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Selection of transcatheter valve size using preprocedural computed tomography (CT) is standardized and well established. However, valve sizing for surgical aortic valve replacement (SAVR) is currently performed intraoperatively by using sizers, which may result in variation among operators and risk for prosthesis-patient mismatch. This study evaluated the usefulness of CT annulus measurement for SAVR valve sizing. This study included patients who underwent SAVR using Inspiris or Magna Ease and received preoperative electrocardiogram-gated CT imaging. Starting from June 2022, study investigators applied a CT sizing algorithm using CT-derived annulus size to guide minimum SAVR label size. The final decision of valve selection was left to the operating surgeon during SAVR. The study compared the appropriateness of valve selection (comparing implanted size with CT-predicted size) and prosthesis-patient mismatch rates without aortic root enlargement between 2 cohorts: 102 cases since June 2022 (CT sizing cohort) and 180 cases from 2020 to 2021 (conventional sizing cohort). Implanted size smaller than CT predicted size and severe prosthesis-patient mismatch were significantly lower by CT sizing than by conventional sizing (12% vs 31% [ P =.001] and 0% vs 6% [ P =.039], respectively). Interoperator variability was a factor associated with implanted size smaller than CT predicted with conventional sizing, whereas it became nonsignificant with CT sizing. Applying CT sizing to SAVR led to improved valve size selection, less prosthesis-patient mismatch, and less interoperator variability. CT sizing for SAVR could also be used to predict prosthesis-patient mismatch before SAVR and identify patients who need aortic root enlargement. [Display omitted] [ABSTRACT FROM AUTHOR]

Quantification of myocardial changes in severe aortic stenosis (AS) is prognostically important. The potential for comprehensive myocardial assessment pre–transcatheter aortic valve replacement (TAVR) by computed tomography angiography (CTA) is unknown. This study sought to evaluate whether quantification of left ventricular (LV) extracellular volume—a marker of myocardial fibrosis—and global longitudinal strain—a marker of myocardial deformation—at baseline CTA associate with post-TAVR outcomes. Consecutive patients with symptomatic severe AS between January 2021 and June 2022 who underwent pre-TAVR CTA were included. Computed tomography extracellular volume (CT-ECV) was derived from septum tracing after generating the 3-dimensional CT-ECV map. Computed tomography global longitudinal strain (CT-GLS) used semi-automated feature tracking analysis. The clinical endpoint was the composite outcome of all-cause mortality and heart failure hospitalization. Among the 300 patients (80.0 ± 9.4 years of age, 45% female, median Society of Thoracic Surgeons Predicted Risk of Mortality score 2.80%), the left ventricular ejection fraction (LVEF) was 58% ± 12%, the median CT-ECV was 28.5% (IQR: 26.2%-32.1%), and the median CT-GLS was −20.1% (IQR: −23.8% to −16.3%). Over a median follow-up of 16 months (IQR: 12-22 months), 38 deaths and 70 composite outcomes occurred. Multivariable Cox proportional hazards model, accounting for clinical and echocardiographic variables, demonstrated that CT-ECV (HR: 1.09 [95% CI: 1.02-1.16]; P = 0.008) and CT-GLS (HR: 1.07 [95% CI: 1.01-1.13]; P = 0.017) associated with the composite outcome. In combination, elevated CT-ECV and CT-GLS (above median for each) showed a stronger association with the outcome (HR: 7.14 [95% CI: 2.63-19.36]; P < 0.001). Comprehensive myocardial quantification of CT-ECV and CT-GLS associated with post-TAVR outcomes in a contemporary low-risk cohort with mostly preserved LVEF. Whether these imaging biomarkers can be potentially used for the decision making including timing of AS intervention and post-TAVR follow-up will require integration into future clinical trials. [Display omitted] [ABSTRACT FROM AUTHOR]

Computed tomography angiography (CTA) assessment of myocardial extracellular volume fraction (CT-ECV) is feasible, although the protocols for imaging acquisition and post-processing methodology have varied. We aimed to identify a pragmatic protocol for CT-ECV assessment encompassing both imaging acquisition and post-processing methodologies to facilitate its clinical implementation. We evaluated consecutive patients with severe aortic stenosis undergoing evaluation for transcatheter aortic valve replacement (TAVR). Pre-contrast and 3-min-delayed CTA were obtained in systole using either helical prospective-ECG-triggered (high-pitch) or axial sequential-ECG-gated acquisition, adding to standard TAVR CTA protocol. Using a dedicated software for co-registration of CTA datasets, three methodologies for ECV measurement were evaluated: (1) mid-septum region of interest (Septal ECV), (2) averaged-global ECV (Global ECV) encompassing 16-AHA segments, and (3) average of septal and lateral segments (Averaged ECVsep and Averaged ECVlat). Among the 142 patients enrolled (median ​= ​81 years, 44% females), 8 were excluded due to significant imaging artifacts precluding Global ECV assessment. High-pitch scan mode was performed in 68 patients (48%). Suboptimal image quality for Global ECV assessment was associated with high-pitch scan mode (odds ratio: OR ​= ​2.26, p ​= ​0.036), along with the presence of intracardiac leads (OR ​= ​4.91, p ​= ​0.002), and BMI≥35 ​kg/m2 (OR ​= ​2.80, p ​= ​0.026). Septal ECV [median ​= ​29.4%] and Averaged ECVsep [29.0%] were similar (p ​= ​0.108), while Averaged ECVlat [27.5%] was lower than Averaged ECVsep (p ​< ​0.001), resulting in lower Global ECV [28.6%]. Myocardial CT-ECV assessment is feasible using a systolic sequential acquisition pre-contrast, and similar additional 3-min delayed scan. Septal ECV measurement provides similar values to Global ECV and is equally reproducible. Myocardial extracellular volume fraction assessment by cardiac computed tomography (CT-ECV) is feasible, however, the methodology for acquisition and post-processing has not been standardized. A practical workflow for myocardial CT-ECV assessment can be achieved using a specific imaging protocol encompassing a systolic sequential acquisition pre-contrast and similar 3-min delayed scan. This could be possible with any vendor. While Global CT-ECV maps allows for the identification of regional myocardial fibrosis and/or artifacts, a pragmatic post-processing with Septal ECV measurement provides similar values and is equally reproducible. [ABSTRACT FROM AUTHOR]

Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) may be associated with adverse hemodynamics, which might affect clinical outcomes. This study sought to evaluate the extent and predictors of transcatheter heart valve (THV) deformity in ViV TAVR and the relation to postprocedural hemodynamics. We examined 53 patients who underwent ViV TAVR in surgical heart valves with self-expanding Evolut prostheses. THV deformation was examined using cardiac computed tomography prospectively performed 30 days after ViV TAVR, and correlated with 30-day echocardiographic hemodynamic data. Near complete expansion of the functional portion of the implanted ViV prostheses (ie, >90%) was observed in 16 (30.2%) patients. Factors related to greater expansion of the functional portion and consequently larger neosinus volume were absence of polymer surgical frame, higher implantation and use of balloon aortic valvuloplasty or bioprosthetic valve fracture during the procedure (all P < 0.05). Underexpansion of the functional portion, but not the valve inflow frame, was closely associated with mean gradient and effective orifice area at 30 days on echocardiography, with and without adjustment for the sizes of the THV and surgical heart valve. Underexpansion of the functional portion of THV prostheses is common during ViV TAVR, occurs more frequently with deep implantation and the presence of a polymer surgical stent frame, and is associated with worse postprocedural hemodynamics. Procedural techniques, such as higher implantation and balloon postdilatation, may be used to help overcome problems with THV underexpansion and improve clinical outcomes. [Display omitted] [ABSTRACT FROM AUTHOR]

Although cardiac computed tomography angiography (CCTA) assessment of right ventricular dysfunction (RVD) is feasible, the incremental prognostic value remains uncertain in patients undergoing transcatheter aortic valve replacement (TAVR) evaluation. This study sought to determine the incremental clinical utility of RVD identification by CCTA while accounting for clinical and echocardiographic parameters. Patients who underwent multiphasic ECG-gated functional CCTA using dual-source system for routine TAVR planning were evaluated. Biphasic contrast protocol injection allowed for biventricular contrast enhancement. CCTA-based RVD was defined as right ventricular ejection fraction (RVEF) ​< ​50%. The association of CCTA-RVD with all-cause mortality and the composite outcome of death or heart failure hospitalization after TAVR was evaluated and examined for its incremental utility beyond clinical risk assessment and echocardiographic parameters. A total of 502 patients were included (median [IQR] age, 82 [77 to 87] years; 56% men) with a median follow-up of 22 [16 to 32] months. Importantly, 126 (25%) patients were identified as having RVD by CCTA that was not identified by echocardiography. CCTA-defined RVD predicted death and the composite outcome in both univariate analyses (HR for mortality, 2.15; 95% CI, 1.44–3.22; p ​< ​0.001; HR for composite outcome, 2.11; 95% CI, 1.48–3.01; p ​< ​0.001) and in multivariate models that included clinical risk factors and echocardiographic findings (HR for mortality, 1.74; 95% CI, 1.11–2.74; p ​= ​0.02; HR for composite outcome, 1.63; 95% CI, 1.09–2.44; p ​= ​0.02). Functional CCTA assessment pre-TAVR correctly identified 25% of patients with RVD that was not evident on 2D echocardiography. The presence of RVD on CCTA independently associates with clinical outcomes post-TAVR. TOC summary: This study evaluated the presence of right ventricular dysfunction (RVD) by functional cardiac computed tomography angiography (CCTA) in 502 patients undergoing routine evaluation for transcatheter aortic valve replacement. CCTA-RVD was defined as right ventricular ejection fraction <50%, and was tested for its prognostic value beyond conventional risk factors and echocardiography. In our study, 25% of patients have RVD on CT that was not present on 2D echocardiography. CT-RVD provides independent prognostic value that is incremental to conventional clinical and echocardiographic characteristics, and therefore should be considered in routine risk stratification of patients with severe AS. [ABSTRACT FROM AUTHOR]

