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Purpose To prospectively evaluate contemporary indications, safety and diagnostic impact of cardiac CTA in patients undergoing cardiac CTA examinations for non-coronary clinical indications. Method We analyzed 1097 consecutive patients from the German Cardiac CT Registry who underwent cardiac CTA between 2009 and 2014 due to clinically indicated non-coronary reasons using 64-slice or newer CT systems in twelve tertiary German heart centers in order to evaluate the impact of clinical indications on procedure-associated parameters. All participating centers electronically submitted patient and examination data including detailed indications, clinical symptoms, procedural parameters, complications and diagnostic results in a predefined template. Results The most frequent indication for non-coronary cardiac CTA was the evaluation of pulmonary vein anatomy (65.9 %, 723/1097). In the remaining cases, most frequent indications were planning before TAVI (44.5 %, 69/155), evaluation of valvular disease (31.6 %, 49/155), and evaluation of implants (5.8 %, 9/155). Non-coronary cardiac CTA required a median amount of iodinated contrast agent of 100.0 mL (IQR 95.0–110.0 mL). Prospectively ECG-triggered acquisition was the most frequently used protocol (74.0 %), followed by retrospectively ECG-gated acquisition with and without tube current modulation (19.9 % and 6.0 %, respectively), resulting in a mean estimated effective dose of 5.2 mSv (IQR 2.9−9.5 mSv, average conversion factor k = 0.026). Overall, complication rate was very low (1.5 %). Non-coronary cardiac CTA revealed a new clinical diagnostic aspect in 3.2 % of all patients, and a new main clinical diagnosis in 2.2 %. Conclusions Non-coronary cardiac CTA as a routinely applied diagnostic modality is associated with a very low procedure-related rate of complications and reasonably low radiation exposure using contemporary CT systems.

To evaluate diagnostic impact of clinical use of coronary computed tomography angiography (CCTA) in patients with suspected stable coronary artery disease (CAD) and its consequences in daily practice for patient management, depending on stress test results in daily practice. Between 2009 and 2014 of a total population of 1352 patients of the German Cardiac Computed Tomography (CT) Registry who had previously undergone stress tests, CCTA visualizations were carried out on the coronary arteries with suspected stable CAD. Patients were divided into three groups according to stress test results: Group 1 with inconclusive (n = 178, 13.2%), Group 2 with ischemia in stress test (n = 372, 27.5%) and Group 3 without ischemia in stress test (n = 802, 59.3%). The test of preference was the stress electrocardiogram (ECG), which was performed more frequently in patients without ischemia in stress test as compared to those with ischemia (96.3% vs. 93.0%, p = 0.015). The incidence of detected obstructive CAD was lower in patients with suggested ischemia in stress test as compared to patients with inconclusive results (14.1% vs. 21.1%, p = 0.037). There was no difference in the incidence of an obstructive CAD in patients with and without ischemia in stress test (14.1% vs. 15.8%, p = 0.440). CCTA is a reliable, non-invasive option for ruling-out obstructive CAD irrespective of the stress test result.

Das vorliegende Curriculum beschreibt einen strukturierten Ausbildungsprozess, mit dem Kardiologen die Zusatzqualifikation „kardiale Computertomographie (CT)“ erlangen konnen. Die Ausbildung wird von der Fachgesellschaft definiert und nach einheitlichen Qualitatskriterien zertifiziert. Drei Ausbildungsstufen gehen mit einer zunehmend hoheren Qualifikation einher, beginnend in Stufe 1 vor allem mit der Indikationsstellung zur kardialen CT, ihrer diagnostischen Wertigkeit sowie dem Vergleich mit alternativen diagnostischen Verfahren. Die 2. Stufe fugt spezielle Kompetenzen in der kardialen CT hinzu, die eine selbststandige Durchfuhrung der Untersuchung ermoglichen. Die 3. Stufe befahigt den Kardiologen, eigenstandig und unter Beachtung der Strahlenschutzvorschriften ein kardiales CT zu betreiben und die Ausbildung zur Zusatzqualifikation kardiale CT zu leiten. Neben der individuellen Weiterbildung werden auch der Zertifizierungsprozess von Ausbildungszentren beschrieben und die Prufung der Ausbildungskandidaten. Dabei wird das kardiologische Weiterbildungscurriculum der deutschen Fachgesellschaft ebenso berucksichtigt wie die nationalen und europaischen Konsensusempfehlungen zur kardiovaskularen Bildgebung.

Cardiac computed tomography permits quantification of coronary calcification as well as detection of coronary artery stenoses after contrast enhancement. Moreover, cardiac CT offers high-resolution morphologic and functional imaging of cardiac structures which is valuable for various structural heart disease interventions and electrophysiology procedures. So far, only limited data exist regarding the spectrum of indications, image acquisition parameters as well as results and clinical consequences of cardiac CT examinations using state-of-the-art CT systems in experienced centers. Twelve cardiology centers with profound expertise in cardiovascular imaging participated in the German Cardiac CT Registry. Criteria for participation included adequate experience in cardiac CT as well of the availability of a 64-slice or newer CT system. Between 2009 and 2014, 7061 patients were prospectively enrolled. For all cardiac CT examinations, patient parameters, procedural data, indication and clinical consequences of the examination were documented. Mean patient age was 61 ± 12 years, 63% were males. The majority (63%) of all cardiac CT examinations were performed in an outpatient setting, 37% were performed during an inpatient stay. 91% were elective and 9% were scheduled in an acute setting. In most examinations (48%), reporting was performed by cardiologists, in 4% by radiologists and in 47% of the cases as a consensus reading. Cardiac CT was limited to native acquisitions for assessment of coronary artery calcification in 9% of patients, only contrast-enhanced coronary CT angiography was performed in 16.6% and combined native and contrast-enhanced coronary CT angiography was performed in 57.7% of patients. Non-coronary cardiac CT examinations constituted 16.6% of all cases. Coronary artery calcification assessment was performed using prospectively ECG-triggered acquisition in 76.9% of all cases. The median dose length product (DLP) was 42 mGy cm (estimated effective radiation dose of 0.6 mSv). Coronary CT angiography was performed using prospectively ECG-triggered acquisition in 77.3% of all cases. Tube voltage was 120 kV in 67.8% of patients and 100 kV in 30.7% of patients, with a resultant median DLP of 256 mGy cm (estimated effective dose of 3.6 mSv). Clinical consequences of cardiac CT were as follows: in 46.8% of the cases, invasive coronary angiography could be avoided; ischemia testing was recommended in 4.7% of the cases, invasive coronary angiography was recommended in 16.4% of the cases and change in medication in 21.6% of the examinations. Cardiac CT is performed in the majority of patients for non-invasive evaluation of the coronary arteries. CT frequently resulted in medication change, and otherwise planned downstream testing including invasive angiography could be avoided in a high percentage of patients. Radiation exposure in experienced centers is relatively low.

