[Show abstract][Hide abstract] ABSTRACT: To characterize and directly quantify regurgitant jets of left atrioventricular valve (LAVV) in patients with corrected atrioventricular septal defect (AVSD) by four-dimensional (4D)Flow Cardiovascular Magnetic Resonance (CMR), streamline visualization and retrospective valve tracking.
Medical ethical committee approval and informed consent from all patients or their parents were obtained. In 32 corrected AVSD patients (age 26 ± 12 years), echocardiography and whole-heart 4DFlow CMR were performed. Using streamline visualization on 2- and 4-chamber views, the angle between regurgitation and annulus was followed throughout systole. On through-plane velocity-encoded images reformatted perpendicular to the regurgitation jet the cross-sectional jet circularity index was assessed and regurgitant volume and fraction were calculated. Correlation and agreement between different techniques was performed with Pearson's r and Spearman's rho correlation and Bland-Altman analysis.
In 8 patients, multiple regurgitant jets over the LAVV were identified. Median variation in regurgitant jet angle within patients was 36°(IQR 18-64°) on the 2-chamber and 30°(IQR 20-40°) on the 4-chamber. Regurgitant jets had a circularity index of 0.61 ± 0.16. Quantification of the regurgitation volume was feasible with 4DFlow CMR with excellent correlation between LAVV effective forward flow and aortic flow (r = 0.97, p < 0.001) for internal validation and moderate correlation with planimetry derived regurgitant volume (r = 0.65, p < 0.001) and echocardiographic grading (rho = 0.51, p = 0.003).
4DFlow CMR with streamline visualization revealed multiple, dynamic and eccentric regurgitant jets with non-circular cross-sectional shape in patients after AVSD correction. 4DFlow with retrospective valve tracking allows direct and accurate quantification of the regurgitation of these complex jets.
Journal of Cardiovascular Magnetic Resonance 12/2015; 17(1). DOI:10.1186/s12968-015-0122-4 · 4.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Acute chest pain (ACP) is one of the most common presenting symptoms at the emergency department. The differential diagnosis is vast. To exclude life-threatening causes, radiologists encounter an increasing amount of thoracic computed tomography (CT) examinations including CT angiography of the heart and great vessels. The dual- and triple-rule CT examinations are currently implemented in clinical practice. We retrospectively identified chest CT examinations in the setting of acute chest pain in our hospitals and collected a variety of common and uncommon cases. In this pictorial essay, we present the most educative cases from patients who presented with acute chest pain in the emergency department of our hospitals and for whom a thoracic CT was ordered. When aortic emergencies, acute coronary syndrome, and pulmonary embolism are excluded, these cases may help the radiologist to suggest alternative diagnoses in the diagnostic challenge of acute chest pain. Teaching Points • The number of chest CT examinations for ACP is increasing.• Chest CT examinations may help suggesting alternative diagnosis in ACP.• Radiologists should be aware of the differential diagnosis of ACP.
Insights into Imaging 09/2015; DOI:10.1007/s13244-015-0429-6
[Show abstract][Hide abstract] ABSTRACT: Diabetic patients with coronary artery disease (CAD) are often free of chest pain syndrome. A useful modality for non-invasive assessment of CAD is coronary computed tomography angiography (CTA). However, the prognostic value of CAD on coronary CTA in diabetic patients without chest pain syndrome is relatively unknown. Therefore, the aim was to investigate the long-term prognostic value of coronary CTA in a large population diabetic patients without chest pain syndrome.
Between 2005 and 2013, 525 diabetic patients without chest pain syndrome were prospectively included to undergo coronary artery calcium (CAC)-scoring followed by coronary CTA. During follow-up, the composite endpoint of all-cause mortality, non-fatal myocardial infarction (MI), and late revascularization (>90 days) was registered.
In total, CAC-scoring was performed in 410 patients and coronary CTA in 444 patients (431 interpretable). After median follow-up of 5.0 (IQR 2.7-6.5) years, the composite endpoint occurred in 65 (14%) patients. Coronary CTA demonstrated a high prevalence of CAD (85%), mostly non-obstructive CAD (51%). Furthermore, patients with a normal CTA had an excellent prognosis (event-rate 3%). An incremental increase in event-rate was observed with increasing CAC-risk category or coronary stenosis severity. Finally, obstructive (50-70%) or severe CAD (>70%) was independently predictive of events (HR 11.10 [2.52;48.79] (P = .001), HR 15.16 [3.01;76.36] (P = .001)). Obstructive (50-70%) or severe CAD (>70%) provided increased value over baseline risk factors.
Coronary CTA provided prognostic value in diabetic patients without chest pain syndrome. Most importantly, the prognosis of patients with a normal CTA was excellent.
