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Introduction: Idiopathic pulmonary arterial hypertension (IPAH) is a severe condition characterized by a poor prognosis, rapid deterioration, and high mortality in the absence of lung transplantation. However, non-invasive prognostic markers in assessing IPAH remain uncertain. We aimed to investigate the prognostic significance of chest CT and alterations in heart contours on chest radiography (CXR) in predicting adverse outcomes in IPAH patients., Methods: A retrospective study analyzed medical records of IPAH patients who underwent right heart catheterization and chest CT at a tertiary center between 2001 and 2023. Clinical, hemodynamic, and CT findings, and changes (Δ) in heart contours on CXR were assessed. Adverse events were defined as IPAH-related death or lung transplantation. Cox regression models evaluated the predictive power of these parameters., Results: In 80 patients with IPAH (mean age 42.6 years; 75 % females), the 3- and 5-year survival rates were 65.8 % and 55.1 %, respectively. Adverse events were associated with a history of cardiac arrest (Hazard ratio [HR], 11.67, p = 0.02), mean pulmonary artery pressure (HR, 1.04, p = 0.001), creatinine (HR, 4.12, p < 0.001), 6-min walk distance (HR, 0.997, p = 0.03), CT-derived right atrial (RA) volume index (HR, 1.01, p = 0.02), and ΔRA contour on CXR (HR, 1.27, p < 0.001). Combined clinical, CT, and CXR findings showed a 3-year event-free survival predictive accuracy of 82.2 % (95 % CI, 69.8-94.7), outperforming clinical factors alone., Conclusion: Rapid increases in RA contour on CXR and CT-derived RA volume index were associated with adverse outcomes in IPAH. Assessing these parameters may be helpful in identifying patients who require proactive treatments., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: We aimed to compare computed tomography (CT)-derived myocardial strain between patients with constrictive pericarditis (CP) and a matched healthy control group and to identify factors associated with clinical outcomes after pericardiectomy., Methods: This retrospective study included 65 patients with CP (mean age: 58.9 ​± ​8.0 years) and 65 healthy individuals (mean age: 58.0 ​± ​6.5 years) who underwent multiphase cardiac CT. The type of CP was classified as calcified CP or fibrotic CP. CT-derived strains from four cardiac chambers were compared between the CP and control groups, as well as between different types of CP. Clinical and CT-derived factors associated with adverse outcomes were identified using Cox regression analysis., Results: Compared with the control group, the CP group showed significantly lower values of left atrium (LA) reservoir strain (15.7 ​% vs. 27.4 ​%), right atrium (RA) reservoir strain (15.1 ​% vs. 27.0 ​%), left ventricle (LV) global longitudinal strain (GLS) (-17.0 ​% vs. -19.5 ​%), and right ventricle free wall longitudinal strain (-21.1 ​% vs. -25.9 ​%) (all p ​< ​0.001). Biatrial reservoir strains and LV GLS were significantly lower in those with calcified CP compared to those with fibrotic CP. LA reservoir strain (hazard ratio, 0.91-95 ​% confidence interval, 0.86-0.96- p ​= ​0.001) was an independent prognostic factor for adverse events in patients with CP., Conclusion: Cardiac strain differences in CP were predominantly observed in the LA and RA compared to the healthy control group. Biatrial reservoir strains were specifically impaired in those with calcified CP than in those with fibrotic CP. LA reservoir strain was associated with prognosis in patients with CP following pericardiectomy., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Objective: Residual aortic dissection (AD) following DeBakey type I AD repair is associated with a high rate of adverse events that need additional intervention or surgery. This study aimed to identify clinical and early post-operative computed tomography angiography (CTA) imaging factors associated with adverse events in patients with type I AD after ascending aorta replacement., Methods: This single centre, retrospective cohort study included consecutive patients with type I AD who underwent ascending aorta replacement from January 2011 to December 2017 and post-operative CTA within three months. The primary outcome was AD related adverse events, defined as AD related death and re-operation due to aortic aneurysm or impending rupture. The location and size of the primary intimal tears, aortic diameter, and false lumen status were evaluated. Regression analyses were performed to identify factors associated with AD related adverse events. A decision tree model was used to classify patients as high or low risk., Results: Of 103 participants (55.43 ± 13.94 years; 49.5% male), 24 (23.3%) experienced AD related adverse events. In multivariable Cox regression analysis, connective tissue disease (hazard ratio [HR] 15.33; p < .001), maximum aortic diameter ≥ 40 mm (HR 4.90; p < .001), and multiple (three or more) intimal tears (HR 7.12; p < .001) were associated with AD related adverse events. The three year cumulative survival free from AD related events was lower in the high risk group with aortic diameter ≥ 40 mm and multiple intimal tears (41.7% vs. 90.9%; p < .001)., Conclusion: Early post-operative CTA findings indicating a maximum aortic diameter ≥ 40 mm and multiple intimal tears may predict a higher risk of adverse events. These findings suggest the need for careful monitoring and more vigilant management approaches in these cases., (Copyright © 2024 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: Segmenting the aorta into zones based on anatomical landmarks is a current trend to better understand interventions for aortic dissection or aneurysm. However, comprehensive reference values for aortic zones are lacking. The aim of this study was to establish reference values for aortic size using a fully automated deep learning based segmentation method., Methods: This retrospective study included 704 healthy adults (mean age 50.6 ± 7.5 years; 407;57.8%] males) who underwent contrast enhanced chest computed tomography (CT) for health screening. A convolutional neural network (CNN) was trained and applied on 3D CT images for automatic segmentation of the aorta based on the Society for Vascular Surgery and Society of Thoracic Surgeons classification. The CNN generated masks were reviewed and corrected by expert cardiac radiologists., Results: Aortic size was significantly larger in males than in females across all zones (zones 