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Objective: To determine the potential impact of on-site CT-derived fractional flow reserve (CT-FFR) on the diagnostic efficiency and effectiveness of coronary CT angiography (CCTA) in patients with obstructive coronary artery disease (CAD) on CCTA. Methods: This observational cohort study included patients with suspected CAD who had been randomized to cardiac CT in the CRESCENT I and II trials. On-site CT-FFR was blindly performed in all patients with at least one ≥ 50% stenosis on CCTA and no exclusion criteria for CT-FFR. We retrospectively assessed the effect of adding CT-FFR to the CT protocol in patients with a stenosis ≥ 50% on CCTA in terms of diagnostic effectiveness, i.e., the number of additional tests required to determine the final diagnosis, reclassification of the initial management strategy, and invasive coronary angiography (ICA) efficiency, i.e., ICA rate without ≥ 50% CAD. Results: Fifty-three patients out of the 372 patients (14%) had at least one ≥ 50% stenosis on CCTA of whom 42/53 patients (79%) had no exclusion criteria for CT-FFR. CT-FFR showed a hemodynamically significant stenosis (≤ 0.80) in 27/53 patients (51%). The availability of CT-FFR would have reduced the number of patients requiring additional testing by 57%-points compared with CCTA alone (37/53 vs. 7/53, p < 0.001). The initial management strategy would have changed for 30 patients (57%, p < 0.001). Reserving ICA for patients with a CT-FFR ≤ 0.80 would have reduced the number of ICA following CCTA by 13%-points (p = 0.016). Conclusion: Implementation of on-site CT-FFR may change management and improve diagnostic efficiency and effectiveness in patients with obstructive CAD on CCTA. Key Points: • The availability of on-site CT-FFR in the diagnostic evaluation of patients with obstructive CAD on CCTA would have significantly reduced the number of patients requiring additional testing compared with CCTA alone. • The implementation of on-site CT-FFR would have changed the initial man

Identifying coronary artery disease (CAD) in atrial fibrillation (AF) patients improves risk stratification and defines clinical management. However, the value of screening for subclinical CAD with cardiac CT in AF patients is unknown. Between 2011 and 2015, 94 consecutive patients without known or suspected CAD (66 (57–73) years, 68% male), who were referred for AF evaluation, underw

The purpose of this study was to compare invasively measured aorta fow with 2D phase contrast fow and 4D fow measurements by cardiovascular magnetic resonance (CMR) imaging in a large animal model. Nine swine (mean weight 63±4 kg) were included in the study. 4D fow CMR exams were performed on a 1.5T MRI scanner. Flow measurements were performed on 4D fow images at the aortic valve level, in the ascending aorta, and main pulmonary artery. Simultaneously, fow was measured using an invasive fow probe, placed around the ascending aorta. Additionally, standard 2D phase contrast fow and 2D left ventricular (LV) volumetric data were used for comparison. The correlations of cardiac output (CO) between the invasive fow probe, and CMR modalities were strong to very strong. CO measured by 4D fow CMR correlated better with the CO measured by the invasive fow probe than 2D fow CMR fow and volumetric LV data (4D fow CMR: Spearman’s rho = 0.86 at the aortic valve level and 0.90 at the ascending aorta level; 2D fow CMR: 0.67 at aortic valve level; LV measurements: 0.77). In addition, there tended to be a correlation between mean pulmonary artery fow and aorta fow with 4D fow (Spearman’s rho=0.65, P=0.07), which was absent in measurements obtained with 2D fow CMR (Spearman’s rho=0.40, P=0.33). This study shows that aorta fow can be accurately measured by 4D fow CMR compared to simultaneously measured invasive fow. This helps to further validate the quantitative reliability of this technique.

Methods and results: A total of 5083 patients with symptoms concerning for coronary artery disease (CAD) and atherosclerosis on CCTA were enrolled at 38 international sites from 15 July 2015 to 20 October 2017. Demographics, symptom status, CCTA and FFRCT findings, treatment plans, and 90 days outcomes were recorded. The primary endpoint of reclassification between core lab CCTA alone and CCTA plus FFRCT-based management plans occurred in 66.9% [confidence interval (CI): 64.8-67.6] of patients. Non-obstructive coronary disease was significantly lower in ICA patients with FFRCT ≤0.80 (14.4%) compared to patients with FFRCT >0.80 (43.8%, odds ratio 0.19, CI: 0.15-0.25, P < 0.001). In total, 72.3% of subjects undergoing ICA with FFRCT ≤0.80 were revascularized. No death/myocardial infarction (MI) occurred within 90 days in patients with FFRCT >0.80 (n = 1529), whereas 19 (0.6%) MACE [hazard ratio (HR) 19.75, CI: 1.19-326, P = 0.0008] and 14 (0.3%) death/MI (HR 14.68, CI 0.88-246, P = 0.039) occurred in subjects with an FFRCT ≤0.80.Conclusions: In a large international multicentre population, FFRCT modified treatment recommendation in two-thirds of subjects as compared to CCTA alone, was associated with less negative ICA, predicted revascularization, and identified subjects at low risk of adverse events through 90 days.Aims: Non-invasive assessment of stable chest pain patients is a critical determinant of resource utilization and clinical outcomes. Increasingly coronary computed tomography angiography (CCTA) with selective CCTA-derived fractional flow reserve (FFRCT) is being used. The ADVANCE Registry, is a large prospective examination of using a CCTA and FFRCT diagnostic pathway in real-world settings, with the aim of determining the impact of this pathway on decision-making, downstream invasive coronary angiography (ICA), revascularization, and major adverse cardiovascular events (MACE).

