, an intensified prophylactic anti-atherosclerotic treatment appears to be warranted in patients with coronary plaques that show spotty calcifications.

10-Year Follow-Up After Coronary Computed Tomography Angiography in Patients With Suspected Coronary Artery Disease.

OBJECTIVES: The aim of this study was to determine the long-term prognostic power of coronary computed tomography angiography (CTA) to predict cardiac death and nonfatal myocardial infarction. BACKGROUND: Prognostic usefulness of coronary CTA has been confirmed for short- and intermediate-term follow-up. However, long-term data for prognostic usefulness is still lacking, but is paramount because of the slowly progressing nature of coronary artery disease (CAD). METHODS: A total of 2,011 patients with suspected but not previously diagnosed CAD were examined by coronary CTA. Mean follow-up was 10.0 years (interquartile range [IQR]: 8.1 to 11.2 years). Cox proportional hazards analysis was used for the composite endpoint of cardiac death and nonfatal myocardial infarction. Event-free survival, which was defined as the years it took to reach a cumulative 1% risk for the composite endpoint and reclassification from clinical risk, was calculated. RESULTS: The study endpoint was reached in 58 patients (42 cardiac deaths, 16 nonfatal myocardial infarctions). Coronary CTA-assessed CAD severity (normal, nonobstructive, or obstructive) showed the best correlation with the endpoint, with an adjusted c-index of 0.704, compared with a univariate c-index of 0.622 for the clinical risk model (Morise score) alone. The annual event rate for patients with normal coronary arteries on baseline coronary CTA was 0.04%, which translated to an event-free survival period of 10 years. The highest annual event rate of 1.33% was found in patients with 3-vessel obstructive CAD. Reclassification from clinical risk (Morise score) was possible in approximately two-thirds of all patients (68%; p < 0.0001), which led to a substantial reduction of the intermediate-risk group (reduction from 74% to 15%) in favor of the low-risk group (increase from 20% to 83%). CONCLUSIONS: Patients with normal coronary CTA results benefitted from an event-free survival period of 10 years against cardiac death and nonfatal myocardial infarction. Risk stratification according to coronary CTA results allowed for the delineation of clearly diverging prognostic groups and reclassified approximately two-thirds of all patients from clinical risk groups.

Sternal reconstruction with titanium plates in complicated sternal dehiscence.

OBJECTIVE: Sternal dehiscence after median sternotomy can be a challenging problem in case of multiple fractures or infection. The use of titanium plates is a promising approach for sternal reconstruction. METHODS: Titanium plate fixation was used in 15 patients (67+/-5.9 years, 171+/-8.2 cm, 93.6+/-14.9 kg, body mass index 32+/-5 kg/m(2)) with unstable thorax after failed attempts of sternal closure and patients in whom failure of conventional rewiring would be expected due to one or more serious risk factors (e.g. multiple fractures or loss of sternum, excessive overweight). In six patients, one of whom had an infection, the Synthes Titanium Sternal Fixation System was used as transverse plate fixation (series 1). In nine other patients, longitudinal titanium plating of the sternum was performed with 2.4mm Synthes locking reconstruction plates, which were cross-connected by wires (series 2). In six of these patients the cross-connection was reinforced by additional short transverse plates. In series 2, sternal instability was complicated by multiple fragments of sternum (n=8) and/or infection (n=3). In case of infection, initial debridement was performed with consecutive antibiotic and topical negative pressure therapy (median 13 days). Clinical examination was done 3-12 months postoperatively. RESULTS: Mean operation time was 133+/-21 min (series 1) and 110+/-12 min (series 2). Transverse plating required more extensive mobilization of pectoral muscle. All patients had an uneventful early postoperative course and were extubated 5.1+/-5.9h (median 4 h) after surgery. Postoperatively, all patients had a stable thorax, but in the long-term three patients from series 1 complained of plate-related pain during breathing, with the subsequent need of plate removal. One multi morbid patient from series 1 died on the 31st postoperative day. The cause of death was not related to the sternal plate refixation. CONCLUSION: Titanium plate fixation is an effective method to stabilize complicated sternal dehiscence. The longitudinal plating technique is easier to apply and seems to be associated with fewer complications.

First successful aortic valve implantation with the CoreValve ReValving System via right subclavian artery access: a case report.

We successfully implanted a bioprosthetic aortic valve via the right subclavian artery within the framework of the CoreValve transapical aortic valve replacement (TAVR) ReValving (CoreValve, Irvine, CA, USA) clinical trial on November 20, 2007, at the Clinic for Cardiovascular Surgery at the German Heart Center Munich, Technical University Munich. The self-expanding aortic valve prosthesis is primarily designed for retrograde delivery across the aortic valve. The described approach via the right subclavian artery was performed because of severe peripheral vascular disease of the femoral and iliac arteries, as well as the left subclavian artery, and because a transapical delivery system was not available at the time of surgery.

Mid-Term Results After Sternal Reconstruction Using Titanium Plates: Is It Worth It to Plate?

