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Background: Subclinical leaflet thrombosis has been reported after bioprosthetic aortic valve replacement, characterized using 4-dimensional computed tomographic imaging by hypoattenuated leaflet thickening (HALT) and reduced leaflet motion (RLM). The incidence and clinical implications of these findings remain unclear.Objectives: The aim of this study was to determine the frequency, predictors, and hemodynamic and clinical correlates of HALT and RLM after aortic bioprosthetic replacement.Methods: A prospective subset of patients not on oral anticoagulation enrolled in the Evolut Low Risk randomized trial underwent computed tomographic imaging 30 days and 1 year after transcatheter aortic valve replacement (TAVR) or surgery. The primary endpoint was the frequency of HALT at 30 days and 1 year, analyzed by an independent core laboratory using standardized definitions. Secondary endpoints included RLM, mean aortic gradient, and clinical events at 30 days and 1 year.Results: At 30 days, the frequency of HALT was 31 of 179 (17.3%) for TAVR and 23 of 139 (16.5%) for surgery; the frequency of RLM was 23 of 157 (14.6%) for TAVR and 19 of 133 (14.3%) for surgery. At 1 year, the frequency of HALT was 47 of 152 (30.9%) for TAVR and 33 of 116 (28.4%) for surgery; the frequency of RLM was 45 of 145 (31.0%) for TAVR and 30 of 111 (27.0%) for surgery. Aortic valve hemodynamic status was not influenced by the presence or severity of HALT or RLM at either time point. The rates of HALT and RLM were similar after the implantation of supra-annular, self-expanding transcatheter, or surgical bioprostheses.Conclusions: The presence of computed tomographic imaging abnormalities of aortic bioprostheses were frequent but dynamic in the first year after self-expanding transcatheter and surgical aortic valve replacement, but these findings did not correlate with aortic valve hemodynamic status after aortic valve replacement in patients at low risk for surgery. (Medtronic Evolut Transcatheter Aortic Valve Replacement in Low Risk Patients; NCT02701283). [ABSTRACT FROM AUTHOR]

Purpose: To compare image interpretability and diagnostic performance of dual-energy CT coronary angiography (DE-CTCA) performed with 50% iodine load reduction versus single energy acquisitions (SE-CTCA) with full iodine load.Materials and Methods: The present prospective study involved patients with suspected coronary artery disease (CAD) clinically referred for CTCA. DE-CTCA with 50% iodine volume load was performed first, and after heart rate returned to baseline SE-CTCA was performed using full iodine volume load. The primary endpoint was to compare image interpretability between groups. DE-CTCA was performed by rapid switching between low and high tube potentials (80-140 kV) from a single source, allowing the generation of monochromatic image reconstructions ranging from 40 to 140 keV. Image quality assessment was performed using a 5-point Likert scale.Results: Thirty-six patients constituted the study population. The mean heart rate before the CT scan (DE-CTCA 57.3 ± 10.7 bpm vs. SE-CTCA 58.5 ± 11.2 bpm, p=0.29) and the mean effective radiation dose (3.5 ± 1.9 mSv vs. 3.8 ± 0.9 mSv, p=0.48) did not differ between groups. Likert image quality scores were similar between groups (DE-CTCA 4.42 ± 0.98 vs. SE-CTCA 4.43 ± 0.84, p=0.67). Signal-to-noise and contrast-to-noise ratios were significantly lower with DE-CTCA, driven by lower signal density levels at 60 keV compared to SE-CTCA. The sensitivity and specificity for the detection of stenosis >50% was indistinguishable between groups (DE-CTCA 84.4% (69.9-93.0%), 87.1% (81.6-91.2%); SE-CTCA 84.4% (69.9-93.0%), 87.1% (81.6-91.2%).Conclusions: In this pilot, prospective study, dual energy CTCA imaging with half iodine load achieved comparable interpretability than full iodine load with single energy CTCA. [ABSTRACT FROM AUTHOR]

Although metabolic syndrome is associated with increased risk of cardiovascular disease and events, its added prognostic value beyond its components remains unknown. This study compared the prevalence, severity of coronary artery disease (CAD), and prognosis of patients with metabolic syndrome to those with individual metabolic syndrome components. The study cohort consisted of 27125 consecutive individuals who underwent ≥64-detector row coronary CT angiography (CCTA) at 12 centers from 2003 to 2009. Metabolic syndrome was defined as per NCEP/ATP III criteria. Metabolic syndrome patients (n=690) were matched 1:1:1 to those with 1 component (n=690) and 2 components (n=690) of metabolic syndrome for age, sex, smoking status, and family history of premature CAD using propensity scoring. Major adverse cardiac events (MACE) were defined by a composite of myocardial infarction (MI), acute coronary syndrome, mortality and late target vessel revascularization. Patients with 1 component of metabolic syndrome manifested lower rates of obstructive 1-, 2-, and 3-vessel/left main disease compared to metabolic syndrome patients (9.4% vs 13.8%, 2.6% vs 4.5%, and 1.0% vs 2.3%, respectively; p<0.05), while those with 2 components did not (10.5% vs 13.8%, 2.8% vs 4.5% and 1.3% vs 2.3%, respectively; p>0.05). At 2.5 years, metabolic syndrome patients experienced a higher rate of MACE compared to patients with 1 component (4.4% vs 1.6%; p=0.002), while no difference observed compared to individuals with 2 components (4.4% vs 3.2% p=0.25) of metabolic syndrome. In conclusion, Metabolic syndrome patients have significantly greater prevalence, severity, and prognosis of CAD compared to patients with 1 but not 2 components of metabolic syndrome. [ABSTRACT FROM AUTHOR]