Cardiac computed tomography (CT) is increasingly used in pediatric patients with congenital heart disease (CHD). Variability of practice and of comprehensive diagnostic risk across institutions is not known. Four centers prospectively enrolled consecutive pediatric CHD patients <18 years of age undergoing cardiac CT from January 6, 2017 to 1/30/2020. Patient characteristics, cardiac CT data and comprehensive diagnostic risk were compared by age and institutions. Risk categories included sedation and anesthesia use, vascular access, contrast exposure, cardiovascular medication, adverse events (AEs), and estimated radiation dose. Cardiac CT was performed in 1045 pediatric patients at a median (interquartile range, IQR) age of 1.7 years (0.3, 11.0). The most common indications were arterial abnormalities, suspected coronary artery anomalies, functionally single ventricle heart disease, and tetralogy of Fallot/pulmonary atresia. Sedation was used in 8% and anesthesia in 11% of patients. Peripheral vascular access was utilized for 93%. Median contrast volume was 2 ​ml/kg. Beta blockers were administered in 11% of cases and nitroglycerin in 2% of cases. The median (IQR) total procedural dose length product (DLP) was 20 ​mGy∗cm (10, 50). Sedation, vascular access, contrast exposure, use of cardiovascular medications and radiation dose estimates varied significantly by institution and age (p ​< ​0.001). Seven minor adverse events (0.7%) and no major adverse events were reported. Cardiac CT for CHD is safe in pediatric patients when appropriate CT technology and expertise are available. Scans can be acquired at relatively low radiation exposure with few minor adverse events. We conducted a prospective multi-institutional evaluation of variability of practice and comprehensive diagnostic risk for cardiac CT in pediatric CHD patients. 1329 scans were performed in 1045 patients at four institutions from January 6, 2017 to 1/30/2020 in patients from 1 day to <18 years of age. Anesthesia and sedation were required in a minority of cases, with a very low rate of adverse events and low radiation exposure (median procedural DLP 20 ​mGy∗cm). However, variation exists between institutions, warranting future exploration and quality improvement initiatives to develop best practice guidelines and reduced practice variability. [ABSTRACT FROM AUTHOR]

Evaluation of prosthesis-patient mismatch (P-PM) after transcatheter aortic valve replacement (TAVR) by transthoracic echocardiography (TTE) has provided conflicting results regarding its impact on outcomes. Whether post-TAVR computed tomography angiography (CTA) evaluation of P-PM can improve our understanding is unknown. We aimed to evaluate the inter-modality (TTE vs. CTA) agreement, inter-valve platform (balloon-expanding valve [BEV] vs. self-expandable valve [SEV]) differences in P-PM severity, and outcomes related to P-PM after TAVR. We analyzed patients with both CTA and TTE before and after TAVR. Indexed effective orifice area was calculated using two methods: TTE-derived left ventricular outflow tract (LVOT) area from measured diameter and post-TAVR CTA-measured area. Body size specific cut-offs for P-PM severity were used: for body mass index (BMI) ​< ​30 ​kg/m2, moderate ​= ​0.66–0.85 ​cm2/m2 and severe≤0.65 ​cm2/m2; for BMI ≥30 ​kg/m2, moderate ​= ​0.56–0.70 ​cm2/m2 and severe≤0.55 ​cm2/m2. A total of 447 patients were included (median age, 83 years; 54% male). The prevalence of P-PM (moderate or severe) was lower with CTA vs. TTE (3.5% vs. 19.5%, p ​< ​0.001). The prevalence of P-PM measured by TTE was more common in BEV compared to SEV (p ​= ​0.002), while CTA assessment showed no difference in P-PM incidence and severity between TAVR platforms (p ​= ​0.40). In multivariable analysis, CTA-defined but not TTE-defined P-PM was associated with mortality after TAVR (HR:3.97; 95%CI,1.55–10.2; p ​= ​0.004). Both CTA-defined and TTE-defined P-PM were associated with the composite of death and heart failure rehospitalization. Although post-TAVR CTA substantially downgraded the prevalence of P-PM compared to TTE, it identified a subset of patients with clinically relevant P-PM which associated with outcomes. [ABSTRACT FROM AUTHOR]

Functional mitral regurgitation (FMR) is a common and complex valve disease, in which severity and risk stratification is still a conundrum. Although risk increases with FMR severity, it is modulated by subjacent left ventricular (LV) disease. The extent of LV remodeling and dysfunction is traditionally evaluated by echocardiography, but a growing body of evidence shows that myocardial fibrosis (MF) assessment by cardiac magnetic resonance (CMR) may complement risk stratification and inform treatment decisions. This review summarizes the current knowledge on the comprehensive evaluation that CMR can provide for patients with FMR, in particular for the assessment of MF and its potential impact in clinical decision-making. [Display omitted] • FMR is a common and complex valve disease, in which proper severity and risk stratification is still a conundrum. • MF assessed by CMR is a robust predictor of adverse events beyond conventional LV function and remodeling and represents an emergent marker of risk and procedural outcomes in patients with FMR. • The precise quantification of LV MF and the hemodynamic severity of FMR in 1-stop elevate CMR as a promising imaging modality to advance the understanding of this challenging disease. • Future research is needed to explore how the use of LV MF quantification can improve candidate selection for evolving transcatheter therapies. [ABSTRACT FROM AUTHOR]

