Recurrent idiopathic carotid and coronary artery vasospasm treated by stent implantations.

Arterial vasospasm is a well known cause of ischemia and, if prolonged, of parenchymal infarction. The clinical presentation varies according to the involved arterial district. We describe a rare case, which occurred in a young lady, of recurrent and multisystem vasospasm, resulting in multiple cerebral and myocardial infarctions. Our patient was resistant to medical therapy, requiring stent implantation of the involved vessels.

[Pulmonary embolism and SARS-CoV-2: analysis of patients hospitalized for pulmonary embolism and COVID-19 in a Northern Italian center]. / Embolia polmonare e SARS-CoV-2: analisi delle caratteristiche dei pazienti ricoverati presso un centro nel nord Italia per embolia polmonare associata a COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has shown high morbidity and mortality and the relationship between pulmonary embolism (PE) and COVID-19 is well established in the literature. METHODS: We describe the characteristics of a cohort of COVID-19 patients (EP-COV) hospitalized at our Centre with PE, investigating how COVID-19 may have influenced their outcomes, as compared to patients without COVID-19 hospitalized for PE in the same months of 2020 (EP-2020) and 2019 (EP-2019). RESULTS: EP-COV patients (n=25) were younger (60.5 ± 8.5 vs 71.4 ± 14.5 vs 70.9 ± 11.8 years, p=0.003), more frequently male (76% vs 48% vs 35%, p=0.016), with a lower history of neoplasia (12% vs 47% vs 40%, p=0.028) and more clinically severe (SOFA score 3.4 ± 1.4 vs 2.2 ± 1.4 vs 1 ± 1.1, p<0.001 and PaO2/FiO2 ratio 223.8 ± 75.5 vs 306.5 ± 49.3 vs 311.8 ± 107.5) than EP-2020 (n=17) and EP-2019 patients (n=20). D-dimer and C-reactive protein were higher in EP-COV (p=0.038 e p<0.001, respectively). The rate of concomitant deep vein thrombosis associated with PE did not differ significantly between the three groups. EP-COV patients developed PE more frequently during in-hospital stay than non-COVID-19 patients (p = 0.016). The mortality rate was higher in EP-COV than in EP-2020 and EP-2019 patients (36% vs 0% vs 5%, p=0.019). CONCLUSIONS: In our study, the risk factors for PE in COVID-19 patients seem to differ from the traditional risk factors for venous thromboembolism; EP-COV patients are clinically more severe and display a higher mortality rate than EP-2020 and EP-2019 patients.

Myocardial Infarct Size in Patients on Long-Term Statin Therapy Undergoing Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction.

Statin pretreatment has been reported to have a cardioprotective effect in patients undergoing elective or urgent percutaneous coronary intervention (PCI). However, data on patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI are still controversial. We prospectively evaluated the effect of long-term statin therapy on infarct size (IS), myocardial salvage index (MSI), and microvascular obstruction (MVO) in consecutive patients with STEMI who underwent primary PCI. Two-hundred thirty patients with STEMI (mean age 61 ± 11 years, 183 men) who underwent primary PCI were evaluated with cardiac magnetic resonance (CMR) imaging during hospitalization (median 4 days after primary PCI). In all patients, we measured peak troponin I level, whereas IS, MSI, and MVO were determined by CMR. Fifty patients (22%) were on long-term statin therapy and showed a significantly lower troponin I peak value compared to patients without previous statins (54 ± 47 vs 88 ± 106 ng/ml; p = 0.02). At CMR evaluation, IS related to the index event was significantly smaller (12.5 ± 11.5 vs 18.5 ± 18.5 g, p = 0.05), and MSI was higher (0.68 ± 0.25 vs 0.52 ± 0.30; p <0.01) in patients with previous statin therapy. MVO was also less frequent (10% vs 20%; p = 0.14) in this group. At multivariate analysis, previous statin therapy remained significantly associated with IS and MSI (p = 0.05 and 0.02, respectively). In conclusion, this study suggests that long-term statin therapy before primary PCI in patients with STEMI is associated with smaller IS and higher MSI. Future studies are warranted to confirm these findings and to investigate potential clinical implications.