Objectives: The goal of this study was to determine the diagnostic performance of noninvasive fractional flow reserve (FFR) derived from standard acquired coronary computed tomography angiography (CTA) datasets (FFRCT) for the diagnosis of myocardial ischemia in patients with suspected stable coronary artery disease (CAD). Background: FFR measured during invasive coronary angiography (ICA) is the gold standard for lesion-specific coronary revascularization decisions in patients with stable CAD. The potential for FFRCT to noninvasively identify ischemia in patients with suspected CAD has not been sufficiently investigated. Methods: This prospective multicenter trial included 254 patients scheduled to undergo clinically indicated ICA for suspected CAD. Coronary CTA was performed before ICA. Evaluation of stenosis (>50% lumen reduction) in coronary CTA was performed by local investigators and in ICA by an independent core laboratory. FFRCT was calculated and interpreted in a blinded fashion by an independent core laboratory. Results were compared with invasively measured FFR, with ischemia defined as FFRCT or FFR ≤0.80. Results: The area under the receiver-operating characteristic curve for FFRCT was 0.90 (95% confidence interval [CI]: 0.87 to 0.94) versus 0.81 (95% CI: 0.76 to 0.87) for coronary CTA (p = 0.0008). Per-patient sensitivity and specificity (95% CI) to identify myocardial ischemia were 86% (95% CI: 77% to 92%) and 79% (95% CI: 72% to 84%) for FFRCT versus 94% (86 to 97) and 34% (95% CI: 27% to 41%) for coronary CTA, and 64% (95% CI: 53% to 74%) and 83% (95% CI: 77% to 88%) for ICA, respectively. In patients (n = 235) with intermediate stenosis (95% CI: 30% to 70%), the diagnostic accuracy of FFRCT remained high. Conclusions: FFRCT provides high diagnostic accuracy and discrimination for the diagnosis of hemodynamically significant CAD with invasive FFR as the reference standard. When compared with anatomic testing by using coronary CTA, FFRCT led to a marked increase in specificity. (HeartFlowNXT–HeartFlow Analysis of Coronary Blood Flow Using Coronary CT Angiography [HFNXT]; NCT01757678) [Copyright &y& Elsevier]

Objectives: This study sought to assess the clinical outcomes and hemodynamic performance associated with a strategy of underexpanding balloon-expandable transcatheter heart valves (THV) when excessive oversizing is a concern. Background: Transcatheter aortic valve replacement depends on the selection of an optimally sized THV. An undersized THV may lead to paravalvular regurgitation, whereas excessive oversizing may lead to annular injury. Methods: Patients (n = 47) who underwent transcatheter aortic valve replacement with an intentionally underexpanded THV (balloon-filling volume reduced ∼10%) were compared with consecutive control patients who had nominal THV balloon deployment (n = 87). Pre- and post-procedural computed tomography imaging and echocardiography were performed to assess THV stent expansion and hemodynamics. Results: Underfilling resulted in THV underexpansion that was maximal at the THV inflow (85.0 ± 7.4% vs. 102.5 ± 6.2%, p < 0.001), in study versus control groups, respectively. The study group received larger THV, although annular injury was not observed. Post-dilation was required in 10.6% and 4.6% of patients of the study and control groups, respectively (p = 0.165). Echocardiographic THV area, gradient, paravalvular regurgitation, and in-hospital outcomes were similar. Conclusions: Intentionally underexpanding balloon-expandable THV by underfilling the deployment balloon did not adversely affect procedural clinical outcomes, THV gradients, or THV areas. A strategy of underexpansion, with post-dilation as necessary, might play in role in reducing the risk of annular injury and paravalvular regurgitation in selected patients. [ABSTRACT FROM AUTHOR]

The article presents a study to assess the diagnostic performance of fractional flow reserve (FFR) and computed tomography (CT) for diagnosis of coronary stenosis. It informs that the coronary computed tomographic (CT) angiography is a noninvasive anatomic test for diagnosis of coronary artery disease (CAD) or stenosis irrespective of ischemia. It further adds that the fractional flow reserve (FFR) is a physiologic measure of coronary stenosis reflecting the amount of coronary flow stenosis and an invasive procedure. It is concluded that the use of noninvasive FFR and CT among stable patients of CAD are associated with improved diagnostic accuracy.

The article provides information on the DeFACTO study which examined the diagnostic performance of fractional flow reserve (FFR) from computed tomography (CT) for the detection and exclusion of hemodynamically significant coronary artery disease (CAD) in a prospective multicenter international study. It outlines inclusion/exclusion criteria of the study participants. It also details study procedures.

Abstract: Objective: To compare prospectively ECG gated CT pulmonary angiography (CTPA) with routine helical ungated CTPA for cardiac related motion artifacts and patient radiation dose. Subjects and methods: Twenty patients with signs and symptoms suspicious for pulmonary embolism and who had a heart rate below 85 were scanned with prospectively ECG gated CTPA. These gated exams were matched for several clinical parameters to exams from twenty similar clinical patients scanned with routine ungated helical CTPA. Three blinded independent reviewers subjectively evaluated all exams for overall pulmonary artery enhancement and for several cardiac motion related artifacts, including vessel blurring, intravascular shading, and double line. Reviewers also measured pulmonary artery intravascular density and image noise. Patient radiation dose for each technique was compared. Fourteen clinical prospectively ECG gated CTPA exams from a second institution were evaluated for the same parameters. Results: Prospectively ECG gated CTPA resulted in significantly decreased motion-related image artifact scores in lung segments adjacent to the heart compared to ungated CTPA. Measured image noise was not significantly different between the two types of CTPA exams. Effective dose was 28% less for prospectively ECG gated CTPA (4.9mSv versus 6.8mSv, p =0.02). Similar results were found in the prospectively ECG gated exams from the second institution. Conclusion: Compared to routine helical ungated CTPA, prospectively ECG gated CTPA may result in less cardiac related motion artifact in lung segments adjacent to the heart and significantly less patient radiation dose. [Copyright &y& Elsevier]