The aim of this study was to describe the anatomic and functional changes in left-sided chambers using computed tomographic angiography (CTA) from baseline to 1 month after transcatheter mitral valve replacement (TMVR) with the Tendyne prosthesis. Data on changes in left atrial and left ventricular (LV) volumes after TMVR implantation are very limited. Patients who underwent TMVR with the Tendyne prosthesis between 2015 and 2018 were analyzed. Changes in LV end-diastolic volume, ejection fraction, LV mass, left atrial volume, and global longitudinal strain were assessed at baseline and 1 month after TMVR using CTA. Specific Tendyne implant characteristics were identified and correlated with remodeling changes. A total of 36 patients (median age 74 years; interquartile range [IQR]: 69 to 78 years; 78% men; 86% with secondary mitral regurgitation) were included in this study. There were significant decreases in LV end-diastolic volume (281 ml [IQR: 210 to 317 ml] vs. 239 ml [IQR: 195 to 291 ml]; p < 0.001), LV ejection fraction (37% [IQR: 31% to 48%] vs. 30% [IQR: 23% to 40%]; p < 0.001), LV mass (126 g [IQR: 96 to 155 g] vs. 116 g [IQR: 92 to 140 g]; p < 0.001), left atrial volume (171 ml [IQR: 133 to 216 ml] vs. 159 ml [IQR: 125 to 201 ml]; p = 0.027), and global longitudinal strain (−11% [IQR: −17% to −8%] vs. −9% [IQR: −12% to −6%]; p < 0.001) from baseline to 1-month follow-up. Favorable LV end-diastolic volume reverse remodeling occurred in the majority (30 of 36 patients [83%]). Closer proximity of the Tendyne apical pad to the true apex (24 mm [IQR: 21 to 29 mm] vs. 35 mm [IQR: 26 to 40 mm]) was predictive of favorable remodeling (p = 0.037). TMVR with Tendyne results in favorable left-sided chamber remodeling in the majority of patients treated, as detected on CTA at 1 month after implantation. CTA identifies favorable post-TMVR changes, which could be related to specific characteristics of the device implantation. [ABSTRACT FROM AUTHOR]

This is an expert consensus document created to provide information about the current use of cardiovascular computed tomography (CT) in patients of all ages with proven or suspected congenital heart disease (CHD). The discussion and recommendations are based on available literature and the judgment of a diverse group of subspecialists with extensive experience in the use of CT imaging in CHD. The field of CHD CT imaging is evolving rapidly with the availability of new scanner technology. In addition, the prevalence of palliated CHD has increased with marked improvements in patient survival. We believe it is important to review the clinical indications, strengths, limitations, and risks of cardiovascular CT in this patient population. This is the first of two complementary documents. It will concentrate on the disease entities and circumstances in which CT may be used. The second document will focus on recommendations for the technical performance of cardiovascular CT in patients with CHD. Successful cardiovascular CT imaging of CHD requires an in depth understanding of the core teaching elements of both cardiology and radiology. The ability to perform and interpret high quality congenital cardiovascular CT in a clinical context requires focused time and effort regardless of the previous background of the cardiac imager. This is reflected by a writing committee that consists of pediatric and adult radiologists and cardiologists, all whom have extensive experience in performing CT in this patient population. Cardiovascular CT is complementary to other imaging modalities and its optimal use will be in centers where all diagnostic modalities are available. The choice of modality for an individual patient should be determined by age, diagnosis, clinical condition, clinical question and patient preference. 1–4 Use of CT in CHD should be reserved for situations in which it is expected to provide unique diagnostic information for the individual patient or clinical indication, and/or less risk than other modalities. This multi-disciplinary document is intended to guide the optimal selection of CHD patients for cardiovascular CT. The goals of this document apply to both pediatric and adult CHD patients and are to: 1) Review the current use of cardiovascular CT. 2) Assess the most up to date information on risks, benefits, as well as limitations of cardiovascular CT. 3) Provide disease-specific indications for cardiovascular CT imaging. 4) Outline a consensus opinion on the essential skills and knowledge needed to optimally perform and interpret cardiovascular CT. [ABSTRACT FROM AUTHOR]

Objective Severe, late functional tricuspid regurgitation is characterized by annulus dilation, right ventricular enlargement, and papillary muscle displacement with leaflet tethering. However, the early stages of mild tricuspid regurgitation and its progression are poorly understood. This study examined structural heart changes in mild, early tricuspid regurgitation. Methods Sequential patients undergoing cardiac computed tomography and transthoracic echocardiography with tricuspid regurgitation were identified and evaluated. The tricuspid annulus area and chamber volumes were measured by computed tomography angiography and categorized by tricuspid regurgitation severity. Results Patients (n = 622) were divided into 3 groups by tricuspid regurgitation severity: no/trace (n = 386), mild (n = 178), and moderate/severe tricuspid regurgitation (n = 58). Annulus area was highly dependent on and proportional to regurgitation severity and correlated with both right/left atrial enlargement. Annulus area most strongly correlated with right and left atrial volume, and the annulus shape changed from elliptical to circular in moderate/severe tricuspid regurgitation. Mild tricuspid regurgitation was associated with less right/left atrial enlargement than significant tricuspid regurgitation, normal right ventricular size, and annular dilation. Significant tricuspid regurgitation was associated with annular dilation, circularization, and right ventricular enlargement. Mild and significant tricuspid regurgitation were differentiated by annulus area and indexed right ventricular volume. Conclusions Tricuspid annular dilation and right/left atrial enlargement comprise early events in mild functional tricuspid regurgitation. Atrial enlargement occurs before right ventricular dilation, which occurs late, when tricuspid regurgitation is severe. Atrial volume and tricuspid annular dilation are early and sensitive indicators of tricuspid regurgitation significance. [ABSTRACT FROM AUTHOR]

