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1
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Mushtaq S, Fazzari F, Mancini ME, Pontone G. The era of interventional imaging has arrived: what role for computed tomography and magnetic resonance? Eur Heart J Suppl 2025; 27:i22-i26. [PMID: 39980793 PMCID: PMC11836692 DOI: 10.1093/eurheartjsupp/suae112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2025]
Abstract
Coronary computed tomography angiography (CCTA) is the first-line investigation test to 'rule out' significant coronary artery disease in low-risk patients. By performing blood flow simulations using computational fluid dynamics, it is possible to derive fractional flow reserve (FFR) from CCTA (FFRCT) images. Coronary computed tomography angiography and FFRCT are now utilized in higher-risk patients to choose the revascularization mode. Furthermore, new applications of CCTA and FFRCT include a planning tool for percutaneous coronary intervention (PCI), which allows the cardiologist to assess lesion-specific ischaemia, plan stent locations and sizes, and use virtual remodelling of the lumen (virtual stenting) to assess the functional impact of PCI. Moreover, CCTA can assist in planning surgical and percutaneous revascularization by determining the disease complexity, vessel size, lesion length, and tissue composition of the atherosclerotic plaque, as well as the best fluoroscopic viewing angle; it may also help in selecting adjunctive percutaneous devices (e.g. rotational atherectomy) and in determining the best landing zone for stents or bypass grafts. Coronary computed tomography angiography has become also the gold standard for pre-procedural annular assessment, device sizing, risk determination of annular injury, coronary occlusion or left ventricular outflow tract obstruction, calcification visualization and quantification of the target structure, and prediction of a co-planar fluoroscopic angulation for transcatheter interventions in patients with structural heart disease. Coronary computed tomography angiography and cardiac magnetic resonance could be used also in electrophysiology procedures of atrial fibrillation and ventricular arrhythmias ablation (imaging during clinical evaluation and pre-procedural evaluation and intra-procedural live integration). The era of interventional imaging has arrived, and it is based on the cooperation of different figures with specific competences (cardio-imagers, electrophysiologists, cardiac surgeons, and invasive cardiologists).
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Affiliation(s)
- Saima Mushtaq
- Perioperative Cardiology and Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Via C. Parea 4, Milan 20138, Italy
- BiND Department: Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo 90088, Italy
| | - Fabio Fazzari
- Perioperative Cardiology and Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Via C. Parea 4, Milan 20138, Italy
- BiND Department: Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, Palermo 90088, Italy
| | - Maria Elisabetta Mancini
- Perioperative Cardiology and Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Via C. Parea 4, Milan 20138, Italy
| | - Gianluca Pontone
- Perioperative Cardiology and Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Via C. Parea 4, Milan 20138, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan 20100, Italy
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2
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Beneki E, Dimitriadis K, Pyrpyris N, Antonopoulos A, Aznaouridis K, Antiochos P, Fragoulis C, Lu H, Meier D, Tsioufis K, Fournier S, Aggeli C, Tzimas G. Computed Tomography Angiography in the Catheterization Laboratory: A Guide Towards Optimizing Coronary Interventions. J Cardiovasc Dev Dis 2025; 12:28. [PMID: 39852306 PMCID: PMC11766008 DOI: 10.3390/jcdd12010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2024] [Revised: 01/04/2025] [Accepted: 01/10/2025] [Indexed: 01/26/2025] Open
Abstract
Cardiac computed tomography (CT) has become an essential tool in the pre-procedural planning and optimization of coronary interventions. Its non-invasive nature allows for the detailed visualization of coronary anatomy, including plaque burden, vessel morphology, and the presence of stenosis, aiding in precise decision making for revascularization strategies. Clinicians can assess not only the extent of coronary artery disease but also the functional significance of lesions using techniques like fractional flow reserve (FFR-CT). By providing comprehensive insights into coronary structure and hemodynamics, cardiac CT helps guide personalized treatment plans, ensuring the more accurate selection of patients for percutaneous coronary interventions or coronary artery bypass grafting and potentially improving patient outcomes.
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Affiliation(s)
- Eirini Beneki
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (E.B.); (N.P.); (A.A.); (K.A.); (C.F.); (K.T.); (C.A.)
| | - Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (E.B.); (N.P.); (A.A.); (K.A.); (C.F.); (K.T.); (C.A.)
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (E.B.); (N.P.); (A.A.); (K.A.); (C.F.); (K.T.); (C.A.)
| | - Alexios Antonopoulos
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (E.B.); (N.P.); (A.A.); (K.A.); (C.F.); (K.T.); (C.A.)
| | - Konstantinos Aznaouridis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (E.B.); (N.P.); (A.A.); (K.A.); (C.F.); (K.T.); (C.A.)
| | - Panagiotis Antiochos
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (H.L.); (D.M.); (S.F.); (G.T.)
| | - Christos Fragoulis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (E.B.); (N.P.); (A.A.); (K.A.); (C.F.); (K.T.); (C.A.)
| | - Henri Lu
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (H.L.); (D.M.); (S.F.); (G.T.)
| | - David Meier
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (H.L.); (D.M.); (S.F.); (G.T.)