Although numerous strategies for radiation dose decrease in coronary computed tomographic angiography are effective, their combined impact on diagnostic performance is not known. We therefore assessed the effect of a standardized coronary computed tomographic angiographic protocol on diagnostic accuracy. We evaluated 80 consecutive patients from 3 sites with coronary computed tomographic angiography and quantitative coronary angiography. All sites initially used nonstandardized protocols; 2 sites then initiated a standardized protocol, and 1 site continued its nonstandardized protocol as a time-overlapping control. Two blinded readers interpreted coronary computed tomographic angiographic studies; a third obtained consensus. A blinded core laboratory performed quantitative coronary angiography. Each segment was graded as <50% or ≥50% diameter stenosis. Compared to those using nonstandardized protocols (n = 35), studies using standardized protocols (n = 45) had a trend to increased use of prospective gating (p = 0.09), lower voltage (p <0.01), decreased current (p <0.01), and shorter scan length (p <0.01). Median (interquartile range) radiation dose decreased from 5.7 mSv (4.0 to 10.8) to 2.0 mSv (1.3 to 3.4, p <0.001). There were no significant differences in sensitivity (100%, 20 of 20, vs 100%, 18 of 18, p = 1.0), specificity (93%, 14 of 15, vs 85%, 23 of 27, p = 0.61), or accuracy (97%, 34 of 35, vs 91%, 41 of 45, p = 0.27) by patient; sensitivity (83%, 33 of 40, vs 83%, 25 of 30, p = 0.93), specificity (92%, 86 of 93, vs 92%, 134 of 146, p = 0.85), or accuracy (89%, 119 of 133, vs 90%, 159 of 176, p = 0.80) by artery; or sensitivity (80%, 44 of 55, vs 72%, 26 of 36, p = 0.74), specificity (94%, 332 of 353, vs 94%, 499 of 531, p = 0.96), or accuracy (92%, 376 of 408, vs 93%, 525 of 567, p = 0.80) by segment. In conclusion, a standardized dose-decrease protocol for coronary computed tomographic angiography decreases radiation dose without affecting diagnostic performance. [Copyright &y& Elsevier]

The article reports the case of a 50-year-old woman who developed shortness of breath and systemic symptoms after starting to smoke fentanyl patches. A computed tomography (CT) scan showed ground glass centrilobular nodules, and a biopsy demonstrated that the patient has pulmonary alveolar proteinosis. After the patient stopped smoking the patches, her symptoms disappeared and her chest imaging changes largely.

The article offers information on the association between ischemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD). It mentions that COPD is a major risk factor for heart disease beyond and above the traditional risk factors which include hypertension or hypercholesterolemia. It states that patients with coronary artery disease and COPD have a less favorable prognosis equated with patients with no COPD.

Objectives: In the United States, the real-world feasibility and outcome of using fractional flow reserve from coronary computed tomography angiography (FFRCT) is unknown. We sought to determine whether a strategy that combined coronary computed tomography angiography (CTA) and FFRCT could safely reduce the need for invasive coronary angiography (ICA), as compared to coronary CTA alone. Methods: The study included 387 consecutive patients with suspected CAD referred for coronary CTA with selective FFRCT and 44 control patients who underwent CTA alone. Lesions with 30–90% diameter stenoses were considered of indeterminate hemodynamic significance and underwent FFRCT. Nadir FFRCT ≤ 0.80 was positive. The rate of patients having ICA, revascularization and major adverse cardiac events were recorded. Results: Using coronary CTA and selective FFRCT, 121 patients (32%) had at least one vessel with ≥50% diameter stenosis; 67/121 (55%) patients had at least one vessel with FFRCT ≤ 0.80; 55/121 (45%) underwent ICA; and 34 were revascularized. The proportion of ICA patients undergoing revascularization was 62% (34 of 55). The number of patients with vessels with 30–50% diameter of stenosis was 90 (23%); 28/90 (31%) patients had at least one vessel with FFRCT ≤ 0.80; 8/90 (9%) underwent ICA; and five were revascularized. In our institutional practice, compared to coronary CTA alone, coronary CTA with selective FFRCT reduced the rates of ICA (45% vs. 80%) for those with obstructive CAD. Using coronary CTA with selective FFRCT, no major adverse cardiac events occurred over a mean follow-up of 440 days. Conclusion: FFRCT safely deferred ICA in patients with CAD of indeterminate hemodynamic significance. A high proportion of those who underwent ICA were revascularized. [ABSTRACT FROM AUTHOR]

