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Background An intrapericardial organized haematoma secondary to chronic type A aortic dissection is an extremely rare cause of right heart failure. Imaging studies are essential in recognising and diagnosis of this distinctive medical condition and guiding the anticipated treatment. Case presentation A 70-year-old male patient was admitted for progressive symptoms of right heart failure. His cardiovascular history exposed an aortic valve replacement 22 years before with a Medtronic Hall 23 tilting valve with no regular follow-up. Classical signs of congestion were recognized at physical examination. Transthoracic two-dimensional echocardiography and thoraco-abdominal computed tomography angiography, as essential parts of multimodality imaging algorithm, established the underlying cause of right heart failure. Under total cardiopulmonary bypass and cardiac arrest, surgical removal of the haematoma and proximal repair of the ascending aorta with a patient-matched vascular graft were successfully performed. The patient was discharged in good condition with appropriate pharmacological treatment, guideline-directed; no imagistic signs of acute post-surgery complications were ascertained. Conclusion This paper highlights the importance of recognizing and providing a timely clinical and imagistic diagnosis of this very rare, potentially avoidable cause of right heart failure in patients with previous cardiac surgery.

Background: The evaluation of site-specific phenotype according to the topographic location of atherosclerotic lesions within the coronary tree has not been studied so far. The present study is based on the premise that the location of coronary plaques can influence their composition and degree of vulnerability. Aim: To evaluate different phenotypes of vulnerable coronary plaques across the three major coronary arteries in terms of composition, morphology, and degree of vulnerability, in patients with chest pain and low-to-intermediate probability of coronary artery disease, using coronary computed tomography angiography (CCTA) and a complex plaque analysis. Material and methods: This was a cross-sectional study on 75 subjects undergoing CCTA for chest pain, who presented at least one vulnerable coronary plaque (VP), defined as the presence of ≥1 CT vulnerability marker (low attenuation plaque, napkin-ring sign, spotty calcifications, positive remodeling). The study included per plaque analysis of 90 vulnerable coronary lesions identified in various locations within the coronary tree as follows: n = 30 VPs in the left anterior descending artery (LAD), n = 30 VPs in the circumflex artery (CXA), and n = 30 VPs in the right coronary artery (RCA). Results: The RCA exhibited significantly longer VPs (p = 0.001), with the largest volume (p = 0.0007) compared to those arising from the LAD and CXA. Vulnerable plaques located in the LAD exhibited a significantly more calcified phenotype (calcified volume: LAD – 44.07 ± 63.90 mm3 vs. CXA – 12.40 ± 19.65 mm3 vs. RCA – 33.69 ± 34.38 mm3, p = 0.002). Plaques from the RCA presented a more non-calcified phenotype, with the largest non-calcified (p = 0.002), lipid rich (p = 0.0005), and fibrotic volumes (p = 0.003). Low-attenuation plaques were most frequent in the RCA (p = 0.0009), while the highest vulnerability degree was present in lesions located in the LAD, which presented the highest number of vulnerability markers per plaque (p = 0.01). Conclusions: Vulnerable plaques arising from the right coronary artery are longer, more vo-luminous and with larger lipid and non-calcified content, whereas those located in the left anterior descending artery present a higher volume of calcium, but also a higher degree of vulnerability. The least vulnerable lesions were present in the circumflex artery.

Coronary artery anomalies represent a heterogeneous group of congenital diseases with various clinical presentations. Over time, the subject of coronary anomalies has been constantly changing in terms of definition, morphology, clinical manifestations, prognosis, and treatment. We present the case of a male patient, aged 53, with coronary artery disease and a medical history of high blood pressure and diabetes mellitus, who had undergone a coronary computed tomography angiography during the one-year follow-up after a percutaneous coronary intervention with drug-eluting stent implantation for a critical stenosis in the middle segment of the left anterior descending artery. Axial images revealed a separate origin of the left anterior descending and circumflex arteries from the left aortic coronary sinus, with the absence of the left main coronary artery.