Coronary artery disease: diagnostic accuracy of CT coronary angiography--a comparison of high and standard spatial resolution scanning.

PURPOSE: To compare the image quality, evaluability, diagnostic accuracy, and radiation exposure of high-spatial-resolution (HR, 0.23-mm) computed tomographic (CT) coronary angiography with standard spatial resolution (SR, 0.625-mm) 64-section imaging in patients at high risk for coronary artery disease (CAD) by using invasive coronary angiography (ICA) as the reference method. MATERIALS AND METHODS: Written informed consent was obtained from all patients, and the study protocol was approved by the institutional ethical committee. Patients at high risk for CAD (n = 184) who were scheduled for ICA were randomly assigned for study with SR (n = 91) or HR (n = 93) coronary CT angiography before they underwent ICA. To compare the two groups, the Student t test or Wilcoxon test were used to evaluate differences in continuous variables. The χ(2) test or Fisher exact test were used, as appropriate, for categorical data. The McNemar test was used to compare the diagnostic performance of coronary CT angiography versus that of ICA in each group. RESULTS: HR coronary CT angiography showed a higher image quality score (3.7 vs 3.4, P < .001) and evaluability (97% vs 92%, P < .002). In a segment-based analysis, HR coronary CT angiography showed a higher specificity, positive predictive value, and accuracy in comparison with SR coronary CT angiography (98%, 91%, and 99% vs 95%, 80%, and 95%, respectively; P < .001). Moreover, HR coronary CT angiography showed a better agreement with ICA for calcified plaques compared with SR coronary CT angiography and ICA (83% vs 53%, P < .001). In a patient-based analysis, HR coronary CT angiography showed higher specificity and accuracy compared with SR coronary CT angiography (91% and 98% vs 46% and 92%, respectively; P < .01). No differences in radiation exposure were found between the two groups. CONCLUSION: Improved evaluability and accuracy were seen with HR compared with SR coronary CT angiography of calcified coronary artery lesions, suggesting a potential use for this technology in patients at high risk for CAD.

Comparison of accuracy of aortic root annulus assessment with cardiac magnetic resonance versus echocardiography and multidetector computed tomography in patients referred for transcatheter aortic valve implantation.

The evaluation of the aortic root in patients referred for transcatheter aortic valve implantation is crucial. The aim of the present study was to compare the accuracy of cardiac magnetic resonance (CMR) evaluation of the aortic annulus (AoA) with transthoracic and transesophageal echocardiography and multidetector computed tomography (MDCT) in patients referred for transcatheter aortic valve implantation. In 50 patients, maximum diameter, minimum diameter and AoA, length of the left coronary, right coronary, and noncoronary aortic leaflets, degree (grades 1 to 4) of aortic leaflet calcification, and distance between AoA and coronary artery ostia were assessed. AoA maximum diameter, minimum diameter, and area by CMR were 26.4 ± 2.8 mm, 20.6 ± 2.3 mm, 449.8 ± 86.2 mm(2), respectively. The length of left coronary, right coronary, and noncoronary leaflets by CMR were 13.9 ± 2.2, 13.3 ± 2.1, and 13.4 ± 1.8 mm, respectively, whereas the score of aortic leaflet calcifications was 2.9 ± 0.8. Finally, the distances between AoA and left main and right coronary artery ostia were 16.1 ± 2.8 and 16.1 ± 4.4 mm, respectively. Regarding AoA area, transthoracic and transesophageal echocardiography showed an underestimation (p <0.01), with a moderate agreement (r: 0.5 and 0.6, respectively, p <0.01) compared with CMR. No differences and excellent correlation were observed between CMR and MDCT for all parameters (r: 0.9, p <0.01), except for aortic leaflet calcifications that were underestimated by CMR. In conclusion, aortic root assessment with CMR including AoA size, aortic leaflet length, and coronary artery ostia height is accurate compared with MDCT. CMR may be a valid imaging alternative in patients unsuitable for MDCT.