Coronary computed tomography angiography (coronary CTA) provides non-invasive evaluation of the coronary arteries with high precision for the detection of significant coronary artery disease (CAD).To investigate whether irregular heart rhythm including atrial fibrillation and premature beats during data acquisition influences (i) radiation and contrast media exposure, (ii) number of non-evaluable coronary segments and (iii) diagnostic impact of coronary CTA.Twelve tertiary care centers with ≥64 slice CT scanners and ≥5 years of experience with cardiovascular imaging participated in this registry. Between 2009 and 2014, 4339 examinations were analysed in patients who underwent clinically indicated coronary CTA for suspected CAD. Clinical and epidemiologic data were gathered from all patients. In addition, clinical presentation, heart rate and rhythm during the scan, Agatston score, radiation and contrast media exposure and the diagnostic impact of coronary CTA were systematically analysed.Of 4339 patients in total, 260 (6.0%) had irregular heart rhythm, whereas the remaining 4079 (94.0%) had stable sinus rhythm. Patients with irregular heart rhythm were older (63.2 ± 12.5yrs versus 58.6 ± 11.4yrs. p 0.001), exhibited a higher rate of pathologic stress tests before CTA (37.1% versus 26.1%, p 0.01) and higher heart rates during CTA compared to those with sinus rhythm (62.5 ± 11.6bpm versus 58.9 ± 8.5bpm, p 0.001). Both contrast media exposure and radiation exposure were significantly higher in patients with irregular heart rhythm (90 mL (95%CI = 80-110 mL) versus 80 mL (95%CI = 70-90 mL) and 6.2 mSv (95%CI = 2.5-11.7) versus 3.3 mSv (95%CI = 1.7-6.9), p 0.001 for both). Coronary CTA excluded significant CAD less frequently in patients with irregular heart rhythm (32.9% versus 44.8%, p 0.001). This was attributed to the higher rate of examinations with at least one non-diagnostic coronary segment in patients with irregular heart rhythm (10.8% versus 4.6%, p 0.001). Subsequent invasive angiography could be avoided in 47.2% of patients with irregular heart rhythm compared to 52.9% of patients with sinus rhythm (p = NS), whereas downstream stress testing was recommended in 3.2% of patients with irregular heart rhythm versus 4.0% of patients with sinus rhythm (p = NS).A significant number of patients scheduled for coronary CTA have irregular heart rhythm in a real-world clinical setting. In such patients, heart rate during coronary CTA is higher, possibly resulting in (i) higher radiation and contrast agent exposure and (ii) more frequent coronary CTA examinations with at least one non-diagnostic coronary artery segment. However, this does not seem to lead to increased downstream stress testing or subsequent invasive procedures.

Coronary computed tomography angiography (CTA) is increasingly used as a test to rule out coronary artery disease (CAD) in patients with a low to intermediate pre-test probability of the disease. We used the database of the German CT registry, collected between 2009 and 2014 in a broad patient population, to analyze contemporary radiation dose associated with coronary CTA in clinical practice. The prospective observational registry included a total of 7061 patients ≥18 years, referred to 12 participating centers for a clinically indicated cardiac CT examination. All centers were cardiology units well experienced in CTA and used multi-slice CT scanners with at least 64 rows. Coronary CTA was performed in a subset of 5001 patients, 59.6 ± 11.8 years, body mass index (BMI) 26.9 ± 4.5 kg/m2, 38% females. Three time periods with approximately equal numbers of patients were created (01/09–03/10, 04/10–03/11, 04/11–07/14). The dose–length product of all examinations and derived effective dose in mSv (conversion factor k = 0.014) as well as the influence of patient characteristics on dose were compared for the three time periods. BMI and proportion of female patients remained stable over time, and mean heart rate decreased from 60.3 ± 9.0 to 58.5 ± 9.3 bpm from the first to the last time period (p

The assessment of CT perfusion images of the myocardium at one time point; the best dynamic semiquantitative parameter, upslope; and the quantitative parameter myocardial blood flow showed similar high diagnostic accuracy without significant differences compared with coronary angiography and fractional flow reserve measurement.

PURPOSE To characterize the evolution of right ventricular (RV) function post-myocardial infarction (MI), to describe the culprit vessel involved with RV injury and to assess the concordance between RV injury on magnetic resonance imaging (MRI) and RV infarct on electrocardiogram (EKG). MATERIALS AND METHODS Thirty-one patients underwent cardiovascular magnetic resonance (CMR) examinations at three time frames post-ST elevation MI (STEMI). RESULTS Of those with an initial normal scan, RV function did not significantly change over time (60.6 ± 6.3, 57.8 ± 6.0, 55.4 ± 5.7, P > 0.05). However, in those whose RVEF (RV ejection fraction) was initially low, it significantly increased from the first scan to the third scan (46.2 ± 3.6, 50 ± 6.6, 51.3 ± 5.2, P < 0.01). Post-hoc testing revealed a significant difference between the 48-hour and the 6-month scan, and between the 48-hour and the 3-week scan; however, there was no significant difference between the 3-week and 6-month scans. Interestingly, 23% of patients with low RVEF at baseline had the left anterior descending (LAD) as the culprit vessel. Only 15% of the low RVEF at baseline group were classified as having an RVMI by EKG criteria. CONCLUSIONS The optimal timepoint to assess for RV injury via CMR may be 3 weeks post-acute MI. Standard EKG criteria may underestimate RV injury when compared to CMR.

Prospective data on the usage of 3-dimensional imaging based annulus sizing on the outcome of TAVI is not available yet and there is general uncertainty about the optimal degree of oversizing. In the current study we therefore assessed a 3-D MSCT guided over-sizing approach and evaluated the clinical outcome of different degrees of oversizing.TAVI-size-selection was done using systolic MSCT-annulus cross-sectional-area (CSA) measurements in 107 patients with severe aortic stenosis with the goal to oversize the 3rd generation balloon expandable Edwards Sapien XT (ESTV) device in relation to the native aortic annulus CSA.Among different degrees of oversizing there were no differences in the occurrence of stroke, myocardial infarction and death. No aortic injuries were observed. The overall rate ofmild postprocedural aortic regurgitation (PAR) was 7.6%. Increasing oversizing ratios are associated with lower rates ofmild PAR (r = -0.236, p0.02) with the lowest rate ofmild PAR in patients with area based oversizing ratios25% and the highest rate in patients with oversizing ratios15% (0% vs. 15.8%, p0.02). The rate of postprocedural permanent pacemakers tended to be lower in patients with15% oversizing compared to those with25% oversizing (5.3 vs. 16.7%, p0.23).MSCT guided ESTV-device sizing is safe and is associated with significantly lower than previously reported rates for PAR. A device/annulus oversizing ratio of 15-25% based on area and 7-12% based on mean diameter appears to provide the best risk-benefit ratio in terms of PAR reduction and conduction disorders.

Complete occlusion of the pulmonary veins (PV) is crucial for successful PV isolation. While two different sizes of cryoballoons (23 and 28 mm) are available, complete occlusion is not always achieved in any given PV. We investigated the role of PV ostial anatomy during cryoballoon PV occlusion grading and atrial fibrillation (AF) recurrence rate.PV ostial diameter was analyzed in 168 consecutive patients (111 men, 61 ± 10 years, 124 paroxysmal (px) and 44 persistent AF) using cardiac computed tomography (CT) prior to procedure. The ovality index at the PV ostial level was calculated in any given PV. During follow-up, 7-day holter monitors were performed at 1, 3, 6, 9, 12, 18 and 24 months post-ablation.The success rate at 12 ± 6 months follow-up was 69% including a 3-month blanking period (px AF: 66%; persistent AF 77%). The ovality index of the left-sided PVs was significantly larger ("more oval") than that of the right-sided PVs (p0.001). An optimized PV occlusion in all individual PVs (complete occlusion, grading 4/4) was achieved during ablation in 49% of patients with AF recurrence and in 73% of patients without AF recurrence (p=0.004). Patients with AF recurrence had "more oval" left-sided PVs compared to patients free from AF recurrence (LSPV 0.40 ± 0.2 vs. 0.33 ± 0.2; p=0.04 and LIPV 0.41 ± 0.3 vs. 0.32 ± 0.2; p=0.03), whereas no significant association was found for right sided PVs.The ostial PV anatomy seems to have an important impact on clinical outcome and should be considered when planning and performing cryoballoon AF ablation procedures.