Percutaneous repair of aortic paravalvular regurgitation can help avoid the need for repeat valve surgery. Although the initial diagnosis of paravalvular regurgitation is usually made with echocardiography, cardiac CT angiography helps to determine the site and morphology of these leaks. The utility of CT is highly dependent on the quality of the data. Herein, we describe a systematic approach to image acquisition and interpretation of cardiac CT angiography in patients with aortic paravalvular regurgitation, which integrates findings from echocardiography. This approach can be used to minimize inaccuracies in the diagnosis and enhance the procedural success for percutaneous repair of aortic paravalvular regurgitation. [ABSTRACT FROM AUTHOR]

Abstract: Background: Cardiac magnetic resonance imaging (MRI) and CT are available in the recent era at many pediatric cardiac centers. Objective: The aim was to provide a contemporary description of diagnostic imaging trends for definition of congenital heart disease (CHD). Methods: Echocardiography, cardiac catheterization, cardiac MRI, and cardiac CT use in patients with congenital heart disease at a single institution was retrospectively recorded (2005–2012). Surgical procedures were recorded. Total and modality-specific rates were estimated by Poisson regression and compared. The median age, studies in patients aged >17 years, and referral diagnosis were tabulated for the last year of review. Results: An average of 11,940 cardiovascular diagnostic tests was performed annually. The number of total studies, echocardiograms, catheterizations, and surgical procedures, did not change significantly across time. Echocardiography comprised 95% to 97% of all studies performed during each year of review. The use of cardiac MRI (2%) and cardiac CT (1%) increased linearly (P < .001), and the use of diagnostic catheterization decreased (0.7%; P = .0005). The median age was 3 years for echocardiography, 15 years for MRI, 11 years for CT, and 3 years for catheterization. The percentage of patients aged >17 years was 9% for echocardiography, 33% for cardiac MRI, 29% for cardiac CT, and 8% for catheterization. Most patients undergoing CT, MRI, and diagnostic catheterization had moderate or complex CHD. Conclusion: Cardiac CT is used increasingly in the recent era for evaluation of CHD. The increased use of both cardiac CT and cardiac MRI are temporally associated with a decrease in diagnostic cardiac catheterization. [Copyright &y& Elsevier]

Abstract: Background: Neonates with complex congenital heart disease (CHD) are at risk of adverse events from anesthesia. CT angiography (CTA) performed free breathing and without sedation has not been reported for evaluation of complex CHD in neonates. Objectives: The aim was to evaluate the image quality and risk of free breathing, non-sedated cardiac CTA for definition of CHD in the neonatal period and to determine accuracy compared with interventional findings. Methods: This is a combined retrospective–prospective single institution review of all non-sedated, free breathing cardiac CT angiograms performed in patients <1 month of age with complex CHD. Diagnosis, scan acquisition parameters, image quality (1- to 4-point scale), adverse events, radiation dose estimates, and accuracy compared with operative and interventional catheterization findings were recorded. Results are reported as median and interquartile range. Results: Nineteen non-sedated, free breathing, neonatal cardiac CT angiograms were performed during the time of review. All studies were diagnostic with a mean image quality score of 1.1 ± 0.3. Median total procedural dose-length product was 11 (range, 10–14), CT dose index volume was 0.47 (range, 0.31–0.5). Median unadjusted radiation dose was 0.15 mSv (range, 0.14–0.2 mSv), age- and size-adjusted radiation dose was 0.86 mSv (range, 0.78–1.1 mSv). No adverse events and no discrepancies compared with surgical or catheterization findings were found in the 17 of 19 patients that had subsequent intervention. Conclusions: Cardiac CTA can be performed in the neonatal period free breathing and without sedation. Image quality is excellent, and there is high accuracy compared with surgical and catheterization findings at the time of intervention. [Copyright &y& Elsevier]

Abstract: Echocardiography and cardiac magnetic resonance imaging are the most commonly performed diagnostic studies in patients with congenital heart disease. A small percentage of patients with congenital heart disease will be referred to cardiac CT subsequent to echocardiography when magnetic resonance imaging is insufficient, contraindicated, or considered high risk. The most common complex lesions referred for CT at our institution are tetralogy of Fallot, transposition complexes, and single ventricle heart disease. This review discusses the most common surgical procedures performed in these patients and the technical considerations for optimal image acquisition on the basis of the prior procedure and the individual patient history. Cardiac CT can provide the functional and anatomic information required for decision making in complex congenital heart disease. Image interpretation is aided by knowledge of the common approaches to operative repair and the residual hemodynamic abnormalities. Acquisition and interpretation that is both individualized to the patient's underlying disease and the specific clinical question is likely to maintain diagnostic accuracy while decreasing the potential risk of cardiac CT. [Copyright &y& Elsevier]