A long-term prognostic value of CT angiography and exercise ECG in patients with suspected CAD.

OBJECTIVES: The aim of the study was to perform a comparison of the prognostic performance of computed tomography coronary angiography (CTA) and exercise electrocardiography (ex-ECG) in patients with suspected coronary artery disease (CAD). BACKGROUND: CAD is a major cause of mortality and morbidity, and its management consumes a large proportion of the health care budget. Therefore, identification of patients at high risk of adverse events is crucial. Despite its limited accuracy, ex-ECG is the most commonly used noninvasive test in CAD evaluation. CTA was recently introduced as alternative test. METHODS: We enrolled 681 patients (age 61.3 ± 10.4 years, 461 men) with atypical or typical angina and no history of CAD. All patients underwent ex-ECG and CTA and were followed for 44 ±12 months. The endpoints were all cardiac events, defined as nonfatal myocardial infarction, cardiac death, and revascularization, and hard cardiac events, defined as all cardiac events excluding revascularization. RESULTS: ex-ECG and CTA were rated as positive in 419 (61%) and 274 (40%) of 681 patients, respectively. In univariate analysis, both ex-ECG and CTA were predictors of all cardiac events (hazard ratio [HR]: 2.09, 95% confidence interval [CI]: 1.5 to 2.8; p < 0.0001 and HR: 21.1, 95% CI: 14.6 to 30.5; p < 0.0001, respectively) and hard cardiac events (HR: 1.9, 95% CI: 1.1 to 3.2; p = 0.02 and HR: 6.8, 95% CI: 3.9 to 11.0; p < 0.0001, respectively), whereas in a multivariate analysis, CAD with ≥50% stenoses detected by CTA was the only independent predictor of hard cardiac events. Stratifying our population by ex-ECG and CTA findings, Kaplan-Meier curves showed that ex-ECG provides only a further risk stratification in the subset of patients with positive findings on CTA and a low to intermediate likelihood of CAD. Moreover, positive findings on CTA identify a shorter event-free period, regardless the ex-ECG findings for both all cardiac events and hard cardiac events, respectively. CONCLUSIONS: CTA may have a higher prognostic value compared with ex-ECG in patients with suspected CAD, mainly in those with a low to intermediate pre-test likelihood of CAD.

Pre-operative CT coronary angiography in patients with mitral valve prolapse referred for surgical repair: comparison of accuracy, radiation dose and cost versus invasive coronary angiography.

BACKGROUND: The aims of this study are to evaluate the accuracy of low dose multidetector computed tomography coronary angiography (MDCT) versus invasive coronary angiography (ICA) in ruling out CAD in patients with mitral valve prolapse and severe mitral regurgitation (MVP) before cardiac surgery and to compare the overall effective radiation dose (ED) and cost of a diagnostic approach in which conventional ICA should be performed only in patients with significant CAD as detected by MDCT. METHODS: Eighty patients with MVP and without history of CAD were randomized to MDCT (Group 1) or ICA (Group 2) to rule out CAD before surgery. However, ICA was also performed as gold standard reference in Group 1 to test the diagnostic accuracy of MDCT. A diagnostic work-up A in whom all patients underwent low-dose MDCT as initial diagnostic test and those with positive findings were referred for ICA was compared with work-up B in which all patients were referred for ICA according to the standard of care in terms of ED and cost. RESULTS: The two groups were homogeneous in terms of gender, age and body mass index. The overall feasibility and accuracy in a patient-based model were 99% and 93%, respectively. The overall ED and costs were significantly lower in diagnostic work-up A compared to diagnostic work-up B. CONCLUSIONS: The accuracy of low dose MDCT for ruling out the presence of significant CAD in patients undergoing elective valve surgery for mitral valve prolapse is excellent with a reduction of overall radiation dose exposure and costs.