Background The economic impact of drug-eluting stent (DES) in-stent restenosis (ISR) is substantial, highlighting the need for cost-effective treatment strategies. Hypothesis Compared to plain old balloon angioplasty (POBA) or repeat DES implantation, drug-coated balloon (DCB) angioplasty is a cost-effective therapy for DES-ISR. Methods A Markov state-transition model was used to compare DCB angioplasty with POBA and repeat DES implantation. Model input parameters were obtained from the literature, and the cost analysis was conducted from a German healthcare payer's perspective. Extensive sensitivity analyses were performed. Results Initial procedure costs amounted to €3488 for DCB angioplasty and to €2782 for POBA. Over a 6-month time horizon, the DCB strategy was less costly (€4028 vs €4169) and more effective in terms of life-years (LYs) gained (0.497 versus 0.489) than POBA. The DES strategy incurred initial costs of €3167 and resulted in 0.494 LYs gained, at total costs of €4101 after a 6-month follow-up. Thus, DCB angioplasty was the least costly and most effective strategy. Base-case results were influenced mostly by initial procedure costs, target lesion revascularization rates, and the costs of dual antiplatelet therapy. Conclusions DCB angioplasty is a cost-effective treatment option for coronary DES-ISR. The higher initial costs of the DCB strategy compared to POBA or repeat DES implantation are offset by later cost savings.

Performance evaluation of a fully automated system for calculating computed tomography (CT) coronary artery calcium scores from contrast medium-enhanced coronary CT angiography (cCTA) studies.One hundred and twenty-seven patients (58 ± 11 years, 71 men) who had undergone cCTA as well as an unenhanced CT calcium scoring study where included. Calcium scores were computed from cCTA by an automated image processing algorithm and compared with calcium scores obtained by standard manual assessment of unenhanced CT calcium scoring studies. Results were compared vis-a-vis (1) absolute calcium score values, (2) age-, gender- and race-dependent percentiles, and (3) commonly used calcium score risk classification categories.One hundred and nineteen out of 127 (93.7%) studies were successfully processed. Mean Agatston calcium score values obtained by traditional non-contrast CT calcium scoring studies and derived from contrast medium-enhanced cCTA did not significantly differ (235.6 ± 430.5 vs 262.0 ± 499.5; P 0.05). Calcium score risk categories and Multi-Ethnic Study of Atherosclerosis (MESA) percentiles showed very high correlation (Spearman rank correlation coefficient = 0.97, P 0.0001/0.95, P 0.0001) between the two approaches.Calcium score values automatically computed from cCTA are highly correlated with standard unenhanced CT calcium scoring studies. These results suggest a radiation dose- and time-saving potential when deriving calcium scores from cCTA studies without a preceding unenhanced CT calcium scoring study.

Encouraging results of ablation therapy in patients with paroxysmal atrial fibrillation (AF) have prompted changes in professional practice guidelines. The most recent European guidelines have suggested that ablation might be offered as first-line therapy in selected patients. Cryoballoon ablation is a promising technology in interventional AF therapy. Two different sizes of the cryoballoon are currently available: a smaller (23 mm) and a larger (28 mm) balloon relative to the ostial diameter of the pulmonary veins. New tools, the circular mapping catheter and the use of intracardiac echocardiography, provide important periprocedural information. A meta-analysis of previous studies revealed outcome data with an AF-free survival rate of 72.83% at the 1-year follow-up in paroxysmal AF patients undergoing cryoballoon ablation. The most frequent, but reversible complication is phrenic nerve palsy with reported incidences up to 10%. All efforts must be taken to overcome this limitation, since the overall major complication rate tends to be lower in cryoballoon compared to radiofrequency ablation. In persistent AF, reported results in cryoballoon ablation had a limited success rate below 50% after a single procedure. A double balloon approach using both cryoballoon sizes might overcome some of the limitations in persistent AF. Prospective data and randomized studies are required. This article outlines the current status of cryoballoon technology in AF ablation therapy.

Objectives: Pericardial adipose tissue (PAT) is associated with coronary artery plaque accumulation and the incidence of coronary heart disease. We evaluated the possible incremental prognostic value of PAT for future cardiovascular events. Methods: 145 patients (94 males, age 60 ± 10 years) with stable coronary artery disease underwent coronary artery calcification (CAC) scanning in a multislice CT scanner, and the volume of pericardial fat was measured. Mean observation time was 5.4 years. Results: 34 patients experienced a severe cardiac event. They had a significantly higher CAC score (1,708 ± 2,269 vs. 538 ± 1,150, p < 0.01), and the CAC score was highly correlated with the relative risk of a future cardiac event: 2.4 (1.8–3.7; p = 0.01) for scores >400, 3.5 (1.9–5.4; p = 0.007) for scores >800 and 5.9 (3.7–7.8; p = 0.005) for scores >1,600. When additionally a PAT volume >200 cm3 was determined, there was a significant increase in the event rate and relative risk. We calculated a relative risk of 2.9 (1.9–4.2; p = 0.01) for scores >400, 4.0 (2.1–5.0; p = 0.006) for scores >800 and 7.1 (4.1–10.2; p = 0.005) for scores >1,600. Conclusions: The additional determination of PAT increases the predictive power of CAC for future cardiovascular events. PAT might therefore be used as a further parameter for risk stratification.

ObjectivesChemerin is a recently discovered adipokine that regulates adipocyte differentiation and modulates chemotaxis and activation of dendritic cells and macrophages. Given the convergence of adipocyte and macrophage function, chemerin may provide an interesting link between obesity, inflammation and atherosclerosis in humans. We sought to examine the relationship of i) chemerin and markers of inflammation, ii) chemerin and components of the metabolic syndrome, and iii) chemerin and coronary atherosclerotic plaque burden and morphology.DesignSerum chemerin levels were determined in 303 patients with stable typical or atypical chest pain who underwent dual-source multi-slice CT-angiography to exclude coronary artery stenosis. Atherosclerotic plaques were classified as calcified, mixed, or non-calcified.ResultsChemerin levels were highly correlated with high sensitivity C-reactive protein (r=0.44, Pr=0.18, P=0.002), tumor necrosis factor-α (r=0.24, Pr=0.28, Pr=0.36, Pr=0.23, P=0.0002), triglycerides (r=0.29, Pr=−0.18, P=0.003), and hypertension (Pr=0.16, P=0.006) and the number of non-calcified plaques (r=0.14, P=0.02). These associations, however, were lost after adjusting for established cardiovascular risk factors (odds ratio, OR 1.17, 95% confidence interval (CI) 0.97–1.41, P=0.11 for coronary plaque burden; OR 1.06, 95% CI 0.96–1.17, P=0.22 for non-calcified plaques).ConclusionsChemerin is strongly associated with markers of inflammation and components of the metabolic syndrome. However, chemerin does not predict coronary atherosclerosis.

Objectives— Pericardial fat as a visceral fat depot may be involved in the pathogenesis of coronary atherosclerosis. To gain evidence for that concept we sought to investigate the relation of pericardial fat volumes to risk factors, serum adiponectin levels, inflammatory biomarkers, and the quantity and morphology of coronary atherosclerosis. Methods and Results— Using Dual source CT angiography pericardial fat volume and coronary atherosclerosis were assessed simultaneously. Plaques were classified as calcified, mixed, and noncalcified, and the number of affected segments served as quantitative score. Patients with atherosclerotic lesions had significant larger PAT volumes (226 cm 3 ±92 cm 3 ) than patients without atherosclerosis (134 cm 3 ±56 cm 3 ; P >0.001). No association was found between BMI and coronary atherosclerosis. PAT volumes >300 cm 3 were the strongest independent risk factor for coronary atherosclerosis (odds ratio 4.1; CI 3.63 to 4.33) also significantly stronger compared to the Framingham score. We furthermore demonstrated that elevated PAT volumes are significantly associated with low adiponectin levels, low HDL levels, elevated TNF-α levels, and hsCRP. Conclusion— In the present study we demonstrated that elevated PAT volumes are associated with coronary atherosclerosis, hypoadiponectinemia, and inflammation and represent the strongest risk factor for the presence of atherosclerosis and may be important for risk stratification and monitoring.