Objective: To assess the accuracy of a virtual stenting tool based on coronary CT angiography (CCTA) and fractional flow reserve (FFR) derived from CCTA (FFRCT Planner) across different levels of image quality. Materials and methods: Prospective, multicenter, single-arm study of patients with chronic coronary syndromes and lesions with FFR ≤ 0.80. All patients underwent CCTA performed with recent-generation scanners. CCTA image quality was adjudicated using the four-point Likert scale at a per-vessel level by an independent committee blinded to the FFRCT Planner. Patient- and technical-related factors that could affect the FFRCT Planner accuracy were evaluated. The FFRCT Planner was applied mirroring percutaneous coronary intervention (PCI) to determine the agreement with invasively measured post-PCI FFR. Results: Overall, 120 patients (123 vessels) were included. Invasive post-PCI FFR was 0.88 ± 0.06 and Planner FFRCT was 0.86 ± 0.06 (mean difference 0.02 FFR units, the lower limit of agreement (LLA) − 0.12, upper limit of agreement (ULA) 0.15). CCTA image quality was assessed as excellent (Likert score 4) in 48.3%, good (Likert score 3) in 45%, and sufficient (Likert score 2) in 6.7% of patients. The FFRCT Planner was accurate across different levels of image quality with a mean difference between FFRCT Planner and invasive post-PCI FFR of 0.02 ± 0.07 in Likert score 4, 0.02 ± 0.07 in Likert score 3 and 0.03 ± 0.08 in Likert score 2, p = 0.695. Nitrate dose ≥ 0.8mg was the only independent factor associated with the accuracy of the FFRCT Planner (95%CI − 0.06 to − 0.001, p = 0.040). Conclusion: The FFRCT Planner was accurate in predicting post-PCI FFR independent of CCTA image quality. Clinical relevance statement: Being accurate in predicting post-PCI FFR across a wide spectrum of CT image quality, the FFRCT Planner could potentially enhance and guide the invasive treatment. Adequate vasodilation during CT acquisition is relevant to improve the accuracy of the FFRCT Planner. Key Points: • The fractional flow reserve derived from coronary CT angiography (FFRCT) Planner is a novel tool able to accurately predict fractional flow reserve after percutaneous coronary intervention. • The accuracy of the FFRCT Planner was confirmed across a wide spectrum of CT image quality. Nitrates dose at CT acquisition was the only independent predictor of its accuracy. • The FFRCT Planner could potentially enhance and guide the invasive treatment. [ABSTRACT FROM AUTHOR]

Hypertrophic cardiomyopathy (HCM) is a common genetic disorder with a well described risk of sudden cardiac death; however, risk stratification has remained a challenge. Recently, novel parameters in cardiac magnetic resonance imaging (CMR) have shown promise in helping to improve upon current risk stratification paradigms. In this manuscript, we have reviewed novel CMR risk markers and their utility in HCM. The results of the review showed that T1, extracellular volume, CMR feature tracking, and other miscellaneous novel CMR variables have the potential to improve sudden death risk stratification and may have additional roles in diagnosis and prognosis. The strengths and weaknesses of these imaging techniques, and their potential utility and implementation in HCM risk stratification are discussed. [ABSTRACT FROM AUTHOR]

Introduction: Patients with family history of premature coronary artery disease (CAD) are at risk of CAD events at younger age. Risk factor based approaches and clinical evaluation are the commonly used methods of assessment. Recently it was shown up to 50% of individual presenting with their first myocardial infarction (MI) were considered "low risk" prior to that event. MI is often a result of plaque rupture preceded by progression of subclinical atherosclerosis. Therefore, detection of subclinical atherosclerosis may help target prevention of plaque progression. In this study, we assessed the predictive value of clinical risk factor, biomarkers and Framingham Risk Score (FRS) in predicting subclinical atherosclerosis in this population. Methods: From 230 referrals,182 individuals with a family history of premature CAD, Patients between the ages of 35 to 55 were enrolled in the Early Atherosclerosis Clinic at St. Paul's Hospital, Vancouver, Canada for evaluation of risk of CAD. Premature CAD was defined as CAD events in first-degree family members (male< 55, female< 65). Patients underwent clinical and risk factor evaluations as well as Cardiac CT or Calcium Score (CS) to assess presence of subclinical/clinical atherosclerosis if indicated by the treating physician. Results: In this pilot, 67 individuals (55% male, mean age 45.8 ± 6.0 years) completed evaluation, 31(46%) had evidence of subclinical atherosclerosis on CT coronary angiography or CT calcium score with a mean segment involvement score (SIS) of 3.1 and mean CS of 128. Aside from male sex and age, other risk factors and biomarkers including diabetes mellitus, hypertension, smoking history, total cholesterol, LDL-C, HDL-C, Cholesterol/HDL-C ratio and FRS were not significantly different between those with or without subclinical atherosclerosis (Table 1). Conclusions: In young individuals with a family history of premature CAD, risk factors, biomarkers, and FRS failed to identify patients with premature, subclinical atherosclerosis in this pilot study. Detection of subclinical atherosclerosis and early implementation of treatment with the aim of stabilizing plaques and stopping progression might prove vital in reducing events in these individuals. Further studies are warranted. [ABSTRACT FROM AUTHOR]

Objectives: Our objective was to report the baseline characteristics of participants in the Canadian HIV and Aging Cohort Study (CHACS) and present amendments to the initial protocol. Methods: CHACS is a multi‐centred prospective cohort study that was initially set from 2011 to 2016 and will now continue recruitment until 2024. Four additional years of follow‐up have been added, and additional outcomes and covariates will be prospectively collected. Frailty will be assessed using a modified version of the Fried's frailty phenotype. The four interrelated aspects of gender—gender roles, gender identity, gender relationships, and institutionalized gender—will be measured using the GENESIS‐PRAXY questionnaire. Diet will be assessed using a validated, web‐based, self‐administered food frequency questionnaire. Results: A total of 1049 participants (77% people living with HIV) were recruited between September 2011 and September 2019. Median age at baseline was 54 years (interquartile range 50–61). Most participants were male (84%) and white (83%). Compared with participants without HIV, those with HIV were more likely to be male; to report lower education levels and incomes; to be more sedentary; to use tobacco, recreational, and prescription drugs; to report a personal history of cardiovascular diseases; and to be frail. Conclusions: The new assessments added to the CHACS protocol will allow for an even more detailed portrait of the pathways leading to accentuated aging for people living with HIV. Participants in the CHACS cohort display important differences in socio‐economic and cardiovascular risk factors according to HIV serostatus. These imbalances must be taken into account for all further inferential analyses. [ABSTRACT FROM AUTHOR]