Aortic annulus area assessment by multidetector computed tomography for predicting paravalvular regurgitation in patients undergoing balloon-expandable transcatheter aortic valve implantation: a comparison with transthoracic and transesophageal echocardiography.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a valid alternative to surgery in high-risk patients with severe aortic stenosis. Aortic annulus (AoA) sizing is crucial for TAVI success. The aim of the study was to compare AoA dimensions measured by multidetector computed tomography (MDCT) vs those obtained with transthoracic (TTE) and transesophageal echocardiography (TEE) for predicting paravalvular aortic regurgitation (PVR) after TAVI. METHODS: Aortic annulus maximum diameter, minimum diameter, and area were assessed using MDCT and compared with TTE and TEE diameter and area for predicting PVR after TAVI in 151 patients (45 men, age 81.2 ± 6.4 years). RESULTS: Aortic annulus maximum, minimum diameter, and area detected by MDCT were 25.04 ± 2.39 mm, 21.27 ± 2.10 mm, and 420.87 ± 76.10 mm(2), respectively. Aortic annulus diameter and area measured by TTE and TEE were 21.14 ± 1.94 mm and 353.82 ± 64.57 mm(2) and 22.04 ± 1.94 mm and 384.33 ± 67.30 mm(2), respectively. A good correlation was found between AoA diameters and area evaluated by MDCT vs TTE and TEE (0.61, 0.65, and 0.69 and 0.61, 0.65, and 0.70, respectively), with a mean difference of 3.90 ± 1.98 mm, 0.13 ± 1.67 mm, and 67.05 ± 55.87 mm(2) and 3.0 ± 2.0 mm, 0.77 ± 1.70 mm, and 36.54 ± 56.43 mm(2), respectively. Grade ≥2 PVR occurred in 46 patients and was related to male gender, higher body mass index, preprocedural aortic regurgitation, and lower mismatch between the nominal area of the implanted prosthesis and AoA area detected by MDCT. CONCLUSIONS: Mismatch between prosthesis area and AoA area detected by MDCT is a better predictor of PVR as compared with echocardiography mismatch. Specific MDCT-based sizing recommendations should be developed.

A long-term prognostic value of coronary CT angiography in suspected coronary artery disease.

OBJECTIVES: The aim of this study was to assess the long-term prognostic role of multidetector computed tomography coronary angiography (CTA) in patients with suspected coronary artery disease (CAD). BACKGROUND: Use of CTA is increasing in patients with suspected CAD. Although there is a large body of data supporting the prognostic role of CTA for major adverse cardiac events in the intermediate term, its long-term prognostic role in patients with suspected CAD is not well studied. METHODS: Between February 2005 and March 2008, 1,304 consecutive patients were prospectively studied with CTA for detecting the presence and assessing extent of CAD (disease extension and coronary plaque scores). Patients were classified according to the presence of normal coronaries and nonobstructive (<50%) and obstructive (>50%) coronary lesions. The composite rates of hard cardiac events (cardiac deaths and nonfatal myocardial infarctions) and all cardiac events (including late revascularization) were the endpoints of the study. RESULTS: Seventy patients were excluded because their CTA data were uninterpretable. Of the remaining 1,234 patients, clinical follow-up (mean 52 ± 22 months) was obtained for 1,196 (97%). A total of 475 events were recorded, with 136 hard events (18 cardiac deaths and 118 nonfatal myocardial infarctions) and 123 late revascularizations. A total of 216 patients with early elective revascularizations were excluded from the survival analysis. Significant independent predictors of events in multivariate analysis were multivessel disease and left main CAD. Cumulative event-free survival was 100% for hard and all events in patients with normal coronary arteries, 88% for hard events and 72% for all events in patients with nonobstructive CAD, and 54% for hard events and 31% for all events in patients with obstructive CAD. Multivessel CAD was associated with a higher rate of hard cardiac events. CONCLUSIONS: CTA provides prognostic information in patients with suspected CAD and unknown cardiac disease, showing excellent long-term prognosis when there is no evidence of atherosclerosis and allowing risk stratification when CAD is present.