BACKGROUND: Sternal dehiscence after median sternotomy is a challenging problem in situations of frail bone, fractures, or complete sternectomy. Plate osteosynthesis offers a promising approach to restore sternal integrity. However, there is only scarce data on mid-term outcome. METHODS: Mid-term data on 34 patients with unstable thorax after open heart operation, requiring sternal refixation with the Synthes Titanium Sternal Fixation System (Oberdorf, Switzerland) between 2005 and 2011, were analyzed. The Titanium Sternal Fixation System was used if conventional rewiring had failed or if failure of rewiring was expected because of risk factors. Follow-up examinations included clinical tests, computed tomographic scans, and pain assessment to evaluate sternal integrity and persistent pain. RESULTS: Median follow-up time was 1.4 years (range, 0.3 to 6.6 years). Clinical examination showed thoracic stability in all patients. Computed tomographic scans demonstrated complete bone consolidation in 25.8%, nearly complete in 38.7%, partial in 9.7%, and missing in 25.8% of patients. Pain assessment revealed no sternal pain in 16 patients (48.5%), mild pain in 9 (27.3%), moderate pain in 3 (9.1%), and severe pain in 5 patients (15.1%). Pain on movement was reported in 12 patients and 5 patients had chronic pain. A total of 13 patients (38%) required plate removal due to pain (n = 8) or infection (n = 5) after a median of 10.9 and 2 months, respectively. CONCLUSIONS: With the use of plates, it was possible to achieve thoracic stabilization in complicated dehiscence. However, the rate of postoperative infection and pain is not negligible. Thus, we recommend plate reconstruction only in sternal high-risk patients, who are unsuitable for standard reclosure.

First successful transapical aortic valve implantation with the Corevalve Revalving system: a case report.

On June 26, 2007, the Clinic for Cardiovascular Surgery at the German Heart Center Technical University in Munich successfully implanted a bioprosthetic valve via the apex of the heart within the framework of the CoreValve TAVR ReValving (Corevalve Inc., Irvine, CA, USA) clinical trial. The self-expanding aortic valve prosthesis is primarily designed for retrograde delivery across the aortic valve. The described transapical approach, however, now allows for treatment in those patients who have, for instance, no adequate "access" in the groin vessels due to peripheral vascular disease. Therefore, its feasibility must be considered as a major step in treating high-risk patients.

Performance of native and contrast-enhanced T1 mapping to detect myocardial damage in patients with suspected myocarditis: a head-to-head comparison of different cardiovascular magnetic resonance techniques.

Myocardial T1 mapping is a novel technique that has proven to be superior to standard imaging for differentiation between healthy individuals in acute myocarditis. Aim of this study was comparison of T1 mapping with a clinical biomarker. We retrospectively investigated 171 patients undergoing cardiovascular magnetic resonance (CMR) examination with suspected myocarditis by performing native and contrast enhanced T1-mapping. Additionally, T2w and T1w images and late gadolinium enhancement sequences (LGE) were utilized for myocardial evaluation; Lake Louise Criteria comprise T1w, T2w and LGE imaging in a score. Reference for positive myocarditis diagnosis was a ten-fold increase of troponin level above normal (0.14 ng/ml). Native T1 and extracellular volume (ECV) showed good association with relevant troponin elevations. Area under the curve (AUC) was 81% (p = 0.0001) for native T1 with an optimal threshold of 979 ms and 86% (p < 0.0001) for ECV with an optimal cutoff of 32.4%. AUC for T2w imaging (T2-signal intensity ratio to skeletal muscle) was 77% (p = 0.0003). AUC for T2w imaging (T2-signal intensity compared to remote myocardium) was 69% (p = 0.012). Additionally, we found positive correlation for native T1 and ECV with the Lake Louise Criteria (r = 0.44, p = 0.0001 for native T1 and r = 0.45, p = 0.0001 for ECV). Correlated to troponin as biomarker, ECV and native T1 mapping perform at least equally well in comparison to established CMR-techniques LGE, T2w imaging and the combined Lake Louise Criteria in detecting acute myocardial damage. Normal ECV values rule out myocardial damage with very high certainty. T1 mapping qualifies for further prospective evaluations to evolve as a separate biomarker.

Unexpected results after sternal reconstruction with plates, cables and cannulated screws.

OBJECTIVES: During the last decade, various plate fixation systems have been developed for the treatment of complicated sternal dehiscence after open-heart surgery. One of them is the Modular Sternal Cable System© (MSCS), which promises optimal distribution of forces along the whole sternum by using plates, cannulated screws and cables. However, in comparison with other systems, there is a lack of outcome data. METHODS: Sternal reconstruction with the MSCS was performed in 11 patients (male n = 10, age 72.0 ± 7.3 years) with complicated sternal dehiscence following cardiac surgery, and 73% of them had a history of sternal infection. Sternal reconstruction included bilateral longitudinal plating and thoracic re-closure with 4-9 cables. Patients received postoperative examination, focusing on sternal wound conditions and clinical stability. If there was any suspicion of recurrent wound infection, computed tomographic scans were done in the early postoperative period or in the long term, in order to evaluate bony consolidation and integrity of osteosynthetic material. RESULTS: The mean operation time was 165 ± 59 min, the mean intubation time 4.7 ± 5.3 min and the mean intensive care unit length of stay was 1 day (median) (range 1-23 days), with a total hospital stay of 9 days (median) (range 5-64 days). Operative mortality was 0%. One patient died on the 65th postoperative day of a non-MSCS-related cause. Sternal wound infection occurred in 6 patients (54.5%) and made hardware removal necessary in 5 of them early postoperatively (median 14 days) and in 1 patient late postoperatively (1058 days). In another patient, material was removed 715 days after MSCS application due to persisting sternal pain. CONCLUSIONS: A high incidence of postoperative wound infections was observed after implantation of the MSCS. It may be speculated that hardware design (e.g. the absence of a locking system, large screws) compromises osseous microcirculation, favouring the development of infection. This should be kept in mind for further development of sternal reconstruction systems.