0 - 8, all p < .001). The aortic size in each zone increased with age, by approximately 1 mm per 10 years of age, e.g., 25.4, 26.7, 27.5, 28.8, and 29.8 mm at zone 2 in men in the age ranges of 30 - 39, 40 - 49, 50 - 59, 60 - 69, and ≥ 70 years, respectively (all p < .001)., Conclusion: The deep learning algorithm provided reliable values for aortic size in each zone, with automatic masks comparable to manually corrected ones. Aortic size was larger in males and increased with age. These findings have clinical implications for the detection of aortic aneurysms and other aortic diseases., (Copyright © 2024 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background & Objective: Aortic dissection (AD) is a serious condition requiring rapid and accurate diagnosis. In this study, we aimed to improve the diagnostic accuracy of AD by presenting a novel method for aortic segmentation in computed tomography images that uses a combination of a transformer and a UNet cascade network with a Zoom-Out and Zoom-In scheme (ZOZI-seg)., Methods: The proposed method segments each compartment of the aorta, comprising the true lumen (TL), false lumen (FL), and thrombosis (TH) using a cascade strategy that captures both the global context (anatomical structure) and the local detail texture based on the dynamic patch size with ZOZI schemes. The ZOZI-seg model has a two-stage architecture using both a "3D transformer for panoptic context-awareness" and a "3D UNet for localized texture refinement." The unique ZOZI strategies for patching were demonstrated in an ablation study. The performance of our proposed ZOZI-seg model was tested using a dataset from Asan Medical Center and compared with those of existing models such as nnUNet and nnFormer., Results: In terms of segmentation accuracy, our method yielded better results, with Dice similarity coefficients (DSCs) of 0.917, 0.882, and 0.630 for TL, FL, and TH, respectively. Furthermore, we indirectly compared our model with those in previous studies using an external dataset to evaluate its robustness and generalizability., Conclusions: This approach may help in the diagnosis and treatment of AD in different clinical situations and provide a strong basis for further research and clinical applications., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Subclinical aortic valve complex (valvular and perivalvular) thrombus is not rare after transcatheter aortic valve replacement (TAVR). The risk factors and clinical implications of these findings remain uncertain., Objectives: This study sought to evaluate the frequency, predictors, and clinical outcome of aortic valve complex thrombus after TAVR., Methods: In the ADAPT-TAVR (Anticoagulation Versus Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization After Transcatheter Aortic Valve Replacement) trial comparing edoxaban vs dual antiplatelet therapy in TAVR patients without an indication for chronic anticoagulation, the frequency of valvular (subclinical leaflet thrombus) and perivalvular (supravalvular, subvalvular, and sinus of Valsalva) thrombus was evaluated by 4-dimensional computed tomography at 6 months. The association of these phenomena with new cerebral thromboembolism on brain magnetic resonance imaging, neurologic and neurocognitive dysfunction, and clinical outcomes was assessed., Results: Among 211 patients with 6-month computed tomography evaluations, 91 patients (43.1%) had thrombus at any aortic valve complex, 30 (14.2%) patients had leaflet thrombus, and 78 (37.0%) patients had perivalvular thrombus. A small maximum diameter of the stent at the valve level and low body surface area were independent predictors of aortic valve complex and perivalvular thrombus, and decreased renal function was an independent predictor of leaflet thrombus. No significant differences were observed in new cerebral lesions, neurologic or neurocognitive functions, or clinical outcomes among patients with or without valvular or perivalvular thrombus., Conclusions: Subclinical aortic valve complex (valvular and perivalvular) thrombus was common in patients who had undergone successful TAVR. However, these imaging phenomena were not associated with new cerebral thromboembolism, neurologic or neurocognitive dysfunction, or adverse clinical outcomes. (Anticoagulation Versus Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization After Transcatheter Aortic Valve Replacement [ADAPT-TAVR]; NCT03284827)., Competing Interests: Funding Support and Author Disclosures This work was partly supported by a grant from the Cardiovascular Research Foundation and Daiichi Sankyo Korea Co, Ltd. Dr S-J Park has received grants and personal fees from Abbott Vascular; has received grants from Daiichi-Sankyo, ChongKunDang Pharm, and Daewoong Pharm; and has received grants and personal fees from Edwards outside the submitted work. Dr D-W Park has received grants from Daiichi-Sankyo, ChongKunDang Pharm, and Daewoong Pharm; has received personal fees from Edwards; has received grants and personal fees from Abbott Vascular; and has received personal fees from Medtronic outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Cardiac allograft vasculopathy (CAV) is a major obstacle limiting long-term graft survival. Effective noninvasive surveillance modalities reflecting both coronary artery and microvascular components of CAV are needed., Objectives: The authors evaluated the diagnostic performance of dynamic computed tomography-myocardial perfusion imaging (CT-MPI) and coronary computed tomography angiography (CCTA) for CAV., Methods: A total of 63 heart transplantation patients underwent combined CT-MPI and CCTA plus invasive coronary angiography (ICA) with intravascular ultrasonography (IVUS) between December 2018 and October 2021. The median interval between CT-MPI and heart transplantation was 4.3 years. Peak myocardial blood flow (MBF) of the whole myocardium (MBF global ) and minimum MBF (MBF min ) among the 16 segments according to the American Heart Association model, except the left ventricular apex, were calculated from CT-MPI. CCTA was assessed qualitatively, and the degree of coronary artery stenosis was recorded. CAV was diagnosed based on both ICA (ISHLT criteria) and IVUS. Patients were followed up for a median time of 2.3 years after CT-MPI and a median time of 5.7 years after transplantation., Results: Among the 63 recipients, 35 (55.6%) had diagnoses of CAV. The median MBF global and MBF min were significantly lower in patients with CAV (128.7 vs 150.4 mL/100 mL/min; P = 0.014; and 96.9 vs 122.8 mL/100 mL/min; P < 0.001, respectively). The combined use of coronary artery stenosis on CCTA and MBF min showed the highest diagnostic performance with an area under the curve of 0.886 (sensitivity: 74.3%, specificity: 96.4%, positive predictive value: 96.3%, and negative predictive value: 75.0%)., Conclusions: The combination of CT-MPI and CCTA demonstrated excellent diagnostic performance for the detection of CAV. One-stop evaluation of the coronary artery and microvascular components involved in CAV using combined CCTA and CT-MPI may be a potent noninvasive screening method for early detection of CAV., Competing Interests: Funding Support and Author Disclosures This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. 2022R1A5A1022977). The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