Radiation dose and diagnostic accuracy of multidetector computed tomography for the detection of significant coronary artery stenoses: a meta-analysis.

We conducted a meta-analysis evaluating the critical ratio between effective radiation dose (ED), feasibility (Fe) and diagnostic accuracy (Ac) of multidetector computed tomography (MDCT) for the detection of significant coronary artery disease. By using our predetermined criteria, we selected human studies published in English in which the ED and raw data of Ac vs. invasive coronary angiography in a segment based model were specified. Data from 31 studies including 3661 patients (mean age 61.9 ± 4.5 years, heart rate 62.5 ± 6.7 bpm) and 50,236 coronary artery segments were analysed and are reported. Overall, Fe, sensitivity, specificity, negative predictive value, positive predictive value, Ac and ED were 95%, 90%, 96%, 99%, 69%, 95% and 10.4 ± 5.4 mSv, respectively. Multivariate analysis showed that prospective ECG-gating (-8.8 mSv CI95% -13.4 to -4.3 mSv, p=0.001), dual-source (-3.7 mSv CI95% -7.9 to 0 mSv, p=0.05) and BMI-adapted scanning protocols (-4.5 mSv CI95% -8.7 to -2.7 mSv, p=0.03) were independent predictors of ED reduction. In patients with low heart rate, the best compromise between ED, Fe and Ac (2.5 mSv, 97% and 98%, respectively) was obtained combining prospective ECG-gating and BMI-adapted scanning protocols, while in patients with high heart rate the strategy associated with the best results (10 mSv, 98% and 97%, respectively) was the use of dual-source MDCT with retrospective ECG gating and modulation dose. In conclusion, careful selection of CT scanning protocols according to the patient's characteristics is critical for keeping the radiation exposure "as low as reasonably achievable" (ALARA) without impairing Fe and Ac.

Feasibility and accuracy of a comprehensive multidetector computed tomography acquisition for patients referred for balloon-expandable transcatheter aortic valve implantation.

BACKGROUND: The aim of this study was to assess the accuracy of a comprehensive multidetector computed tomography (MDCT) evaluation of the aortic annulus (AoA), coronary artery disease (CAD), and peripheral vessels in patients referred for transcatheter aortic valve implantation (TAVI). METHODS: In 60 patients referred for TAVI, the following parameters were assessed with 64-slices MDCT and compared with transesophageal echocardiography (TEE), invasive coronary angiography (ICA), and peripheral angiography: AoA maximum diameter (Max-AoA-D(MDCT)), minimum diameter (Min-AoA-D(MDCT)), and area; lumen morphology index ([Max-AoA-D(MDCT)/Min-AoA-D(MDCT)]); length of the left, right, and non-coronary aortic leaflets; degree (grades 1-4) of aortic leaflet calcifications; distance between AoA and left main coronary ostium and between AoA and right coronary ostium CAD and peripheral vessel disease. RESULTS: The Max-AoA-D(MDCT) and Min-AoA-D(MDCT) were 25.1 ± 2.8 and 21.2 ± 2.2 mm, respectively, with high correlation versus AoA diameter measured with TEE (r = 0.82 and 0.86, respectively). The area of AoA, systolic and diastolic lumen morphology index were 410 ± 81.5 mm(2), 1.19 ± 0.1 and 1.22 ± 0.11, respectively. Aortic leaflet calcification score was 3.3 ± 0.5. The lengths of left, right, and non-coronary aortic leaflets were 14.2 ± 2.4, 13.7.1 ± 2.1, and 14.5 ± 2.6 mm, whereas distances between AoA and the left main coronary ostium and between AoA, and the right coronary ostium were 13.7 ± 2.9 and 15.8 ± 3.5 mm, respectively. Feasibility, negative predictive value, and accuracy for CAD detection versus ICA were 87%, 100% (CI 100-100), and 96% (95% CI 94-100), respectively. All patients (N = 17) who were ineligible for TAVI were correctly detected by MDCT. CONCLUSIONS: A comprehensive MDCT evaluation of patients referred for TAVI is feasible, provides more accurate assessment than TEE of AoA morphology, and may replace peripheral angiography in all patients and ICA in patients without significant CAD.

