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Aims: To investigate the variability between site and core laboratory (CL) calculation of the anatomical SYNTAX score (SS) based on coronary computed tomography angiography (CTA) alone and functional SS based on coronary CTA and fractional flow reserve derived from computed tomography (FFRCT) in the SYNTAX III trial., Methods and Results: The SYNTAX III trial was a multicentre, international study that included 223 patients with three-vessel disease with or without left main involvement. Functional SS was computed by subtracting non-flow limiting stenoses (FFRCT > 0.80) from anatomical SS. SS was combined with clinical information to generate the SYNTAX score II (SS II) that provides treatment recommendations. The mean anatomical SS based on coronary CTA alone was 33.4 ± 12.7 by sites and 37.1 ± 13.4 by CL (P < 0.001). The mean functional SS based on coronary CTA and FFRCT was 30.5 ± 13.0 by sites and 33.3 ± 13.6 by CL (P < 0.001). The intraclass correlation coefficient was 0.49 [95% confidence interval (CI) 0.37-0.59) in anatomical SS and 0.62 (95% CI 0.52-0.70) in functional SS. The Cohen's κ comparing treatment recommendation between sites and CL was 0.68 (95% CI 0.58-0.78) based on anatomical SS and 0.71 (95% CI 0.60-0.82) based on functional SS., Conclusion: The mean anatomical SS derived from coronary CTA alone and functional SS based on coronary CTA and FFRCT were higher when assessed by the CL than by the sites themselves. However, substantial agreement in treatment recommendation by SS II between sites and CL was demonstrated., Clinical Trials.gov Identifier: NCT02385279., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: The emerging role of coronary computed tomography angiography (CCTA) as a non-invasive tool for atherosclerosis evaluation is supported by data reporting a good correlation between CCTA and intravascular ultrasound (IVUS) for plaque volume quantification. Aim of the present study was to evaluate whether a last generation CT-scanner may improve coronary plaque volume assessment using IVUS as standard-of-reference., Methods and Results: From a registry of 1915 consecutive, all-comers, patients who underwent a clinically indicated IVUS evaluation we enrolled 59 patients who underwent CCTA with a 64-slice CT (Group 1) and 59 patients who underwent CCTA with whole-heart coverage CT scanner (Group 2). Patients who underwent CCTA with unfavourable heart rhythm were not excluded from the analysis. Image quality (4-point Likert scale) focused on plaque analysis was evaluated. Plaque volume quantification by CCTA was compared to IVUS. No difference in clinical characteristics was found between Group 1 and Group 2. Plaque volume quantification by CCTA was considered not feasible in 11 plaques of Group 1 and in 4 plaques of Group 2 (P = 0.09). Higher correlation for plaque volume quantification by CCTA vs. IVUS was demonstrated in Group 2 when compared with Group 1 (r = 0.9888 vs. 0.9499; P < 0.0001). The Bland-Altman analysis showed plaque volume overestimation by CCTA of 11.9 mm3 in Group 1 and 4 mm2 in Group 2 (P < 0.001). Effective radiation dose of CCTA was significantly lower in Group 2 vs. Group 1 (2.7 ± 0.9 vs. 8.1 ± 3.6 mSv, respectively; P < 0.001)., Conclusions: CCTA using a new scanner generation showed to be an accurate non-invasive tool to assess and quantify coronary plaque volume., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Aims: To compare the diagnostic accuracy of stress computed tomography myocardial perfusion (CTP) for the detection of significant coronary artery disease with visual approach vs. quantitative analysis with transmural perfusion ratio (TPR) in consecutive symptomatic patients scheduled for invasive coronary angiography (ICA) plus invasive fractional flow reserve (FFR)., Methods and Results: Eighty-eight consecutive symptomatic patients underwent rest coronary computed tomography angiography (cCTA) followed by static stress-CTP. Diagnostic accuracy of cCTA + stress-CTP with visual evaluation and with TPR measurement was calculated and compared with ICA and invasive FFR. Addition of stress-CTP with qualitative evaluation to rest-cCTA showed sensitivity, specificity, negative and positive predictive values, and accuracy at a vessel and patient level of 92%, 92%, 97%, 82%, 92% and 98%, 80%, 97%, 82%, 89%, respectively indicating a significant improvement of specificity, positive predictive value, and accuracy values vs. rest-cCTA in both models. Similarly, addition of stress-CTP with TPR evaluation to rest-cCTA showed sensitivity, specificity, negative and positive predictive values, and accuracy at a vessel and patient level of 84%, 90%, 93%, 76%, 88% and 91%, 71%, 89%, 75%, 81%, respectively indicating a significant improvement of specificity, positive predictive value values vs. rest-cCTA only in a vessel-based model and of positive predictive value in a patient-based model. When cCTA + stress-CTP with qualitative evaluation was compared with cCTA + stress-CTP with TPR estimation, no differences were found in terms of diagnostic performance., Conclusion: The addition of stress-CTP with visual evaluation to cCTA imaging has similar diagnostic performance when compared with the quantitative analysis of myocardial perfusion based on TPR measurement.

