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Cardiac computed tomography (CT) was initially developed as a non-invasive diagnostic tool to detect and quantify coronary stenosis. Thanks to the rapid technological development, cardiac CT has become a comprehensive imaging modality which offers anatomical and functional information to guide patient management. This is the second of two complementary documents endorsed by the European Association of Cardiovascular Imaging aiming to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. In this article, emerging CT technologies and biomarkers, such as CT-derived fractional flow reserve, perfusion imaging, and pericoronary adipose tissue attenuation, are described. In addition, the role of cardiac CT in the evaluation of atherosclerotic plaque, cardiomyopathies, structural heart disease, and congenital heart disease is revised.

With this summarized document we share the standard for positron emission tomography (PET)/(diagnostic)computed tomography (CT) imaging procedures in cardiovascular diseases that are inflammatory, infective, infiltrative, or associated with dysfunctional innervation (4Is) as recently published in the European Journal of Nuclear Medicine and Molecular Imaging. This standard should be applied in clinical practice and integrated in clinical (multicentre) trials for optimal standardization of the procedurals and interpretations. A major focus is put on procedures using [18F]-2-fluoro-2-deoxyglucose ([18F]FDG), but 4Is PET radiopharmaceuticals beyond [18F]FDG are also described in this summarized document. Whilst these novel tracers are currently mainly applied in early clinical trials, some multicentre trials are underway and we foresee in the near future their use in clinical care and inclusion in the clinical guidelines. Diagnosis and management of 4Is related cardiovascular diseases are generally complex and often require a multidisciplinary approach by a team of experts. The new standards described herein should be applied when using PET/CT and PET/magnetic resonance, within a multimodality imaging framework both in clinical practice and in clinical trials for 4Is cardiovascular indications.

Cardiac CT image artefacts can be patient- or scan-related, and failure to recognize them can lead to misdiagnosis. Some artefacts can be avoided or reduced by appropriate patient and device selection, optimal preparation, and by adjustments in scan protocols or image reconstruction. The most common cardiac CT artefacts are blurring or discontinuity artefacts from motion (mostly cardiac); hence, the most effective measure to improve image quality is to decrease heart rate and heart rate variability. Other common artefacts include partial volume effects, beam hardening, excessive image noise, slab or banding artefacts, and low contrast enhancement.

With this document, we provide a standard for PET/(diagnostic) CT imaging procedures in cardiovascular diseases that are inflammatory, infective, infiltrative, or associated with dysfunctional innervation (4Is). This standard should be applied in clinical practice and integrated in clinical (multicenter) trials for optimal procedural standardization. A major focus is put on procedures using [18F]FDG, but 4Is PET radiopharmaceuticals beyond [18F]FDG are also described in this document. Whilst these novel tracers are currently mainly applied in early clinical trials, some multicenter trials are underway and we foresee in the near future their use in clinical care and inclusion in the clinical guidelines. Finally, PET/MR applications in 4Is cardiovascular diseases are also briefly described. Diagnosis and management of 4Is-related cardiovascular diseases are generally complex and often require a multidisciplinary approach by a team of experts. The new standards described herein should be applied when using PET/CT and PET/MR, within a multimodality imaging framework both in clinical practice and in clinical trials for 4Is cardiovascular indications.

Cardiovascular (CV) imaging is an important tool in baseline risk assessment and detection of CV disease in oncology patients receiving cardiotoxic cancer therapies. This position statement examines the role of echocardiography, cardiac magnetic resonance, nuclear cardiac imaging and computed tomography in the management of cancer patients. The Imaging and Cardio-Oncology Study Groups of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) in collaboration with the European Association of Cardiovascular Imaging (EACVI) and the Cardio-Oncology Council of the ESC have evaluated the current evidence for the value of modern CV imaging in the cardio-oncology field. The most relevant echocardiographic parameters, including global longitudinal strain and three-dimensional ejection fraction, are proposed. The protocol for baseline pre-treatment evaluation and specific surveillance algorithms or pathways for anthracycline chemotherapy, HER2-targeted therapies such as trastuzumab, vascular endothelial growth factor tyrosine kinase inhibitors, BCr-Abl tyrosine kinase inhibitors, proteasome inhibitors and immune checkpoint inhibitors are presented. The indications for CV imaging after completion of oncology treatment are considered. The typical consequences of radiation therapy and the possibility of their identification in the long term are also summarized. Special populations are discussed including female survivors planning pregnancy, patients with carcinoid disease, patients with cardiac tumours and patients with right heart failure. Future directions and ongoing CV imaging research in cardio-oncology are discussed.