A global multidisciplinary workshop was convened to discuss the multimodality diagnostic evaluation of aortic regurgitation (AR). Specifically, the focus was on assessment tools for AR severity and analyzing evolving data on the optimal timing of aortic valve intervention. The key concepts from this expert panel are summarized as: 1) echocardiography is the primary imaging modality for assessment of AR severity; however, when data is incongruent or incomplete, cardiac magnetic resonance may be helpful; 2) assessment of left ventricular size and function is crucial in determining the timing of intervention; 3) recent evidence suggests current cutpoints for intervention in asymptomatic severe AR patients requires further scrutiny; 4) left ventricular end-systolic volume index has emerged as an additional parameter that has promise in guiding timing of intervention; and 5) the role of additional factors (including global longitudinal strain, regurgitant fraction, and myocardial extracellular volume) is worthy of future investigation. [Display omitted] • Assessing the hemodynamic impact of AR on the LV involves integrating various imaging parameters pertaining to LV size and systolic function to determine the optimum time for intervention. • Conventional criteria for surgical intervention in patients with AR include: LVEF ≤55%, LVESD ≥25 mm/m2, progressive decline in LVEF to 55% to 60%, or increase in LVEDD to >65 mm. • Additional studies are needed to determine whether lower thresholds (eg, LVEF <60% and LVESD >20 mm/m2) for valve intervention would improve long-term outcomes for patients with chronic, severe AR. [ABSTRACT FROM AUTHOR]

Background: Subclinical leaflet thrombosis, characterized by hypoattenuated leaflet thickening (HALT) and reduced leaflet motion observed on 4-dimensional computed tomography (CT), may represent a form of bioprosthetic valve dysfunction.Objectives: The U.S. Food and Drug Administration mandated CT studies to understand the natural history of this finding, differences between transcatheter and surgical valves, and its association with valve hemodynamics and clinical outcomes.Methods: The PARTNER 3 (The Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low-Risk Patients With Aortic Stenosis) CT substudy randomized 435 patients with low-surgical-risk aortic stenosis to undergo transcatheter aortic valve replacement (n = 221) or surgery (n = 214). Serial 4-dimensional CTs were performed at 30 days and 1 year and were analyzed independently by a core laboratory.Results: The incidence of HALT increased from 10% at 30 days to 24% at 1 year. Spontaneous resolution of 30-day HALT occurred in 54% of patients at 1 year, whereas new HALT appeared in 21% of patients at 1 year. HALT was more frequent in transcatheter versus surgical valves at 30 days (13% vs. 5%; p = 0.03), but not at 1 year (28% vs. 20%; p = 0.19). The presence of HALT did not significantly affect aortic valve mean gradients at 30 days or 1 year. Patients with HALT at both 30 days and 1 year, compared with those with no HALT at 30 days and 1 year, had significantly increased aortic valve gradients at 1 year (17.8 ± 2.2 mm Hg vs. 12.7. ± 0.3 mm Hg; p = 0.04).Conclusions: Subclinical leaflet thrombosis was more frequent in transcatheter compared with surgical valves at 30 days, but not at 1 year. The impact of HALT on thromboembolic complications and structural valve degeneration needs further assessment. [ABSTRACT FROM AUTHOR]

It has been believed that most acute coronary events result from the rupture of mildly stenotic plaques, based on studies in which angiographic information was available from many months to years before the event. However, serial studies in which angiographic data were available from the past as also within 1 to 3 months of myocardial infarction have clarified that nonobstructive lesions progressively enlarged relatively rapidly before the acute event occurred. Noninvasive computed tomography angiography imaging data have confirmed that lesions that did not progress voluminously over time rarely led to events, regardless of the extent of luminal stenosis or baseline high-risk plaque morphology. Therefore, plaque progression could be proposed as a necessary step between early, uncomplicated atherosclerosis and plaque rupture. On the other hand, it has been convincingly demonstrated that intensive lipid-lowering therapy (to a low-density lipoprotein cholesterol level of <70 mg/dl) halts plaque progression. Given the current ability to noninvasively detect the presence of early atherosclerosis, the importance of plaque progression in the pathogenesis of myocardial infarction, and the efficacy of maximum lipid-lowering therapy, it has been suggested that plaque progression is a modifiable step in the evolution of atherosclerotic plaque. A personalized approach based on the detection of early atherosclerosis can trigger the necessary treatment to prevent plaque progression and hence plaque instability. Therefore, this approach can redefine the traditional paradigm of primary and secondary prevention based on population-derived risk estimates and can potentially improve long-term outcomes. [ABSTRACT FROM AUTHOR]