Background: High heart rates and radiation sensitivity have limited the use of coronary computed tomography angiography (CTA) in pediatric patients. Objective: A contemporary evaluation of image quality and reduction in radiation exposure with dual-source CT technology has not been reported in a large cohort of pediatric patients undergoing coronary angiography. Methods: Consecutive coronary CTA scans (n = 71) in 70 pediatric patients were retrospectively reviewed. Metoprolol was administered for heart rate control. Scans were divided by acquisition mode into 3 groups: retrospective electrocardiogram (ECG)–triggered spiral, prospective ECG-triggered, and prospective ECG-triggered high-pitch spiral scans. Heart rate, radiation dose, image quality, and diagnostic confidence were compared between groups. Results: Median decrease in heart rate with metoprolol was 24% ± 14%. Median effective age-adjusted radiation dose for the entire group was 0.97 ± 1.20 mSv. Retrospective ECG-triggered scans had a median dose of 1.71 ± 1.4 mSv, prospectively ECG-triggered scans had a median dose of 0.9 ± 1.1 mSv, and prospectively ECG-triggered high-pitch spiral scans had a median effective dose of 0.27 ± 0.4 mSv. The difference between groups was statistically significant (P < 0.05). The contrast-to-noise ratio and the image quality score were similar between groups. Conclusion: Dual-source coronary CTA with a β-blocker protocol uniformly achieves diagnostic coronary scans at a low radiation dose in pediatric patients. Image quality and diagnostic confidence are excellent for all scan modes in a wide spectrum of patients. [ABSTRACT FROM AUTHOR]

Background: Pediatric cardiac patients often undergo repeat diagnostic testing, resulting in relatively high cumulative medical radiation exposure. Low-dose CT scanning techniques used to decrease radiation exposure may result in reduced image quality. Objective: This study evaluates a prototype iterative reconstruction algorithm, sinogram-affirmed iterative reconstruction (SAFIRE), to determine the effect on qualitative and quantitative measures of image quality in pediatric cardiac CT datasets, compared with a standard weighted filtered back projection (wFBP) algorithm. Methods: Seventy-four datasets obtained on a 128-slice dual-source CT system were evaluated for image quality using both the wFBP and the prototype iterative reconstruction algorithm. Contrast, noise, contrast-to-noise ratio, signal-to-noise ratio, and qualitative image quality were compared between groups. Data were analyzed as medians and 25th and 75th percentiles, and groups were compared with the use of the Wilcoxon singed-rank test or k sample equality of medians test. Results: There was a 34% decrease in noise, a 41% increase in contrast-to-noise ratio, and a 56% increase in signal-to-noise ratio in the prototype iterative reconstruction, compared with wFBP. All differences were statistically significant (P < 0.001). Qualitative measures of image noise and noise texture were also improved in the iterative reconstruction group (P < 0.001 for both). Diagnostic confidence was similar between reconstruction techniques. Median scan dose length product was 15.5 mGy · cm. Conclusion: The prototype iterative reconstruction algorithm studied significantly reduces image noise and improves qualitative and quantitative measures of image quality in low-dose pediatric CT datasets, compared with standard wFBP. [ABSTRACT FROM AUTHOR]

Examinees of the first Certifying Examination in Cardiovascular Computed Tomography were surveyed regarding their training and experience in cardiac computed tomography. The results support the current training pathways within the American College of Cardiology/American Heart Association competency criteria that include either experience-based or formal training program in cardiovascular computed tomography. Increased duration in clinical practice, the number of scans clinically interpreted in practice, and level 3 competency were associated with higher passing rates. [Copyright &y& Elsevier]