Acute myocardial infarction (AMI) is a major cause of morbidity and mortality worldwide. AMI causes necrosis of cardiac cells and triggers a complex inflammatory response, affecting infarct size, cardiac function and clinical outcomes. This inflammatory response can be divided into 3 phases: 1) the pro-inflammatory phase, in which the release of damage-associated molecular patterns from necrotic cells triggers the secretion of pro-inflammatory mediators and attracts immune cells to clean the debris, further damaging viable myocardium, 2) the reparative phase, in which anti-inflammatory signals activate immune-modulating cells and trigger the production of a stable scar, 3) the maturation phase, in which inflammatory and fibrotic signals are suppressed, but may persist, leading to left ventricular adverse remodelling. Thus, the inflammatory response is an appealing therapeutic target to improve the outcomes of patients with AMI. Numerous anti-inflammatory therapies have shown potential in animal models, but the translation to human trials exhibited limited benefit. Glucocorticoids and non-steroidal anti-inflammatory drugs showed signals of harm due to their non-specific effects. Other broad inhibitors, e.g., methotrexate, cyclosporine, or colchicine, did not improve clinical outcomes as acute therapies for MI. Specific inhibitors of the complement cascade, adhesion molecules, or inflammatory mediators were mostly disappointing in humans. However, an interleukin-1 inhibitor (anakinra) and a matrix metalloproteinase inhibitor (doxycycline) improved clinical outcomes in patients with AMI. Promising RNAse1, anti-toll-like receptor 2 antibodies, and inflammasome inhibitors still need to be tested in humans. Finally, positive results should be replicated in large clinical trials before they can be implemented into the standard AMI therapy.

In daily clinical practice, clinicians integrate available data to ascertain the diagnostic and prognostic probability of a disease or clinical outcome for their patients. For patients with suspected or known cardiovascular disease, several anatomical and functional imaging techniques are commonly performed to aid this endeavor, including coronary computed tomography angiography (CCTA) and nuclear cardiology imaging. Continuous improvement in positron emission tomography (PET), single-photon emission computed tomography (SPECT), and CT hardware and software has resulted in improved diagnostic performance and wide implementation of these imaging techniques in daily clinical practice. However, the human ability to interpret, quantify, and integrate these data sets is limited. The identification of novel markers and application of machine learning (ML) algorithms, including deep learning (DL) to cardiovascular imaging techniques will further improve diagnosis and prognostication for patients with cardiovascular diseases. The goal of this position paper of the European Association of Nuclear Medicine (EANM) and the European Association of Cardiovascular Imaging (EACVI) is to provide an overview of the general concepts behind modern machine learning-based artificial intelligence, highlights currently prefered methods, practices, and computational models, and proposes new strategies to support the clinical application of ML in the field of cardiovascular imaging using nuclear cardiology (hybrid) and CT techniques.

Given the current increase in the incidence of coronary artery disease in younger women as well as the high lifetime risk of developing an x-ray-induced malignancy in this population, we aimed at assessing chest radiation in 206 women ≤55 years old undergoing coronary calcium scoring (CACS) by using a Monte Carlo simulation tool. Our data indicate that the simulated radiation dose of the female breast during CACS depends substantially on the starting position of the x-ray tube, with an almost 2 times excess of breast radiation exposure being measured during anterior-posterior tube positioning. Thus, an additional technical feature taking into account the position of the x-ray tube when acquisition is triggered might be an important tool to reduce radiation exposure of the female breast during CACS.

A surface 12-lead electrocardiogram (ECG) is widely available, fast, inexpensive, and safe. However, its value to predict a true myocardial scar in patients with ischemic cardiomyopathy (ICM) has not been studied extensively yet. This study was conducted to assess whether Q waves on resting surface 12-lead ECG are predictive of non-viable myocardium in patients with ICM. We analyzed resting ECGs of 149 patients with ICM undergoing cardiac positron emission tomography (PET) with 13N-ammonia (NH3) and 18F-fluorodeoxyglucose (FDG) at our institution. Pathological Q waves and QS complexes were assigned to one of three coronary artery territories and compared to the PET findings. Myocardial scar was defined as 2 or more contiguous myocardial segments with an average (matched) reduction of NH3 and FDG uptake