Journal of Nuclear Cardiology 07/2015; DOI:10.1007/s12350-015-0213-5 · 2.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Impairment of myocardial fatty acid metabolism assessed by nuclear imaging is associated with increased cardiac mortality for patients undergoing hemodialysis. The reanalysis of beta-methyl- p-iodophenyl pentadecanoic acid (BMIPP) SPECT Analysis for Decreasing Cardiac Events in Hemodialysis Patients (B-SAFE) tried to identify determinants of sudden cardiac death (SCD) for future establishment of prophylactic strategy against SCD.
Methods and Results: This study analyzed clinical and scintigraphic data from 677 B-SAFE patients, who had undergone cardiac I-123-BMIPP imaging then had been prospectively followed up, to identify determinants of all-cause mortality. During a 3-year interval, 20 SCDs were observed. SCD patients had a greater C-reactive protein level, more frequently abnormal Q-wave and increased BMIPP abnormality compared to non-SCD patients. There, however, was no significant difference in other clinical, laboratory or hemodialysis parameters between them. Univariate Cox regression analysis identified greater C-reactive protein level (>2.38mg/dl), abnormal Q-wave and greater BMIPP abnormality (summed score>16) as significant prognostic factors for SCD with hazards ratios of 6.83 (95% confidence interval (CI): 1.76–26.47, P=0.005), 17.73 (95%CI: 4.91–63.98, P<0.001) and 10.58 (95%CI, 3.84–29.14, P<0.001), respectively. The patients who had two of the three identified conditions had lower SCD-free rates (log-rank test, P<0.001). Similarly, in multivariate Cox analysis, it showed the maximal hazard ratio of 145.22 (95%CI: 30.34–695.10, P<0.0001) and ROC-AUC of 0.677, when patients had two or all of the SCD risks such as a C-reactive protein level more than 2.38mg/dl, abnormal Q-wave and BMIPP score more than 16.
Conclusions: In addition to electrocardiographic abnormality, an increased C-reactive protein level and impaired myocardial fatty acid metabolism are closely and incrementally related to SCD risks in patients undergoing hemodialysis, contributing to appropriate selection of high-risk patients for SCD who could benefit most from a prophylactic approach against SCD.
[Show abstract][Hide abstract] ABSTRACT: Background: While area detector computed tomography (ADCT) is a useful tool for coronary artery disease (CAD) evaluation, myocardial perfusion imaging (MPI) with single photon emission computed tomography is a well-established method of predicting functional relevance of CAD. Purpose: We assess the usefulness for decision making using both ADCT and MPI and discussed from the standpoint of cost for diagnostic work-up and contrast agent. Method: Between January, 2013 to September, 2014, 78 patients underwent both ADCT and MPI within two months were analyzed their therapeutic strategy. From ADCT, severity of stenosis was divided non-significant(less than 50%), moderate (over or equal to 50% and less than 75%) and severe (over or equal to 75%). Summed difference score of MPI was judged as ischemia positive.
Result: Table showed the result and executed treatment strategy. Patients with significant stenosis by ADCT were 40 patients (51.3%) and patients with ischemia positive were 25 patients (33.8%). Invasive revasculization was performed higher (82.3%, p<0.01) for the patients with significant stenosis and ischemia than moderate stenosis with ischemia (25%) or significant stenosis without ischemia (39.1%). Before taking invasive therapy, examination with ADCT and MPI saved 63700 yen and about 100ml of contrast agent in each case based study as it was compared with the case with ADCT and coronary angiography without MPI in spite of slightly higher radiation dose (4mSv). Conclusion: The combined use of ADCT and MPI could choose effectively treatment strategy of CAD with a reduction of cost and contrast agent.
European heart journal cardiovascular Imaging; 05/2015
[Show abstract][Hide abstract] ABSTRACT: Patients with end-stage renal failure (ESRF) are high risk patients for cardiovascular events and are usually evaluated in what concerns myocardial left ventricular ejection fraction (LVEF) and myocardial perfusion before renal transplant. Gated-SPECT myocardial perfusion imaging (G-SPECT MPI) could be used for this evaluation. The aim of this study was to find the prevalence and the predictors of left ventricular dysfunction (LVEF under 45%) and / or an abnormal myocardial perfusion in patients referred for G-SPECT MPI with ESRF before renal transplantation.