High diagnostic accuracy of prospective ECG-gating 64-slice computed tomography coronary angiography for the detection of in-stent restenosis: in-stent restenosis assessment by low-dose MDCT.

OBJECTIVES: The accuracy of computed tomography (CT) for assessment of coronary stents is as yet unproven and radiation exposure has been a concern. The aim of our study is to compare radiation dose and diagnostic performance of CT with prospective ECG-triggering versus retrospective ECG-triggering for the detection of in-stent restenosis (ISR). METHODS: We enrolled 168 consecutive patients with suspected ISR, 83 studied using CT with prospective ECG-triggering (group 1) and 85 using retrospective ECG-triggering (group 2). RESULTS: Prevalence of ISR according to catheter angiography was 24% in both groups. The overall evaluability was similar (93% in group 1 vs 95% in group 2). Artefact sub-analysis showed a significantly lower number of blooming and higher number of slice misalignment in group 1 vs group 2. In the stent-based analysis using only evaluable stents, specificity, positive predictive value and accuracy were significantly higher in group 1 (100%, 100% and 99%, respectively) than in group 2 (97%, 91% and 95%, respectively, p < 0.05). Group 1 was exposed to a lower radiation dose compared with group 2 (4.3 ± 1.4 mSv vs 18.5 ± 5.5 mSv, p < 00.1). CONCLUSIONS: CT with prospective ECG-triggering can improve diagnostic accuracy of non-invasive imaging of coronary stents with a significant reduction in radiation exposure.

Comparison of the diagnostic performance of 64-slice computed tomography coronary angiography in diabetic and non-diabetic patients with suspected coronary artery disease.

BACKGROUND: Diabetics have high prevalence of subclinical coronary artery disease (CAD) with typical characteristics (diffuse disease, large calcifications). Although 64-slice multidetector computed tomography (MDCT) coronary angiography has high diagnostic accuracy to detect CAD, its diagnostic performance in diabetics with suspected CAD is unknown. To compare the diagnostic performance of 64-slice MDCT between diabetics and non-diabetics with suspected CAD scheduled for invasive coronary angiography (ICA). METHODS: We enrolled one hundred and five diabetic patients (92 men, age 65 +/- 9 years, Group 1) and 105 non-diabetic patients (63 men, age 63+/-5 years, Group 2) with indication to ICA for suspected CAD undergoing coronary 64-slice MDCT before ICA. RESULTS: In Group 1, the overall feasibility of coronary artery visualization was 93.8%. The most frequent artifact was blooming due to large coronary calcifications (54 artifacts, 67%). In Group 2, the overall feasibility was significantly higher vs. Group 1 (97%, p < 0.0001). In Group 1, the segment-based analysis showed a MDCT sensibility, specificity, positive predictive value, negative predictive value and accuracy for the detection of ≥50% luminal narrowing of 77%, 90%, 70%, 93% and 87%, respectively. In Group 2, all these parameters were significantly higher vs. Group 1. In the patient-based analysis, specificity, negative predictive value and accuracy were significantly lower in Group 1 vs. Group 2. CONCLUSIONS: Although MDCT has high sensitivity for early identification of significant CAD in diabetics, its diagnostic performance is significantly reduced in these patients as compared to non-diabetics with similar clinical characteristics.

Trastuzumab-induced cardiotoxicity: clinical and prognostic implications of troponin I evaluation.