The human pathophysiology of stunned, hibernating and scarred myocardium in ischemic cardiomyopathy is a subject of controversy. While the “smart heart” theory postulates that reduced myocardial blood flow (MBF) at rest is responsible for myocytes switching to a state of hibernation, other theories suggest that a reduced myocardial flow reserve (MFR) may be the cause. We included 110 patients with ischemic cardiomyopathy. Based on quantitative myocardial perfusion assessment and viability imaging with 13N-NH3 and 18F-FDG positron emission tomography, respectively, as well as wall motion assessment from echocardiography, myocardial tissue was characterized as remote (i.e., normal myocardium), stunned (i.e., dysfunctional but viable myocardium with normal rest perfusion), hibernating (i.e., dysfunctional but viable myocardium with impaired rest perfusion), or scarred myocardium (i.e., non-viable myocardium). Compared to remote myocardium, dysfunctional but viable myocardium (including stunned and hibernating) had reduced rest MBF (0.89 mL/min/g vs. 0.79 and 0.76 mL/min/g, respectively; p

It is ascertained that the epidemiology and social impact of ischemic heart disease is substantially different between the two genders. Moreover, there is substantial evidence that gender is able to modulate the clinical manifestation of most cardiac diseases, and specifically of coronary artery disease. Particularly, women present less angiographically significant coronary artery disease, smaller vessel lumen, and less plaque rupture occurrence as compared to men. On the contrary, manifestations as vasospasm, impaired vasodilatation at epicardial level, and microvascular dysfunction are more common in female. In clinical practice, it is important to know the gender-based aspects of clinical disease expression and how to diversify the diagnostic work-up. Cardiac Computed Tomography and Cardiac Magnetic Resonance are relatively new diagnostic imaging tools employed for studying both the cardiac structures and the pathophysiology of the cardiovascular system. In this paper, we aim to overview the non-invasive diagnostic role in a gender's dimension, mainly focusing on Cardiac Computed Tomography and Cardiac Magnetic Resonance in ischemic heart disease, and to understand whether the existing evidences support a different diagnostic work-up approach.

Objectives The aim of this study was to assess the additional utility of measuring left atrial (LA) pressure as a complement to transesophageal echocardiography (TEE) and Doppler imaging. Background The efficacy of the MitraClip (MC) is assessed intraoperatively by TEE. However, TEE measures are operator dependent and can be influenced by left ventricular (LV) function and changes in LA compliance. Methods Fifty patients undergoing MC therapy with continuous left-sided heart pressure measurements were analyzed. LA V-wave pressure (LAvP), LA mean pressure (LAmP), LV systolic pressure, and LV end-diastolic pressure were measured continuously. LA pressures were indexed to LV pressures to account for changes in afterload during the procedure. Results Most patients (70%) had degenerative mitral regurgitation (MR). TEE MR grade decreased from 3+ to 0+. LAvP (p Conclusions This study demonstrates the value of real-time monitoring of LA pressure during MC therapy to predict clinical outcomes. An increase in LAmP was a predictive of worse clinical outcomes at short-term follow-up, independent from echocardiographic findings.

Since the first coronary angioplasty by Andreas Gruuml;ntzig in Zurich in 1977, the number of cardiac interventional procedures has steadily increased. The aim of this report is to summarise the state of catheter-based cardiac interventions in adults in Switzerland in 2018. Since 1987, the Working Group Interventional Cardiology of the Swiss Society of Cardiology has collected annually aggregate data from all facilities with cardiac catheterisation laboratories in the country, currently 36 institutions in 17 cantons of Switzerland. Over past years, the numbers of coronary angiography procedures (CAs) and percutaneous coronary interventions (PCIs) increased steadily reaching 57,309 for CA and 27,318 for PCI in 2018. Among structural heart interventions, a broad spectrum of transcatheter procedures is currently available in Switzerland. Numbers of transcatheter aortic valve implantations similarly increased, with 1781 implantations in 2018.