In electrocardiography (ECG) gated cardiac CT angiography (CCTA), multiple images covering the entire cardiac cycle are taken continuously, so reduction of the accumulated radiation dose could be an important issue for patient safety. Although ECG-gated dose modulation (so-called ECG pulsing) is used to acquire many phases of CT images at a low dose, the reduction of the radiation dose introduces noise into the image reconstruction. To address this, we developed a high performance unsupervised deep learning method using noise disentanglement that can effectively learn the noise patterns even from extreme low dose CT images. For noise disentanglement, we use a wavelet transform to extract the high-frequency signals that contain the most noise. Since matched low-dose and high-dose cardiac CT data are impossible to obtain in practice, our neural network was trained in an unsupervised manner using cycleGAN for the extracted high frequency signals from the low-dose and unpaired high-dose CT images. Once the network is trained, denoised images are obtained by subtracting the estimated noise components from the input images. Image quality evaluation of the denoised images from only 4% dose CT images was performed by experienced radiologists for several anatomical structures. Visual grading analysis was conducted according to the sharpness level, noise level, and structural visibility. Also, the signal-to-noise ratio was calculated. The evaluation results showed that the quality of the images produced by the proposed method is much improved compared to low-dose CT images and to the baseline cycleGAN results. The proposed noise-disentangled cycleGAN with wavelet transform effectively removed noise from extreme low-dose CT images compared to the existing baseline algorithms. It can be an important denoising platform for low-dose CT., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Compared with invasive fractional flow reserve (FFR), coronary CT angiography (cCTA) is limited in detecting hemodynamically relevant lesions. cCTA-based FFR (CT-FFR) is an approach to overcome this insufficiency by use of computational fluid dynamics. Applying recent innovations in computer science, a machine learning (ML) method for CT-FFR derivation was introduced and showed improved diagnostic performance compared to cCTA alone. We sought to investigate the influence of stenosis location in the coronary artery system on the performance of ML-CT-FFR in a large, multicenter cohort., Methods: Three hundred and thirty patients (75.2% male, median age 63 years) with 502 coronary artery stenoses were included in this substudy of the MACHINE (Machine Learning Based CT Angiography Derived FFR: A Multi-Center Registry) registry. Correlation of ML-CT-FFR with the invasive reference standard FFR was assessed and pooled diagnostic performance of ML-CT-FFR and cCTA was determined separately for the following stenosis locations: RCA, LAD, LCX, proximal, middle, and distal vessel segments., Results: ML-CT-FFR correlated well with invasive FFR across the different stenosis locations. Per-lesion analysis revealed improved diagnostic accuracy of ML-CT-FFR compared with conventional cCTA for stenoses in the RCA (71.8% [95% confidence interval, 63.0%-79.5%] vs. 54.8% [45.7%-63.8%]), LAD (79.3 [73.9-84.0] vs. 59.6 [53.5-65.6]), LCX (84.1 [76.0-90.3] vs. 63.7 [54.1-72.6]), proximal (81.5 [74.6-87.1] vs. 63.8 [55.9-71.2]), middle (81.2 [75.7-85.9] vs. 59.4 [53.0-65.6]) and distal stenosis location (67.4 [57.0-76.6] vs. 51.6 [41.1-62.0])., Conclusion: In a multicenter cohort with high disease prevalence, ML-CT-FFR offered improved diagnostic performance over cCTA for detecting hemodynamically relevant stenoses regardless of their location., Competing Interests: Declaration of competing interest Dr. Renker has received speaker fees from Abbott. Dr. Baumann has received consulting fees from Phillips Volcano. Dr. Tesche has received research support and honoraria for speaking from Siemens. Dr. Kim received proctor/speaker fees from Abbott, Boston Scientific, Edwards Lifesciences, Medtronic, Meril. Dr. Nieman reports unrestricted institutional support from Siemens Healthineers, Bayer, GE, and Heartflow Inc., and consultancy honoraria from Siemens Medical Solutions USA. Dr. Persson reports on institutional support from Siemens Healthineers. Dr. Schoepf has received grants and/or personal fees from Bayer, Bracco, Elucid BioImaging, GE, Guerbet, HeartFlow Inc., Keya Medical, and Siemens. All other authors declare that they have no financial disclosures., (Copyright © 2021 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Competing Interests: FUNDING SUPPORT AND AUTHOR DISCLOSURES This research was supported by the Basic Science Research Program, through the National Research Foundation of Korea (NRF), funded by the Ministry of Science, ICT & Future Planning (NRF-2020R1A2C2003843). Drs. Yang and Kim hold stock in Anymedi Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Purpose: To perform comprehensive in vitro experiments using six-directional icosahedral flow encoding (ICOSA6) 4D flow magnetic resonance imaging (MRI) under various scan conditions to analyze the robustness of velocity and turbulence quantification., Materials and Methods: In vitro flow phantoms with steady flow rates of 10 and 20 L/min were scanned using both conventional 4D flow MRI and ICOSA6. Experiments focused on comparisons between ICOSA6 and conventional four point (4P) methods, and the effects of contrast agents, velocity encoding range (Venc), and scan direction on velocity and turbulence quantification., Results: The results demonstrated that 1) ICOSA6 improves the velocity-to-noise ratio (VNR) of velocity estimation by 33% (on average) and results in similar turbulent kinetic energy (TKE) estimation as the 4P method. 