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (E.B.); (N.P.); (A.A.); (K.A.); (C.F.); (K.T.); (C.A.)
| | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (H.L.); (D.M.); (S.F.); (G.T.)
| | - Constantina Aggeli
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (E.B.); (N.P.); (A.A.); (K.A.); (C.F.); (K.T.); (C.A.)
| | - Georgios Tzimas
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; (P.A.); (H.L.); (D.M.); (S.F.); (G.T.)
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3
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Ozaki Y, Kitabata H, Takahata M, Katayama Y, Wada T, Hikida R, Taruya A, Shiono Y, Kuroi A, Yamano T, Tanimoto T, Tanaka A. Intracoronary Near-Infrared Spectroscopy to Predict No-Reflow Phenomenon During Percutaneous Coronary Intervention in Acute Coronary Syndrome. Am J Cardiol 2024; 219:17-24. [PMID: 38490338 DOI: 10.1016/j.amjcard.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/05/2024] [Accepted: 03/03/2024] [Indexed: 03/17/2024]
Abstract
Near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) can identify the lipid-rich lesions, described as high lipid-core burden index (LCBI). The aim of this study was to investigate the relation between lipid-core plaque (LCP) in the infarct-related lesion detected using NIRS-IVUS and no-reflow phenomenon during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). We investigated 371 patients with ACS who underwent NIRS-IVUS in the infarct-related lesions before PCI. The extent of LCP in the infarct-related lesion was calculated as the maximum LCBI for each of the 4-mm longitudinal segments (maxLCBI4mm) measured by NIRS-IVUS. The patients were divided into 2 groups using a maxLCBI4mm cut-off value of 400. The overall incidence of no-reflow phenomenon was 53 of 371 (14.3%). No-reflow phenomenon more frequently occurred in patients with maxLCBI4mm ≥400 compared with those with maxLCBI4mm<400 (17.5% vs 2.5%, p <0.001). After propensity score matching, multivariable logistic regression analysis demonstrated that maxLCBI4mm (odds ratio: 1.008; 95% confidence interval: 1.005 to 1.012, p <0.001) was independently associated with the no-reflow phenomenon. The maxLCBI4mm of 719 in the infarct-related lesion had the highest combined sensitivity (69.8%) and specificity (72.1%) for the identification of no-reflow phenomenon. In conclusion, in patients with ACS, maxLCBI4mm in the infarct-related lesion assessed by NIRS-IVUS was independently associated with the no-reflow phenomenon during PCI.
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Affiliation(s)
- Yuichi Ozaki
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan.
| | - Hironori Kitabata
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masahiro Takahata
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yosuke Katayama
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Teruaki Wada
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ryo Hikida
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Akira Taruya
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Akio Kuroi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Yamano
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takashi Tanimoto
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
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Yamamoto T, Kawamori H, Toba T, Sasaki S, Fujii H, Hamana T, Osumi Y, Iwane S, Naniwa S, Sakamoto Y, Matsuhama K, Fukuishi Y, Hirata K, Otake H. Impact of Pericoronary Adipose Tissue Attenuation on Periprocedural Myocardial Injury in Patients With Chronic Coronary Syndrome. J Am Heart Assoc 2024; 13:e031209. [PMID: 38240235 PMCID: PMC11056154 DOI: 10.1161/jaha.123.031209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 11/15/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Perivascular inflammation contributes to the development of atherosclerosis and microcirculatory dysfunction. Pericoronary adipose tissue (PCAT) attenuation, measured by coronary computed tomography angiography, is a potential indicator of coronary inflammation. However, the relationship between PCAT attenuation, microcirculatory dysfunction, and periprocedural myocardial injury (PMI) remains unclear. METHODS AND RESULTS Patients with chronic coronary syndrome who underwent coronary computed tomography angiography before percutaneous coronary intervention were retrospectively identified. PCAT attenuation and adverse plaque characteristics were assessed using coronary computed tomography angiography. The extent of microcirculatory dysfunction was evaluated using the angio-based index of microcirculatory resistance before and after percutaneous coronary intervention. Overall, 125 consecutive patients were included, with 50 experiencing PMI (PMI group) and 75 without PMI (non-PMI group). Multivariable analysis showed that older age, higher angio-based index of microcirculatory resistance, presence of adverse plaque characteristics, and higher lesion-based PCAT attenuation were independently associated with PMI occurrence (odds ratio [OR], 1.07 [95% CI, 1.01-1.13]; P=0.02; OR, 1.06 [95% CI, 1.00-1.12]; P=0.04; OR, 6.62 [95% CI, 2.13-20.6]; P=0.001; and OR, 2.89 [95% CI, 1.63-5.11]; P<0.001, respectively). High PCAT attenuation was correlated with microcirculatory dysfunction before and after percutaneous coronary intervention and its exacerbation during percutaneous coronary intervention. Adding lesion-based PCAT attenuation to the presence of adverse plaque characteristics improved the discriminatory and reclassification ability in predicting PMI. CONCLUSIONS Adding PCAT attenuation at the culprit lesion level to coronary computed tomography angiography-derived adverse plaque characteristics may provide incremental benefit in identifying patients at risk of PMI. Our results highlight the importance of microcirculatory dysfunction in PMI development, particularly in the presence of lesions with high PCAT attenuation. REGISTRATION URL: https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000057722; Unique identifier: UMIN000050662.