Aims The Swiss national registry on percutaneous mitral valve interventions (MitraSwiss) was established in 2011 to monitor safety/efficacy of percutaneous mitral valve repair (PMVR) with the MitraClip device. The aim of this analysis was to report the outcome after PMVR in a real-world, all-comers population and its predictors after inclusion of more than 1,200 patients, stratifying the results according to mitral regurgitation (MR) aetiology. Here we report the in-hospital, short and midterm outcomes of all patients prospectively enrolled. Methods and results Since 2011, MitraSwiss has enrolled 1,212 patients with moderate and severe MR of functional (FMR) or degenerative (DMR) aetiology treated with PMVR in 10 centres. Pre-specified endpoints included clinical, echocardiographic and functional parameters with follow-up planned up to five years. Outcomes are compared according to MR aetiology. Acute procedural success was achieved in 91.5% of cases, with no differences between FMR and DMR and sustained good midterm results. NYHA class and pulmonary pressure improved significantly in both cohorts. Cumulative probability of death at five years was 54% (95% CI: 45-63) in FMR and 45% (95% CI: 37-54) in DMR (HR 1.15, p=0.009). Age, anaemia, impaired renal function and reduced left ventricular ejection fraction resulted in being independent predictors of death at five years. Conclusions In a large contemporary cohort of non-surgical patients with severe MR, the safety and effectiveness of PMVR have been confirmed. At midterm follow-up, mortality and MACE were lower in DMR patients, though MR aetiology was not directly and independently associated with outcome.

International audience; In the latest update of the European Society of Cardiology (ESC) guidelines for the management of infective endocarditis (IE), imaging is positioned at the centre of the diagnostic work-up so that an early and accurate diagnosis can be reached. Besides echocardiography, contrast-enhanced CT (ce-CT), radiolabelled leucocyte (white blood cell, WBC) SPECT/CT and [F-18]FDG PET/CT are included as diagnostic tools in the diagnostic flow chart for IE. Following the clinical guidelines that provided a straightforward message on the role of multimodality imaging, we believe that it is highly relevant to produce specific recommendations on nuclear multimodality imaging in IE and cardiac implantable electronic device infections. In these procedural recommendations we therefore describe in detail the technical and practical aspects of WBC SPECT/CT and [F-18]FDG PET/CT, including ce-CT acquisition protocols. We also discuss the advantages and limitations of each procedure, specific pitfalls when interpreting images, and the most important results from the literature, and also provide recommendations on the appropriate use of multimodality imaging.

Resumen El termino «tecnicas de imagen hibridas en cardiopatia isquemica» se refiere a la fusion de la informacion obtenida con varias tecnicas de imagen en dicho contexto clinico, lo que permite evaluar la presencia, la extension y la gravedad de la enfermedad coronaria ateroesclerotica junto con la importancia hemodinamica de las lesiones o la funcion miocardica. Se ha adoptado en varios centros la fusion de las imagenes de la coronariografia no invasiva obtenidas por tomografia computarizada con las de perfusion miocardica obtenidas por tomografia computarizada por emision monofotonica o tomografia por emision de positrones, y su implementacion se recoge en las guias internacionales de enfermedad arterial coronaria. Las nuevas modalidades hibridas que incorporan la estimacion de la reserva fraccional de flujo y la tomografia computarizada de perfusion han ganado terreno, lo cual resulta muy prometedor para la evaluacion diagnostica y terapeutica de los pacientes con enfermedad arterial coronaria. En esta revision se comentan las tecnicas de imagen hibridas no invasivas disponibles actualmente en la practica clinica y las futuras y prometedoras innovaciones tecnologicas en este campo.

Left ventricular (LV) ejection fraction (EF) during high dobutamine stress (HD) by real-time gated-SPECT myocardial perfusion imaging (MPI) on a cadmium-zinc-telluride (CZT) gamma camera was validated versus cardiac magnetic resonance imaging (CMR). After injecting 99mTc-tetrofosmin (320 MBq) in 50 patients (mean age 64 +/− 11 years), EF at rest and post-stress as well as relevant changes in EF at HD (ΔEF ≥ 5%) were assessed. CZT and CMR rest EF values yielded an excellent correlation and agreement (r = 0.96; P < 0.001; Bland–Altman limits of agreement (BA): + 0 to 14.8%). HD EF acquisition was feasible using CZT and correlated better to HD CMR EF than did post-stress CZT EF (r = 0.85 vs 0.76, respectively, all P < 0.001). Agreement in ΔEF detection between HD CMR and immediate post-stress CZT (reflecting standard acquisition using conventional SPECT camera unable to scan during stress) was 45%, while this increased to 85% with real-time HD CZT scan. Real-time ultrafast dobutamine gated-SPECT MPI with a CZT device is feasible and provides accurate measurements of HD LV performance.