Purpose: With the hypothesis that 4D flow can be used in evaluation of cardiac shunts, we seek to evaluate the multilevel and interreader reproducibility of measurements of the blood flow, shunt fraction and shunt volume in patients with atrial septum defect (ASD) in practice at multiple clinical sites. Materials and methods: Four-dimensional flow MRI examinations were performed at four institutions across Europe and the US. Twenty-nine patients (mean age, 43 years; 11 male) were included in the study. Flow measurements were performed at t

To establish the accuracy of coronary computed tomography angiography (CTA) for in-scaffold quantitative evaluation with opti

Objective: To assess the image quality of coronary CT angiography (CCTA) for suspected acute coronary syndrome (ACS) outside office hours. Methods: Patients with symptoms suggestive of an ACS underwent CCTA at the emergency department 24 hours, 7 days a week. A total of 118 patients, of whom 89 (75 %) presented during office hours (weekdays between 07:00 and 17:00) and 29 (25 %) outside office hours (weekdays between 17:00 and 07:00, weekends and holidays) underwent CCTA. Image quality was evaluated per coronary segment by two experienced readers and graded on an ordinal scale ranging from 1 to 3. Results: There were no significant differences in acquisition parameters, beta-blocker administration or heart rate between patients presenting during office hours and outside office hours. The median quality score per patient was 30.5 [interquartile range 26.0–33.5] for patients presenting during office hours in comparison to 27.5 [19.75–32.0] for patients presenting outside office hours (p=0.043). The number of non-evaluable segments was lower for patients presenting during office hours (0 [0–1.0] vs. 1.0 [0–4.0], p=0.009). Conclusion: Image quality of CCTA outside office hours in the diagnosis of suspected ACS is diminished. Key Points: • Quality scores were higher for coronary-CTA during office hours.• There were no differences in acquisition parameters.• There was a non-significant trend towards higher heart rates outside office hours.• Coronary-CTA on the ED requires state-of-the-art scanner technology and sufficiently trained staff.• Coronary-CTA on the ED needs preparation time and optimisation of

Heart valve disease is common and a major indication for imaging. Echocardiography is the first-line imaging technique for diagnosis, assessment, and serial surveillance. However, other modalities, notably cardiac magnetic resonance imaging and computerized tomography, are used if echocardiographic imaging is suboptimal or to obtain complementary information, particularly to aid risk assessment in individual patients. This review is a summary of current evidence for state-of-the-art clinical practice to inform appropriateness criteria for heart valve disease. It is divided according to common clinical scenarios: detection of valve disea

Objectives: Multidetector CT (MDCT) is a valuable tool for functional prosthetic heart valve (PHV) assessment. However, radiation exposure remains a concern. We assessed a novel CT-acquisition protocol for comprehensive PHV evaluation at limited dose. Methods: Patients with a PHV were scanned using a third-generation dual-source CT scanner (DSCT) and iterative reconstruction technique (IR). Three acquisitions were obtained: a non-enhanced scan; a contrast

Objectives: To investigate the additional value of transmural perfusion ratio (TPR) in dynamic CT myocardial perfusion imaging for detection of haemodynamically significant coronary artery disease compared with fractional flow reserve (FFR). Methods: Subjects with suspected or known coronary artery disease were prospectively included and underwent a CT-MPI examination. From the CT-MPI time-point data absolute myocardial blood flow (MBF) values were temporally resolved using a hybrid deconvolution model. An absolute MBF value was measured in the suspected perfusion defect. TPR was defined as the ratio between the subendocardial and subepicardial MBF. TPR and MBF results were compared with invasive FFR using a threshold of 0.80. Results: Forty-three patients and 94 territories were analysed. The area under the receiver operator curve was larger for MBF (0.78) compared with TPR (0.65, P = 0.026). No significant differences were found in diagnostic classification between MBF and TPR with a territory-based accuracy of 77 % (67-86 %) for MBF compared with 70 % (60-81 %) for TPR. Combined MBF and TPR classification did not improve the diagnostic classification. Conclusions: Dynamic CT-MPI-based transmural perfusion ratio predicts haemodynamically significant coronary artery disease. However, diagnostic performance of dynamic CT-MPI-derived TPR is inferior to quantified MBF and has limited incremental value. Key Points: • The transmural perfusion ratio from dynamic CT-MPI predicts functional obstructive coronary artery disease• Performance of the transmural perfusion ratio is inferior to quantified myocardial blood flow• The incremental value of the transmural perfusion ratio is limited