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Affiliation(s)
- Tetsuya Yamamoto
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Hiroyuki Kawamori
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Takayoshi Toba
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Satoru Sasaki
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Hiroyuki Fujii
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Tomoyo Hamana
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yuto Osumi
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Seigo Iwane
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Shota Naniwa
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yuki Sakamoto
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Koshi Matsuhama
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yuta Fukuishi
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Ken‐ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Hiromasa Otake
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
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5
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Ohashi H, Bouisset F, Buytaert D, Seki R, Sonck J, Sakai K, Belmonte M, Kitslaar P, Updegrove A, Amano T, Andreini D, De Bruyne B, Collet C. Coronary CT Angiography in the Cath Lab: Leveraging Artificial Intelligence to Plan and Guide Percutaneous Coronary Intervention. Interv Cardiol 2023; 18:e26. [PMID: 38125928 PMCID: PMC10731535 DOI: 10.15420/icr.2023.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/15/2023] [Indexed: 12/23/2023] Open
Abstract
The role of coronary CT angiography for the diagnosis and risk stratification of coronary artery disease is well established. However, its potential beyond the diagnostic phase remains to be determined. The current review focuses on the insights that coronary CT angiography can provide when planning and performing percutaneous coronary interventions. We describe a novel approach incorporating anatomical and functional pre-procedural planning enhanced by artificial intelligence, computational physiology and online 3D CT guidance for percutaneous coronary interventions. This strategy allows the individualisation of patient selection, optimisation of the revascularisation strategy and effective use of resources.
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Affiliation(s)
- Hirofumi Ohashi
- Cardiovascular Center OLVAalst, Belgium
- Department of Cardiology, Aichi Medical UniversityAichi, Japan
| | - Frédéric Bouisset
- Cardiovascular Center OLVAalst, Belgium
- Department of Cardiology, Toulouse University HospitalToulouse, France
| | | | | | | | - Koshiro Sakai
- Cardiovascular Center OLVAalst, Belgium
- Department of Cardiology, Showa University HospitalTokyo, Japan
| | - Marta Belmonte
- Cardiovascular Center OLVAalst, Belgium
- Department of Advanced Biomedical Sciences, University Federico IINaples, Italy
| | | | | | - Tetsuya Amano
- Department of Cardiology, Aichi Medical UniversityAichi, Japan
| | - Daniele Andreini
- Division of Cardiology and Cardiac Imaging, IRCCS Ospedale Galeazzi – Sant’AmbrogioMilan, Italy
- Department of Biomedical and Clinical Sciences, University of MilanMilan, Italy
| | - Bernard De Bruyne
- Cardiovascular Center OLVAalst, Belgium
- Department of Cardiology, University Hospital of LausanneLausanne, Switzerland
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6
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Andreini D, Collet C, Leipsic J, Nieman K, Bittencurt M, De Mey J, Buls N, Onuma Y, Mushtaq S, Conte E, Bartorelli AL, Stefanini G, Sonck J, Knaapen P, Ghoshhajra B, Serruys PW. Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography. EUROINTERVENTION 2022; 18:e872-e887. [PMID: 35994043 PMCID: PMC9743242 DOI: 10.4244/eij-e-22-00036] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/05/2022] [Indexed: 12/12/2022]
Abstract
Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.
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Affiliation(s)
- Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | | | - Jonathon Leipsic
- St Paul's Hospital & University of British Columbia, Vancouver, British Columbia Vancouver, Canada
| | - Koen Nieman
- Stanford University School of Medicine, Departments of Medicine and Radiology, USA
| | - Marcio Bittencurt
- Division of Internal Medicine, University Hospital, University of São Paulo, São Paulo, Brazil
- DASA, São Paulo, Brazil
- Division of Cardiology and the Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - Johan De Mey
- Department of Radiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
| | - Nico Buls
- Department of Radiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
| | - Yoshinobu Onuma
- Clinical Science Institute, National University of Ireland, Galway, Ireland
| | | | - Edoardo Conte
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Antonio L Bartorelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLVZ Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples, Federico II, Naples, Italy
| | - Paul Knaapen
- Vrije Universiteit Medical Center, Amsterdam, Netherlands
| | - Brian Ghoshhajra
- Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Patrick W Serruys
- Clinical Science Institute, National University of Ireland, Galway, Ireland
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7
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Andreini D, Collet C, Leipsic J, Nieman K, Bittencurt M, De Mey J, Buls N, Onuma Y, Mushtaq S, Conte E, Bartorelli AL, Stefanini G, Sonck J, Knaapen P, Ghoshhajra B, Serruys P. Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2022; 16:558-572. [PMID: 36008263 DOI: 10.1016/j.jcct.2022.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 06/07/2022] [Accepted: 08/05/2022] [Indexed: 10/15/2022]
Abstract
Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.