PURPOSE: Treatment of breast cancer with trastuzumab is complicated by cardiotoxicity in up to 34% of the patients. In most patients, trastuzumab-induced cardiotoxicity (TIC) is reversible: left ventricular ejection fraction (LVEF) improves after trastuzumab withdrawal and with, or sometimes without, initiation of heart failure (HF) therapy. The reversibility of TIC, however, is not foreseeable, and identification of patients at risk and of those who will not recover from cardiac dysfunction is crucial. The usefulness of troponin I (TNI) in the identification of patients at risk for TIC and in the prediction of LVEF recovery has never been investigated. PATIENTS AND METHODS: In total, 251 women were enrolled. TNI was measured before and after each trastuzumab cycle. LVEF was evaluated at baseline, every 3 months during trastuzumab therapy, and every 6 months afterward. In case of TIC, trastuzumab was discontinued, and HF treatment with enalapril and carvedilol was initiated. TIC was defined as LVEF decrease of > 10 units and below 50%. Recovery from TIC was defined as LVEF increase above 50%. RESULTS: TIC occurred in 42 patients (17%) and was more frequent in patients with TNI elevation (TNI+; 62% v 5%; P < .001). Twenty-five patients (60%) recovered from TIC. LVEF recovery occurred less frequently in TNI+ patients (35% v 100%; P < .001). At multivariate analysis, TNI+ was the only independent predictor of TIC (hazard ratio [HR], 22.9; 95% CI, 11.6 to 45.5; P < .001) and of lack of LVEF recovery (HR, 2.88; 95% CI,1.78 to 4.65; P < .001). CONCLUSION: TNI+ identifies trastuzumab-treated patients who are at risk for cardiotoxicity and are unlikely to recover from cardiac dysfunction despite HF therapy.

Additional clinical role of 64-slice multidetector computed tomography in the evaluation of coronary artery variants and anomalies.

It is unknown whether multidetector computed tomography (MDCT) has an additional clinical value compared to invasive coronary angiography (ICA) in the characterization of congenital coronary artery anomalies (CAA). We studied 2757 consecutive patients with 64-slice MDCT and classified CAA according to anatomical criteria and pathophysiology-clinical relevance. The prevalence of anatomical variants was: left dominance circulation (8%), absence of left main artery (1.3%), presence of intermediate ramus (22.6%), origin of conus branch from aorta (10.6%) and of the sinus node branch from the left circumflex coronary artery (15.3%). Among 380 CAA (13.8 %) detected with MDCT, 322 (85%) were an occasional finding. In the remaining 58 patients, MDCT performed after ICA confirmed CAA in 40 (69%) cases and detected or provided additional and more detailed informations in 18 (31%). Of these 18 patients, 14 showed malignant CAA. MDCT is the ideal method for the evaluation of CAA, not only allowing a precise anatomic visualization of coronary tree, but also adding important details in malignant congenital anomalies.

Imaging of cardiac venous system in patients with dilated cardiomyopathy by 64-slice computed tomography: comparison between non-ischemic and ischemic etiology.

It is unknown whether dilated cardiomyopathy (DCM) etiology influences cardiac veins (CVs) anatomy. By multidetector computed tomography (MDCT) we studied CVs of 93 patients with normal cardiac function (Group1) and of 99 DCM patients. In the latter we used a standard scanning coronary artery protocol (Group2, n=62) or a protocol specifically tailored to assess CVs in DCM (Group3, n=37). We also performed in all patients invasive coronary angiography. Group 1 had more CVs (83%) vs. DCM patients (72% and 76% in Groups 2 and 3 respectively, p<0.05). Group 2 had a higher percentage of CVs with insufficient imaging quality score (43 out of 224 veins, 19%) vs. Group 1 (6%, p<0.01) and Group 3 (11%, p<0.05) mainly due to low signal/noise ratio (32 out of 43 veins, 74%). Ischemic DCM patients had a lower CVs number (86/135, 64%) vs. both Group 1 patients and vs. non-ischemic DCM. Therefore MDCT is feasible for assessing CVs in DCM using scanning CVs tailored protocols. Ischemic DCM patients have a lower number of CVs compared to normal systolic function or non-ischemic DCM patients.