2) Measurements with a contrast agent resulted in more than a 2.5 fold increase in average VNR. However, the improvement of total TKE quantification was not obvious. 3) TKE estimation was less affected by Venc and the scan direction, whereas turbulence production (TP) estimation was largely affected by these measurement conditions. The effects of Venc and scan direction accounted for less than 11.63% of TKE estimation, but up to 33.89% of TP estimation., Conclusion: The ICOSA6 scheme is compatible with conventional 4D flow MRI for velocity and TKE measurement. Contrast agents are effective at increasing VNR, but not signal-to-noise ratio for TKE quantification. The effects of Venc and scan direction influence total TP more than total TKE., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: There are limited data regarding the relation between serum phosphorus concentration (SPC) and subclinical coronary atherosclerosis in the asymptomatic healthy population without kidney dysfunction., Objectives: We aimed to investigate the relation between SPC and characteristics of atherosclerotic plaques and cardiac events according to SPCs using a large cohort of asymptomatic Korean individuals., Methods: We evaluated 6329 asymptomatic Korean individuals [mean age: 53.6 ± 7.6 y, 4611 men (72.9%)] without kidney dysfunction and coronary artery disease who voluntarily underwent coronary computed tomography angiography (CCTA) as part of a general health examination. Study participants were stratified into quartiles according to their SPCs (≤3.0, 3.1-3.3, 3.4-3.7, ≥3.8 mg/dL). The degree and extent of subclinical coronary atherosclerosis were evaluated with CCTA. Stenosis of diameter ≥50% was defined as significant. A cardiac event was defined as a composite of all-cause death, myocardial infarction, unstable angina, and coronary revascularization., Results: After adjustment for cardiovascular disease risk factors, the risk of any atherosclerotic plaque was significantly higher with increasing SPC quartiles (P = 0.001). In particular, the risk of calcified plaque increased in the second (OR: 1.27; 95% CI: 1.07, 1.51; P = 0.006), third (OR: 1.39; 95% CI: 1.17, 1.64; P < 0.001), and fourth SPC quartiles (OR: 1.50; 95% CI: 1.24, 1.82; P < 0.001) compared with that in the first quartile. However, there were no significant differences in the adjusted ORs for noncalcified plaque, mixed plaque, or significant stenosis. During a follow-up of median 5.4 y, there was no significant difference in cardiac events between the SPC quartiles., Conclusions: In asymptomatic Korean individuals without kidney dysfunction, a high SPC was an independent predictor of calcified plaques without any difference in cardiac events. Further long-term prospective studies are required to validate these results., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2020.)

Objectives: This study was conducted to investigate the influence of coronary artery calcium (CAC) score on the diagnostic performance of machine-learning-based coronary computed tomography (CT) angiography (cCTA)-derived fractional flow reserve (CT-FFR)., Background: CT-FFR is used reliably to detect lesion-specific ischemia. Novel CT-FFR algorithms using machine-learning artificial intelligence techniques perform fast and require less complex computational fluid dynamics. Yet, influence of CAC score on diagnostic performance of the machine-learning approach has not been investigated., Methods: A total of 482 vessels from 314 patients (age 62.3 ± 9.3 years, 77% male) who underwent cCTA followed by invasive FFR were investigated from the MACHINE (Machine Learning based CT Angiography derived FFR: a Multi-center Registry) registry data. CAC scores were quantified using the Agatston convention. The diagnostic performance of CT-FFR to detect lesion-specific ischemia was assessed across all Agatston score categories (CAC 0, >0 to <100, 100 to <400, and ≥400) on a per-vessel level with invasive FFR as the reference standard., Results: The diagnostic accuracy of CT-FFR versus invasive FFR was superior to cCTA alone on a per-vessel level (78% vs. 60%) and per patient level (83% vs. 73%) across all Agatston score categories. No statistically significant differences in the diagnostic accuracy, sensitivity, or specificity of CT-FFR were observed across the categories. CT-FFR showed good discriminatory power in vessels with high Agatston scores (CAC ≥400) and high performance in low-to-intermediate Agatston scores (CAC >0 to <400) with a statistically significant difference in the area under the receiver-operating characteristic curve (AUC) (AUC: 0.71 [95% confidence interval (CI): 0.57 to 0.85] vs. 0.85 [95% CI: 0.82 to 0.89], p = 0.04). CT-FFR showed superior diagnostic value over cCTA in vessels with high Agatston scores (CAC ≥ 400: AUC 0.71 vs. 0.55, p = 0.04) and low-to-intermediate Agatston scores (CAC >0 to <400: AUC 0.86 vs. 0.63, p < 0.001)., Conclusions: Machine-learning-based CT-FFR showed superior diagnostic performance over cCTA alone in CAC with a significant difference in the performance of CT-FFR as calcium burden/Agatston calcium score increased. (Machine Learning Based CT Angiography Derived FFR: a Multicenter, Registry [MACHINE] NCT02805621)., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background and Aims: There are limited data on the association between serum uric acid (SUA) level and subclinical coronary atherosclerosis. This study investigated the influence of SUA level on subclinical coronary atherosclerosis, as detected by coronary computed tomography angiography (CCTA), in an asymptomatic population., Methods: We evaluated 6431 asymptomatic individuals (mean age 53.6 ± 7.6 years, 4691 men [72.9%]) with no prior history of coronary artery disease, who voluntarily underwent laboratory tests and CCTA as part of a general health examination. The participants were stratified into quartiles according to their SUA levels. Coronary atherosclerotic plaques (calcified, mixed, and non-calcified plaques) were assessed using CCTA. Logistic regression analysis was used to determine the association between SUA levels and subclinical coronary atherosclerosis., Results: The prevalence of any atherosclerotic, calcified, mixed, and non-calcified plaques increased with SUA quartiles (all p < 0.001). After adjustment for cardiovascular