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Affiliation(s)
- Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy.
| | | | - Jonathon Leipsic
- St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Vancouver, Canada
| | - Koen Nieman
- Stanford University School of Medicine, Departments of Medicine and Radiology, USA
| | - Marcio Bittencurt
- Division of Internal Medicine, University Hospital, University of São Paulo, São Paulo, Brazil; DASA, São Paulo, Brazil; Division of Cardiology and the Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
| | - Johan De Mey
- Department of Radiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
| | - Nico Buls
- Department of Radiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
| | - Yoshinobu Onuma
- Clinical Science Institute, National University of Ireland, Galway, Ireland
| | | | - Edoardo Conte
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Antonio L Bartorelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLVZ Aalst, Belgium; Department of Advanced Biomedical Sciences, University of Naples, Federico II, Naples, Italy
| | - Paul Knaapen
- Vrije Universiteit Medical Center, Amsterdam, Netherlands
| | - Brian Ghoshhajra
- Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Patrick Serruys
- Clinical Science Institute, National University of Ireland, Galway, Ireland
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8
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Mair J, Jaffe A, Lindahl B, Mills N, Möckel M, Cullen L, Giannitsis E, Hammarsten O, Huber K, Krychtiuk K, Mueller C, Thygesen K. The clinical approach to diagnosing peri-procedural myocardial infarction after percutaneous coronary interventions according to the fourth universal definition of myocardial infarction - from the study group on biomarkers of the European Society of Cardiology (ESC) Association for Acute CardioVascular Care (ACVC). Biomarkers 2022; 27:407-417. [PMID: 35603440 PMCID: PMC9344934 DOI: 10.1080/1354750x.2022.2055792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/15/2022] [Indexed: 12/05/2022]
Abstract
PURPOSE This review intends to illustrate basic principles on how to apply the Fourth Universal Definition of Myocardial Infarction (UDMI) for the diagnosis of peri-procedural myocardial infarction (MI) after percutaneous coronary interventions (PCI) in clinical practice. METHODS AND RESULTS Review of routine case-based events. Increases in cardiac troponin (cTn) concentrations are common after elective PCI in patients with chronic coronary syndrome (CCS). Peri-procedural PCI-related MI (type 4a MI) in CCS patients should be diagnosed in cases of major peri-procedural acute myocardial injury indicated by an increase in cTn concentrations of >5-times the 99th percentile upper reference limit (URL) together with evidence of new peri-procedural myocardial ischaemia as demonstrated by electrocardiography (ECG), imaging, or flow-limiting peri-procedural complications in coronary angiography. Measurement of cTn baseline concentrations before elective PCI is useful. In patients presenting with acute MI undergoing PCI, peri-procedural increases in cTn concentrations are usually due to their index presentation and not PCI-related, apart from obvious major peri-procedural complications, such as persistent occlusion of a large side branch or no-reflow after stent implantation. CONCLUSION The distinction between type 4a MI, PCI-related acute myocardial injury, and chronic myocardial injury can be challenging in individuals undergoing PCI. Careful integration of all available clinical data is essential for correct classification.
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Affiliation(s)
- Johannes Mair
- Department of Internal Medicine III – Cardiology and Angiology, Heart Center, Medical University Innsbruck, Innsbruck, Austria
| | - Allan Jaffe
- Mayo Clinic and Medical School, Rochester, MN, USA
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Nicholas Mills
- University/BHF Centre for Cardiovascular Science and Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Martin Möckel
- Division of Emergency Medicine and Department of Cardiology, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Louise Cullen
- Emergency and Trauma Center, Royal Brisbane and Women`s Hospital, University of Queensland, Queensland, Australia
| | - Evangelos Giannitsis
- Medizinische Klinik III, Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Ola Hammarsten
- Department of Clinical Chemistry and Transfusion Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University Medical School, Vienna, Austria
| | - Konstantin Krychtiuk
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Kristian Thygesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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9
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Carrabba N, Pontone G, Andreini D, Buffa V, Cademartiri F, Carbone I, Clemente A, Guaricci AI, Guglielmo M, Indolfi C, La Grutta L, Ligabue G, Liguori C, Mercuro G, Mushtaq S, Neglia D, Palmisano A, Sciagrà R, Seitun S, Vignale D, Francone M, Esposito A. Appropriateness criteria for the use of cardiac computed tomography, SIC-SIRM part 2: acute chest pain evaluation; stent and coronary artery bypass graft patency evaluation; planning of coronary revascularization and transcatheter valve procedures; cardiomyopathies, electrophysiological applications, cardiac masses, cardio-oncology and pericardial diseases evaluation. J Cardiovasc Med (Hagerstown) 2022; 23:290-303. [PMID: 35486680 DOI: 10.2459/jcm.0000000000001303] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the past 20 years, cardiac computed tomography (CCT) has become a pivotal technique for the noninvasive diagnostic workup of coronary and cardiac diseases. Continuous technical and methodological improvements, combined with fast growing scientific evidence, have progressively expanded the clinical role of CCT. Randomized clinical trials documented the value of CCT in increasing the cost-effectiveness of the management of patients with acute chest pain presenting in the emergency department, also during the pandemic. Beyond the evaluation of stents and surgical graft patency, the anatomical and functional coronary imaging have the potential to guide treatment decision-making and planning for complex left main and three-vessel coronary disease. Furthermore, there has been an increasing demand to use CCT for preinterventional planning in minimally invasive procedures, such as transcatheter valve implantation and mitral valve repair. Yet, the use of CCT as a roadmap for tailored electrophysiological procedures has gained increasing importance to assure maximum success. In the meantime, innovations and advanced postprocessing tools have generated new potential applications of CCT from the simple coronary anatomy to the complete assessment of structural, functional and pathophysiological biomarkers of cardiac disease. In this complex and revolutionary scenario, it is urgently needed to provide an updated guide for the appropriate use of CCT in different clinical settings. This manuscript, endorsed by the Italian Society of Cardiology (SIC) and the Italian Society of Medical and Interventional Radiology (SIRM), represents the second of two consensus documents collecting the expert opinion of cardiologists and radiologists about current appropriate use of CCT.