Summary Multi-detector row computed tomography (MDCT) offers an alternative to diagnostic coronary angiography for visualizing coronary arteries. The major limitation of recently published studies, aside from being monocentric in nature and the low number of patients included, is the selection of patients. These studies do not provide any answers for patients who are seen daily in cardiology consultation. The purpose of our study was to determine the diagnostic accuracy of MDCT as compared with coronary angiography on a population of average patients who were not selected. Materials and methods Forty-eight patients with suspected coronary artery disease successively underwent 64-slice MDCT followed by coronary angiography with 24 to 48 hours. The diagnostic accuracy detection of significant coronary stenoses (greater than 50% stenoses in arteries greater than 1.5 mm in diameter) was determined and the two techniques were compared. Results Nearly half of the patients included had known histories of coronary artery disease ( N = 24; 50%). The sensitivity, specificity, positive and negative predictive value, and the diagnostic accuracy of MDCT in detecting significant coronary stenoses were 81.2, 98.2, 87.5, 97 and 93.9% in per-segment evaluation. During the per-patient evaluation, the efficacy of MDCT dropped with the values being 77.4, 92.3, 87.8, 79.2 and 81.6% respectively. Conclusion The use of 64-slice MDCT results in excellent diagnostic accuracy and in an increased negative predictive value for detecting significant coronary stenoses in per-segment analysis. Per-patient analysis significantly reduced the value of the scan, demonstrating that patients with a high probability of coronary artery disease do not benefit from this type of non-invasive approach.

Rationale and Objectives Our aim was to evaluate the correlation of test bolus (TB) curve parameters with main bolus (MB) contrast density for cardiac 16-slice computed tomography, and to correlate observed enhancement with patient body weight. Materials and Methods Sixty patients with known or suspected coronary artery disease were included in a prospective double-blind study. Contrast material containing 300 mg iodine/mL (Iomeprol 300; Imeron 300, Bracco Imaging SpA, Milan, Italy) and 400 mg iodine/mL (Iomeprol 400; Imeron 400) was injected at a rate of 1 g of iodine/second. Contrast densities (Hounsfield units) of the MB were determined in the left cardiac system. The peak density (PD) of maximum attenuation and the area under the curve (AUC) of the TB curve were calculated for each patient. The dependency of MB contrast attenuation on these parameters and on patient body weight was evaluated. Results Positive correlations (r = 0.52 and r = 0.56, respectively; P Conclusions Strong correlation of the PD and AUC of the TB curve with the mean density of the MB is observed when patient body weight is considered. Contrast injection protocols may be optimized, and variations of MB contrast density in the left ventricle and main coronary arteries reduced, by taking these TB parameters and the weight of the patient into account.

The aim of the present study was to characterize coronary plaques by Multi-Slice Computed Tomography (Siemens sensation 16, Forcheim, Germany) before significant angiographic progression occurred and to compare them to non-progressing lesions. The MSCT-morphology of coronary plaques leading to a rapid angiographic disease progression is not yet studied. In a series of 68 patients who were scheduled for surveillance angiography 6 months later, MSCT-angiography was done shortly after the baseline catheterisation-procedure. After surveillance angiography rapid progressive lesions with an increase of the stenosis severity of >20% were identified and analysed on the baseline MSCT-scan and were compared to non-progressing lesions. Six months after coronary stenting we observed significant progression of de novo stenoses in 10/438 coronary segments. The progression of four lesions lead to angina pectoris symptoms and the remaining six lesions progressed silently. Analysis of the lesion morphology by MSCT revealed that 5/10 (50%) progressing lesions were non-calcified 3/10 (30%) were predominantly non-calcified and 2/10 (20%) were mainly calcified on the baseline MSCT-scan. In the 428 segments without disease progression atherosclerotic lesions were found in 225 segments on MSCT. Non-calcified plaques were identified in 46 (20%), predominantly non-calcified lesions in 58 (26%) and predominantly calcified lesions in 121 (54%) segments. The average number of diseased coronary segments between patients with and without lesion progression was not significantly different between progressors and non-progressors with a higher prevalence of non-calcified segments in the progressor group (1.1 vs. 0.63). Rapid progression of the angiographic stenosis severity during a 6 months period occurs most frequently in coronary segments revealing non-calcified or predominantly non-calcified plaques as determined by MSCT, whereas lesion progression is rare in predominantly calcified segments. This represents first evidence that non-calcified lesions may be involved in the process of plaque rupture.

The aim of this study was to evaluate the diagnostic accuracy of dual-source computed tomography (DSCT) with reference to invasive coronary angiography in the diagnosis of coronary artery disease (CAD) on a per-patient as well as on a per-segment basis.Thirty-five patients with known or suspected CAD underwent both DSCT (Somatom Definition, Siemens Medical Solutions) and quantitative x-ray coronary angiography (QCA). Parameters of CT acquisition were gantry rotation time 0.330 seconds (ie, temporal resolution 83 milliseconds), tube voltage 120 kV, tube current 560 mA with ECG-triggered tube current modulation and full current at 70% of the cardiac cycle for heart rates below 70 beats per minute or full current between 30% and 80% for higher and arrhythmic heart rates. The pitch was also adapted to the heart rate, ranging from 0.2 to 0.43. Volume and flow rate of contrast material (Ultravist 370, Schering AG) were adapted to the patient's body weight. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of DSCT in the detection or exclusion of significant CAD (ie, stenoses50%) were evaluated on a per-patient and per-segment basis.All 35 CT angiograms were of diagnostic image quality. QCA demonstrated significant CAD in 48% (n = 17) and nonsignificant disease or normal coronary angiograms in 52% (n = 18) of the patients. Sensitivity, specificity, PPV, and NPV of DSCT on a per-patient basis were 100%, 89%, 89%, and 100%, respectively. On a per-segment basis, 473 of 481 coronary artery segments were assessable (98%). QCA demonstrated stenoses50% in 32 segments (7%), and no disease or nonsignificant disease in 433 segments (93%). For the detection of stenoses50% on a per-segment basis, DSCT showed a sensitivity, specificity, PPV, and NPV of 88%, 98%, 78%, and 99%, respectively.The comparison of coronary DSCT with QCA shows a very robust image quality and a high diagnostic accuracy in a patient-based as well as a per-segment analysis. Maximal sensitivity and NPV in the per-patient analysis show the strength of the technique in ruling out significant CAD.

Seit kurzem stehen Dual-source-Computertomographie-Systeme (DSCT) zur Verfugung, die eine hohere zeitliche Auflosung als herkommliche Single-source-Systeme besitzen. Ziele unserer Untersuchungen waren die Korrelation der Bildqualitat mit der Herzfrequenz und die Evaluation linksventrikularer Funktionsparameter mit der DSCT im Vergleich zur Magnetresonanztomographie (MRT). Bei 21 Patienten (mittleres Alter 62±8 Jahre; 15 mannlich, 6 weiblich) wurde an einem Dual-source-CT (Somatom Defintion, Siemens Medical Solutions, Forchheim) eine CT-Angiographie der Koronararterien durchgefuhrt. Die Bildqualitat der Darstellung der Koronararterien, Herzklappen sowie des linksventrikularen Myokards wurde anhand einer 3-Punkte-Skala bewertet. Bei 10 Patienten dieses Kollektivs wurde unter Verwendung einer SSFP- (Steady-state-free-precession-)Sequenz eine Funktions-MRT des Herzens votgenommen. Die linksventrikulare Ejektionsfraktion (LV-EF), das endsystolische Volumen (ESV) und das enddiastolische Volumen (EDV) wurden in den DSCT- und den MRT-Datensatzen bestimmt. Die Evaluation der Bildqualitat ergab selbst fur Patienten mit hoher Herzfrequenz eine diagnostische Bildqualitat mit 1,42±0,49 bei Beurteilung der Koronararterien. Die Analyse der linksventrikularen Funktionsparameter am DSCT im Vergleich mit den MRT-Datensatzen ergab eine gute Korrelation (LV-EF: r=0,75; p=0,01; ESV: r=0,72; p=0,019; EDV: r=0,71; p=0,02). Das Dual-source-CT-System bietet auch bei Patienten mit hohen Herzfrequenzen eine robuste und reproduzierbare Abbildungsqualitat der Koronararterien und Herzklappen sowie des Myokards und erlaubt eine ausreichend genaue Bestimmung der linksventrikularen Funktionsparameter.