The aim of this research was finding the influence of anatomy-based and functional-based outflow boundary conditions for computational fluid dynamics (CFD) on fractional flow reserve (FFR) and wall shear stress (WSS) in mildly diseased coronary bifurcations.For 10 patient-specific bifurcations thre

Patients with diabetes mellitus (DM) are at increased risk for atherosclerosis-related events compared to non-DM (NDM) patients. With an expected worldwide epidemic of DM, early detection of anatomic and functional coronary atherosclerotic changes is gaining attention. To improve our understanding of early atherosclerosis development, we studied a swine model that gradually developed coronary atherosclerosis. Interestingly, optical coherence tomography, near-infrared spectroscopy (NIRS), vascular function, and histology demonstrated no differences between development of early atherosclerosis in fast-food-fed (FF) DM swine and that in FF-NDM swine. Coronary computed tomography angiography did not detect early atherosclerosis, but optical coherence tomography and near-infrared spectroscopy demonstrated coronary atherosclerosis development in FF-DM and FF-NDM swine.

Rationale and Objectives: Magnetic resonance angiography (MRA) is a well-established modality for the assessment of renal artery stenosis. Using dedicated quantitative analyses, MRA can become a useful tool for assessing renal artery dimensions in patients referred for renal sympathetic denervation (RDN) and for providing accurate measurements of vascular response after RDN. The purpose of this study was to test the reproducibility of a novel MRA quantitative imaging tool and to validate these measurements against intravascular ultrasound (IVUS). Materials and Methods: In nine patients referred for renal denervation, renal artery dimensions were measured. Bland-Altman analysis was used to assess the intraobserver and interobserver reproducibility. Results: Mean lumen diameter was 5.8 ± 0.7 mm, with a very good intraobserver and interobserver variability of 0.7% (reproducibility: bias, 0 mm; standard deviation [SD], 0.1 mm) and 1.2% (bias, 0 mm; SD, 0.1 mm), respectively. Mean total lumen volume was 1035.3 ± 403.6 mm3 with good intraobserver and interobserver variability of 2.9% (bias, -9.7 mm3; SD, 34.0 mm3) and 2.8% (bias, -11.4 mm3; SD, 42.4 mm3). The correlation (Pearson R) between mean lumen diameter measured with MRA and IVUS was 0.750 (P = .002). Conclusions: Using a novel MRA quantitative imaging tool, renal artery dimensions can be measured with good reproducibility and accuracy. MRA-derived diameters and volumes correlated well with IVUS measurements.

Background Endothelial dysfunction precedes coronary artery disease (CAD) and can be measured by peripheral arterial tonometry (PAT). We examined the applicability of PAT to detect a low risk of CAD in a chest pain clinic. Methods In 93 patients, PAT was performed resulting in reactive hyperaemia (RHI) and augmentation (AIx) indices. Patients were risk classified according to HeartScore, Diamond and Forrester pretest probability (DF), exercise testing (X-ECG), and computed tomography calcium scoring (CCS) and angiography (CTA). Correlations, risk group differences and prediction of revascularisation within 1 year were calculated. Results RHI correlated with HeartScore (r = − 0.21, p = 0.05), AIx with DF (r = 0.26, p = 0.01). However, both were not significantly different between normal and ischaemic X-ECG groups. In addition RHI and AIx were similar between low risk as compared with intermediate-to-high risk, based on risk algorithms (RHI: 1.98 (0.67) vs 1.94 (0.78); AIx: 0.0 (21) vs 5.0 (25); p = NS), or CCS and CTA (RHI: 1.99 (0.58) vs 1.89 (0.82); AIx: − 2.0 (24) vs 4.0 (25); p = NS). Finally, RHI and AIx failed to predict revascularisation (RHI: OR 1.42, CI 0.65–3.1; AIx: OR 1.02, CI 0.98–1.05). Conclusions PAT cannot detect a low risk of CAD, possibly because RHI and AIx versus X-ECG, CCS and CTA represent independent processes.