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Affiliation(s)
- Nazario Carrabba
- Department of Cardiothoracovascular Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence
| | | | - Daniele Andreini
- Centro Cardiologico Monzino IRCCS.,Department of Clinical Sciences and Community Health, University of Milan, Milan
| | - Vitaliano Buffa
- Department of Radiology, Azienda Ospedaliera San Camillo Forlanini, Rome
| | | | - Iacopo Carbone
- Department of Radiological, Oncological and Pathological Sciences, 'Sapienza' University of Rome, Rome
| | - Alberto Clemente
- Department of Radiology, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Massa
| | - Andrea Igoren Guaricci
- University Cardiology Unit, Cardiothoracic Department, Policlinic University Hospital, Bari
| | | | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro
| | - Ludovico La Grutta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties-ProMISE, University of Palermo
| | - Guido Ligabue
- Department of Medical and Surgical Sciences, Modena and Raggio Emilia University.,Radiology Department, AOU of Modena, Modena
| | - Carlo Liguori
- Radiology Unit, Ospedale del Mare -A.S.L Na1- Centro, Naples
| | - Giuseppe Mercuro
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari
| | | | - Danilo Neglia
- Cardiovascular Department, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Pisa
| | - Anna Palmisano
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
| | - Roberto Sciagrà
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences 'Mario Serio', University of Florence, Florence
| | - Sara Seitun
- Radiology Department, Ospedale Policlinico San Martino, IRCCS Per L'Oncologia e le Neuroscienze, Genoa, Italy
| | - Davide Vignale
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
| | - Marco Francone
- Department of Radiological, Oncological and Pathological Sciences, 'Sapienza' University of Rome, Rome
| | - Antonio Esposito
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
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10
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Tzimas G, Gulsin GS, Takagi H, Mileva N, Sonck J, Muller O, Leipsic JA, Collet C. Coronary CT Angiography to Guide Percutaneous Coronary Intervention. Radiol Cardiothorac Imaging 2022; 4:e210171. [PMID: 35782760 PMCID: PMC8893214 DOI: 10.1148/ryct.210171] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 11/08/2021] [Accepted: 11/22/2021] [Indexed: 05/03/2023]
Abstract
Coronary CT angiography (CCTA) has emerged as a powerful noninvasive tool for characterizing the presence, extent, and severity of coronary artery disease (CAD) in patients with stable angina. Recent technological advancements in CT scanner hardware and software have augmented the rich information that can be derived from a single CCTA study. Beyond merely identifying the presence of CAD and assessing stenosis severity, CCTA now allows for the identification and characterization of plaques, lesion length, and fluoroscopic angle optimization, as well as enables the assessment of the physiologic extent of stenosis through CT-derived fractional flow reserve, and may even allow for the prediction of the response to revascularization. These and other features make CCTA capable of not only guiding invasive coronary angiography referral, but also give it the unique ability to help plan coronary intervention. This review summarizes current and future applications of CCTA in procedural planning for percutaneous coronary intervention, provides rationale for wider integration of CCTA in the workflow of the interventional cardiologist, and details how CCTA may help improve patient care and clinical outcomes. Keywords: CT Angiography © RSNA, 2022.
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Affiliation(s)
- Georgios Tzimas
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Gaurav S. Gulsin
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Hidenobu Takagi
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Niya Mileva
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Jeroen Sonck
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Olivier Muller
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Jonathon A. Leipsic
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
| | - Carlos Collet
- From the Department of Medicine and Radiology, University of British
Columbia, 1081 Burrard St, Vancouver, BC, Canada V6T 1Z4 (G.T., G.S.G., H.T.,
J.A.L.); Department of Heart Vessels, Cardiology Service, Lausanne University
Hospital and University of Lausanne, Lausanne, Switzerland (G.T., O.M.);
University of Leicester and the Leicester NIHR Biomedical Research Centre,
Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, England
(G.S.G.); Department of Diagnostic Radiology, Tohoku University Hospital,
Sendai, Japan (H.T.); Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
(N.M., J.S., C.C.); and Department of Advanced Biomedical Sciences, Federico II
University, Naples, Italy (J.S.)