Objective In animal models, G-CSF based progenitor cell mobilization combined with a DPP4 inhibitor leads to increased homing of bone marrow derived progenitor cells to the injured myocardium via the SDF1/CXCR4 axis resulting in improved ejection fraction and survival after acute myocardial infarction (AMI). Research design and methods After successful revascularization in AMI, 174 patients were randomized 1:1 in a multi-centre, prospective, placebo-controlled, parallel group, double blind, phase III efficacy and safety trial to treatment with G-CSF and Sitagliptin (GS) or placebo. Diabetic and non-diabetic patients were included in our trial. The primary efficacy endpoint hierarchically combined global left and right ventricular ejection fraction changes from baseline to 6months of follow-up (Δ LVEF , Δ RVEF ), as determined by cardiac MRI. Results At follow-up Δ LVEF as well as Δ RVEF did not differ between the GS and placebo group. Patients in the placebo group had a similar risk for a major adverse cardiac event within 12months of follow-up as compared to patients under GS. Conclusion Progenitor cell therapy comprising the use of G-CSF and Sitagliptin after successfully revascularized acute myocardial infarction fails to show a beneficial effect on cardiac function and clinical events after 12months. (EudraCT: 2007–003,941-34; ClinicalTrials.gov: NCT00650143, funding: Heinz-Nixdorf foundation).

Rationale and Objectives Restenosis remains a major limitation of coronary catheter–based stent placement. Therefore, a reliable noninvasive diagnostic method for the evaluation of stented coronary arteries would be highly desirable. Our aim was to evaluate the diagnostic accuracy of high-resolution 64-slice computed tomography (64SCT) in a pilot study for the assessment of the lumen of coronary artery stents. Materials and Methods Twenty-five patients underwent 64SCT of the coronary arteries and quantitative x-ray coronary angiography (QCA) after coronary artery stent placement. 64SCT coronary angiography was performed with the following parameters: spatial resolution = 0.4 × 0.4 × 0.4 mm; temporal resolution = 83–165 milliseconds; contrast agent = 80 mL at a flow rate of 5 mL/second; retrospective electrocardiogram gating. The 64SCT scans were evaluated for image quality and for the presence of significant in-stent and peri-stent (proximal and distal) stenoses. Determinations were made of the sensitivity, specificity, diagnostic accuracy, and positive and negative predictive values (PPV and NPV) of 64SCT for the detection or exclusion of stenoses. Results A total of 46 stents were evaluated, of which 45 (98%) were of diagnostic image quality. Significant in-stent restenosis or occlusion was detected on QCA in 8/45 cases (≥50% stenosis = 6; occlusion = 2). The sensitivity, specificity, accuracy, PPV, and NPV of 64SCT for the detection of significant in-stent disease was 75%, 92%, 89%, 67%, and 94%, respectively. Both occluded coronary artery stents were correctly identified. The sensitivity, specificity, and accuracy values of 64SCT for the detection of significant proximal peri-stent stenoses were 75%, 95%, and 93%, respectively, whereas the values for detection of significant distal peri-stent stenoses were 67%, 85%, and 84%, respectively. Conclusion The high spatial and temporal resolution of 64SCT may permit improved assessment of stent occlusion and peri-stent disease, although detection of in-stent stenosis remains difficult.

The aim of this study was to evaluate the potential clinical value of a new generation of 64-MDCT systems with that of invasive coronary angiography in the diagnosis of coronary artery disease (CAD).Seventy-two consecutive patients with known or suspected CAD underwent both 64-MDCT and quantitative coronary angiography (QCA). A CT system with acquisition of 64 slices per gantry rotation was used with a spatial resolution of 0.4 x 0.4 x 0.4 mm and a gantry rotation time of 330 milliseconds. Sensitivity, specificity, and diagnostic accuracy of 64-MDCT in the detection or exclusion of CAD were evaluated on both a per patient and a per segment basis.Sixty-eight of 72 coronary CT angiograms (CTAs) (94%) were of diagnostic image quality. QCA showed significant CAD (i.e., one or more stenoses in50%) in 57% (39/68) and nonsignificant disease or healthy CTAs in 43% (29/68) of the patients. Sensitivity, specificity, and the negative predictive value (NPV) of 64-MDCT per patient were 97%, 79%, and 96%, respectively. Per segment, 923 of 1,020 coronary artery segments were assessable (90%). For the detection of stenoses of more than 50% and more than 75% per segment, 64-MDCT showed a sensitivity of 82% and 86%, respectively. Per segment, specificity and NPV were as high as 95% and 97%, respectively.In clinical routine, coronary CTA will primarily be used for risk stratification on a per patient basis. In the present study, coronary 64-MDCT showed a high diagnostic accuracy on both per patient and per segment analyses.

The relation of heart rate and image quality in the depiction of coronary arteries, heart valves and myocardium was assessed on a dual-source computed tomography system (DSCT). Coronary CT angiography was performed on a DSCT (Somatom Definition, Siemens) with high concentration contrast media (Iopromide, Ultravist 370, Schering) in 24 patients with heart rates between 44 and 92 beats per minute. Images were reconstructed over the whole cardiac cycle in 10% steps. Two readers independently assessed the image quality with regard to the diagnostic evaluation of right and left coronary artery, heart valves and left ventricular myocardium for the assessment of vessel wall changes, coronary stenoses, valve morphology and function and ventricular function on a three point grading scale. The image quality ratings at the optimal reconstruction interval were 1.24+/-0.42 for the right and 1.09+/-0.27 for the left coronary artery. A reconstruction of diagnostic systolic and diastolic images is possible for a wide range of heart rates, allowing also a functional evaluation of valves and myocardium. Dual-source CT offers very robust diagnostic image quality in a wide range of heart rates. The high temporal resolution now also makes a functional evaluation of the heart valves and myocardium possible.

Objectives We evaluated the accuracy of a new 64-slice computed tomography (CT) scanner, compared with intravascular ultrasound, to visualize atherosclerosis in the proximal coronary system. Background Noninvasive determination of plaque composition and plaque burden may be important to improve risk stratification. Methods In 20 patients, a 64-slice CT scan (Sensation 64, Siemens Medical Solutions, Forchheim, Germany) and an intravascular ultrasound investigation of vessels without stenosis >50% was performed. Diagnostic image quality with 64-slice CT was obtained in 36 vessels in 19 patients. Results In these vessels, which were divided in 3-mm sections, 64-slice CT enabled a correct detection of plaque in 54 of 65 (83%) sections containing noncalcified plaques, 50 of 53 (94%) sections containing mixed plaques, and 41 of 43 (95%) sections containing calcified plaques. In 192 of 204 (94%) sections, atherosclerotic lesions were excluded correctly. In addition, 64-slice CT enabled the visualization of 7 of 10 (70%) sections revealing a lipid pool and could identify a spotty calcification pattern in 27 of 30 (90%) sections. The correlation coefficient to determine plaque volumes per vessel was r2= 0.69 (p Conclusions We conclude that 64-slice CT reveals encouraging results to noninvasively detect different types of coronary plaques located in the proximal coronary system. The ability to determine plaque burden currently is hampered by mainly an insufficient reproducibility.