The aim of our study was to investigate the correlation between volumes of thoracic fat distributed in different compartments and the geometry of vulnerable coronary plaques assessed by coronary computed tomography angiography (CCTA), in patients with acute chest pain. Methods: This was a non-randomized, observational, single-center study, including 50 patients who presented in the emergency department with acute chest pain who underwent 128-slice single-source CCTA. Plaque geometry was evaluated in transversal and longitudinal planes, and the assessment of adipose tissue was performed using the Syngo.via Frontier (Siemens AG, Healthcare Sector, Forchheim, Germany) research platform. Results: Eccentric plaques presented a significantly higher incidence of spotty calcification (40% vs. 22%, p = 0.018), whereas positive remodeling, volume of low attenuation plaque, and incidence of napkin-ring sign were not significantly different between the study groups or in ascending versus descending plaques. The volume of pericoronary fat around the plaque was significantly larger near eccentric lesions (707.68 ± 454.08 mm3 vs. 483.25 ± 306.98 mm3, p = 0.046) and descendent plaques (778.26 ± 479.37 mm3 vs. 473.60 ± 285.27 mm3, p = 0.016). Compared to ascending lesions, descendent ones presented a significantly larger volume of thoracic fat (1,599.25 ± 589.12 mL vs. 1,240.71 ± 291.50 mL), while there was no significant correlation between thoracic fat and cross-sectional eccentricity. Conclusions: The phenotype of plaque distribution and geometry seems to be associated with a higher vulnerability of coronary lesions and may be influenced by the local accumulation of inflammatory mediators released by the pericoronary epicardial adipose tissue.

Background: The independent role of each plaque feature in relation to plaque vulnerability is still the subject of ongoing research. This study aimed to compare the morphologic characteristics of vulnerable atheromatous coronary plaques with the ones of stable, non-vulnerable plaques, and in plaques with different locations in the coronary tree, in order to identify the most relevant imaging-based biomarkers associated with coronary plaque vulnerability. Material and methods: This was a prospective observational, non-randomized study that included 50 patients with unstable angina who underwent computed tomography angiography for assessment of the entire coronary artery tree followed by complex morphologic analysis of all lesions, divided into two groups: group 1 – 25 patients with vulnerable plaque (VP) and group 2 – 25 age- and gender-matched patients with non-vulnerable plaque (NVP). Results: Lesions with a stenosis degree >70% were significantly longer than those with a stenosis degree 3 vs. 83.35 ± 8.47 mm3, p = 0.04), larger volumes of necrotic core (82.03 ± 47.85 mm3 vs. 45.84 ± 43.72 mm3, p = 0.02) and fibrofatty tissue (53.23 ± 31.92 mm3 vs. 23.76 ± 20.90 mm3, p = 0.02) than the ones situated in the left coronary artery. Conclusions: VPs from the culprit lesions exhibit a different phenotype than non-vulnerable ones, and vulnerability features are present in a significantly larger extent in VPs from the right coronary artery as compared to those from the left coronary artery.

Background: Epicardial adipose tissue (EAT) has been recently identified as a major player in the development of the atherosclerotic process. This study aimed to investigate the role of EAT as a marker associated with a higher vulnerability of atheromatous coronary plaques in patients with acute myocardial infarction (AMI) as compared to patients with stable angina. Material and methods: This analysis enrolled a total of 89 patients, 47 with stable angina (SA) and 42 with AMI, who underwent echocardiographic investigations and epicardial fat measurement in 2D-parasternal long axis view. The study lot was divided as follows: Group 1 included patients with prior AMI, and Group 2 included patients with SA. Results: There were no significant differences between the two groups regarding cardiovascular risk factors, excepting smoking status, which was recorded more frequently in Group 1 as compared to Group 2 (36.17% vs. 11.63%, p = 0.02). The mean epicardial fat diameter was 9.12 ± 2.28 mm (95% CI: 8.45–9.79 mm) in Group 1 and 6.30 ± 2.03 mm (95% CI: 5.675–6.93 mm) in Group 2, the difference being highly significant statistically (p Conclusions: The increased thickness of EAT was associated with other serum- or image-based biomarkers of disease severity, such as the left ventricular ejection fraction, end-systolic diameter of the left ventricle, and total cholesterol. Our results indicate that EAT is significantly higher in patients with acute coronary syndrome, proving that EAT could serve as a marker of vulnerability in cardiovascular diseases.