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11
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Implementing Coronary Computed Tomography Angiography in the Catheterization Laboratory. JACC Cardiovasc Imaging 2021; 14:1846-1855. [DOI: 10.1016/j.jcmg.2020.07.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 01/05/2023]
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12
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Prevention of distal embolization during directional coronary atherectomy. J Cardiol Cases 2020; 21:213-216. [DOI: 10.1016/j.jccase.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 02/12/2020] [Indexed: 11/23/2022] Open
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13
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Mizukami T, Tanaka K, Sonck J, Vandeloo B, Roosens B, Lochy S, Argacha JF, Schoors D, Suzuki H, Belsack D, Andreini D, Barbato E, De Mey J, De Bruyne B, Cosyns B, Collet C. Evaluation of epicardial coronary resistance using computed tomography angiography: A Proof of Concept. J Cardiovasc Comput Tomogr 2020; 14:177-184. [DOI: 10.1016/j.jcct.2019.09.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/20/2019] [Accepted: 09/21/2019] [Indexed: 11/16/2022]
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14
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Multimodality coronary imaging to predict periprocedural myocardial necrosis after an elective percutaneous coronary intervention. Coron Artery Dis 2019; 29:237-245. [PMID: 29215469 DOI: 10.1097/mca.0000000000000595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although multiple imaging modalities have been tested to predict periprocedural myocardial necrosis (PMN), the superior predictive efficacy of these imaging findings has not been established fully. We sought to evaluate which findings of the coronary imaging tools would best provide predictive efficacy of PMN among optical coherence tomography (OCT), intravascular ultrasound (IVUS), and coronary computed tomography (CCT) angiography. PATIENTS AND METHODS A total of 130 patients with stable angina pectoris who underwent OCT, IVUS, and CCT examinations for a single de-novo preprocedural lesion were investigated. PMN was defined on the basis of two different thresholds of cardiac troponin I (cTnI) elevation: moderate PMN [five times the upper reference limit (URL)<postpercutaneous coronary intervention peak cTnI level<20 times the URL] and major PMN (peak cTnI levels>20 times the URL). RESULTS Moderate PMN and major PMN were observed in 25 (19.2%) and 10 (7.7%) patients, respectively. Multivariate logistic regression analysis identified four independent predictors of PMN (moderate PMN and major PMN): IVUS-defined echo-attenuated plaque (EAP), OCT-defined thin-cap fibroatheroma, OCT-defined plaque rupture, and CCT-defined low-attenuation plaque (P<0.05 for all variables). For major PMN, EAP length [odds ratio=1.80 (95% confidence interval: 1.20-2.69), P<0.01] and OCT minimum cap thickness [odds ratio=0.95 (95% confidence interval: 0.91-0.99), P<0.01] were identified as independent predictors. CONCLUSION IVUS-derived EAP length and OCT minimum cap thickness were significant and specific predictors of major PMN among the examined multimodality plaque features, although all three modalities independently provided imaging findings of significant predictive efficacy for PMN more than five times the URL for cTnI.
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15
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Matsumoto H, Watanabe S, Kyo E, Tsuji T, Ando Y, Otaki Y, Cadet S, Gransar H, Berman DS, Slomka P, Tamarappoo BK, Dey D. Standardized volumetric plaque quantification and characterization from coronary CT angiography: a head-to-head comparison with invasive intravascular ultrasound. Eur Radiol 2019; 29:6129-6139. [PMID: 31028446 DOI: 10.1007/s00330-019-06219-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We sought to evaluate the accuracy of standardized total plaque volume (TPV) measurement and low-density non-calcified plaque (LDNCP) assessment from coronary CT angiography (CTA) in comparison with intravascular ultrasound (IVUS). METHODS We analyzed 118 plaques without extensive calcifications from 77 consecutive patients who underwent CTA prior to IVUS. CTA TPV was measured with semi-automated software comparing both scan-specific (automatically derived from scan) and fixed attenuation thresholds. From CTA, %LDNCP was calculated voxels below multiple LDNCP thresholds (30, 45, 60, 75, and 90 Hounsfield units [HU]) within the plaque. On IVUS, the lipid-rich component was identified by echo attenuation, and its size was measured using attenuation score (summed score ∕ analysis length) based on attenuation arc (1 = < 90°; 2 = 90-180°; 3 = 180-270°; 4 = 270-360°) every 1 mm. RESULTS TPV was highly correlated between CTA using scan-specific thresholds and IVUS (r = 0.943, p < 0.001), with no significant difference (2.6 mm3, p = 0.270). These relationships persisted for calcification patterns (maximal IVUS calcium arc of 0°, < 90°, or ≥ 90°). The fixed thresholds underestimated TPV (- 22.0 mm3, p < 0.001) and had an inferior correlation with IVUS (p < 0.001) compared with scan-specific thresholds. A 45-HU cutoff yielded the best diagnostic performance for identification of lipid-rich component, with an area under the curve of 0.878 vs. 0.840 for < 30 HU (p = 0.023), and corresponding %LDNCP resulted in the strongest correlation with the lipid-rich component size (r = 0.691, p < 0.001). CONCLUSIONS Standardized noninvasive plaque quantification from CTA using scan-specific thresholds correlates highly with IVUS. Use of a < 45-HU threshold for LDNCP quantification improves lipid-rich plaque assessment from CTA. KEY POINTS • Standardized scan-specific threshold-based plaque quantification from coronary CT angiography provides an accurate total plaque volume measurement compared with intravascular ultrasound. • Attenuation histogram-based low-density non-calcified plaque quantification can improve lipid-rich plaque assessment from coronary CT angiography.