BACKGROUND The efficacious prophylaxis of myocardial infarction requires an accurate identification of patients at risk. Conventional risk stratification is often insufficient for this. We therefore examined the predictive value of coronary calcifications for future cardiovascular events. METHODS We determined the extent of coronary calcification by multi-slice computed tomography in 924 patients (443 men, 481 women, aged 59.4 +/- 18.7 years) after coronary artery disease had been excluded by coronary angiography. To quantify coronary calcifications the volume score was calculated. After an observation period of 36 months was calculated the incidence of coronary revascularisation, myocardial infarction, and cardiac death. RESULTS During the observation period the event rates for coronary revascularization (5.4 %/ year vs. 2.9 %/ year), myocardial infarction (3.8 %/ year vs. 1.8 %/ year), and cardiac death (2.1 %/ year vs. 1.0 %/ year) in patients with volume scores above the 75th percentile were significantly higher compared to the total study group. Correspondingly the scores in patients with revascularization (397 +/- 187), myocardial infarction (412 +/- 176), and cardiac death (422 +/- 184) were significantly higher compared to patients without cardiovascular events (218 +/- 167). In addition future cardiovascular events were excluded in patients without coronary calcifications. CONCLUSIONS By determining coronary calcifications it was possible to identify patients at risk for myocardial infarction could be identified. Future cardiovascular events could not be observed in patients without coronary calcifications.

Objectives The aim of the present study was to determine the diagnostic accuracy of 64-slice computed tomography (CT) to identify and quantify atherosclerotic coronary lesions in comparison with catheter-based angiography and intravascular ultrasound (IVUS). Background Currently, the ability of multislice CT to quantify the degree of coronary artery stenosis and dimensions of coronary plaques has not been evaluated. Methods We included 59 patients scheduled for coronary angiography due to stable angina pectoris. A contrast-enhanced 64-slice CT (Senation 64, Siemens Medical Solutions, Forchheim, Germany) was performed before the invasive angiogram. In a subset of 18 patients, IVUS of 32 vessels was part of the catheterization procedure. Results In 55 of 59 patients, 64-slice CT enabled the visualization of the entire coronary tree with diagnostic image quality (American Heart Association 15-segment model). The overall correlation between the degree of stenosis detected by quantitative coronary angiography compared with 64-slice CT was r = 0.54. Sensitivity for the detection of stenosis 50%, and stenosis >75% was 79%, 73%, and 80%, respectively, and specificity was 97%. In comparison with IVUS, 46 of 55 (84%) lesions were identified correctly. The mean plaque areas and the percentage of vessel obstruction measured by IVUS and 64-slice CT were 8.1 mm2versus 7.3 mm2(p < 0.03, r = 0.73) and 50.4% versus 41.1% (p < 0.001, r = 0.61), respectively. Conclusions Contrast-enhanced 64-slice CT is a clinically robust modality that allows the identification of proximal coronary lesions with excellent accuracy. Measurements of plaque and lumen areas derived by CT correlated well with IVUS. A major limitation is the insufficient ability of CT to exactly quantify the degree of stenosis.

Electron-beam computed tomography (EBCT) allows non-invasive imaging of coronary calcification and has been promoted as a screening tool for coronary artery disease (CAD) in asymptomatic high-risk subjects. This study assessed the relation of coronary calcifications to alterations in coronary vascular reactivity by means of positron emission tomography (PET) in asymptomatic subjects with a familial history of premature CAD. Twenty-one subjects (mean age 51+/-10 years) underwent EBCT imaging for coronary calcifications expressed as the coronary calcium score (CCS according to Agatston) and rest/adenosine-stress nitrogen-13 ammonia PET with quantification of myocardial blood flow (MBF) and coronary flow reserve (CFR). The mean CCS was 237+/-256 (median 146, range 0-915). The CCS was100 in eight subjects and100 units in 13. As defined by age-related thresholds, 15 subjects had an increased CCS (75th percentile). Overall mean resting and stress MBF and CFR were 71+/-16 ml 100 g(-1) min(-1), 218+/-54 ml 100 g(-1) min(-1) and 3.20+/-0.77, respectively. Three subjects with CCS ranging from 114 to 451 units had an abnormal CFR (2.5). There was no relation between CCS and resting or stress MBF or CFR ( r=0.17, 0.18 and 0.10, respectively). In asymptomatic subjects a pathological CCS was five times more prevalent than an abnormal CFR. The absence of any close relationship between CCS and CFR reflects the fact that quantitative myocardial perfusion imaging with PET characterises the dynamic process of vascular reactivity while EBCT is a measure of more stable calcified lesions in the arterial wall whose presence is closely related to age.

Objectives We evaluated the accuracy of contrast-enhanced multidetector spiral computed tomography (MDCT) for the noninvasive detection and classification of coronary plaques and compared it with intracoronary ultrasound (ICUS). Background Noninvasive determination of plaque composition and plaque burden may be important to improve risk stratification and to monitor progression of coronary atherosclerosis. Methods We included 46 consecutive patients with a distinctive risk profile, who were investigated by ICUS (Goldvision, 20 MHz, Jomed Inc., Rancho Cordova, California). Due to the inability to slow the heart rate below 65 beats/min (n = 7) and due to renal insufficiency (n = 2), nine of 46 consecutive patients could not be studied by MDCT (Sensation 16, Siemens, Forchheim, Germany). Results In the remaining 37 patients, 68 vessels were investigated by ICUS, and 58 of these vessels were visualized by MDCT with image quality sufficient for analysis. In these vessels that were divided in 3-mm sections, MDCT correctly classified 62 of 80 (78%) sections containing hypoechoic plaque areas, 87 of 112 (78%) sections containing hyperechoic plaque areas, and 150 of 158 (95%) sections containing calcified plaque tissue. In 484 of 525 (92%) sections, atherosclerotic lesions were correctly excluded. The MDCT-derived density measurements within coronary lesions revealed significantly different values for hypoechoic (49 HU [Hounsfield Units] ± 22), hyperechoic (91 HU ± 22), and calcified plaques (391 HU ± 156, p Conclusions This study demonstrates that, in the case of diagnostic image quality, contrast-enhanced MDCT permits an accurate identification of coronary plaques and that computed tomography density values measured within plaques reflect echogenity and plaque composition.

Ziel der Studie war die Evaluierung der Mehrzeilendetektorcomputertomographie (MDCT) zur Darstellung atherosklerotischer Gefaswandveranderungen der Koronararterien. Zunachst wurden in einer Ex-vivo-Studie 17 menschliche Leichenherzen im Vergleich zum histopathologischen Praparat untersucht. Dabei wurden fur verschiedene Plaquetypen bildmorphologische Kriterien im CT evaluiert. Anschliesend wurden 94 koronare MDCT-Angiogramme (MDCTA) von Patienten mit Verdacht auf eine koronare Herzkrankheit retrospektiv hinsichtlich der diagnostischen Aussagekraft sowie der Verteilung und Anzahl der in der Ex-vivo-Studie beschriebenen Plaquetypen ausgewertet. Zusatzlich wurde eine Volumetrie der verkalkten und nichtkalzifizierten Plaqueareale durchgefuhrt. In der Ex-vivo-Studie zeigte die MDCT eine hohe Sensitivitat sowohl fur kalzifizierte als auch fur nichtkalzifizierte Plaques. Im Vergleich zur Histopathologie konnten charakteristische Bildmerkmale der MDCT fur fetthaltige, fibrose und kalzifizierte Plaquekomponenten ermittelt werden. In der In-vivo-Studie wurden mit der kontrastverstarkten MDCT-Koronarangiographie bei 38% der Patienten nichtverkalkte Plaques nachgewiesen. Bei 5 Patienten mit unauffalligem Kalziumscreening konnte erst durch die Durchfuhrung der MDCTA eine Atherosklerose nachgewiesen werden. Die MDCT ist in der Lage, sowohl ex vivo als auch in vivo verschiedene Plaquetypen zu differenzieren. Die kontrastverstarkte MDCT-Angiographie der Koronararterien erlaubt im Gegensatz zum traditionellen Kalziumscreening die Detektion nichtkalzifizierter Gefaswandveranderungen. Eine Volumetrie nichtverkalkter Plaqueanteile ist in vivo moglich.