Sixty-four-slice multidetector computed tomography: an accurate imaging modality for the evaluation of coronary arteries in dilated cardiomyopathy of unknown etiology.

BACKGROUND: The goal of this study was to assess the safety, feasibility, and diagnostic accuracy of 64-slice multidetector computed tomography (MDCT) for the evaluation of coronary arteries in dilated cardiomyopathy (DCM) of unknown etiology. Sixteen-slice MDCT is useful in patients affected by DCM. However, technical limitations, such as cardiac arrhythmias, an inability of patients to sustain a long breath-hold, and the need of a high dose of contrast agent may limit its accuracy and widespread use. METHODS AND RESULTS: Invasive coronary angiography (ICA) and MDCT coronary angiography were performed on 132 consecutive patients (82 men; age 63+/-11 years) affected by DCM (ejection fraction, 34+/-10%) of unknown etiology. In 2 patients (1.5%), MDCT was not feasible because of atrial fibrillation. Of the remaining 130 patients, 88 exhibited normal and 42 exhibited diseased coronary arteries in both MDCT and ICA. All patients with coronary artery disease except for 1 were correctly classified by MDCT as 1-vessel (11 cases), 2-vessel (13 cases), and 3-vessel (18 cases) disease. In the segment-based analyses, the overall feasibility for MDCT was 98.5% (1902 of 1930 segments). Segment-based and patient-based analyses for the detection of luminal stenosis of >50% and >70% were performed. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MDCT for the detection of >50% stenosis were 98.1%, 99.9%, 98.7%, 99.8%, and 99.7%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MDCT for the detection of >70% stenosis were 99.5%, 98.6%, 94.1%, 99.9%, and 99.4%, respectively. CONCLUSIONS: Excellent feasibility and diagnostic accuracy, combined with low invasiveness, make 64-slice MDCT an ideal imaging modality for the anatomic evaluation of coronary circulation in patients with DCM of unknown etiology.

Diagnostic accuracy of coronary computed tomography angiography: a comparison between prospective and retrospective electrocardiogram triggering.

OBJECTIVES: The aim of this study was to compare the diagnostic performance of multidetector computed tomography (MDCT) with prospective electrocardiogram (ECG) triggering versus retrospective ECG triggering. BACKGROUND: MDCT allows the noninvasive visualization of the coronary arteries. However, radiation exposure is a reason for concern. METHODS: One hundred eighty consecutive patients scheduled for invasive coronary angiography were enrolled in this study. Twenty patients were excluded due to contraindications to sustain MDCT. Of the 160 remaining patients, 80 were studied with MDCT with prospective ECG triggering (Group 1) and 80 with a retrospective ECG triggering (Group 2). The individual radiation dose exposure was estimated. RESULTS: In nonstented segments, the evaluability of Groups 1 and 2 was 96% versus 97%, respectively (p = 0.05), the accuracy in segment-based model was 93% versus 96%, respectively (p < 0.05) including diagnostic segments and 91% versus 94%, respectively (p < 0.01) including all segments, whereas the accuracy in a patient-based model was 98% in both groups. In stented segments the evaluability in Groups 1 and 2 was 92% versus 94%, respectively, and the accuracy was 93% versus 92%, respectively, including diagnostic stented segments and 90% versus 89%, respectively, including all stented segments. Group 1 presented lower radiation dose compared with Group 2 (5.7 +/- 1.5 mSv vs. 20.5 +/- 4.3 mSv, p < 0.01). CONCLUSIONS: Prospective ECG-triggering computed tomography allows an accurate detection of coronary stenosis, despite a slight reduction of diagnostic performance, with a low radiation dose.