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Affiliation(s)
- Hidenari Matsumoto
- Department of Imaging and Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA.
| | - Satoshi Watanabe
- Department of Cardiology, Kusatsu Heart Center, Kusatsu, Shiga, Japan
| | - Eisho Kyo
- Department of Cardiology, Kusatsu Heart Center, Kusatsu, Shiga, Japan
| | - Takafumi Tsuji
- Department of Cardiology, Kusatsu Heart Center, Kusatsu, Shiga, Japan
| | - Yosuke Ando
- Department of Cardiology, Kusatsu Heart Center, Kusatsu, Shiga, Japan
| | - Yuka Otaki
- Department of Imaging and Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Sebastien Cadet
- Department of Imaging and Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Heidi Gransar
- Department of Imaging and Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Daniel S Berman
- Department of Imaging and Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Piotr Slomka
- Department of Imaging and Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Balaji K Tamarappoo
- Department of Imaging and Medicine, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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16
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Quantitative measurement of lipid rich plaque by coronary computed tomography angiography: A correlation of histology in sudden cardiac death. Atherosclerosis 2018; 275:426-433. [DOI: 10.1016/j.atherosclerosis.2018.05.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 05/08/2018] [Accepted: 05/16/2018] [Indexed: 11/21/2022]
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17
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Sato T, Aizawa Y, Suzuki N, Taya Y, Yuasa S, Kishi S, Koshikawa T, Fuse K, Fujita S, Ikeda Y, Kitazawa H, Takahashi M, Okabe M. The utility of total lipid core burden index/maximal lipid core burden index ratio within the culprit plaque to predict filter-no reflow: insight from near-infrared spectroscopy with intravascular ultrasound. J Thromb Thrombolysis 2018; 46:203-210. [PMID: 29915959 DOI: 10.1007/s11239-018-1697-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Filter-no reflow (FNR) is a phenomenon wherein flow improves after the retrieve of distal protection. Near-infrared spectroscopy with intravascular ultrasound (NIRS-IVUS) enables lipid detection. We evaluated the predictors of FNR during PCI using NIRS-IVUS. Thirty-two patients who underwent PCI using the Filtrap® for acute coronary syndrome (ACS) were enrolled. The culprit plaque (CP) was observed using NIRS-IVUS. Total lipid-core burden index (T-LCBI) and maximal LCBI over any 4-mm segment (max-LCBI4mm) within CP were evaluated. T-LCBI/max-LCBI4mm ratio within CP was calculated as an index of the extent of longitudinal lipid expansion. The attenuation grade (AG) and remodeling index (RI) in CP were analyzed. AG was scored based on the extent of attenuation occupying the number of quadrants. The patients were divided into FNR group (N = 8) and no-FNR group (N = 24). AG was significantly higher in FNR group than in no-FNR group (1.6 ± 0.6 vs. 0.9 ± 0.42, p = 0.01). RI in FNR group tended to be greater than in no-FNR group. T-LCBI/max-LCBI4mm ratio within the culprit plaque was significantly higher in FNR group than in no-FNR group (0.50 ± 0.10 vs. 0.33 ± 0.13, p < 0.01). In multivariate logistic regression analysis, AG > 1.04 (odds ratio [OR] 18.4, 95% confidence interval [CI] 1.5-215.7, p = 0.02) and T-LCBI/max-LCBI4mm ratio > 0.42 (OR 14.4, 95% CI 1.2-176.8, p = 0.03) were independent predictors for the occurrence of FNR. The use of T-LCBI/max-LCBI4mm ratio within CP might be an effective marker to predict FNR during PCI in patients with ACS.
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Affiliation(s)
- Takao Sato
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan.