Recent studies have shown that systemic inflammation caused by periodontal disease (PD) can determine important changes in the coronary arteries, favoring atherosclerosis progression and the development of acute coronary syndromes (ACS). The aim of the ATHERODENT study (Protocol Record Number CM0117-ATD) is to assess the interrelation between PD, inflammation, and the progression of coronary atherosclerosis in patients with ACS. Material and methods: This case-control observational study will enroll 100 patients (group 1 – ACS and associated PD, and group 2 – ACS and no PD), in whom the following data will be collected: (1) demographic and clinical data; (2) cardiovascular risk factors; (3) full characterization of PD markers; (4) systemic inflammatory biomarkers; (5) imaging biomarkers derived from transthoracic echocardiography, computed tomography, coronary angiography, optical coherence tomography, and intravascular ultrasound; and (6) assessment of the presence of specific oral bacteria in samples of coronary plaques collected by coronary atherectomy, which will be performed during percutaneous revascularization interventions, when indicated in selected cases, in the atherectomy sub-study. The follow-up will be performed at 1, 3, 6, 12, 15, 18, and 24 months. The primary endpoint of the study will be represented by the rate of major adverse cardiovascular events (MACE) in PD vs. non-PD patients and in correlation with: (1) the level of systemic inflammation triggered by PD and/or by ACS at baseline; (2) the vulnerability degree of atheromatous plaques in the coronary tree (culprit and non-culprit lesions); and (3) the presence and burden of oral bacteria in atheromatous plaques. Secondary endpoints will be represented by: (1) the rate of progression of vulnerability degree of non-culprit coronary plaques; (2) the rate of progression of atheromatous burden and calcium scoring of the coronary tree; and (3) the rate of occurrence of left ventricular remodeling and post-infarction heart failure. The ATHERODENT study has been registered in clinicaltrials.gov (ClinicalTrials.gov Identifier: NCT03395041).

Cardiac magnetic resonance imaging is an evolving imaging method that can be used in cardiovascular pathology evaluation. Technological developments have increased the clinical utility of cardiac magnetic resonance in the exploration of various cardiac abnormalities. The most important imaging techniques and their utility will be presented in this review, together with the advantages and limitations of cardiac magnetic resonance and with a brief presentation of common cardiac disorders that can be assessed by cardiac magnetic resonance including ischemic heart disease, cardiomyopathies and myocarditis.

Funding Acknowledgements Research grant PlaqueImage, contract number 26/01.09.2016, SMIS code 103544, Project funded by the European Union and the Government of Romania Background The coronary CT angiography (CCTA)-based differences in composition, morphology and vulnerability of coronary plaques (CPs), according to their location within the coronary tree, have not been investigated so far. Purpose We sought to perform a comparative analysis between plaques located at different levels within the coronary tree, to identify the differences in plaque composition, morphology, and vulnerability between the three major coronary branches. Methods We conducted a cross-sectional, observational study on 75 patients with stable coronary artery disease who underwent CCTA for assessment of coronary lesions that exhibited at least one vulnerable plaque (VP) in the coronary tree. After image acquisition, coronary plaque analysis was performed with the use of the Syngo.via Frontier (Siemens) software. Plaque analysis also included evaluation of presence of VM: low attenuation plaque – LAP; napkin ring sign – NRS; spotty calcifications – SC; positive remodeling – PR. VP were defined as lesions that presented at least 1 vulnerability marker (VM). In total, 90 coronary VPs located at the level of the left anterior descending (LAD; n = 30), circumflex (CXA; n = 30) and right coronary artery respectively (RCA; n = 30) were identified and analyzed. Results Lesions located in the RCA presented a significantly higher length (LAD - 18.67± 5.49 vs. CXA - 15.48 ±3.73 vs. RCA - 20.47 ± 5.97 mm, p = 0.001), a higher degree of stenosis (LAD - 57.77 ± 8.62 vs. CXA - 54.50 ± 11.25 vs. RCA - 59.63 ± 10.42 mm, p = 0.022), and were more voluminous (LAD - 187.9 ± 86.03 vs. CXA - 146.9 ± 102.4 vs. RCA - 248.1 ± 11.4 mm3, p = 0.0007) compared to those located in the LAD and CXA, but no difference was observed regarding the remodeling (p = 0.180) or eccentricity indexes (p = 0.423). Plaque composition was also significantly different according to plaque location: calcified volume (LAD - 44.07 ± 63.90 vs. CXA - 12.40 ± 19.65 vs. RCA - 33.69 ± 34.38 mm3, p = 0.002), non-calcified volume (LAD - 143.8 ± 76.02 vs. CXA - 134.5 ± 102.2 vs. RCA - 214.4 ± 99.67 mm3, p = 0.002), lipid rich volume (LAD - 14.95 ± 22.69 vs. CXA - 6.44 ± 13.42 vs. RCA -16.07 ± 15.74 mm3, p = 0.0005), fibrotic volume (LAD - 128.9 ± 66.10 vs. CXA - 128.1 ± 91.56 vs. RCA - 198.3 ± 92.34 mm3, p = 0.003). The highest number of VM per plaque was present in the LAD (LAD - 2.2 ± 0.8 vs. CXA - 1.6 ± 0.7 vs. RCA - 1.8 ± 0.6, p = 0.01), as well as highest rate of VPs (LAD – 80%, CXA – 46.6%, RCA – 70%, p = 0.01). No difference was registered between coronary arteries on the presence of SCs (p = 0.670), NRS (p = 0.455), PR (p = 0.833), but LAPs were more frequently located in the LAD (p = 0.0009). Conclusions Coronary plaques located in the RCA were more voluminous and exhibited a higher volume of lipid rich and non-calcified atheroma. However, compared to the RCA and CXA, the left anterior descending artery presented CPs with a more expressed degree of vulnerability, a higher number of vulnerability markers per plaque, and a higher incidence of LAP.