Objectives: Recommendations regarding sports restriction are lacking for middle-aged athletes with anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS). Methods: Sixty-three patients with ACAOS were subdivided into ACAOS with (n = 38) or without (n = 25) an interarterial course (IAC). Sports behavior, either competitive (COMP) or recreational (REC), was evaluated at the time of diagnosis and after a median follow-up of 4.2 years. Results: Mean age was 56 ± 11 years and 48 (76.2%) patients were engaged in sports. Three individuals (4.8%) were surgically corrected after diagnosis. Thirty-eight (60.3%) patients were aware of their diagnosis at follow-up and 12 (19.0%) were counseled by their physician about sports restrictions. Sports behavior at the time of diagnosis and at follow-up did not differ significantly, neither in patients engaged in COMP (17.5 vs. 12.7%, p = 0.619) nor those engaged in REC (58.7 vs. 61.9%, p = 0.856). Sport-related symptoms were not significantly different between ACAOS patients with and without IAC. No athlete had died at follow-up. Conclusions: The majority of middle-aged individuals with ACAOS were involved in sports activities at the time of diagnosis and at follow-up. Awareness and counseling about ACAOS diagnosis had no significant effect on sports behavior. IAC did not have an impact on sport-related symptoms, and outcomes were favorable in all athletes, regardless of surgical correction.

Restrictive cardiomyopathies (RCMs) are a diverse group of myocardial diseases with a wide range of aetiologies, including familial, genetic and acquired diseases and ranging from very rare to relatively frequent cardiac disorders. In all these diseases, imaging techniques play a central role. Advanced imaging techniques provide important novel data on the diagnostic and prognostic assessment of RCMs. This EACVI consensus document provides comprehensive information for the appropriateness of all non-invasive imaging techniques for the diagnosis, prognostic evaluation, and management of patients with RCM.

AIMS: Positron emission tomography (PET) myocardial perfusion imaging (MPI) can non-invasively measure myocardial blood flow reserve (MBFR). We aimed to examine whether MBFR identifies patients with a survival benefit after revascularization, helping to guide post-test management. METHODS AND RESULTS: We examined all-cause mortality in 12 594 consecutive patients undergoing Rb(82) rest/stress PET MPI from January 2010 to December 2016, after excluding those with cardiomyopathy, prior coronary artery bypass surgery (CABG), and missing MBFR. Myocardial blood flow reserve was calculated as the ratio of stress to rest absolute myocardial blood flow. A Cox model adjusted for patient and test characteristics, early revascularization (percutaneous coronary intervention or CABG ≤90 days of MPI), and the interaction between MBFR and early revascularization was developed to identify predictors of all-cause mortality. After a median follow-up of 3.2 years, 897 patients (7.1%) underwent early revascularization and 1699 patients (13.5%) died. Ischaemia was present in 4051 (32.3%) patients, with 1413 (11.2%) having ≥10% ischaemia. Mean MBFR was 2.0 ± 1.3, with MBFR

OBJECTIVES: The aim of the study was to assess indications, procedural success, complications, echocardiographic, and clinical outcomes of percutaneous pulmonary valve implantation (PPVI) in adult patients with congenital heart disease (CHD). BACKGROUND: PPVI offers a non-surgical treatment option for failing prosthetic conduits in pulmonary position. However, efficacy and clinical outcomes after PPVI are still underreported. METHODS: From January 2008 to March 2016, 25 adult CHD patients with right ventricular outflow tract (RVOT) stenosis and/or pulmonary regurgitation underwent PPVI in our institution. Clinical and echocardiographic data was collected at baseline, at 12 months of follow-up and yearly afterwards. RESULTS: Tetralogy of Fallot and repaired pulmonary atresia were among the most prevalent underlying congenital defects. Twenty-one (84%) received a Medtronic Melody® and four (16%) patients an Edwards Sapien valve prosthesis. The PPVI procedure was successful in all 25 patients. Pre-stenting was performed in all but two (8%) patients. PPVI reduced peak-to-peak pulmonary valve gradient from 43 (IQR 28-60) mmHg to 16 (IQR 14-22) mmHg (P