Interest in the pathophysiology, etiology, management, and outcomes of patients with tricuspid regurgitation (TR) has grown in the wake of multiple natural history studies showing progressively worse outcomes associated with increasing TR severity, even after adjusting for multiple comorbidities. Historically, isolated tricuspid valve surgery has been associated with high in-hospital mortality rates, leading to the development of transcatheter treatment options. The aim of this first Tricuspid Valve Academic Research Consortium document is to standardize definitions of disease etiology and severity, as well as endpoints for trials that aim to address the gaps in our knowledge related to identification and management of patients with TR. Standardizing endpoints for trials should provide consistency and enable meaningful comparisons between clinical trials. A second Tricuspid Valve Academic Research Consortium document will focus on further defining trial endpoints and will discuss trial design options. [Display omitted] • There is an independent relationship between increasing TR and worse outcomes, but gaps exist in understanding of pathophysiology, diagnosis, and treatment. • Refinement of classification categories, novel methods for assessing and grading TR, and better selection of outcome measures should inform the design of clinical trials. • This document provides recommendations for classification of disease etiology, standardized definitions and methods to assess disease severity, and trial endpoints. • Transcatheter alternatives to surgical intervention are under investigation; yet, more work is needed to define patient selection criteria, goals of therapy, and clinical outcomes. [ABSTRACT FROM AUTHOR]

The authors reflects on computed axial tomography (CT) scans' economic costs. The authors state that the expense of CT scans for patients and the healthcare system remains an issue that needs to be addressed. However, the authors mention that two studies suggest that emphysema's CT-based measurements in smokers prove crucial in determining who is at high risk of lung cancer and chronic obstructive pulmonary disease (COPD) progression.

The article discusses the efficacy of coronary computed tomography angiography (CTA) for medical screening which allows the detection of coronary artery stenosis. It examines the standardization of coronary CTA with invasive coronary angiography. It also cites the use of coronary CTA in routine practice of the medical personnel.

Hemodynamic and plaque characteristics can be analyzed using coronary CT angiography (CTA). We aimed to explore long-term prognostic implications of hemodynamic and plaque characteristics using coronary CT angiography (CTA). Invasive fractional flow reserve (FFR) and CTA-derived FFR (FFR CT) were undertaken for 136 lesions in 78 vessels and followed-up to 10 years until December 2020. FFR CT , wall shear stress (WSS), change in FFR CT across the lesion (ΔFFR CT), total plaque volume (TPV), percent atheroma volume (PAV), and low-attenuation plaque volume (LAPV) for target lesions [L] and vessels [V] were obtained by independent core laboratories. Their collective influence was evaluated for the clinical endpoints of target vessel failure (TVF) and target lesion failure (TLF). During a median follow-up of 10.1 years, PAV[V] (per 10% increase, HR 2.32 [95% CI 1.11–4.86], p = 0.025), and FFR CT [V] (per 0.1 increase, HR 0.56 [95% CI 0.37–0.84], p = 0.006) were independent predictors of TVF for the per-vessel analysis, and WSS[L] (per 100 dyne/cm2 increase, HR 1.43 [1.09–1.88], p = 0.010), LAPV[L] (per 10 mm3 increase, HR 3.81 [1.16–12.5], p = 0.028), and ΔFFR CT [L] (per 0.1 increase, HR 1.39 [1.02–1.90], p = 0.040) were independent predictors of TLF for the per-lesion analysis after adjustment for clinical and lesion characteristics. The addition of both plaque and hemodynamic predictors improved the predictability for 10-year TVF and TLF of clinical and lesion characteristics (all p < 0.05). Vessel- and lesion-level hemodynamic characteristics, and vessel-level plaque quantity, and lesion-level plaque compositional characteristics assessed by CTA offer independent and additive long-term prognostic value. [Display omitted] • FFR CT and PAV were independent predictors of 10-year target vessel failure. • WSS, ΔFFR CT , and LAPV were independent predictors of 10-year target lesion failure. • Plaque and hemodynamic predictors have additive predictability for 10-year outcome. [ABSTRACT FROM AUTHOR]

Background: Low-density lipoprotein cholesterol (LDL-C) is an important causal risk factor for atherosclerotic cardiovascular disease (ASCVD). However, a sizable proportion of middle-aged individuals with elevated LDL-C level have not developed coronary atherosclerosis as assessed by coronary artery calcification (CAC). Whether presence of CAC modifies the association of LDL-C with ASCVD risk is unknown. We evaluated the association of LDL-C with future ASCVD events in patients with and without CAC. Methods: The study included 23 132 consecutive symptomatic patients evaluated for coronary artery disease using coronary computed tomography angiography (CTA) from the Western Denmark Heart Registry, a seminational, multicenter-based registry with longitudinal registration of patient and procedure data. We assessed the association of LDL-C level obtained before CTA with ASCVD (myocardial infarction and ischemic stroke) events occurring during follow-up stratified by CAC>0 versus CAC=0 using Cox regression models adjusted for baseline characteristics. Outcomes were identified through linkage among national registries covering all hospitals in Denmark. We replicated our results in the National Heart, Lung, and Blood Institute –funded Multi-Ethnic Study of Atherosclerosis. Results: During a median follow-up of 4.3 years, 552 patients experienced a first ASCVD event. In the overall population, LDL-C (per 38.7 mg/dL increase) was associated with ASCVD events occurring during follow-up (adjusted hazard ratio [aHR], 1.14 [95% CI, 1.04–1.24]). When stratified by the presence or absence of baseline CAC, LDL-C was only associated with ASCVD in the 10 792/23 132 patients (47%) with CAC>0 (aHR, 1.18 [95% CI, 1.06–1.31]); no association was observed among the 12 340/23 132 patients (53%) with CAC=0 (aHR, 1.02 [95% CI, 0.87–1.18]). Similarly, a very high LDL-C level (> 193 mg/dL) versus LDL-C <116 mg/dL was associated with ASCVD in patients with CAC>0 (aHR, 2.42 [95% CI, 1.59–3.67]) but not in those without CAC (aHR, 0.92 [0.48–1.79]). In patients with CAC=0, diabetes, current smoking, and low high-density lipoprotein cholesterol levels were associated with future ASCVD events. The principal findings were replicated in the Multi-Ethnic Study of Atherosclerosis. Conclusions: LDL-C appears to be almost exclusively associated with ASCVD events over ≈5 years of follow-up in middle-aged individuals with versus without evidence of coronary atherosclerosis. This information is valuable for individualized risk assessment among middle-aged people with or without coronary atherosclerosis. [ABSTRACT FROM AUTHOR]

