Computed tomography and scintigraphy vs. cardiac catheterization for coronary disease screening prior to noncardiac surgery.

OBJECTIVE: The goal of this study was to investigate the utility of multidetector-row computed tomography (MDCT) and adenosine triphosphate stress cardiac single photon emission computed tomography (ATP-SPECT) in evaluating coronary artery disease (CAD) in patients scheduled for non-cardiac surgery. PATIENTS AND METHODS: We routinely performed echocardiography and exercise stress electrocardiography as preoperative cardiac screening examinations for patients scheduled for non-cardiac surgery under general anesthesia. Of 848 consecutive preoperative patients (Non-invasive Group), 49 patients with abnormalities of these screening examinations had MDCT and ATP-SPECT. Of 809 consecutive preoperative patients studied at an earlier time (Invasive Group), 58 patients with abnormalities of these screening examinations had cardiac catheterization as an additional cardiac examination. RESULTS: The number of patients in the non-invasive and invasive subgroups having additional screening examinations was comparable, and there was no significant difference in perioperative cardiac events between the two subgroups. Based on results of the additional tests in the two subgroups, preoperative prophylactic invasive treatment for CAD was carried out in a small number of patients, again with no significant differences between the groups. However, total medical expenses for the additional cardiac examinations were significantly reduced in the non-invasive subgroup compared with the invasive subgroup (140,030+/-34,800 vs. 187,170+/-26,120 yen, respectively, p=0.0002). CONCLUSION: Non-invasive examination prior to noncardiac surgery using MDCT and ATP-SPECT in a subgroup of patients suspected of having CAD appears to be a useful screening procedure. Compared with invasive cardiac catheterization, CT testing has comparable diagnostic utility without an increase in perioperative cardiac events, and in addition, it has an improved cost-benefit profile.

Quadricuspid aortic valve illustrated by 64-slice multidetector computed tomography: Surgical treatment of a rare cause of severe aortic regurgitation.

The quadricuspid aortic valve (QAV) is a rare congenital malformation that usually presents with aortic regurgitation (AR). The first case was reported in 1862. Most cases were diagnosed at the time of surgery or postmortem examination. With advances in imaging techniques, more cases have been diagnosed before surgery. We describe a 59-year-old man whose QAV had not been noted until the current admission. Transthoracic echocardiography revealed dilation of the left ventricle, severe AR, and suspected QAV. The QAV was confirmed by transesophageal echocardiography and 64-slice multidetector computed tomography. This case was a QAV with three equal cusps and one smaller cusp (type B in Hurwitz and Roberts classification). Because the cardiac catheterization and aortography showed severe AR and a QAV, the patient underwent elective surgery. The surgery consisted of replacing the QAV by a mechanical prosthesis. There were no post-operative complications. The patient revealed no symptoms in the post-operative 7 months.

Transcatheter coil embolization of coronary artery fistulas.

Congenital coronary artery fistulas (CAFs), which have been known since 1865, are rare congenital cardiac abnormalities. Most of the CAFs are discovered incidentally during coronary angiography. We described our experience with successful transcatheter coil embolization of CAFs in an adult, leading to improvement of symptoms. The patient had chest pain or dyspnea on exertion. The CAFs originated from the left anterior descending coronary artery and the circumflex artery. They all drained into the pulmonary trunk. The coils were implanted through a microcatheter, which was passed through a 7F guiding catheter. The coils were used to occlude the CAFs completely. The procedures were uncomplicated. Patient's chest pain or dyspnea resolved after the procedures. Although the patient had small residual flow at the CAFs from the circumflex artery at follow-up coronary angiography, the patient was asymptomatic. Therefore, we considered the coil embolization to be successful. Transcatheter closure of CAFs with coil is a valid option, and can be regarded as an acceptable alternative to surgery nowadays.