Cardiogenic shock continues to be a lifethreatening condition carrying a high mortality and morbidity, where the prognosis remains poor despite intensive modern treatment modalities. In recent years, mainly technical improvements have led to a more widespread use of short- and long-term mechanical circulatory support, such as venoarterial extracorporeal membrane oxygenation (VA-ECMO) and left ventricular assist devices (LVADs). Currently, LVADs are indispensable as 'bridge' to cardiac recovery, heart transplantation (HTX), and/or as destination therapy Importantly, both LVADs and HTX put a vast burden on financial resources, besides significant short- and long-term risks of morbidity and mortality. These considerations underscore the importance of optimal timing and appropriate patient selection for LVAD therapy, avoiding as much as possible an unfortunate and costly clinical path. In this report, we present a series of three cases with acute refractory cardiogenic shock ('crash and burn', INTERMACS profile 1) successfully treated by ECMOand early optimal medical therapy preventing a certain path towards LVAD and/or HTX, for which they were initially referred. This conservative approach in INTERMACS profile one patients warrants very early introduction of adequate medical heart failure therapy under the umbrella of a combination of short-term mechanical circulatory and inotropic support by phosphodiesterase inhibitors. Therefore, this novel combined medical-mechanical approach could have important clinical implications for this extremely challenging patient category, as it may avoid an unnecessary and costly clinical path towards LVAD and/or heart transplantation.

Objectives The current study evaluates the incremental value of transluminal attenuation gradient (TAG), TAG with corrected contrast opacification (CCO), and TAG with exclusion of calcified coronary segments (ExC) over coronary computed tomography angiogram (CTA) alone using fractional flow reserve (FFR) as the gold standard. Background TAG is defined as the contrast opacification gradient along the length of a coronary artery on a coronary CTA. Preliminary data suggest that TAG provides additional functional information. Interpretation of TAG is hampered by multiple heartbeat acquisition algorithms and coronary calcifications. Two correction models have been proposed based on either dephasing of contrast delivery by relating coronary density to corresponding descending aortic opacification (TAG-CCO) or excluding calcified coronary segments (TAG-ExC). Methods Eighty-five patients with intermediate probability of coronary artery disease were prospectively included. All patients underwent step-and-shoot 256-slice coronary CTA. TAG, TAG-CCO, and TAG-ExC analyses were performed followed by invasive coronary angiography in conjunction with FFR measurements of all major coronary branches. Results Thirty-four patients (40%) were diagnosed with hemodynamically-significant coronary artery disease (i.e., FFR ≤0.80). On a per-vessel basis (n = 253), 59 lesions (23%) were graded as hemodynamically significant, and the diagnostic accuracy of coronary CTA (diameter stenosis ≥50%) was 95%, 75%, 98%, and 54% for sensitivity, specificity, negative predictive value, and positive predictive value, respectively. TAG and TAG-ExC did not discriminate between vessels with or without hemodynamically significant lesions (-13.5 ;plusmn& 17.1 HU [Hounsfield units] ;times&10 mm;bsupesup&vs. -11.6 ;plusmn&13.3 HU ;times&10 mm;bsupesup&, p = 0.36; and 13.1 ;plusmn&15.9 HU ;times&10 mm;bsupesup&vs. -11.4 ;plusmn&11.7 HU ;times&10 mm;bsupesup&, p = 0.77, respectively). TAG-CCO was lower in vessels

Aim: To investigate the effects of inotropic agents on parameters of tissue perfusion in patients with cardiogenic shock. Methods and Results: Thirty patients with cardiogenic shock were included. Patients received dobutamine, enoximone, or norepinephrine. We performed hemodynamic measurements at baseline and after titration of the inotropic agent until cardiac index (CI) ≥2.5 L.min-1.m-2 or mixed-venous oxygen saturation (SvO 2) ≥70% (dobutamine or enoximone), and mean arterial pressure (MAP) ≥70 mmHg (norepinephrine). As parameters of tissue perfusion, we measured central-peripheral temperature gradient (delta-T) and sublingual perfused capillary density (PCD). All patients reached predefined therapeutic targets. The inotropes did not significantly change delta-T. Dobutamine did not change PCD. Enoximone increased PCD (9.1 [8.9-10.2] vs. 11.4 [8.4-13.9] mm.mm-2; p<0.05), and norepinephrine tended to decrease PCD (9.8 [8.5-11.9] vs. 8.8 [8.2-9.6] mm.mm22, p = 0.08). Fifteen patients (50%) died within 30 days after admission. Patients who had low final PCD (#10.3 mm.mm -2; 64%) were more likely to die than patients who had preserved PCD (>10.3 mm.mm-2; mortality 72% vs. 17%, p = 0.003). Conclusion: This study demonstrates the effects of commonly used inotropic agents on parameters of tissue perfusion in patients with cardiogenic shock. Despite hemodynamic optimization, tissue perfusion was not sufficiently restored in most patients. In these patients, mortality was high. Interventions directed at improving microcirculation may eventually help bridging the gap between improved hemodynamics and dismal patient outcome in cardiogenic shock.