Computed tomography coronary angiography (CTCA) is a non-invasive diagnostic modality that provides a comprehensive anatomical assessment of the coronary arteries and coronary atherosclerosis, including plaque burden, composition and morphology. The past decade has witnessed an increase in the role of CTCA for evaluating patients with both stable and acute chest pain, and recent international guidelines have provided increasing support for a first line CTCA diagnostic strategy in select patients. CTCA offers some advantages over current functional tests in the detection of obstructive and non-obstructive coronary artery disease, as well as for ruling out obstructive coronary artery disease. Recent randomised trials have also shown that CTCA improves prognostication and guides the use of guideline-directed preventive therapies, leading to improved clinical outcomes. CTCA technology advances such as fractional flow reserve, plaque quantification and perivascular fat inflammation potentially allow for more personalised risk assessment and targeted therapies. Further studies evaluating demand, supply, and cost-effectiveness of CTCA for evaluating chest pain are required in Australia. This discussion paper revisits the evidence supporting the use of CTCA, provides an overview of its implications and limitations, and considers its potential role for chest pain evaluation pathways in Australia. [ABSTRACT FROM AUTHOR]

Background: Thoracic computed tomography (CT) scans are widely performed in clinical practice, often leading to detection of airway or parenchymal abnormalities in asymptomatic or minimally symptomatic individuals. However, clinical relevance of CT abnormalities is uncertain in the general population. Methods: We evaluated data from 1361 participants aged ≥40 years from a Canadian prospective cohort comprising 408 healthy never-smokers, 502 healthy ever-smokers, and 451 individuals with spirometric evidence of chronic obstructive pulmonary disease (COPD) who had thoracic CT scans. CT images of subjects were visually scored for respiratory bronchiolitis(RB), emphysema(E), bronchial-wall thickening(BWT), expiratory air-trapping(AT), and bronchiectasis(B). Multivariable logistic regression models were used to assess associations of CT features with respiratory symptoms, dyspnea, health status as determined by COPD assessment test, and risk of clinically significant exacerbations during 12 months follow-up. Results: About 11% of life-time never-smokers demonstrated emphysema on CT scans. Prevalence increased to 30% among smokers with normal lung function and 36%, 50%, and 57% among individuals with mild, moderate or severe/very severe COPD, respectively. Presence of emphysema on CT was associated with chronic cough (OR,2.11; 95%CI,1.4–3.18); chronic phlegm production (OR,1.87; 95% CI,1.27–2.76); wheeze (OR,1.61; 95% CI,1.05–2.48); dyspnoea (OR,2.90; 95% CI,1.41–5.98); CAT score≥10(OR,2.17; 95%CI,1.42–3.30) and risk of ≥2 exacerbations over 12 months (OR,2.17; 95% CI, 1.42–3.0). Conclusions: Burden of thoracic CT abnormalities is high among Canadians ≥40 years of age, including never-smokers and smokers with normal lung function. Detection of emphysema on CT scans is associated with pulmonary symptoms and increased risk of exacerbations, independent of smoking or lung function. [ABSTRACT FROM AUTHOR]

Background: The baseline coronary plaque burden is the most important factor for rapid plaque progression (RPP) in the coronary artery. However, data on the independent predictors of RPP in the absence of a baseline coronary plaque burden are limited. Thus, this study aimed to investigate the predictors for RPP in patients without coronary plaques on baseline coronary computed tomography angiography (CCTA) images. Methods: A total of 402 patients (mean age: 57.6 ± 10.0 years, 49.3% men) without coronary plaques at baseline who underwent serial coronary CCTA were identified from the Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging (PARADIGM) registry and included in this retrospective study. RPP was defined as an annual change of ≥ 1.0%/year in the percentage atheroma volume (PAV). Results: During a median inter-scan period of 3.6 years (interquartile range: 2.7–5.0 years), newly developed coronary plaques and RPP were observed in 35.6% and 4.2% of the patients, respectively. The baseline traditional risk factors, i.e., advanced age (≥ 60 years), male sex, hypertension, diabetes mellitus, hyperlipidemia, obesity, and current smoking status, were not significantly associated with the risk of RPP. Multivariate linear regression analysis showed that the serum hemoglobin A1c level (per 1% increase) measured at follow-up CCTA was independently associated with the annual change in the PAV (β: 0.098, 95% confidence interval [CI]: 0.048–0.149; P < 0.001). The multiple logistic regression models showed that the serum hemoglobin A1c level had an independent and positive association with the risk of RPP. The optimal predictive cut-off value of the hemoglobin A1c level for RPP was 7.05% (sensitivity: 80.0%, specificity: 86.7%; area under curve: 0.816 [95% CI: 0.574–0.999]; P = 0.017). Conclusion: In this retrospective case–control study, the glycemic control status was strongly associated with the risk of RPP in patients without a baseline coronary plaque burden. This suggests that regular monitoring of the glycemic control status might be helpful for preventing the rapid progression of coronary atherosclerosis irrespective of the baseline risk factors. Further randomized investigations are necessary to confirm the results of our study. Trial registration: ClinicalTrials.gov NCT02803411. [ABSTRACT FROM AUTHOR]