risk factors, there were no statistically significant differences in the adjusted odds ratios for calcified plaque (1.19; 95% CI 0.98-1.46; p = 0.080) and mixed plaque (1.25; 95% CI 0.94-1.67; p = 0.132) in the fourth SUA quartile compared to the first quartile. However, the adjusted odds ratios for any atherosclerotic plaque (1.39; 95% CI 1.16-1.68; p < 0.001) and non-calcified plaque (1.38; 95% CI 1.11-1.72; p = 0.004) were significantly higher in the fourth SUA quartile., Conclusions: In asymptomatic individuals, high SUA level was an independent predictor of non-calcified plaques, suggesting an increased cardiovascular risk., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: To use adenosine-induced stress CT myocardial perfusion imaging (CT-MPI) to determine normal reference values for left ventricle (LV) wall thickness (WT) and motion parameters., Methods: This study included 106 Korean subjects (52 men and 54 women) who underwent CT-MPI due to chest pain, but were not found to have any detectable mild or severe coronary artery disease or myocardial perfusion defect. The following quantitative parameters were assessed on the CT-MPI according to a 17-segment model: LV myocardial thickness at end-systolic (WT ES ) and end-diastolic (WT ED ) phases, systolic wall thickening (SWT), and wall motion (WM). The associations of the measured parameters with the subjects' demographic characteristics and comorbidities were also analyzed., Results: Septal wall (7.2 mm) and basal-level (7.7 mm) LV myocardium demonstrated significantly higher WT (p < 0.001). SWT was highest in lateral (77.8%, p < 0.014) and apical (78.9%, p = 0.009) myocardium, while lateral (7.7 mm) and basal (6.7 mm) myocardium exhibited the greatest WM (p < 0.001). WT was significantly higher in men and younger (<60 years) subjects (all, p < 0.001). Hypertensive individuals presented with significantly higher SWT (79.9%, p = 0.024). LV WT exhibited statistically significant correlations (all positive, except for age) with age, height, weight, body surface area, body mass index, and systolic blood pressure (all, p < 0.010)., Conclusions: The present study provides CT-MPI reference values for LV myocardial WT, SWT, and WM measured on an adult Korean population. Knowledge of such normal reference measurements would be beneficial for the efficient interpretation of CT-MPI examinations in populations of Asian ethnicity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: This study examined the incremental value of subtended myocardial mass (V sub ) as assessed by coronary computed tomography angiography (CTA) for identifying lesion-specific ischemia verified by invasive fractional flow reserve (FFR) in quantitative coronary CTA., Background: FFR is determined not only by coronary stenosis severity, but also by V sub . One-step evaluation of combined V sub and coronary lesion morphology may improve the accuracy of coronary CTA for identifying ischemia-producing lesions., Methods: A total of 246 intermediate coronary artery lesions (30% to 80% diameter stenosis) in 220 patients (mean age 61.7 years, 168 men) interrogated by FFR were retrospectively studied. Coronary CTA data were used to assess the V sub by coronary artery stenosis, minimal lumen area (MLA), percentage of aggregated plaque volume (%APV), positive remodeling, and low-attenuation plaque. The ability of V sub /MLA 2 to discriminate lesions with FFR ≤0.80 was examined. Diagnostic performance, odds ratios, and category-less net reclassification improvements of coronary CTA parameters for FFR-verified (≤0.80) ischemia were evaluated. On-site computed tomography (CT) derived-FFR (CT-FFR) and quantitative coronary angiography (QCA) data were also compared., Results: Of 246 lesions, 84 (34.1%) showed an FFR ≤0.80. V sub was independently associated with an FFR ≤0.80 (odds ratio: 1.04/1 cm 3 ; p = 0.032) and showed incremental value over MLA. V sub /MLA 2 >4.16 was the best single parameter for discriminating an FFR ≤0.80 with 83.3% sensitivity and 67.9% specificity. The area under the curve (AUC) of V sub /MLA 2 >4.16 (0.80 [95% confidence interval: 0.75 to 0.85]) was better than that of MLA (change in [Δ]AUC: 0.069; p < 0.001), %APV (ΔAUC: 0.096; p = 0.017), and diameter stenosis of QCA (ΔAUC: 0.080; p = 0.037) and was comparable to that of CT-FFR (AUC 0.77; ΔAUC: 0.035; p = 0.304)., Conclusions: V sub is an independent determinant of an FFR ≤0.80. The mathematical index of V sub /MLA 2 >4.16 assessed by coronary CTA shows better diagnostic performance for the detection of ischemia-producing lesions than CT-derived MLA alone or %APV and QCA parameters and was comparable to that of on-site CT-FFR., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: We aimed to compare the myocardial ischemic burden assessed using semi-quantitative and quantitative analysis of computed tomography-myocardial perfusion imaging (CT-MPI) with that of single-photon emission computed tomography (SPECT)., Methods: From 2011 to 2013, 97 patients who underwent CT-MPI and SPECT were evaluated. The extent and severity of perfusion defects were assessed on a 5-point scale using a standard 16-segment model, and were expressed as summed stress score (SSS) and summed difference score (SDS). Receiver operating characteristic (ROC) curves for quantitative parameters were generated for the diagnosis of abnormal perfusion defect (SSS ≥ 4) and presence of ischemia (SDS ≥ 2) on SPECT., Results: On CT-MPI, 298 (19.2%) of the 1552 segments showed perfusion abnormalities during stress, whereas perfusion abnormalities were shown in 179 (11.5%) segments on SPECT-MPI. On a per-person basis, there was good agreement, with intraclass correlation coefficients of 0.78 for SSS and 0.72 for SDS. A significant reduction of attenuation in stress and myocardial perfusion reserve index, along with an increase in % defect volume of CT-MPI, were demonstrated as the degree of perfusion defect or ischemia on SPECT increased. On the ROC curves, % defect volume on CT-MPI demonstrated the highest area under the curve: 0.91 for abnormal perfusion defect and 0.89 (all p < 0.001) for the presence of ischemia on SPECT., Conclusions: Semi-quantitative analysis of CT-MPI showed good accordance with SPECT. A quantitative approach for CT-MPI, especially % defect volume, may provide additional value in the identification of myocardial perfusion abnormalities., Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT01696006., (Copyright © 2018. Published by Elsevier B.V.)