Objective To determine the diagnostic accuracy of copeptin in patients with suspected acute coronary syndrome (ACS) and its correlation with obstructive coronary artery disease (CAD) on coronary CT angiography (CTA). Methods Copeptin was measured at arrival in 65 consecutive patients (56±10 years, 45 men) suspected of ACS and no indication for immediate invasive angiography. All patients underwent coronary CTA without disclosure of the results to the treating physician, and outcomes were classified as obstructive CAD (>50% stenosis) or no obstructive CAD (≤50%) in one or more vessel. Results The final diagnosis of ACS was established in 10 (15%) patients, 6 myocardial infarctions and 4 unstable angina pectoris. Coronary CTA detected obstructive CAD in all patients with ACS and in 10 (15%) patients with no ACS. Copeptin concentrations were higher in patients with ACS (median 7.42 pmol/l (IQR 3.71–18.72)) vs patients with no ACS (3.40 pmol/l (1.13–6.27), p=0.02). Copeptin was not higher in patients with obstructive CAD on coronary CTA (4.87 pmol/l (2.90–8.51) vs 3.60 pmol/l (1.21–6.23), p=0.20) compared with patients with no obstructive CAD. Conclusions Copeptin seems to be elevated in patients with ACS while there is no strong correlation with obstructive coronary disease on CTA.

OBJECTIVE. Echocardiography, radionuclide myocardial perfusion imaging (MPI), and coronary CT angiography (CTA) are the three main imaging techniques used in the emergency department for the diagnosis of acute coronary syndrome (ACS). The purpose of this article is to quantitatively examine existing evidence about the diagnostic performance of these imaging tests in this setting. CONCLUSION. Our systematic search of the medical literature showed no significant difference between the modalities for the detection of ACS in the emergency department. There was a slight, positive trend favoring coronary CTA. Given the absence of large differences in diagnostic performance, practical aspects such as local practice, expertise, medical facilities, and individual patient characteristics may be more important.

Objectives: To evaluate to what extent treatment decisions for patients with stable angina pectoris can be made based on hybrid myocardial perfusion single-photon emission CT (SPECT) and CT coronary angiography (CCTA). It has been shown that hybrid SPECT/CCTA has good performance in the diagnosis of significant coronary artery disease (CAD). The question remains whether these imaging results lead to similar treatment decisions as compared to standalone SPECT and invasive coronary angiography (CA). Methods: We prospectively included 107 patients (mean age 62.8±10.0 years, 69% male) with stable anginal complaints and an intermediate to high pre-test likelihood for CAD. Hybrid SPECT/CCTA was performed prior to CA in all patients. The study outcome was the treatment decision categorised as: no revascularisation, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Treatment decisions were made by two interventional cardiologists and one cardiothoracic surgeon in two steps: first, based on the results of hybrid SPECT/CCTA; second, based on SPECT and CA. Results: Revascularisation (PCI or CABG) was indicated in 54 (50%) patients based on SPECT and CA. Percentage agreement of treatment decisions in all patients based on hybrid SPECT/CCTA versus SPECT and CA on the necessity of revascularisation was 92%. Percentage agreement of treatment decisions in patients with matched, unmatched and normal hybrid SPECT/CCTA findings was 95%, 84% and 100%, respectively. Conclusions: Panel evaluation shows that patients could be accurately indicated for and deferred from revascularisation based on hybrid SPECT/CCTA.

Objectives To compare Magnetic Resonance (MR) and Computed Tomography (CT) for the assessment of left (LV) and right (RV) ventricular functional parameters. Methods Seventy nine patients underwent both Cardiac CT and Cardiac MR. Images were acquired using short axis (SAX) reconstructions for CT and 2D cine b-SSFP (balanced- steady state free precession) SAX sequence for MR, and evaluated using dedicated software. Results CT and MR images showed good agreement: LV EF (Ejection Fraction) (52±14% for CT vs. 52±14% for MR; r0 0.73; p>0.05); RV EF (47±12% for CT vs. 47±12% for MR; r00.74; p>0.05); LV EDV (End Diastolic Volume) (74± 21 ml/m 2 for CT vs. 76±25 ml/m 2 for MR; r00.59; p>0.05); RV EDV (84±25 ml/m 2 for CT vs. 80±23 ml/m 2 for MR; r0 0.58; p>0.05); LV ESV (End Systolic Volume)(37±19 ml/m 2 for CT vs. 38±23 ml/m 2 for MR; r00.76; p>0.05); RV ESV (46±21 ml/m 2 for CT vs. 43±18 ml/m 2 for MR; r00.70; p>0.05). Intra- and inter-observer variability were good, and the performance of CT was maintained for different EF subgroups. Conclusions Cardiac CT provides accurate and reproducible LVand RV volume parameters compared with MR, and can be considered as a reliable alternative for patients who are not suitable to undergo MR. Key Points • Cardiac-CT is able to provide Left and Right Ventricular function. • Cardiac-CT is accurate as MR for LV and RV volume assessment. • Cardiac-CT can provide accurate evaluation of coronary arteries and LV and RV function.