Funding Acknowledgements PlaqueImage financed by the National Authority of Scientific Research and Innovation and the Romanian Ministry of European Funding Background The relationship between periodontal disease (PD) and chronic inflammation is well established. PD leads to increased cardiovascular risk and favours development of acute coronary syndromes; however, the association between PD and markers of subclinical atherosclerosis has not been elucidated so far. Purpose To evaluate the interrelation between severity of PD, coronary calcium, subclinical atherosclerosis and plaque vulnerability in patients with unstable angina, who underwent coronary computed tomography angiography (CCTA). Methods Fifty-two patients with unstable angina were enrolled in the ATHERODENT clinical trial (NCT03395041). All patients underwent: (1) complex dental examination for assessment of periodontal status, expressed by the total periodontal index (PI) evaluating the following indices: gingival index, plaque index, tantrum index, furcation index, mobility, loss of attachment, pocket depth and papillary bleeding index, (2) CCTA for analysis of morphology, composition and vulnerability features of the culprit plaques causing myocardial schema. For each patient, coronary calcium score, body mass index, neck circumference, abdominal circumference and Intima-media thickness of the carotid artery were calculated. According to the median value of the total PI (set by 22) the study population was divided into two groups: group 1 included 26 patients with low PI (normal gum or gingivitis) and group 2 included 26 patients with high PI (periodontitis and severe PD). Results In patients with high PI the plaque volume (p = 0.019) and the non-calcified volume (p = 0.002) were more increased compared with patients with low PI. In patients with high risk features in the culprit coronary plaques (positive remodelling, low density atheroma, spotty calcification and napkin ring sign) the severity of PD was more expressed compared with those with low risk plaques (28.20+/-13.34 vs. 18.71+/-11.31, p = 0.001). From all PI indices, loss of gingival attachments (3.6 +/-2.91 vs. 1.66 +/- 1.8, p = 0.009) and papillary bleeding index (4.5 +/-3.06 vs. 2.04+/-1.96, p = 0.002) were significantly correlated with the plaque vulnerability. there was no significant correlation between PI and the markers of subclinical atherosclerosis expressed by the neck circumference, abdominal circumference and IMT of the carotid artery. However, total PI presented significantly correlation with the total coronary artery calcium score (r = 0.45, p = 0.0008). A higher calcium score was identified in patients with high PI compared with those with low PI (505.29 +/-478.64 vs. 93.82+/-233.0, p = 0.0001). Conclusions In patients with vulnerable coronary plaques, subclinical atherosclerosis is not correlated with PI. However, the severity of PD is directly associated with the total calcium score and with a more vulnerable phenotype of the atheromatous coronary plaques.