Aims: Scarce data are available on the long-term structural and functional changes of prosthetic valves after transcatheter aortic valve implantation (TAVI). The objective was to evaluate with echocardiography the long-term structural and functional changes of prosthetic valves after TAVI., Methods and Results: Structural valve deterioration (SVD) was defined as leaflet thickening ≥3mm, presence of calcification and abnormal leaflet motion. Five-year echocardiographic follow-up was available in 96 out of 318 patients who underwent TAVI with a balloon-expandable device between April 2008 and December 2011. At 1-year follow-up, no patient showed SVD. At 5-year follow-up, SVD were observed in 29 (30%) patients who showed also a significant reduction of aortic valve area (AVA) together with an increase of mean and peak aortic pressure gradients at the latest echocardiography evaluation. Moreover, rate of central aortic valve regurgitation ≥2 was higher in SVD patients as compared to those without SVD, while there was no difference in terms of paravalvular regurgitation. Despite SVD, one patient only reached the criteria for severe stenosis and no reintervention was needed at 5-year follow-up. Variables independently associated with SVD were female sex, small body surface area, use of a 23 mm valve, and small AVA at pre-discharge echocardiogram., Conclusion: At 5-year follow-up, 30% of patients who underwent TAVI with a balloon-expandable valve showed initial SVD. However, SVD was not associated with severe stenosis in most of the patients and had no significant impact on and clinical outcome.

Aims: Recent studies suggested that even non-obstructive coronary artery disease (CAD) increases major cardiovascular adverse events (MACE) rate. Aim of this study was to evaluate whether coronary computed tomography angiography (CCTA) may detect specific plaque characteristics that may affect prognosis in patients with non-obstructive CAD., Methods: We enrolled 245 patients who underwent CCTA between April 2004 and April 2007 for suspected CAD and were found to have non-obstructive CAD. Positive remodelling index (PRI), low-attenuation plaque (LAP), plaque burden (PB), spotty calcification (SC), and napkin-ring sign (NRS) have been evaluated for each coronary plaque detected. Acute coronary syndrome, all-cause/cardiac death, and very late elective revascularization (vl-ER) were the endpoints of the study., Results: A total of 28 events were recorded (2 STEMI, 4 NSTEMI, 6 UA, 2 cardiac deaths, 4 non-cardiac death, and 10 vl-ERs) at long-term follow-up (98 ± 20 months). When adjusted for significant clinical variables PRI > 1.4 (HR 3.31 CI 95% 1.11-9.91, P = 0.0392), LAP (HR 8.45 CI 95% 2.22-32.21, P = 0.0019), PB > 0.7 (HR 5.25 CI 95% 1.45-19.03, P = 0.0120), and NRS (HR 12.52 CI 95% 1.51-103.90, P = 0.0198) were still significantly associated with higher rate of hard cardiac events at follow-up. The Kaplan-Meyer curves confirmed lower cumulative hard cardiac events-free survival in patients presenting at least one coronary plaque with two or more high-risk characteristics when compared with patients with no lesion with more than one high-risk plaque characteristics (log-rank P < 0.0001)., Conclusions: High-risk plaque characteristics at CCTA (PRI > 1.4, PB > 0.7, LAP, and NRS) seem to be promising for risk stratification of patients with non-obstructive CAD., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Aims: To evaluate the relationship between an incremental model including cardiovascular risk factors, carotid disease, and inflammatory biomarkers to predict the presence of obstructive coronary artery disease (CAD)., Methods and Results: A total of 134 consecutive and asymptomatic intermediate-risk patients (mean age 61 ± 9 years, 52% men) were enrolled. Each subject underwent circulating levels assessment of interleukin (IL)-2r, IL-6, IL-8, IL-10, high-sensitivity C-reactive protein (hs-CRP) and carotid and coronary artery evaluation using carotid ultrasound and coronary computed tomography angiography (CCTA), respectively. Carotid disease was diagnosed in 71 (53%) patients. Obstructive and multi-vessel CAD were found in 50 (37%) and 18 (14%) patients, respectively. Patients in whom CCTA showed multi-vessel CAD had a higher rate of carotid disease (89 vs. 46%, P = 0.001) and increased values of all interleukins when compared with patients without multi-vessel obstructive CAD. The univariate and multivariate analysis showed that male gender, diabetes, carotid disease, and IL-6 were independently associated with obstructive CAD. At receiver operating characteristic curve analysis, the multivariate model (including male gender, carotid disease, IL-6 > 5.9 pg/mL, and diabetes) showed the highest area under the curve for prediction of obstructive CAD, multi-vessel CAD, and high-risk plaque defined as mixed and/or remodelled plaque when compared with all other models (P < 0.001)., Conclusion: Among asymptomatic intermediate-risk patients, the presence of increased IL6 levels in addition to traditional risk factors (male gender with diabetes) and carotid artery disease predicts higher rates of obstructive CAD and it could be of help to identify which subset of asymptomatic patients could be referred to CCTA for screening., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Aims: Despite expected improvement in left ventricular (LV) systolic and diastolic function after transcatheter aortic valve implantation (TAVI), the complex relationship between pre-existent LV systolic and diastolic function and changes in LV haemodynamics and clinical symptoms have been scarcely investigated. This study investigated the presence of pre-operative LV diastolic dysfunction and its improvement over time after TAVI alongside improvement in New York Heart Association (NYHA) class in high-risk patients with severe aortic stenosis., Methods and Results: The study population (n = 358) was divided into two groups according to baseline LV ejection fraction (LVEF): LVEF < 50% (n = 96) and LVEF ≥ 50% (n = 262). We compared clinical and echocardiographic parameters between groups before TAVI, at 6 and 12 months follow-up. Grade III LV diastolic dysfunction was more frequent in patients with LVEF < 50% compared with patients with LVEF ≥ 50% (50.0 vs. 16.3%, P < 0.001). Systolic and diastolic echocardiographic parameters improved after TAVI together with improvement in NYHA class both in patients with LVEF < 50% (diastolic dysfunction grade ≥2: baseline 100% of patients; 12 months 58.8%, P < 0.001; NYHA III/IV: baseline, 93.8%; 12 months, 9.7%, P < 0.001) and with LVEF ≥ 50% (diastolic dysfunction grade ≥2: baseline, 87.1%; 12 months, 61.2%; NYHA III/IV: baseline, 74.5%; 12 months, 2.6%, P < 0.001). All-cause mortality was comparable between groups., Conclusion: TAVI exerts favourable effects on LV systolic and diastolic function with a remarkable improvement in LV diastolic function associated with improvement in NYHA functional class at follow-up. Prognosis at 1 year after TAVI was not influenced by baseline LV diastolic dysfunction both in patients with and without LV systolic dysfunction., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Aims: To evaluate the feasibility of ultra-low-dose CT for left atrium and pulmonary veins using new model-based iterative reconstruction (MBIR) algorithm., Methods and Results: Two hundred patients scheduled for catheter ablation were randomized into two groups: Group 1 (100 patients, Multidetector row CT (MDCT) with MBIR, no ECG triggering, tube voltage and tube current of 100 kV and 60 mA, respectively) and Group 2 [100 patients, MDCT with adaptive statistical iterative reconstruction algorithm (ASIR), no ECG triggering, and kV and mA tailored on patient BMI]. Image quality, CT attenuation, image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) of left atrium (LA) and pulmonary veins, and effective dose (ED) were evaluated for each exam and compared between two groups.No significant differences between groups in terms of population characteristics, cardiovascular risk