To conduct a comparison of the diagnostic performance of exercise bicycle testing and singlephoton emission computed tomography (SPECT) with computed tomography coronary angiography (CTCA) for the detection of obstructive coronary artery disease (CAD) in patients with stable angina. 376 symptomatic patients (254 men, 122 women, mean age 60.4 ± 10.0 years) referred for noninvasive stress testing (exercise bicycle test and/or SPECT) and invasive coronary angiography were included. All patients underwent additional 64-slice CTCA. The diagnostic performance of exercise bicycle testing (ST segment depression), SPECT (reversible perfusion defect) and CTCA (≥50% lumen diameter reduction) was presented as sensitivity, specificity, positive and negative predictive value (PPV and NPV) to detect or rule out obstructive CAD with quantitative coronary angiography as reference standard. Comparisons of exercise bicycle testing versus CTCA (n = 334), and SPECT versus CTCA (n = 61) were performed. The diagnostic performance of exercise bicycle testing was significantly (P value<0.001) lower compared to CTCA: sensitivity of 76% (95% CI, 71-82) vs. 100% (95% CI, 97-100); specificity of 47% (95% CI, 36-58) vs. 74% (95% CI, 63-82).We observed a PPV of 70% (95% CI, 65-75) vs. 91% (95% CI, 87-94); and NPV of 30% (95%, 25-35) vs. 99% (95%, 90-100). There was a statistically significant difference in sensitivity (P value<0.05) between SPECT and CTCA: 89% (95% CI, 75-96) vs. 98% (95% CI, 87-100); but not in specificity (P value>0.05): 77% (95% CI, 50-92) vs. 82% (95% CI, 56-95). We observed a PPV of 91% (95% CI, 77-97) vs. 93% (95% CI, 81-98); andNPVof 72% (95%, 46-89) vs. 93% (95%, 66-100). SPECT and CTCA yielded higher diagnostic performance compared to traditional exercise bicycle testing for the detection and rule out of obstructive CAD in patients with stable angina.

Objectives To investigate the diagnostic accuracy of CT coronary angiography (CTCA) in women at low to intermediate pre-test probability of coronary artery disease (CAD) compared with men. Methods In this retrospective study we included symptomatic patients with low to intermediate risk who underwent both invasive coronary angiography and CTCA. Exclusion criteria were previous revascularisation or myocardial infarction. The pre-test probability of CAD was estimated using the Duke risk score. Thresholds of less than 30 % and 30-90 % were used for determining low and intermediate risk, respectively. The diagnostic accuracy of CTCA in detecting obstructive CAD (≥50 % lumen diameter narrowing) was calculated on patient level. P<0.05 was considered significant. Results A total of 570 patients (46 % women [262/570]) were included and stratified as low (women 73 % [80/109]) and intermediate risk (women 39 % [182/461]). Sensitivity, specificity, PPV and NPV were not significantly different in and between women and men at low and intermediate risk. For women vs. men

Purpose: To compare the coronary atherosclerotic burden in patients with and without type-2 diabetes using CT Coronary Angiography (CTCA). Methods and Materials: 147 diabetic (mean age: 65 ± 10 years; male: 89) and 979 nondiabetic patients (mean age: 61 ± 13 years; male: 567) without a history of coronary artery disease (CAD) underwent CTCA. The per-patient number of diseased coronary segments was determined and each diseased segment was classified as showing obstructive lesion (luminal narrowing >50%) or not. Coronary calcium scoring (CCS) was assessed too. Results: Diabetics showed a higher number of diseased segments (4.1 ± 4.2 vs. 2.1 ± 3.0; p < 0.0001); a higher rate of CCS > 400 (p < 0.001), obstructive CAD (37% vs. 18% of patients; p < 0.0001), and fewer normal coronary arteries (20% vs. 42%; p < 0.0001), as compared to nondiabetics. The percentage of patients with obstructive CAD paralleled increasing CCS in both groups. Diabetics with CCS ≤ 10 had a higher prevalence of coronary plaque (39.6% vs. 24.5%, p = 0.003) and obstructive CAD (12.5% vs. 3.8%, p = 0.01). Among patients with CCS ≤ 10 all diabetics with obstructive CAD had a zero CCS and one patient was asymptomatic. Conclusions: Diabetes was associated with higher coronary plaque burden. The present study demonstrates that the absence of coronary calcification does not exclude obstructive CAD especially in diabetics.