112 consecutive patients with ESRF and without known CAD were included. Perfusion was abnormal in 22.3%, LVEF was ≤ 45% in 13.4% and one or both features in 27.7%. Using logistic regression analysis it was found that the predictors LV dysfunction and / or abnormal perfusion imaging were the rest heart rate, (OR=1.1; CI 0.0–1.1; p = 0.007), the QRS width (OR=1.0; CI 1.0–1.1; p = 0.003) and an ECG suggestive of ischemia (OR=2.6; CI 1.0–6.4; p = 0.04). Patients age (OR=1.0; CI 0.9–1.0; p = 0.7) and male gender (OR=1.3; CI 0.5–3.6; p = 0.6), presence of risk factors, namely, diabetes (OR=1.5; CI 0.7–3.6; p = 0.3) or hypertension (OR=0.5; CI 0.2–1.2; p = 0.1), or the presence of angina (OR=1.4; CI 0.4–4.9; p = 0.6) were not predictors of an abnormal perfusion and / or left ventricular dysfunction.
In this study, an abnormal G-SPECT MPI study was found in 27.7% of ESRF patients and it was mainly related with ECG findings (rest heart rate, QRS width and an ECG suggestive of ischemia). Atherosclerotic risk factors or even the presence of symptoms were not related with abnormal images.
European heart journal cardiovascular Imaging; 05/2015
[Show abstract][Hide abstract] ABSTRACT: Coronary computed tomography angiography (CTA) has important prognostic value. Additionally, quantitative CTA (QCT) provides a more detailed accurate assessment of coronary artery disease (CAD) on CTA. Potentially, a risk score incorporating all quantitative stenosis parameters allows accurate risk stratification. Therefore, the purpose of this study was to determine if an automatic quantitative assessment of CAD using QCT combined into a CTA risk score allows risk stratification of patients. In 300 patients, QCT was performed to automatically detect and quantify all lesions in the coronary tree. Using QCT, a novel CTA risk score was calculated based on plaque extent, severity, composition, and location on a segment basis. During follow-up, the composite end point of all-cause mortality, revascularization, and nonfatal infarction was recorded. In total, 10% of patients experienced an event during a median follow-up of 2.14 years. The CTA risk score was significantly higher in patients with an event (12.5 [interquartile range 8.6 to 16.4] vs 1.7 [interquartile range 0 to 8.4], p <0.001). In 127 patients with obstructive CAD (≥50% stenosis), 27 events were recorded, all in patients with a high CTA risk score. In conclusion, the present study demonstrated that a fully automatic QCT analysis of CAD is feasible and can be applied for risk stratification of patients with suspected CAD. Furthermore, a novel CTA risk score incorporating location, severity, and composition of coronary lesion was developed. This score may improve risk stratification but needs to be confirmed in larger studies.
The American journal of cardiology 04/2014; 113(12). DOI:10.1016/j.amjcard.2014.03.034 · 3.28 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Purpose:
Automated software tools have permitted more comprehensive, robust and reproducible quantification of coronary stenosis, plaque burden and plaque location of coronary computed tomography angiography (CTA) data. The association between these quantitative CTA (QCT) parameters and the presence of myocardial ischaemia has not been explored. The aim of the present investigation was to evaluate the association between QCT parameters of coronary artery lesions and the presence of myocardial ischaemia on gated myocardial perfusion single-photon emission CT (SPECT).
Included in the study were 40 patients (mean age 58.2 ± 10.9 years, 27 men) with known or suspected coronary artery disease (CAD) who had undergone multidetector row CTA and gated myocardial perfusion SPECT within 6 months. From the CTA datasets, vessel-based and lesion-based visual analyses were performed. Consecutively, lesion-based QCT was performed to assess plaque length, plaque burden, percentage lumen area stenosis and remodelling index. Subsequently, the presence of myocardial ischaemia was assessed using the summed difference score (SDS ≥2) on gated myocardial perfusion SPECT.
Myocardial ischaemia was seen in 25 patients (62.5%) in 37 vascular territories. Quantitatively assessed significant stenosis and quantitatively assessed lesion length were independently associated with myocardial ischaemia (OR 7.72, 95% CI 2.41-24.7, p < 0.001, and OR 1.07, 95% CI 1.00-1.45, p = 0.032, respectively) after correcting for clinical variables and visually assessed significant stenosis. The addition of quantitatively assessed significant stenosis (χ(2) = 20.7) and lesion length (χ(2) = 26.0) to the clinical variables and the visual assessment (χ(2) = 5.9) had incremental value in the association with myocardial ischaemia.
Coronary lesion length and quantitatively assessed significant stenosis were independently associated with myocardial ischaemia. Both quantitative parameters have incremental value over baseline variables and visually assessed significant stenosis. Potentially, QCT can refine assessment of CAD, which may be of potential use for identification of patients with myocardial ischaemia.
European Journal of Nuclear Medicine 05/2013; 40(8). DOI:10.1007/s00259-013-2437-4 · 5.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Splenic injury is normally associated with trauma, but spontaneous splenic rupture has been described in various systemic diseases.