Funding Acknowledgements Funded by the research grant PlaqueImage, contract number 26/01.09.2016, SMIS code 103544, by the European Union and the Government of Romania Background The inflammatory response in the acute phase of a myocardial infarction, as well as in later phases contributes to the healing process of the infarcted myocardium and the left ventricular remodeling. Restoration and improvement of LV function highly depends on the magnitude of scar formation. Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging has been validated for an accurate determination of the myocardial scar size and transmurality. The recovery of ST segment elevation is a liable marker of vessel patency following PCI. Purpose The aim of the study was to validate a new integrated score of ST segment elevation score (ISSTE) as a new predictor of the myocardial scar tissue size, in relation with increased inflammatory biomarkers, with the extent of myocardial fibrosis at one month, assessed with LGE-CMR, after STEMI. Methods We included 65 patients with STEMI who underwent urgent revascularization with PCI in the first 12 hours from the onset of symptoms. The ISSTE was determined by summing the ST segment elevation in all registered ECG leads at presentation (ISSTE-1) and at 2 hours (ISSTE-2) after primary PCI. Blood samples were also collected at baseline and day-5 for determination of serum hs-CRP levels. At 1-month follow-up all patients under LGE-CMR (1.5T scanner) for evaluation of the myocardial scar extent (volume, percentage, transmurality). Results ISSTE-2 was significantly correlated with day-5 hs-CRP serum levels (r = 0.546, 95%CI: 0.030-0.832, p = 0.037), although no significant correlations were noted with baseline hs-CRP levels (r= 0.238, p = 0.407). There were no significant correlations between ISSTE-1 score and the myocardial scar percentage (r = 0.241, p = 0.11) or high transmurality volume (r = 0.194, p = 0.21), while ISSTE-2 significantly correlated with myocardial scar mass (r = 0.406, 95%CI: 0.107-0.637 p = 0.007) and high transmurality volume (r = 0.344, 95%CI: 0.0320-0.596, p = 0.0273). The restoration of the ST segment, reflected by the difference between ISSTE-1 and ISSTE -2 is correlated with the infarct size mass (r = 0.336, 95%CI: 0.0307 -0.584, p = 0.027). Conclusion The magnitude of ST segment elevation determined at 2 hours after PCI was associated with the inflammatory response at day 5 after STEMI and it may serve as a predictor for the extent of the myocardial scar tissue determined with LGE-CMR at 1 month following STEMI. The ISSTE-1 score calculated at presentation does not reflect extent of the affected myocardial tissue following PCI.

Introduction: Multimodality assessment of coronary artery lesions has demonstrated superior effectiveness compared to the conventional approach, for assessing both anatomical and functional significance of a coronary stenosis. Multiple imaging modalities can be integrated into a fusion imaging tool to better assess myocardial ischemia. Material and methods: The FUSE-HEART trial is a single center, prospective, cohort study that will assess the impact of a coronary artery stenosis on myocardial function and viability, based on advanced fusion imaging technics derived from Cardiac Computed Tomography Angiography (CCTA). Moreover, the study will investigate the correlation between morphology and composition of the coronary plaques and myocardial ischemia in the territory irrigated by the same coronary artery. At the same time, imaging parameters will be correlated with inflammatory status of the subjects. The trial will include 100 subjects with coronary lesions found on CCTA examination. The study population will be divided into 2 groups: first group will consist of subjects with anatomically significant coronary lesions on native coronary arteries and the second one will include subjects surviving an acute myocardial infarction. The vulnerability score of the subjects will be calculated based on presence of CCTA vulnerability markers of the coronary plaques: napkin ring sign, positive remodeling, spotty calcifications, necrotic core, and low-density plaques. 3D fusion images of the coronary tree will be generated, integrating the images reflecting wall motion with the ones of coronary circulation. The fusion models will establish the correspondence between plaque composition and wall motion in the subtended myocardium of the coronary artery. The study primary outcome will be represented by the rate of major adverse cardiac events related to myocardial ischemia at 1-year post assessment, in correlation with the degree of coronary artery stenosis and myocardial ischemia or viability. The secondary outcomes are represented by the rate of re-hospitalization, rate of survival and rate of major adverse cardiovascular events (including cardiovascular death or stroke), in correlation with the morphology and composition of atheromatous plaques located in a coronary artery, and myocardial ischemia in the territory irrigated by the same coronary artery. Conclusion: In conclusion, FUSE-HEART will be a study based on modern imaging tools that will investigate the impact of a coronary artery stenosis on myocardial function and viability, using advanced fusion imaging technics derived from CCTA, sighting to validate plaque composition and morphology, together with inflammatory biomarkers, as predictors to myocardial viability.