Background & Aims: There are limited data on the association between non-alcoholic fatty liver disease (NAFLD) and subclinical coronary atherosclerosis. This study investigated the influence of NAFLD on subclinical coronary atherosclerosis as detected by coronary computed tomography angiography (CCTA) in an asymptomatic population., Methods: A total of 5,121 consecutive asymptomatic individuals with no prior history of coronary artery disease or significant alcohol intake voluntarily underwent abdominal ultrasonography and CCTA as part of a general health examination. Fatty liver was assessed by ultrasonography examination. The fatty liver index and NAFLD fibrosis score were also calculated. Coronary atherosclerotic plaques on CCTA were evaluated. The association between NAFLD and subclinical coronary atherosclerosis was determined by logistic regression analysis., Results: Of the study participants, 1,979 (38.6%) had ultrasonography-diagnosed NAFLD. After adjustment for cardiovascular risk factors, there were no statistically significant differences in the adjusted odds ratios of NAFLD for calcified plaque (1.03; 95% CI 0.89-1.20; p = 0.673) and mixed plaque (1.15; 95% CI 0.93-1.42; p = 0.214). However, adjusted odds ratios for any atherosclerotic plaque (1.18; 95% CI 1.03-1.35; p = 0.016) and non-calcified plaque (1.27; 95% CI 1.08-1.48; p = 0.003) were significantly higher in NAFLD. In addition, there was a significant association of fatty liver index ≥30 with non-calcified plaque (1.37; 95% CI 1.14-1.65; p = 0.001) and NAFLD fibrosis score ≥-1.455 with non-calcified plaque (1.20; 95% CI 1.08-1.42; p = 0.030)., Conclusions: In this large cross-sectional study of asymptomatic individuals undergoing CCTA, NAFLD was consistently associated with non-calcified plaque, suggesting an increased cardiovascular risk., Lay Summary: In asymptomatic individuals, non-alcoholic fatty liver disease (NAFLD) was an independent risk factor for non-calcified plaque, which has been known as a vulnerable plaque associated with sudden and unexpected cardiac events. Therefore, appropriate medical therapy for NAFLD was required to reduce future cardiac events., (Copyright © 2017 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background: There are limited data regarding the influence of glycemic status on the risk of subclinical coronary atherosclerosis on coronary computed tomographic angiography (CCTA) in asymptomatic individuals., Methods: We analyzed 6434 asymptomatic individuals who underwent CCTA. The degree and extent of subclinical coronary atherosclerosis were assessed by CCTA, and ≥50% diameter stenosis was defined as significant. Of study participants, 2197 (34.1%), 3122 (48.5%), and 1115 (17.3%) were categorized as normal, prediabetic and diabetic individuals, respectively., Results: Compared with normal individuals, there were no statistically differences in the adjusted odds ratios of prediabetic individuals for significant coronary artery stenosis (0.98, 95% confidence interval [CI] 0.80-1.22, p=0.888), any plaque (0.96, 95% CI 0.86-1.07, p=0.483), calcified plaque (0.90, 95% CI 0.79-1.01, p=0.080), non-calcified plaque (1.02, 95% CI 0.88-1.17, p=0.803), and mixed plaque (1.00, 95% CI 0.82-1.22, p=0.983). However, adjusted odds ratios for significant coronary artery stenosis (1.71, 95% CI 1.34-2.19, p<0.001), any plaque (1.45, 95% CI 1.26-1.68, p<0.001), calcified plaque (1.35, 95% CI 1.15-1.57, p<0.001), non-calcified plaque (1.33, 95% CI 1.11-1.59, p=0.002), and mixed plaque (1.64, 95% CI 1.30-2.07, p<0.001) of diabetic individuals were significantly higher than those of the normal individuals., Conclusion: In asymptomatic individuals, diabetic individuals had a higher risk for subclinical coronary atherosclerosis, but prediabetic individuals were not associated with an increased risk of subclinical coronary atherosclerosis., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: This study sought to evaluate the long-term prognostic value of coronary computed tomography angiography (CTA) in asymptomatic patients with type 2 diabetes mellitus., Background: There are limited data on the long-term prognostic impact of coronary CTA in asymptomatic patients with type 2 diabetes mellitus., Methods: This study analyzed clinical outcomes of 591 consecutive asymptomatic patients with type 2 diabetes mellitus who underwent coronary CTA (mean age 62.2 ± 8.3 years and 352 men [59.6%]). A cardiac event was defined as a composite of cardiac death, nonfatal myocardial infarction, unstable angina requiring hospitalization, or late coronary revascularization. Patients were categorized into 3 groups according to severity of coronary artery disease (CAD) on coronary CTA: normal coronary arteries, nonobstructive CAD (<50%), and obstructive CAD (≥50%)., Results: One hundred sixty-eight patients (28.4%) had normal coronary arteries, whereas 236 (39.9%) patients had nonobstructive CAD and 187 (31.6%) had obstructive CAD. During the follow-up period (median 5.3 years [interquartile range: 4.7 to 5.8 years]), 37 cardiac events occurred in 29 patents: 10 cardiac deaths, 2 nonfatal myocardial infarctions, 8 cases of unstable angina, and 17 late coronary revascularizations. The 6-year event-free survival rates were 99.3 ± 0.7% in patients with normal coronary arteries, 96.7 ± 1.2% in patients with nonobstructive CAD, and 86.2 ± 3.0% in patients with obstructive CAD (log-rank p < 0.001)., Conclusions: Asymptomatic patients with type 2 diabetes mellitus with normal coronary arteries or nonobstructive CAD on coronary CTA show excellent clinical outcomes over a follow-up period of more than 5 years, whereas prognosis is worse in patients with obstructive CAD. These findings suggest long-term prognostic value of coronary CTA for asymptomatic type 2 diabetes mellitus., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Quantifying turbulence velocity fluctuation is important