Die Elektronenstrahltomographie gilt als Goldstandard fur den Nachweis und die Quantifizierung von koronaren Kalzifizierungen (Kalkscore). Mit der Mehrschicht-Spiral-Computertomographie (MSCT) steht seit 1999 ein konventionelles CT-Verfahren mit vergleichbarer diagnostischer Bildqualitat zur Verfugung. In der vorliegenden Untersuchung wurde bei 54 mannlichen Patienten (Alter 58±11 Jahre) mit V.a. koronare Herzerkrankung eine Koronarkalkuntersuchung mit beiden Verfahren nach einem standardisierten Protokoll durchgefuhrt. Mit EBT wurden 40 axiale Schichten (Belichtungszeit=100ms, Schichtdicke=3mm) in einer Atemanhaltephase (35±5 s), EKG getriggert (80% RR-Intervall) akquiriert. Fur das MSCT erfolgte die simultane Akquisition von vier axialen Schichten (Belichtungszeit=250 ms, Schichtdicke=2,5mm) in einer Atemanhaltephase (25±5 s) bei 450ms vor der R-Zacke. Der mittlere EBT-Agatstonscore aller Patienten betrug 88±111 (Median=45) und lag zwischen der 25. und 75. alters- und geschlechtskorrigierten Percentile fur asymptomatische Patienten. Fur den Methodenvergleich wurde der Agatston- und Volumetrische Kalziumscore, sowie die Anzahl, Masse und Dichte der kalzifizierten Lasionen bestimmt. Es zeigte sich bezuglich des Volumetrischen Kalziumscores, der Masse, Dichte sowie der Anzahl der kalzifizierten Lasionen zwischen beiden Methoden kein statistisch signifikanter Unterschied. Die mittlere Variabilitat des Volumetrischen Calciumscores zwischen beiden Untersuchungen betrug 24% und lag somit im Bereich der Variabilitat wiederholter Untersuchungen der EBT (14–44,9%). Das Mehrschicht-Spiral-CT ist unter Anwendung des Volumetrischen Calciumscores bei prospektiver EKG-Triggerung der EBT gleichwertig. Die Variabilitat der Scorewerte beider Methoden liegt im Bereich von Wiederholungsuntersuchungen der Elektronenstrahltomographie. Der Agatstonscore liefert signifikant unterschiedliche Ergebnisse in beiden Verfahren und kann zur Befundinterpretation nicht herangezogen werden. Durch die Applikation des Spiralmodus mit retrospektivem EKG-Gating und dunneren Schichtdicken mit Overlap ist fur das MSCT eine weitere Optimierung der Untersuchungsvariabilitat zu erwarten, die Voraussetzung fur das Follow-up von Patienten zur Bestimmung der Progression von Koronarkalk ist.

Electron-beam Computed Tomography (EBCT) has been used for years to quantify coronary artery calcification as a marker of coronary atherosclerosis. The aim of this study was to determine the diagnostic accuracy of a new scanner, the Multi-slice Spiral CT (MSCT), for the assessment of coronary calcification and to compare this new technique to EBCT. The study population consisted of 99 male patients, aged 60 ± 10 years with suspected or known coronary artery disease. With EBCT 40 axial slices, ECG-triggered (scan time = 100 ms, slice thickness = 3 mm), were acquired in one breath-hold (35 ± 5 s). For MSCT simultaneous acquisition of four axial slices (scan time = 250 ms, slice thickness = 2.5 mm), allowed the entire heart (48 slices) to be covered in one breath-hold of 25 ± 5 s. For quantification of coronary calcium the Volumetric Calcium Score (VCS) was calculated. There was an excellent correlation for the VCS (r = 0.994, p = 0.01, mean difference = 97 ± 115) between both scanners. Comparison of low (1–100), moderate (101–400), high (401–1000) and very high score values (>1000) showed no significant differences. The number of calcified lesions and densities were statistically not different. Mean variability of the two scans was 17%. The MSCT scanner is equivalent to EBCT for the determination and quantification of coronary calcium and can therefore be used for calcium screening. With application of the spiral mode technique further improvement in variability can be expected, thus allowing for follow-up studies to determine progression or regression of atherosclerosis with high accuracy.

The aim of this study was to investigate the reliability of calcium scoring (CS) and electron beam computed tomographic angiography (EBCTA) as a noninvasive tool in the diagnosis of coronary artery disease (CAD): 93 consecutive patients (aged 59 ± 9 years) with symptoms suspicious for CAD underwent CS. In 87 of these subjects, an additional EBCTA investigation was performed. Using receiver-operating characteristic curve analysis, we determined a calcium score cut point providing an overall sensitivity of 80% and a specificity of 72% in detecting patients with CAD. For clinical purposes the use of cut points is difficult. We therefore determined score ranges providing >80% specificity (high score range) and >85% sensitivity (low score range) and determined the scores between these ranges as equivocal borderline scores. Calculated on a per-segment basis in assessable proximal and midcoronary segments, the sensitivity for detecting coronary stenoses >50% was 78%, and the specificity was 93%. Thus, 32 of 44 patients with significant CAD and 24 of 49 patients without CAD were correctly classified. The combination of CS and EBCTA predicted CAD in 77% (72 of 93) of patients. No or low calcium scores provided high specificity for ruling out CAD. The addition of EBCTA in those patients improved sensitivity. In patients with high calcium scores, accuracy of EBCTA was not significantly different from CS alone (72% vs 83%), whereas in patients with borderline scores it was significantly superior (80% vs 58%, p

OBJECTIVES This study correlated the electron beam computed tomographic (EBCT) calcium scores with the results of coronary angiography in symptomatic patients in order to assess its value to predict or exclude significant coronary artery disease (CAD). BACKGROUND Electron beam computed tomography is a sensitive method to detect coronary calcium. However, it is unclear whether it may play a role as a filter before invasive procedures in symptomatic patients. METHODS A total of 1,764 patients (1,225 men and 539 women) with suspected CAD from a single center were included in our study. All patients underwent calcium screening with EBCT (C150XP Imatron) and conventional coronary angiography. RESULTS Fifty-six percent of men and 47% of women revealed significant coronary stenoses (≥50%). Total exclusion of coronary calcium (14% of the study group) was associated with an extremely low probability of stenosis (

Electron beam computed tomography (EBCT) is the most sensitive and accurate method of measuring coronary calcium which indicates coronary atherosclerosis. We performed a prospective study in 1764 symptomatic patients who were referred to our hospital for coronary angiography because of suspected coronary artery disease. In all of these patients cardiac catheterization and coronary calcium scanning was performed within 3.2 +/- 4 days. 454/1225 men (37.0%) and 165/539 women (30.6%) had significant coronary stenoses > or = 75%. Only two men (0.4%) and no single woman (0.0%) with stenoses > or = 75% and only 3/323 patients (0.9%) with moderate stenoses (50-75%) did not exhibit coronary calcium. Coronary angiography excluded stenoses in 822 patients. Of these patients 261 (29.4%) did not reveal coronary calcium. In younger patients (< 60 years) without stenosis exclusion of coronary calcium was a frequent finding: 31% of men and 55.8% of women were free of coronary calcium. Thus, exclusion of coronary calcium with electron beam tomography defines a substantial subgroup of patients who have an extremely low risk of significant coronary stenosis despite suspected coronary artery disease in history and non-invasive testing. Determination of coronary calcium might, therefore, be an effective filter before invasive angiography in selected groups of symptomatic patients.