Introduction: Coronary computed tomography angiography (CCTA) has emerged as a valuable noninvasive imaging tool for assessing atheromatous plaque morphology and composition, and several CCTA features have been validated as reliable indicators of the plaque-associated risk. However, the role of lesion geometry as a CCTA feature of plaque vulnerability has not been investigated so far. Material and methods: Here we present the study protocol of the GEOMETRY trial, a prospective, single center, cohort study in which we aim to investigate the relationship between plaque geometry (as expressed by cross-sectional and longitudinal plaque eccentricity) and the risk for major adverse cardiac events (MACE) during 2 years of follow-up, in order to validate plaque eccentricity as a new CCTA marker of coronary plaque vulnerability. One thousand patients with suspected coronary artery disease (CAD) and pretest probability of CAD between 15% and 85%, who undergo CCTA and in whom CCTA identifies the presence of at least 1 significant coronary plaque (producing a luminal narrowing of at least 50%) will be enrolled in the study. Based on the results of complex image post-processing and plaque analysis, patients will be divided into 2 groups: group 1—patients in whom CCTA analysis identifies only non-eccentric coronary plaque; and group 2—patients in whom CCTA analysis reveals the presence of at least 1 eccentric significant coronary plaque producing a significant luminal narrowing. Study outcomes will consist in the rate of major cardiovascular events and the rate of plaque progression during follow-up. The study is funded by the Romanian Ministry of European Funds, the Romanian Government and the European Union, as part of the research grant number 103544/2016 – PlaqueIMAGE (contract number 26/01.09.2016). Conclusion: In conclusion, GEOMETRY will be the first CCTA-based study that will investigate the impact of geometric distribution of coronary atheromatous plaque on the future risk of cardiovascular events and on the rate of plaque progression, introducing and validating a new potential feature of plaque vulnerability represented by plaque geometry.

Abstract. Background: The role of vascular calcifications in iliac arteries for predicting global atherosclerotic burden in still unknown. The aim of this study was to investigate whether iliac calcium score (ICS), a new computed tomographic angiography (CTA) derived biomarker of vascular calcification, can predict the severity and complexity of peripheral arterial disease (PAD) as well as the global atherosclerotic burden. Patients and methods: This was a single centre, non-randomized, observational prospective study on 84 consecutive patients with symptomatic peripheral arterial disease, undergoing peripheral CTA examination of the lower limbs, divided into high (n = 42) and low ICS (n = 42) groups with a median value for ICS of 3934 HU. Results: Patients with high ICS were significantly older (66.2 ± 8.0 vs. 62.8 ± 11.2, p < 0.0001) and were more frequently diabetic (61.9 vs. 38.1 %, p = 0.04). ICS was significantly higher in patients with Rutherford stage 5–6 vs. 1–2 (p = 0.03) and in TASC D or TASC C vs. TASC B class (p = 0.01). Mean iliac intima-media thickness (i-IMT) was significantly higher in the high ICS group compared to the low ICS group (1.3 ± 0.2 vs. 0.9 ± 0.2, p < 0.0001). Linear regression analysis demonstrated a very good correlation between ICS and i-IMT (r = 0.59, p < 0.0001 for right, r = 0.57, p < 0.0001 for left and r = 0.67, p < 0.0001 for both iliac arteries averaged). Patients with high ICS presented a significantly lower left ventricular ejection fraction compared to those with low ICS (45.3 ± 4.3 vs. 53.8 ± 4.8, p < 0.0001). Linear regression analysis demonstrated significant inverse correlation between ICS and left ventricular EF (r = –0.54, p < 0.0001). Conclusions: Increased values of ICS, a new CTA marker of vascular calcification, are associated with a higher severity and complexity of PAD and a more depressed left ventricular function. High ICS values are also associated with increased i-IMT. Both can represent new surrogate markers of an increased atherosclerotic burden.

Introduction:Interventional ablation has been demonstrated to represent an effective therapy in patients with atrial fibrillation (AF), leading to restoration and maintenance of sinus rhythm in the majority of cases. However, recurrence of AF is encountered in 35% to 40% of cases, and the ca