Extensive left main (LM) coronary artery thrombus is a rare and life-threatening angiographic finding with usual dramatic clinical presentation including hemodynamic instability and sudden cardiac death. The proper management of a big LM thrombus extending into aorta remains a challenging issue with no clear guidelines. In the following case report we present a 45-year-old patient with no apparent risk factors for coronary artery disease who presented with acute infero-lateral ST-elevation myocardial infarction (STEMI). The examination was performed using a right transfemoral approach and it revealed the presence of a large mobile, hazy mass within the left main coronary artery (LMCA) extending into the aorta. To confirm the extension of that structure we performed intravascular ultrasound (IVUS) which revealed a circumferential mass in the LMCA extending with its two-thirds into the aorta with no evidence of atherosclerotic plaques. After a long discussion within our Heart team we decided to transfer the patient for urgent surgical removal. Such decision was made with regard to the large size of the mass and in order to avoid systemic or distal embolization into coronary arteries. Perioperative transesophageal echocardiography (TEE) confirmed diagnosis and excluded presence of patent foramen ovale (PFO). Surgical removal was done successfully with complete resolution of ST-segment elevation and rapid fall of cardiac enzymes to normal levels. Postoperative course was uneventful. The mass was defined as a thrombus by pathophysiology examination. Patient was discharged well from our hospital after 1 week. Cardiol Res. 2017;8(6):331-335 doi: https://doi.org/10.14740/cr598e

Background Estimation of hemodynamic relevance of a coronary stenosis from coronary computed angiography (CCTA) has raised substantial interest. Recently, the corrected coronary opacification (CCO) decrease and the transluminal attenuation gradient (TAG) have been suggested as faster alternatives to the FFR CT . The aim of the study was to evaluate whether the diagnostic accuracy of CCO decrease and TAG translates into an added prognostic value in patients evaluated for coronary artery disease (CAD). Methods This retrospective study consists of 162 consecutive patients referred for evaluation of known or suspected CAD by CCTA. CCO decrease was defined as difference of mean luminal coronary attenuation normalized to aorta attenuation proximal–distal of a stenosis. To calculate TAG, mean attenuation was measured at 5-mm intervals from the ostium to a distal segment with a minimal cross-sectional area of 2.0mm 2 . Death, myocardial infarction, unstable angina requiring hospitalization, and coronary revascularization were defined as major adverse cardiac events (MACE). Multivariate analysis included covariates age, sex, ≥3 cardiovascular risk factors and stenosis severity. Results Follow-up was completed in 154 patients, CAD was found in 72. During median follow-up of 6.1years (interquartile range, 5.8–6.9years), 55 patients experienced a MACE. Among CAD patients, the presence of an abnormal CCO decrease (p Conclusion In CAD patients, CCO decrease adds long-term prognostic value over clinical characteristics and stenosis severity while TAG does not.

Coronary artery disease (CAD) is a major cause of death and disability. Several diagnostic tests, such as myocardial perfusion scintigraphy (MPS), are accurate for the detection of CAD, as well as having prognostic value for the prediction of cardiovascular events. Nevertheless, the diagnostic and prognostic value of these tests should be cost-effective and should lead to improved clinical outcome. We have reviewed the literature on the cost-effectiveness of MPS in different circumstances: (i) the diagnosis and management of CAD; (ii) comparison with exercise electrocardiography (ECG) and other imaging tests; (iii) as gatekeeper to invasive coronary angiography (ICA), (iv) the impact of appropriate use criteria; (v) acute chest pain, and (vi) screening of asymptomatic patients with type-2 diabetes. In total 57 reports were included. Although most non-invasive imaging tests are cost-effective compared with alternatives, the data conflict on which non-invasive strategy is the most cost-effective. Different definitions of cost-effectiveness further confound the subject. Computer simulations of clinical diagnosis and management are influenced by the assumptions made. For instance, diagnostic accuracy is often defined against an anatomical standard that is wrongly assumed to be perfect. Conflicting data arise most commonly from these incorrect or differing assumptions.