A 56-year-old male on oral anticoagulation presented to the emergency department with epigastric pain, nausea, and left upper quadrant tenderness. There was no history of trauma. Contrast-enhanced CT imaging revealed a large subcapsular haematoma of the spleen. Oral anticoagulation was antagonised with vitamin K and the patient was discharged in good condition after 3 days of clinical observation.
Non-traumatic splenic rupture is a rare complication of oral anticoagulation.
International Journal of Emergency Medicine 05/2013; 6(1):16. DOI:10.1186/1865-1380-6-16
[Show abstract][Hide abstract] ABSTRACT: Purpose: In diabetes, generalised microvascular disease and coronary artery disease (CAD) are likely to occur in parallel. We used a sidestream dark field (SDF) handheld imaging device to determine the relation between the labial microcirculation parameters and CAD in asymptomatic patients with diabetes.Methods: SDF imaging was validated for assessment of labial capillary density and tortuosity. Thereafter, mean labial capillary density and tortuosity were evaluated and compared in non-diabetic controls, and in asymptomatic patients with type 1 and type 2 diabetes. In diabetic patients, mean capillary density and tortuosity were compared according to the presence of CAD.Results: Both type 1 and type 2 diabetes were associated with increased capillary density and tortuosity. In diabetes, mean capillary density was an independent predictor of elevated coronary artery calcium (CAC) (p = 0.03) and obstructive CAD on computed tomography angiography (p = 0.01). Using a cut-off mean capillary density of 24.9 (per 0.63 mm(2)) the negative predictive value was 84% and 89% for elevated CAC and obstructive CAD. Likewise, capillary tortuosity was an independent predictor of increased CAC (p = 0.01) and obstructive CAD (p = 0.04).Conclusion: Assessment of labial microcirculation parameters using SDF imaging is feasible and conveys the potential to estimate vascular morbidity in patients with diabetes, at bedside.
[Show abstract][Hide abstract] ABSTRACT: To determine the rate of subsequent invasive coronary angiography (ICA) and revascularization in relation to computed tomography coronary angiography (CTA) results. In addition, independent determinants of subsequent ICA and revascularization were evaluated. CTA studies were performed using a 64-row (n = 413) or 320-row (n = 224) multidetector scanner. The presence and severity of CAD were determined on CTA. Following CTA, patients were followed up for 1 year for the occurrence of ICA and revascularization. A total of 637 patients (296 male, 56 ± 12 years) were enrolled and 578 CTA investigations were available for analysis. In patients with significant CAD on CTA, subsequent ICA rate was 76 %. Among patients with non-significant CAD on CTA, subsequent ICA rate was 20 % and among patients with normal CTA results, subsequent ICA rate was 5.7 % (p < 0.001). Of patients with significant CAD on CTA, revascularization rate was 47 %, as compared to a revascularization rate of 0.6 % in patients with non-significant CAD on CTA and no revascularizations in patients with a normal CTA results (p < 0.001). Significant CAD on CTA and significant three-vessel or left main disease on CTA were identified as the strongest independent predictors of ICA and revascularization. CTA results are strong and independent determinants of subsequent ICA and revascularization. Consequently, CTA has the potential to serve as a gatekeeper for ICA to identify patients who are most likely to benefit from revascularization and exclude patients who can safely avoid ICA.
The international journal of cardiovascular imaging 05/2012; 29(1). DOI:10.1007/s10554-012-0059-8 · 1.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Limited information is available regarding the relationship between coronary vessel dominance and prognosis. Therefore, the purpose of this study was to determine the prognostic value of coronary vessel dominance in relation to significant coronary artery disease (CAD) in patients referred for computed tomography coronary angiography (CTA).
The study population consisted of 1425 patients (869 men, 57 ± 12 years) referred for CTA. To evaluate the impact of vessel dominance and significant CAD on CTA on outcome, patients were followed during a median period of 24 months for the occurrence of non-fatal myocardial infarction and all-cause mortality. The presence of a left dominant system was identified as a significant predictor for non-fatal myocardial infarction and all-cause mortality (HR: 3.20; 95% CI: 1.67-6.13, P < 0.001) and had incremental value over baseline risk factors and severity of CAD on CTA. In addition, in the subgroup of patients with significant CAD on CTA, patients with a left dominant system had a worse outcome compared with patients with a right dominant system (cumulative event rates: 9.5% and 35% at 3-year follow-up for a right and left dominant coronary artery system, respectively, log-rank P < 0.001).
The presence of a left dominant system was identified as an independent predictor of non-fatal myocardial infarction and all-cause mortality, especially in patients with significant CAD on CTA. Therefore, the assessment of coronary vessel dominance on CTA may further enhance risk stratification beyond the assessment of significant CAD on CTA.
European Heart Journal 03/2012; 33(11):1367-77. DOI:10.1093/eurheartj/ehs034 · 15.20 Impact Factor