Zielsetzung: Anforderungen an die kardiale Bildgebung sind die Darstellung der Anatomie der Herzhohlen, Herzklappen, Koronararterien und der grosen Gefase, Parameter der Ventrikel- und Klappenfunktion, der Myokardperfusion, Myokardvitalitat und des myokardialen Stoffwechsels. Material und Methode: In der Bildgebung kommen neben den etablierten Standardverfahren wie Rontgen, Angiographie, Echokardiographie und nuklearmedizinischen Methoden auch neuere Verfahren der Computer- und Magnetresonanztomographie zum Einsatz. Ergebnisse: Die Koronarangiographie ist der Goldstandard in der Darstellung des gesamten Koronarsystems. In der Diagnostik der koronaren Herzerkrankung zeigen schnelle CT-Verfahren wie die Elektronenstrahltomographie (EBT) und die Mehrzeilendetektor-CT (MDCT) Vorteile gegenuber der Kernspintomographie. Fruhstadien der koronaren Arteriosklerose konnen nur mit dem intravaskularen Ultraschall (IVUS) erkannt werden. Nuklearmedizinische Methoden sind in der Untersuchung der Myokardperfusion und -vitalitat etabliert. Mit der MRT scheint eine qualitative und quantitative Bestimmung der regionalen Perfusion, Funktion und Vitalitat moglich zu sein. Die Untersuchung der linksventrikularen Funktion und der Herzklappen ist die Domane der Echokardiographie. Schlussfolgerung: In der klinischen Routine sind die Angiographie, Echokardiographie und die Nuklearmedizin etablierte Methoden. Der Stellenwert der Magnetresonanz- und Computertomographie in der Diagnostik der koronaren Herzerkrankung und der Herzfunktion, Perfusion und Vitaltat ist noch nicht definiert.

Fragestellung: Mit dem Mehrzeilendetektorspiral-CT (MSCT) sind effektive Aufnahmezeiten von 250 ms moglich. Die Moglichkeiten und Grenzen dieser CT-Technologie zur nativen und kontrastverstarkten Untersuchung der Koronargefase sollen in dieser Arbeit dargestellt werden. Methode: Die native Untersuchung der Koronargefase zur Quantifizierung von Koronarkalk wurde bei einem Patienten mit Adipositas (140 kg) mit dem Elektronenstrahl-CT (EBCT) und dem MSCT vorgenommen. Bei 56 Patienten wurde eine kontrastverstarkte MSCT-Angiographie der Koronargefase vorgenommen und festgestellt, bei welcher Herzfrequenz eine diagnostisch ausreichende Bildqualitat zu erreichen ist. Ergebnisse: Bei der Untersuchung des Patienten mit Adipositas konnte mit dem MSCT eine erheblich bessere Bildqualitat erreicht werden, die eine Quantifizierung von Koronarkalk erheblich erleichterte. Mit der MSCT-Angiographie der Koronargefase konnte bei einer Herzfrequenz von 59±8 Schlagen/min eine diagnostisch gute Bildqualitat erreicht werden. Schlussfolgerung: Auch wenn mit einer effektiven Aufnahmezeit von 250 ms Limitationen bei hoheren Herzfrequenzen zu erwarten sind, konnen mit dem MSCT entscheidende Vorteile in der Bildqualitat in der nativen und kontrastverstarkten Untersuchung der Koronargefase erreicht werden.

Background Functional assessment of myocardial perfusion in computed tomography (CT) is a challenge. Objective To evaluate CT dynamic myocardial perfusion imaging (MPI) using a wide-detector scanner. Methods Time to peak (TTP), peak enhancement (PE), upslope (US), and the area under the curve (AUC) were calculated in 12 pigs (256-slice multidetector CT scanner). Results The entire myocardium was covered by the scan volume. TTP was increased, and PE, US, and AUC were decreased in poststenotic myocardium. Conclusion CT MPI with complete coverage of the myocardium is feasible, providing evaluation of the physiological significance of coronary artery stenosis.

Aims To assess image quality and diagnostic performance of 3.0 Tesla (3T) cardiac magnetic resonance (CMR) myocardial perfusion imaging with a dual radiofrequency source to detect functional relevant coronary artery disease (CAD), using coronary angiography and invasive pressure-derived fractional flow reserve (FFR) as reference standard. Methods and results We included 116 patients with suspected or known CAD, who underwent 3T adenosine myocardial perfusion CMR (resolution 2.97 × 2.97 mm) and coronary angiography plus FFR measurements in intermediate lesions. Image quality of myocardial perfusion CMR was graded on a 4-point scale (1 = poor to 4 = excellent). Diagnostic accuracy was assessed by ROC analyses using a 16-myocardial segment-based summed perfusion score (0 = normal to 3 = transmural perfusion defect) and by determining sensitivity, specificity, positive and negative predictive value on the coronary vessel territory and the patient level. Diagnostic image quality was achieved for all stress myocardial perfusion CMR studies with an average quality score of 2.5, 3.1, and 3.0 for LAD, LCX, and RCA territories. The ability of the myocardial perfusion CMR perfusion score to detect significant coronary artery stenosis yielded an area under the curve of 0.93 on ROC analysis. Values for sensitivity, specificity, positive and negative predictive value on a vessel territory level and the patient level were 89, 95, 87, 96% and 85, 87, 77, 92%, respectively. Conclusion In patients with suspected or known significant CAD, 3T myocardial perfusion CMR with standard perfusion protocols provides consistently high image quality and an excellent diagnostic performance.

Chest pain associated with cocaine use represents an increasing problem in the emergency department (ED). Cocaine use has been linked to the acute coronary syndrome (ACS) and acute myocardial infarction (AMI). We used coronary computed tomography angiography (cCTA) to evaluate the prevalence, severity and composition of atherosclerotic lesions in cocaine users. We studied 78 patients with non-occasional cocaine use (52 men, 44 +/- 7 years, 23 under the acute influence) and acute chest pain but without ACS, who had undergone cCTA in the ED. Patients were matched one-to-one by gender, race, symptoms, and risk-factors with a control cohort (n = 78; 52 men, 45 +/- 6 years) not using cocaine. Each coronary segment was evaluated for the presence and composition (calcified, non-calcified, partially calcified) of atherosclerotic plaque and for stenosis. The prevalence of coronary stenosis was not significantly different between patients with and without cocaine use (13% versus 5%, P > 0.05). However, cocaine users on average had significantly more atherosclerotic plaques (0.44 +/- 0.88 versus 0.29 +/- 0.83, P 0.05) and non-calcified plaques (0.26 +/- 0.63 versus 0.17 +/- 0.57, P > 0.05), yet not reaching statistical significance. Furthermore, cocaine users had significantly more partially calcified plaques (0.41 +/- 0.61 versus 0.17 +/- 0.41, P

To characterize the evolution of right ventricular (RV) function post-myocardial infarction (MI), to describe the culprit vessel involved with RV injury and to assess the concordance between RV injury on magnetic resonance imaging (MRI) and RV infarct on electrocardiogram (EKG).Thirty-one patients underwent cardiovascular magnetic resonance (CMR) examinations at three time frames post-ST elevation MI (STEMI).Of those with an initial normal scan, RV function did not significantly change over time (60.6 ± 6.3, 57.8 ± 6.0, 55.4 ± 5.7, P0.05). However, in those whose RVEF (RV ejection fraction) was initially low, it significantly increased from the first scan to the third scan (46.2 ± 3.6, 50 ± 6.6, 51.3 ± 5.2, P0.01). Post-hoc testing revealed a significant difference between the 48-hour and the 6-month scan, and between the 48-hour and the 3-week scan; however, there was no significant difference between the 3-week and 6-month scans. Interestingly, 23% of patients with low RVEF at baseline had the left anterior descending (LAD) as the culprit vessel. Only 15% of the low RVEF at baseline group were classified as having an RVMI by EKG criteria.The optimal timepoint to assess for RV injury via CMR may be 3 weeks post-acute MI. Standard EKG criteria may underestimate RV injury when compared to CMR.

This angiographically correlated study reports on, for the first time, age- and gender-based distribution of the volumetric calcium score in a large group of patients with suspected coronary artery disease. Volumetric calcium data predicted significant coronary artery disease (>/=50% lumen diameter stenosis) as well as the traditional Agatston score. Exclusion of any calcium was highly accurate in ruling out obstructive disease in symptomatic subjects >/=50 years of age.