Background: To evaluate additional adenosine magnetic resonance perfusion (MRP) imaging in the diagnostic workup of patients with suspected stable angina with computed tomography coronary angiography (CTCA) as first-line diagnostic modality. Methods and Results: Two hundred and thirty symptomatic patients (male, 52%; age, 56 year) with suspected stable angina underwent CTCA. In patients with a stenosis of >50% as visually assessed, MRP was performed and the quantitative myocardial perfusion reserve index (MPRI) was calculated. Coronary flow reserve (CFR) using invasive coronary flow measurements served as the standard of reference. CTCA showed non-significant CAD in 151/230 (66%) patients and significant CAD in 79/230 patients (34%), of whom 50 subsequently underwent MRP and CFR. MRP showed reduced perfusion in 32 patients (64%), which was confirmed by CFR in 27 (84%). All 18 cases of normal MRP (36%) were confirmed by CFR. The positive likelihood ratio of MRP for the presence of functional significant disease in patients with a lesion on CTCA was 4.49 (95% confidence interval [CI] 2.12-9.99). The negative likelihood ratio was 0.05 (95%CI 0.01-0.34). Conclusions: CTCA as first-line diagnostic modality excluded coronary artery disease in a high percentage of patients referred for diagnostic workup of suspected stable angina. MRP made a significant contribution to the detection

Aims: We compared the measurement of aortic leaflet calcification on contrast and non-contrast MSCT and investigated predictors of the need for balloon post-dilatation after TAVI. Methods and results: In 110 patients, who had TAVI with a Medtronic CoreValve prosthesis (MCS) for symptomatic aortic stenosis, calcification of the aortic root was measured on non-contrast MSCT (conventionally) and on contrast MSCT (signal attenuation >450 Houndsfield units). Calcium volume was underestimated on contrast- when compared to non-contrast MSCT: median (IQ-range)=759 (466 to 1295) vs. 2016 (1376 to 3262) and the difference between the two methods increased with higher calcium volumes (correlation coefficient r=0.90). Calcium mass was only slightly underestimated on contrast vs. non-contrast MSCT: median (IQ-range)=441 (268 to 809) vs. 555 (341 to 950) and there was no association between the differences and increasing calcium mass (r=0.17). Balloon post-dilatation was performed for significant aortic regurgitation after TAVI in 11 of 110 patients. When compared to controls, the patients who required balloon post-dilatation had higher aortic leaflet calcium on contrast CT (p<0.01), higher aortic annulus diameters (p<0.01) and higher annulus to prosthesis area ratio (p=0.01). ROC curves demonstrated that aortic root or aortic leaflet calcium measured on either contrast- or non-contrast MSCT showed excellent discrimination for the requirement of balloon post-dilatation (area under ROC >0.80 for all), whereas the discriminatory value of aortic annulus dimensions was moderate (area under ROC=0.69) and that of prosthesis to annulus ratio was poor (area under ROC=0.36). Conclusions: Dense aortic leaflet calcification measured on contrast MSCT discerned well the need for balloon post-dilatation after TAVI with an MCS for significant PAR. Non-contrast MSCT may no longer be needed to quantify aortic root calcium before TAVI.

Purpose: To retrospectively compare sensitivity and specificity of four generations of multidetector computed tomographic (CT) scanners for diagnosing significant (≥50%) coronary artery stenosis, with quantitative conventional coronary angiography as reference standard. Materials and Methods: The institutional review board approved this study. All patients consented to undergo CT studies prior to conventional coronary angiography, after they were informed of the additional radiation dose, and to the use of their data for future retrospective research. Two hundred four patients (157 men, 47 women; mean age, 58 years ± 11 [standard deviation]), classified in four groups of 51 patients each, underwent coronary CT angiography with four-section, first- and second-generation 16-section, and 64-section CT scanners. Patients in sinus rhythm scheduled for conventional coronary angiography (stable angina, atypical chest pain) were included. Patients with bypass grafts and stents were excluded. Two readers unaware of results of conventional coronary angiography evaluated CT scans. Coronary artery segments of 2 mm or larger in diameter were included for comparative evaluation with quantitative coronary angiography. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for detection of significant stenoses (≥50% luminal diameter reduction) were calculated. Results: Image quality was rated poor for the following percentages of coronary artery segments: 33.1% at four-section CT, 14.4% at first-generation 16-section CT, 6.3% at second-generation 16-section CT, and 2.6% at 64-section CT. Sensitivity, specificity, PPV, and NPV, respectively, were as follows: 57%, 91%, 60%, and 90% at four-section CT; 90%, 93%, 65%, and 99% at first-generation 16-section CT; 97%, 98%, 87%, and 100% at second-generation 16-section CT; and 99%, 96%, 80%, and 100% at 64-section CT. Diagnostic performance of four-section CT was significantly poorer than that of sec

Purpose: To determine the optimal width and timing of the electrocardiographic (ECG) pulsing window within the cardiac cycle in relation to heart rate (HR), image quality, and radiation exposure in patients who are suspected of having coronary artery disease. Materials and Methods: The institutional review board approved the study, and all patients gave informed consent. Dual-source computed tomography (CT) was performed in 301 patients (mean HR, 70.1 beats per minute ± 13.3 [standard deviation]; range, 43-112 beats per minute) by using a wide ECG pulsing window (25%-70% of the R-R interval). Data sets were reconstructed in 5% steps from 20%-75% of R-R interval. Image quality was assessed by two observers on a per-segment level and was classified as good or impaired. High-quality data sets we