Implantation of an Amplatzer Closure Device (St. Jude Medical, St. Paul, Minnesota) has been successfully used to treat residual mitral regurgitation (MR) after MitraClip (Abbott, Abbott Park, Illinois) implantation in selected situations to obliterate the residual jet. Different types and sizes of

Aims Anomalous origin of a coronary artery from the opposite sinus (ACAOS) has been associated with adverse cardiac events in the young. It remains unknown whether this holds true for middle-aged patients with uncorrected ACAOS as well. We assessed the outcome in middle-aged patients with newly diagnosed ACAOS by coronary computed tomography angiography (CCTA) compared with a matched cohort. Methods and results We retrospectively identified 68 consecutive patients with ACAOS documented by CCTA. ACAOS with a course of the anomalous vessel between the aorta and pulmonary artery were classified as interarterial course (IAC). Each patient with ACAOS was matched to two controls without ACAOS. Major adverse cardiac events (i.e. myocardial infarction, revascularization and cardiac death) were recorded for all patients and controls. Two (3%) patients were lost to follow-up. Thus, 66 patients with ACAOS were included in the final analysis and matched with 132 controls. Mean age of patients was 56 ± 11 years, 73% were male and the mean follow-up was 49 months. Forty (65%) patients were classified as having ACAOS with IAC. The annual event rate of ACAOS vs. controls was 4.9 and 4.8%, the hazard ratio (HR) 0.94 (0.39–2.28, P = 0.89). The annual event rate of ACAOS with IAC compared with their matched controls was 5.2 and 4.3%, and the HR 1.01 (95% CI 0.39–2.58, P = 0.99). Conclusions In middle-aged individuals with newly diagnosed ACAOS mid-term outcome is not statistically different to a matched control cohort without coronary artery anomalies, regardless of whether ACAOS with or without IAC variants are present.

Aims To test the hypothesis that virtual functional assessment index (vFAI) is related with regional flow parameters derived by quantitative positron emission tomography (PET) and can be used to assess abnormal vasodilating capability in coronary vessels with stenotic lesions at coronary computed tomography angiography (CCTA). Methods and results vFAI, stress myocardial blood flow (MBF), and myocardial flow reserve (MFR) were assessed in 78 patients (mean age 62.2 ± 7.7 years) with intermediate pre-test likelihood of coronary artery disease (CAD). Coronary stenoses ≥50% were considered angiographically significant. PET was considered positive for significant CAD, when more than one contiguous segments showed stress MBF ≤2.3 mL/g/min for15O-water or 13N-ammonia. MFR thresholds were ≤2.5 and ≤2.0, respectively. vFAI was lower in vessels with abnormal stress MBF (0.76 ± 0.10 vs. 0.89 ± 0.07,P P 15O-water and 82.7% and 71.2% in13N-ammonia studies, respectively. Addition of vFAI to anatomical CCTA data increased the ability for predicting abnormal stress MBF and MFR in15O-water studies [AUCccta + vfai = 0.866, 95% confidence interval (CI) 0.783–0.949;P = 0.013 and AUCccta + vfai = 0.737, 95% CI 0.648–0.825;P = 0.007, respectively]. An incremental value was also demonstrated for prediction of stress MBF (AUCccta + vfai = 0.887, 95% CI 0.799–0.974;P = 0.001) in13N-ammonia studies. A similar trend was recorded for MFR (AUCccta + vfai = 0.780, 95% CI 0.632–0.929;P = 0.13). Conclusion vFAI identifies accurately the presence of impaired vasodilating capability. In combination with anatomical data, vFAI enhances the diagnostic performance of CCTA.

To explore the feasibility of coronary artery calcium (CAC) measurement from low-dose contrast enhanced coronary CT angiography (CCTA) as this may obviate the need for an unenhanced CT scan. 52 patients underwent unenhanced cardiac CT and prospectively ECG triggered contrast enhanced CCTA (Discovery HD 750, GE Healthcare, Milwaukee, WI, USA). The latter was acquired in single-source dual-energy mode [gemstone spectral imaging (GSI)]. Virtual unenhanced images were generated from GSI CCTA by monochromatic image reconstruction of 70 keV allowing selective iodine material suppression. CAC scores from virtual unenhanced CT were compared to standard unenhanced CT including a linear regression model. After iodine subtraction from the contrast enhanced CCTA the attenuation in the ascending aorta decreased significantly from 359 ± 61 to 54 ± 8 HU (P < 0.001), the latter comparing well to the value of 64 ± 55 HU found in the standard unenhanced CT (P = ns) confirming successful iodine subtraction. After introducing linear regression formula the mean values for Agatston, Volume and Mass scores of virtual unenhanced CT were 187 ± 321, 72 ± 114 mm(3), and 27 ± 46 mg/cm(3), comparing well to the values from standard unenhanced CT (187 ± 309, 72 ± 110 mm(3), and 27 ± 45 mg/cm(3)) yielding an excellent correlation (r = 0.96, r = 0.96, r = 0.92; P < 0.001). Mean estimated radiation dose revealed 0.83 ± 0.02 mSv from the unenhanced CT and 1.70 ± 0.53 mSv from the contrast enhanced CCTA. Single-source dual-energy scanning with GSI allows CAC quantification from low dose contrast enhanced CCTA by virtual iodine contrast subtraction.