Bioprosthetic valve dysfunction (BVD) and bioprosthetic valve failure (BVF) may be caused by structural or nonstructural valve dysfunction. Both surgical and transcatheter bioprosthetic valves have limited durability because of structural valve deterioration. The main objective of this summary of experts participating in a virtual workshop was to propose standardized definitions for nonstructural and structural BVD and BVF following aortic or mitral biological valve replacement with the goal of facilitating research reporting and implementation of these terms in clinical practice. Definitions of structural BVF, based on valve reintervention or death, underestimate the true incidence of BVF. However, definitions solely based on the presence of high transprosthetic gradient at a given echocardiogram during follow-up overestimate the incidence of structural BVD and BVF. Definitions of aortic or mitral structural BVD must therefore include the confirmation by imaging of permanent structural changes to the leaflets alongside evidence of deterioration in valve hemodynamic function at echocardiography follow-up. [ABSTRACT FROM AUTHOR]

Body composition (fat mass [FM] and skeletal muscle mass [SMM]) predicts clinical outcomes. In particular, loss of SMM (sarcopenia) is associated with frailty and mortality. There are no data on the prevalence and impact of FM and SMM in patients undergoing transcatheter aortic valve implantation (TAVI). The objective of this study is to determine body composition from pre-TAVI computed tomography (CT) and evaluate its association with clinical outcomes in patients who underwent TAVI. A total of 460 patients (mean age 81 ± 8 years, men: 51%) were included. Pre-TAVI CTs of the aorto-ilio-femoral axis were analyzed for FM and SMM cross-sectional area at the level of the third lumbar vertebrae (L3). Regression equations correlating cross-sectional area at L3 to total body FM and SMM were used to determine prevalence of sarcopenia, obesity, and sarcopenic obesity in patients (64%, 65%, and 46%, respectively). Most TAVI procedures were performed through a transfemoral approach (59%) using a balloon-expandable valve (94%). The 30-day and mid-term (median 12 months [interquartile range 6 to 27]) mortality rates were 6.1% and 29.6%, respectively. FM had no association with clinical outcomes, but sarcopenia predicted cumulative mortality (hazard ratio 1.55, 95% confidence interval 1.02 to 2.36, p = 0.04). In conclusion, body composition analysis from pre-TAVI CT is feasible. Sarcopenia, obesity, and sarcopenic obesity are prevalent in the TAVI population, with sarcopenia predictive of cumulative mortality. [ABSTRACT FROM AUTHOR]

We explored whether intracycle motion correction algorithms (MCAs) might be applicable to dual energy computed tomography coronary angiography in patients with intermediate to high likelihood of coronary artery disease. MCA reconstructions were associated with higher interpretability rates (96.7% vs. 87.9%, P < .001), image quality scores (4.12±0.9 vs. 3.76±1.0; P < .0001), and diagnostic performance [area under the curve of 0.95 (95% confidence interval [CI] 0.92–0.97) vs. 0.89 (95% CI 0.86–0.92); P < .0001] compared to conventional reconstructions. In conclusion, application of intracycle MCA reconstructions to dual energy computed tomography acquisitions was feasible and resulted in significantly higher image quality scores, interpretability, and diagnostic performance. [ABSTRACT FROM AUTHOR]

Interstitial lung disease ( ILD) classification requires a multidisciplinary review that includes input from an ILD clinician, chest radiologist, and lung pathologist. We report a case of ILD that remained unclassifiable due to discordant clinical, radiological, and pathological findings despite a thorough evaluation that included examination of explanted lung tissue. This case demonstrates that ILD can remain unclassifiable even with a complete evaluation and illustrates one approach to the management of such patients. [ABSTRACT FROM AUTHOR]

Background: Transcatheter heart valve (THV) dysfunction with an elevated gradient or paravalvular leak (PVL) may be documented late after THV implantation. Medical management, paravalvular plugs, redo THV replacement, or surgical valve replacement may be considered. However, late balloon dilatation is rarely utilized because of concerns about safety or lack of efficacy.Objectives: We aimed to evaluate the safety and efficacy of late dilatation in the management of THV dysfunction.Methods: All patients who underwent late dilatation for symptomatic THV dysfunction at 2 institutions between 2016 and 2021 were identified. Baseline, procedural characteristics, and clinical and echocardiographic outcomes were documented. THV frame expansion was assessed by multislice computed tomography before and after late dilatation.Results: Late dilatation was performed in 30 patients a median of 4.6 months (IQR: 2.3-11.0 months) after THV implantation in the aortic (n = 25; 83.3%), mitral (n = 2; 6.7%), tricuspid (n = 2; 6.7%) and pulmonary (n = 1; 3.3%) position. THV underexpansion was documented at baseline, and frame expansion substantially improved after late dilatation. The mean transvalvular gradient fell in all patients. For aortic THVs specifically, mean transaortic gradient fell from 25.4 ± 13.9 mm Hg to 10.8 ± 4.1 mm Hg; P < 0.001. PVL was reduced to ≤mild in all 11 patients with a previous >mild PVL. Embolic events, stroke, annular injury, and bioprosthetic leaflet injury were not observed. Symptomatic benefit was durable at 19.6 months (IQR: 14.8-36.1 months) follow-up.Conclusions: Balloon dilatation late after THV implantation appears feasible and safe in appropriately selected patients and may result in THV frame expansion resulting in improvements in hemodynamic performance and PVL. [ABSTRACT FROM AUTHOR]