Objectives This study was designed to prospectively evaluate the diagnostic performance of multislice spiral computed tomography (MSCT) coronary angiography for the detection of significant lesions in all segments of the coronary tree potentially suitable for revascularization. Background Noninvasive MSCT coronary angiography is a promising coronary imaging technique. Methods Sixteen-row MSCT coronary angiography was performed in 128 patients (89% men, mean age 58.9 ± 11.7 years) in sinus rhythm with stable angina pectoris scheduled for conventional coronary angiography. Sixty percent (77 of 128) of patients received pre-scan oral beta-blockers, resulting in a mean heart rate of 57.7 ± 7.7 beats/min. The diagnostic performance of MSCT for detection of significant lesions (≥50% diameter reduction) was compared with that of quantitative coronary angiography (QCA). Results The sensitivity of MSCT for detection of significant lesions was 92% (216 of 234, 95% confidence interval [CI]: 88 to 95). Specificity was 95% (1,092 of 1,150, 95% CI: 93 to 96), positive predictive value 79% (216 of 274, 95% CI: 73 to 88), and negative predictive value 98% (1,092 of 1,110, 95% CI: 97 to 99). Two ≥50% lesions were missed because of motion artifacts and two because of severe coronary calcifications. The rest (78%, 14 of 18) were detected but incorrectly classified as <50% obstructions. All patients with and 86% (18 of 21) of patients without significant lesions on QCA were correctly classified by MSCT. All patients with significant left main disease or total occlusions were correctly identified on MSCT. Conclusions Sixteen-row MSCT coronary angiography permits reliable detection of significant obstructive coronary artery disease in patients with stable angina in sinus rhythm.

This dissertation describes the use and clinical potential of ECG gated multislice spiral computed tomography in patients with coronary artery disease. First the use of other non invasive cardiac imaging, i.e. the previously mentioned electron beam CT and magnetic resonance imaging is reviewed (chapter 2.1). Part 3 contains studies related to the characteristics of multislice spiral CT for the imaging of the heart and coronary arteries, and the diagnostic potential of ECG gated spiral CT coronary angiography to detect and visualize obstructive coronary artery disease in symptomatic patients, using conventional coronary angiography as the standard of reference. Part 4 is focussed on the feasibility and characteristics of coronary wall imaging by CT, including the assessment of non calcified atherosclerotic plaque material. The usefulness of contrast enhanced multislice spiral CT in symptomatic patients who previously underwent coronary artery bypass grafting and percutaneous coronary intervention with stent implantation is discussed in part 5. Finally, the first results with the latest generation 16 slice computed tomography scanners and patient preparation with ~ receptor blockers are described in part 6, including a review and future outlook on the continuing development and clinical use of non invasive coronary angiography with spiral computed tomography.

OBJECTIVE: To evaluate the impact of heart rate on the diagnostic accuracy of coronary angiography by multislice spiral computed tomography (MSCT). DESIGN: Prospective observational study. PATIENTS: 78 patients who underwent both conventional and MSCT coronary angiography for suspicion of de novo coronary artery disease (n=53) or recurrent coronary artery disease after percutaneous intervention (n=25). SETTING: Tertiary referral centre. METHODS: Intravenously contrast enhanced MSCT coronary angiography was done during a single breath hold, and ECG synchronised images were reconstructed retrospectively. All coronary segments of > or = 2.0 mm without stents were evaluated by two investigators and compared with quantitative coronary angiography. Patients were classified according to the average heart rate (mean (SD)) into three equally sized groups: group 1, 55.8 (4.1) beats/min; group 2, 66.6 (2.8) beats/min; group 3, 81.7 (8.8) beats/min. RESULTS: Image quality was sufficient for analysis in 78% of the coronary segments in patients in group 1, 73% in group 2, and 54% in group 3 (p < 0.01). The sensitivity and specificity for detecting significant stenoses (> or = 50% lumen reduction) in these assessable segments were: 97% (95% confidence interval (CI) 84% to 100%) and 96% in group 1; 74% (52% to 89%) and 94% in group 2; and 67% (33% to 90%) and 94% in group 3 (p < 0.05). Accounting for all segments of > or = 2.0 mm, including lesions in non-assessable segments as false negatives, the sensitivity decreased to 82% (28/34 lesions, 95% CI 69% to 91%), 61% (14/23 lesions, 42% to 77%), and 32% (6/19 lesions, 15% to 50%), respectively (p < 0.01). CONCLUSIONS: MSCT allows reliable coronary angiography in patients with low heart rates.