factors, anatomical features, prevalence of persistent atrial fibrillation and image quality score. Statistically significant differences were found between Group 1 and Group 2 in mean attenuation, SNR, and CNR of LA. Significantly, lower values of noise were found in Group 1 versus Group 2. Group 1 showed a significantly lower mean ED in comparison with Group 2 (0.41 ± 0.04 versus 4.17 ± 2.7 mSv)., Conclusion: The CT for LA and pulmonary veins imaging using MBIR is feasible and allows examinations with very low-radiation exposure without loss of image quality., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Aims: Motion artefacts due to high or irregular heart rate (HR) are common limitations of coronary computed tomography (CT) angiography (CCTA). The aim of the study was to evaluate the impact of a new motion-correction (MC) algorithm used in conjunction with low-dose prospective ECG-triggering CCTA on motion artefacts, image quality, and coronary assessability., Methods and Results: Among 380 patients undergoing CCTA for suspected CAD, we selected 120 patients with pre-scanning HR >70 bpm or HR variability (HRv) >10 bpm during scanning irrespective of pre-scanning HR or both conditions. In patients with pre-scanning HR <65 or ≥65 bpm, prospective ECG triggering with padding of 80 ms (58 cases) or padding of 200 ms (62 cases) was used, respectively. Mean pre-scanning HR and HRv were 70 ± 7 and 10.9 ± 4 bpm, respectively. Overall, the mean effective dose was 3.4 ± 1.3 mSv, while a lower dose (2.4 ± 0.9 mSv) was measured for padding of 80 ms. In a segment-based analysis, coronary assessability was significantly higher (P < 0.0001) with MC (97%) when compared with standard (STD) reconstruction (81%) due to a significant reduction (P < 0.0001) in severe artefacts (54 vs. 356 cases, respectively). An artefact sub-analysis showed significantly lower number of motion artefacts and artefacts related to chest movement with MC (16 and 4 cases) than with STD reconstruction (286 and 24 cases, P < 0.0001 and P < 0.05, respectively). The number of coronary segments ranked among those of excellent image quality was significantly higher with MC (P < 0.001)., Conclusions: The MC algorithm improves CCTA image quality and coronary assessability in patients with high HR and HRv, despite low radiation dose., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Aims: Proper measurement of the aortic annulus (AoA) is crucial for the success of transcatheter aortic valve implantation (TAVI). Transthoracic echocardiography (TTE) is the first step to assess AoA diameter, but a two-dimensional TTE (2DTTE) measurement is no longer accepted as the sole determinant of prosthetic size. The aims of the study were to evaluate feasibility and accuracy of three-dimensional TTE (3DTTE) estimation of AoA dimensions in comparison with multidetector computer tomography (MDCT)., Methods and Results: We enrolled 100 consecutive patients referred for TAVI. Feasibility of AoA evaluation was 91% for 3DTTE and in 90% for MDCT. In 81 of 100 patients, AoA maximum diameter (max-D), minimum diameter (min-D), and area were measured and compared using 2DTTE, 3DTTE, and MDCT. Image quality of 3DTTE was sufficient in 47, good in 46 and optimal in 7%. High correlations (P < 0.001) were found between MDCT and 3DTTE (max-D: r = 0.89; min-D r = 0.86; area: r = 0.93), and between MDCT and 2DTTE (min-D: r = 0.81; area 0.78). The 3DTTE measurements were found to be highly reproducible on intra- and interobserver variability analyses. Regarding the choice of prosthesis size, agreement between 3DTTE and MDCT was very good (k = 0.84, P < 0.001) while it was poor between 2DTTE and MDCT (k = 0.36, P < 0.001)., Conclusions: 3DTTE may be a valid imaging alternative in patients unsuitable for MDCT during the preoperative evaluation for TAVI. Evaluation of AoA through 3DTTE is feasible, and measurements closely approximate those of MDCT thus improving TTE accuracy in identifying the correct prosthesis size., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)