Background: Initial clinical trials from Europe have demonstrated that the administration of bone marrow–derived mononuclear cells (BMCs) may improve left ventricular (LV) function in patients following ST-elevation myocardial infarction (STEMI). However, results from trials performed in the United States have not yet been presented. Methods: We developed a phase 1, randomized, placebo-controlled, double-blind trial to investigate the effects of BMC administration in patients following STEMI on recovery of LV function using cardiac magnetic resonance imaging (cMRI). Forty patients with moderate to large anterior STEMIs were randomized to 100 million intracoronary BMCs versus placebo 3 to 10 days following successful primary angioplasty and stenting (percutaneous coronary intervention) of the left anterior descending coronary artery. Results: Administration of BMC was safely performed in a high-risk cohort with minimal major adverse clinical event rates, and all patients remain alive to date. Left ventricular ejection fraction increased from 49.0% ± 9.5% at baseline to 55.2% ± 9.8% at 6 months by cMRI in the BMC group (P < .05), which was not different from the increase in the placebo group (48.6% ± 8.5% to 57.0% ± 13.4%, P < .05). Left ventricular end-diastolic volume decreased by 4 mL/m2 in the BMC group at 6 months but increased significantly in the placebo group (17 mL/m2, P < .01). Conclusions: This phase 1 study from the United States confirms the ongoing safety profile of BMC administration in patients following STEMI. The improvement in LV ejection fraction at 6 months by cMRI in the cell therapy group was not different than the placebo group. However, BMC administration had a favorable effect on LV remodeling at 6 months. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to assess, in a general cardiology cohort screened for obstructive coronary artery disease (CAD), the effectiveness and frequency with which multidetector computed tomography (MDCT) angiography unexpectedly imaged and identified other nonatherosclerotic cardiovascular diseases. Background: MDCT angiography is a novel imaging strategy employed primarily to diagnose CAD that, in the course of these studies, can also potentially identify other important but previously unrecognized cardiovascular abnormalities. Methods: Consecutive 64-slice MDCT angiography studies were obtained in 4,543 patients with suspected atherosclerotic CAD at the Minneapolis Heart Institute, over a 29-month period (2005 to 2007). Results: Nonatherosclerotic-related cardiovascular abnormalities judged to be of potential clinical relevance were identified in 201 patients (4.4%). In 50 of these patients (1.1% of 4,543) the abnormality was previously unrecognized despite other imaging studies performed in 40%. Most common among the 50 patients were: congenital coronary artery anomalies (38%; largely right coronary artery from the left aortic sinus); ascending aortic aneurysms ≥45 mm (22%); hypertrophic cardiomyopathy with apical left ventricular (LV) wall thickening (14%); valvular heart diseases (8%), congenital heart diseases, including ventricular septal defect (6%); pulmonary embolus (6%); as well as LV noncompaction, left atrial myxoma, and LV apical aneurysm (2% each). As a consequence of MDCT angiography findings, new management strategies were instituted in 15 of 50 patients (30%), including surgical correction of coronary artery anomalies of wrong sinus origin, ascending aneurysm graft repair, thrombolytic therapy for pulmonary embolism, and myxoma resection. Conclusions: Approximately 1% of patients undergoing MDCT angiography for suspicion of CAD proved to have otherwise unsuspected, but clinically relevant, cardiovascular abnormalities unrelated to coronary atherosclerosis. Almost one-third of these patients had cardiovascular diseases with major clinical implications for subsequent therapy. These findings underscore the value of MDCT angiography and the importance of careful assessment of scans for the recognition of a variety of cardiovascular abnormalities. [Copyright &y& Elsevier]

Abstract: Coronary CT angiography is a novel noninvasive imaging technology that provides a unique view of cardiac and coronary artery pathologies. Despite proper preparation, artifacts and noisy scans can occur and are usually caused by cardiac or respiratory motion or both and obesity. This article formulates a practical approach for salvaging difficult or potentially uninterpretable studies by diagnosing the causes of artifacts and providing an approach for scan improvement with the reconstruction of new data sets. Multiple pictorial examples of scan editing are provided. In addition, tables link the likelihood that a specific cause of an artifact will allow a scan to be salvaged. An approach for interpreting scans with excess noise is also discussed. [Copyright &y& Elsevier]

Abstract: Physician certification is critical in all areas of cardiovascular imaging to assure optimal performance and interpretation of quality studies for patient diagnosis and management. This is especially important in the field of cardiovascular computed tomography where practitioners have varied training and expertise that may not cover the full range of skills in the technical, image interpretative and clinical application of the results for patient management. The Certification Board of Cardiovascular Computed Tomography was developed to test the minimal level of competence of physicians performing cardiovascular computed tomography. In this article, the process of defining the content areas, determining candidate eligibility and the process of examination development and testing will be defined. [Copyright &y& Elsevier]

Stress (takotsubo) cardiomyopathy (SC) is a recently recognized syndrome with clinical and electrocardiographic (ECG) presentation resembling ST elevation anterior myocardial infarction. As experience with this condition has evolved, a more diverse spectrum of 12-lead ECG patterns has emerged that may affect differential diagnosis. Fifty-nine consecutive patients with SC were prospectively identified at a large community-based cardiology practice. All were women aged 32 to 90 years (mean 66 ± 13) with acute chest pain triggered by emotional or physical incidents and with akinesia of the mid-distal left ventricle; each patient recovered and was discharged within a median of 4 days. On electrocardiography, anterior ST elevation was most common (33 [56%]), with magnitudes less than in controls with left anterior descending coronary artery occlusions (1.4 ± 1.5 vs 2.4 ± 2.2 mm, p <0.001), with considerable overlap. ECG findings in 26 other patients (44%) without ST elevation revealed diffuse T-wave inversion (10 [17%]) and healed anterior infarctions (6 [10%]) or were nonspecific (5 [8.5%]) or normal (5 [8.5%]). Troponin elevations occurred in 56 patients with SC (95%). The mean peak troponin T level was significantly lower in patients with SC (0.64 ± 0.86 ng/ml) than in those with left anterior descending coronary artery occlusions (3.88 ± 4.9 ng/ml) (p <0.0001). Patients with SC with or without ST elevation did not differ with respect to the ejection fraction (29 ± 9% vs 34 ± 9%, respectively, p = NS) or Thrombolysis In Myocardial Infarction (TIMI) frame counts. During recovery, diffuse T-wave inversion evolved in 49 patients with SC (83%). In conclusion, patients with SC present with diverse ECG findings, and no single pattern alone can reliably distinguish this condition from acute coronary syndromes. The diagnosis of SC requires heightened awareness of its unique clinical profile as well as coronary arteriography and left ventriculography. [Copyright &y& Elsevier]