because it indicates the fluid energy dissipation of the blood flow, which is closely related to the pressure drop along the blood vessel. This study aims to evaluate the effects of scan parameters and the target vessel size of 4D phase-contrast (PC)-MRI on quantification of turbulent kinetic energy (TKE). Comprehensive 4D PC-MRI measurements with various velocity-encoding (VENC), echo time (TE), and voxel size values were carried out to estimate TKE distribution in stenotic flow. The total TKE (TKEsum), maximum TKE (TKEmax), and background noise level (TKEnoise) were compared for each scan parameter. The feasibility of TKE estimation in small vessels was also investigated. Results show that the optimum VENC for stenotic flow with a peak velocity of 125cm/s was 70cm/s. Higher VENC values overestimated the TKEsum by up to six-fold due to increased TKEnoise, whereas lower VENC values (30cm/s) underestimated it by 57.1%. TE and voxel size did not significantly influence the TKEsum and TKEnoise, although the TKEmax significantly increased as the voxel size increased. TKE quantification in small-sized vessels (3-5-mm diameter) was feasible unless high-velocity turbulence caused severe phase dispersion in the reference image., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To investigate the details of the flow structure of a plug-like jet that had a vortex ring in pulsatile stenotic phantoms using 4D flow MRI., Method: Pulsatile Newtonian flows in two stenotic phantoms with 50% and 75% reductions in area were scanned by 4D flow MRI. Blood analog working fluid was circulated via the stenotic phantom using a pulsatile pump at a constant pulsating frequency of 1Hz. The velocity and vorticity fields of the plug-like jet with a vortex ring were quantitatively analyzed in the spatial and temporal domains., Results: Pulsatile stenotic flow showed a plug-like jet at the specific stenotic degree of 50% in our pulsatile waveform design. This plug-like jet was found at the decelerating period in the post-stenotic region of 26.4mm (1.2 D). It revealed a vortex ring structure with vorticity strength in the range of ±100s(-1)., Conclusion: We observed a plug-like jet with a vortex ring in pulsatile stenotic flow by in vitro visualization using 4D flow MRI. In this plug-like jet, the local fastest flow region occurred at the post-systole phase in the post-stenotic region, which was distinguishable from a typical stenotic jet flow at systole phase., (Copyright © 2015 Elsevier Inc. All rights reserved.)

A 69-year-old female underwent cardiac CT to evaluate prosthetic valve (PHV) dysfunction detected on echocardiography. A CT coronal and en face views of the mitral annular plane showed a low-density, mass-like lesion on the left atrial side of the PHV and a high-density, plate-like lesion on the left ventricular side of PHV. A repeat of the mitral valve replacement was performed, and preoperative CT findings of both the thrombus on the left atrial side and pannus formation on the LV side were confirmed in the operative findings., (Copyright © 2016 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: Elevated serum gamma-glutamyltransferase (GGT) has been demonstrated to be associated with coronary artery calcification (CAC). CAC progression is an important marker of atherosclerosis and correlates with future cardiovascular risk. However, there is a lack of research that directly examines the association between serum GGT and CAC progression. The aim of this study was to elucidate the association between serum GGT activity and CAC progression., Methods: We enrolled 1246 asymptomatic participants who underwent repeated CAC score measurement during routine health examinations. To eliminate the dependence of the inter scan variability on the baseline CAC scores, square root-transformed CAC scores were used to analyze CAC progression. In addition, the annualized rate of change in CAC scores was computed., Results: Serum GGT activities were significantly higher in "progressors" than "nonprogressors". The prevalence of progression increased with the GGT tertile (11.9%, 20.1% and 27.9% in the 1st, 2nd, and 3rd GGT tertiles, respectively; p < 0.001). In the multivariate logistic regression analysis, the odds ratio (95% confidence interval) for CAC score progression was 1.85 (1.14-3.00) in the highest GGT tertile group. By multivariate linear regression analysis, baseline serum GGT activity demonstrated a positive association with the annualized change in CAC score (β = 0.002; p = 0.006) after adjusting for cardiovascular risk factors., Conclusion: Elevated serum GGT levels are independently associated with CAC progression. Serum GGT levels may be a potential biomarker of future coronary atherosclerosis and prognosis., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background: Anterior cruciate ligament (ACL) rupture is one of the most common injuries associated with the knee. After ACL injury, knee joint stability can be altered, resulting in abnormal loading during functional activities. Since ACL-deficient (ACLD) knees are also vulnerable to translational and rotational instability, patients need to be wary of certain motions encountered in daily life. The present study investigated the effect of walking speed and pivoting directional change during gait on knee joint kinematics of ACLD knees. We hypothesized that faster walking and crossover turning would induce severe kinematic changes., Methods: Thirty-five patients (22 males and 13 females) having a unilateral isolated subacute ACLD knee (from 1 to 3 months after injury) and contralateral intact (CLI) knee participated in this study. Spatiotemporal parameters, three-dimensional (3D) knee joint angles, and anterior-posterior (AP) translation were obtained by a 3D high-speed motion-capturing system. The CLI knee of each patient served as the control. The calculated AP stability and knee joint angles were used