Aims To investigate the prognostic relevance of coronary anatomy, coronary function, and early revascularization in patients with stable coronary artery disease (CAD). Methods and results From March 2009 to June 2012, 430 patients with suspected CAD (61 ± 9 years, 62% men) underwent coronary anatomical imaging by computed tomography coronary angiography (CTCA) and coronary functional imaging followed by invasive coronary angiography (ICA) if at least one non-invasive test was abnormal. Obstructive CAD was documented by ICA in 119 patients and 90 were revascularized within 90 days of enrolment. Core laboratory analysis showed that 134 patients had obstructive CAD by CTCA (>50% stenosis in major coronary vessels) and 79 significant ischaemia by functional imaging [>10% left ventricular (LV) myocardium]. Over mean follow-up of 4.4 years, major adverse events (AEs) (all-cause death, non-fatal myocardial infarction, or hospital admission for unstable angina or heart failure) or AEs plus late revascularization (LR) occurred in 40 (9.3%) and 58 (13.5%) patients, respectively. Obstructive CAD at CTCA was the only independent imaging predictor of AEs [hazard ratio (HR) 3.2, 95% confidence interval (CI) 1.10–9.30; P = 0.033] and AEs plus LR (HR 4.3, 95% CI 1.56–11.81; P = 0.005). Patients with CAD in whom early revascularization was performed in the presence of ischaemia and deferred in its absence had fewer AEs, similar to patients without CAD (HR 2.0, 95% CI 0.71–5.51; P = 0.195). Conclusion Obstructive CAD imaged by CTCA is an independent predictor of clinical outcome. Early management of CAD targeted to the combined anatomical and functional disease phenotype improves clinical outcome.

To assess the functional relevance of a coronary artery stenosis, corrected coronary opacification (CCO) decrease derived from coronary computed tomography angiography (CCTA) has been proposed. The present study aims at validating CCO decrease with quantitative 13N-ammonia positron emission tomography (PET) myocardial perfusion imaging (MPI). This retrospective study consists of 39 patients who underwent hybrid CCTA/PET-MPI. From CCTA, attenuation in the coronary lumen was measured before and after a stenosis and corrected to the aorta to calculate CCO and its decrease. Relative flow reserve (RFR) was calculated by dividing the stress myocardial blood flow (MBF) of a vessel territory subtended by a stenotic coronary by the stress MBF of the reference territories without stenoses. RFR was abnormal in 11 vessel territories (27%). CCO decrease yielded a sensitivity, specificity, negative predictive value, positive predictive value, and accuracy for prediction of an abnormal RFR of 73%, 70%, 88%, 47%, and 70%, respectively. CCTA-derived CCO decrease has moderate diagnostic accuracy to predict an abnormal RFR in PET-MPI. However, its high negative predictive value to rule out functional relevance of a given lesion may confer clinical implications in the diagnostic work-up of patients with a coronary stenosis.

A surface 12-lead electrocardiogram (ECG) is widely available, fast, inexpensive, and safe. However, its value to predict a true myocardial scar in patients with ischemic cardiomyopathy (ICM) has not been studied extensively yet. This study was conducted to assess whether Q waves on resting surface 12-lead ECG are predictive of non-viable myocardium in patients with ICM.We analyzed resting ECGs of 149 patients with ICM undergoing cardiac positron emission tomography (PET) with 13N-ammonia (NHPathological Q waves had a sensitivity and specificity of 70% and 40%, respectively, and a PPV and NPV of 37% and 73%, respectively, to detect myocardial scar on FDG PET. For QS complexes, sensitivity and specificity were 46% and 59%, respectively, and PPV and NPV were 36% and 68%, respectively. Sensitivity was lower, but specificity was significantly higher in both the LCX and RCA compared to the LAD territory (p0.001), particularly for QS complexes.Pathological Q waves on resting 12-lead ECG have poor or at best moderate sensitivity and specificity to detect myocardial scar on FDG PET. These findings support the use of more advanced imaging techniques to assess myocardial viability in ICM.