Cardiovascular magnetic resonance (CMR) is a high spatial resolution, 3-dimensional tomographic imaging technique which may identify regions of massive left ventricular hypertrophy (particularly when confined to the anterolateral free wall) in which the extent of wall thickness is underestimated with traditional 2-dimensional echocardiography in patients with hypertrophic cardiomyopathy (HC). This observation may have potential implications on management strategies as extreme left ventricular hypertrophy is a primary risk factor for sudden death in HC and therefore supports an expanding role for CMR in the evaluation of HC patients. [Copyright &y& Elsevier]

Percutaneous pulmonary valve replacement has emerged as an alternative to operation for some patients with congenital heart disease requiring intervention. Endocarditis is increasingly described as an adverse event during follow-up [1–4] . Diagnosis is difficult because of the poor visualization of the prosthetic valve in the pulmonary position by transthoracic and transesophageal echocardiogram and by the metallic artifact that degrades the image quality of magnetic resonance imaging (MRI). Two cases of percutaneous pulmonary valve obstruction diagnosed by cardiac computed tomographic angiography are presented. These cases demonstrate the utility of cardiac computed tomography for noninvasive imaging of suspected thrombus or endocarditis in a percutaneously placed pulmonary valve. [ABSTRACT FROM AUTHOR]

Left ventricular apical aneurysms, in absence of coronary artery disease, occur in approximately 1% of patients with hypertrophic cardiomyopathy (HC). Identical twins, age 44 years, are presented with HC and identical LV morphology, including apical aneurysms. These cases demonstrate a genetic predisposition to the development of apical aneurysm, as well as overall LV morphology, in patients with HC. [Copyright &y& Elsevier]

Although tako-tsubo cardiomyopathy (TTC) is regarded as a reversible condition with favorable outcome, a malignant clinical course evolves in some subjects. In this single-institution experience, we describe the clinical profile of patients with adverse TTC outcome. A cohort of 249 consecutive patients with TTC was interrogated for those with acute unstable presentation during the first 24 hours. Forty-seven patients (19%) experienced early complicated clinical course with cardiac arrest in 9 (ventricular fibrillation, n = 4, pulseless electrical activity, n = 3, and asystole, n = 2) or marked hypotension in 38 (systolic blood pressure =90 mm Hg requiring vasopressors and/or balloon pump). Of the 47 patients, Killip class III to IV heart failure was present in 30 (64%). Despite treatment, 8 patients (3%; all women) died inhospital due to respiratory failure, cardiogenic shock, or anoxic brain injury. All 8 inhospital deaths occurred among the 47 patients with unstable presentation, including 2 after cardiac arrest and 6 with marked hypotension. Post-TTC event mortality for a period of 4.7 ± 3.4 years significantly exceeded that in a matched general US population (standardized mortality ratio 1.4; 95% confidence interval 1.1 to 1.9; p = 0.005) largely due to noncardiac co-morbidities. In conclusion, contrary to widespread perception, TTC is not an entirely benign and reversible condition. Among this large cohort, a high-risk subgroup was identified with cardiac arrest or hemodynamic instability, accounting for all hospital deaths. Hospital nonsurvivors had a variety of irreversible co-morbid conditions with the potential to compromise clinical status and adversely affect short-term survival. Long-term survival after hospital discharge was also reduced compared with the general population because of noncardiac co-morbidities [ABSTRACT FROM AUTHOR]

Objectives: This study was designed to define more completely the clinical spectrum and consequences of stress cardiomyopathy (SC) beyond the acute event. Background: Stress cardiomyopathy is a recently recognized condition characterized by transient cardiac dysfunction with ventricular ballooning. Methods: Clinical profile and outcome were prospectively assessed in 136 consecutive SC patients. Results: Patients were predominantly women (n = 130; 96%), but 6 were men (4%). Ages were 32 to 94 years (mean age 68 ± 13 years); 13 (10%) were ≤50 years of age. In 121 patients (89%), SC was precipitated by intensely stressful emotional (n = 64) or physical (n = 57) events, including 22 associated with sympathomimetic drugs or medical/surgical procedures; 15 other patients (11%) had no evident stress trigger. Twenty-five patients (18%) were taking beta-blockers at the time of SC events. Three diverse ventricular contraction patterns were defined by cardiovascular magnetic resonance (CMR) imaging, usually with rapid return to normal systolic function, although delayed >2 months in 5%. Right and/or left ventricular thrombi were identified in 5 patients (predominantly by CMR imaging), including 2 with embolic events. Three patients (2%) died in-hospital and 116 (85%) have survived, including 5% with nonfatal recurrent SC events. All-cause mortality during follow-up exceeded a matched general population (p = 0.016) with most deaths occurring in the first year. Conclusions: In this large SC cohort, the clinical spectrum was heterogeneous with about one-third either male, ≤50 years of age, without a stress trigger, or with in-hospital death, nonfatal recurrence, embolic stroke, or delayed normalization of ejection fraction. Beta-blocking drugs were not absolutely protective and SC was a marker for increased noncardiac mortality. These data support expanded management and surveillance strategies including CMR imaging and consideration for anticoagulation. [Copyright &y& Elsevier]