to test the research hypothesis. Mixed two-way repeated measures analysis of variance was performed to clarify the effects of walking speed and pivoting direction with a significance of 0.05. When a significance of mean comparison was detected, a post hoc test was performed., Results: Significant and consistent increased AP translation of the tibia relative to the femur at the whole stance phase of the gait cycle was evident in ACLD knees compared to CLI knees for normal and faster (20 % greater than normal) walking speeds. Faster walking speed did not induce significantly more anterior location of the tibia. In addition, ACLD knees were significantly less extended than CLI knees during a large portion of midstance. Although there was a consistent varus offset between the curves of ACLD and CLI knees, the difference did not reach statistical significance during the stance phase. Also, ACLD knees did not show any significant difference in tibial rotation compared to CLI knees during the entire stance phase of the gait cycle. For pivoting turns, ACLD knees showed significantly less extended and varus offset than CLI knees only during the cutting turn. ACLD knees exhibited less tibial internal rotation during the crossover turn and less tibial external rotation during the cutting turn than CLI knees., Conclusions: In ACLD knees, the tibia tended to shift more anteriorly and changed with less extension at walking. However, faster walking speed did not induce any significant difference compared with normal-speed walking. In addition, ACLD knees displayed kinematic changes during pivoting, but not the crossover turn.

Crosstalk between cancer cells and carcinoma-associated fibroblasts (CAFs) has earned recognition as an interaction that plays a pivotal role in carcinogenesis. Thus, we attempted to clarify whether increase in the level of CAFs promotes cancer progression by proportionally enhancing the interaction between cancer cells and CAFs. We first analyzed clinical correlation between the levels of fibroblasts and cancer progression and found that the level of CAFs made a noticeable difference on the prognosis of patients with oral squamous cell carcinoma (OSCC). In vivo animal study also demonstrated that tumor volume depended on the dose of CAFs that was co-injected with OSCC cells. The same tendency was observed in an in vitro study. We also found that interleukin-1α (IL-1α) secreted from OSCC cells had dual effects on CAFs: IL-1α not only promoted the proliferation of CAFs but also upregulated the secretion of cytokines in CAFs such as CCL7, CXCL1, and IL-8. The induction activity of cytokine secretion by IL-1α surpassed that of proliferation in OSCC cells. In summary, we unraveled an important interactive mechanism of carcinogenesis: IL-1α released from carcinoma stimulates the proliferation of CAFs and the simultaneous increase in cytokine secretion from CAFs promotes cancer progression in human OSCC. On the basis of these findings, we propose that the level of CAFs is eligible for being selected as a prognostic factor that will be useful in routine diagnosis. We also propose that blockage of reciprocal interaction between cancer cells and CAFs will provide an insight for developing novel chemotherapeutic strategy.

A 24-year-old man presented to our hospital with symptoms of dyspnea and palpitation for 2 weeks. Cardiac CT showed not only a leaflet coaptation defect in the aortic valve but also a small ventricular septal defect (VSD) immediately beneath the prolapsed right coronary cusp. A shunt flow in the direction of the right ventricular outflow tract though the defect indicated the doubly committed juxta-arterial type of VSD. A doubly committed juxta-arterial VSD of 3 mm was confirmed and repaired via pulmonary arteriotomy., (Copyright © 2014 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Objectives: We sought to define the clinical importance of an integrated classification of bicuspid aortic valve (BAV) phenotypes and aortopathy using multidetector computed tomography (MDCT)., Background: An association between BAV phenotypes and the pattern of valvular dysfunction or bicuspid aortopathy has yet to be definitely established., Methods: The study cohort included 167 subjects (116 men, age 54.6 ± 14.4 years) who underwent both MDCT and transthoracic echocardiography from 2003 to 2010. Two BAV phenotypes-fusion of the right and left coronary cusps (BAV-AP) and fusion of the right or left coronary cusp and noncoronary cusp (BAV-RL)-were identified. Forty-five patients showed normal aortic dimensions and were classified as type 0. In the remaining patients, hierarchic cluster analysis showed 3 different types of bicuspid aortopathy according to the pattern of aortic dilation: type 1 (aortic enlargement confined to the sinus of Valsalva [n = 34]), type 2 (aortic enlargement involving the tubular portion of the ascending aorta [n = 49]), and type 3 (aortic enlargement extending to the transverse aortic arch [n = 39])., Results: The prevalence of BAV-AP and BAV-RL was 55.7% and 44.3%, respectively. Comparing BAV-AP and BAV-RL, no differences in age or in the prevalence of male sex were determined. However, significant differences in the valvular dysfunction pattern were noted, with moderate-to-severe aortic stenosis predominating in patients with BAV-RL (66.2% vs. 46.2% in BAV-AP; p = 0.01), and moderate-to-severe aortic regurgitation in BAV-AP (32.3% vs. 6.8% in BAV-RL; p < 0.0001). A normal aorta was the most common phenotype in BAV-AP patients (33.3% vs. 18.9% in BAV-RL; p = 0.037), and type 3 aortopathy was the most common phenotype in BAV-RL patients (40.5% vs. 9.7% in BAV-AP; p < 0.0001)., Conclusions: The patterns of valvular dysfunction and bicuspid aortopathy differed significantly between the 2 BAV phenotypes, suggesting the possibility of etiologically different entities., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)