| | - Yoshifusa Aizawa
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
| | - Naomasa Suzuki
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
| | - Yuji Taya
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
| | - Sho Yuasa
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
| | - Shohei Kishi
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
| | - Tomoyasu Koshikawa
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
| | - Koichi Fuse
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
| | - Satoshi Fujita
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
| | - Yoshio Ikeda
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
| | - Hitoshi Kitazawa
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
| | - Minoru Takahashi
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
| | - Masaaki Okabe
- Cardiology, Tachikawa General Hospital, 561-1 Jyojyomachi Aza Yauchi, Nagaoka, Japan
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Predictive performance of dual modality of computed tomography angiography and intravascular ultrasound for no-reflow phenomenon after percutaneous coronary stenting in stable coronary artery disease. Heart Vessels 2018; 33:1121-1128. [PMID: 29644449 PMCID: PMC6133068 DOI: 10.1007/s00380-018-1160-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 03/30/2018] [Indexed: 02/07/2023]
Abstract
Attenuated plaque on intravascular ultrasound (IVUS) and low attenuation plaque on computed tomography angiography (CTA) are associated with no-reflow phenomenon during percutaneous coronary intervention (PCI). However, evaluation by a single modality has been unable to satisfactorily predict this phenomenon. We investigated whether the combination of IVUS and CTA findings can ameliorate the predictive potential for no-reflow phenomenon after stent implantation during PCI in stable coronary artery disease (CAD). A total of 988 lesions of 707 stable CAD patients who underwent coronary CTA before PCI were enrolled. PCI was performed with preprocedural IVUS and stent implantation. As for plaque characters, very low attenuation plaque (CTA v-LAP) whose minimum density was < 0 Hounsfield units on CTA and attenuated plaque (IVUS AP) on IVUS were evaluated. No-reflow phenomenon was observed in 22 lesions (2.2%) of 19 patients (2.7%). Both CTA v-LAP and IVUS AP were much more frequently observed in patients with no-reflow phenomenon. Positive (PPV) and negative predictive values (NPV) and accuracy for prediction of no-reflow were almost equivalent between CTA v-LAP (13.2, 99.6, and 87.0%) and IVUS AP (15.7, 99.8, and 89.0%). The combination of CTA v-LAP and IVUS AP markedly ameliorated PPV (31.7%) without deterioration of NPV (99.7%) and increased the diagnostic accuracy (95.5%). These findings showed that the combination of CTA v-LAP and IVUS AP improved the predictive power for no-reflow phenomenon after coronary stenting in stable CAD patients, suggesting the usefulness of combined estimation by using CTA and IVUS for predicting no-reflow phenomenon during PCI in clinical practice.
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20
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Role of CT Imaging for Coronary and Non-coronary Interventions. CURRENT CARDIOVASCULAR IMAGING REPORTS 2017. [DOI: 10.1007/s12410-017-9410-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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21
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Kitagawa K, Amano T, Uetani T, Ishii H, Okumura T, Suzuki S, Takashima H, Kurita A, Ando H, Matsubara T, Murohara T. Association between plaque characteristics and the amount of debris captured by a filter-type distal protection device in patients with acute coronary syndrome. Atherosclerosis 2017; 258:72-78. [DOI: 10.1016/j.atherosclerosis.2017.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/28/2017] [Accepted: 02/02/2017] [Indexed: 11/28/2022]
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22
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Usui E, Lee T, Murai T, Kanaji Y, Matsuda J, Araki M, Yonetsu T, Yamakami Y, Kimura S, Kakuta T. Efficacy of Multidetector Computed Tomography to Predict Periprocedural Myocardial Injury After Percutaneous Coronary Intervention for Chronic Total Occlusion. Int Heart J 2017; 58:16-23. [DOI: 10.1536/ihj.16-114] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Eisuke Usui
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Tetsumin Lee
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Tadashi Murai
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Yoshihisa Kanaji
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Junji Matsuda
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | - Makoto Araki
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | | | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
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Pathan F, Negishi K. Prediction of cardiovascular outcomes by imaging coronary atherosclerosis. Cardiovasc Diagn Ther 2016; 6:322-39. [PMID: 27500091 DOI: 10.21037/cdt.2015.12.08] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Over the last two decades, several invasive and non-invasive coronary atherosclerosis imaging modalities have emerged as predictors of cardiovascular outcomes in at-risk population. These modalities have demonstrated independent or incremental prognostic information over existing/standard risk stratification schemes, such as the Framingham risk score (FRS), by identifying characteristics of coronary artery diseases (CADs). In this review, we begin with discussing the importance of pre-test probability and quality of outcome measure, followed by specific findings of each modality in relation to prognosis. We focused on both short and long term prognostic aspects of coronary computed tomography (CT) (including coronary calcium score and coronary angiography) and magnetic resonance imaging as non-invasive tools, as well as invasive modalities including intravascular ultrasound (IVUS), optical coherence tomography (OCT), near infrared spectroscopy and Angioscopy.
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Affiliation(s)
- Faraz Pathan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Kazuaki Negishi
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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25
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Sato A, Aonuma K. Coronary plaque morphology on multi-modality imagining and periprocedural myocardial infarction after percutaneous coronary intervention. IJC HEART & VASCULATURE 2016; 11:43-48. [PMID: 28616524 PMCID: PMC5441347 DOI: 10.1016/j.ijcha.2016.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 03/04/2016] [Indexed: 11/17/2022]
Abstract
Percutaneous coronary intervention (PCI) may be complicated by periprocedural myocardial infarction (PMI) as manifested by elevated cardiac biomarkers such as creatine kinase (CK)-MB or troponin T. The occurrence of PMI has been shown to be associated with worse short- and long-term clinical outcome. However, recent studies suggest that PMI defined by biomarker levels alone is a marker of atherosclerosis burden and procedural complexity but in most cases does not have independent prognostic significance. Diagnostic multi-modality imaging such as intravascular ultrasound, optical coherence tomography, coronary angioscopy, near-infrared spectroscopy, multidetector computed tomography, and magnetic resonance imaging can be used to closely investigate the atherosclerotic lesion in order to detect morphological markers of unstable and vulnerable plaques in the patients undergoing PCI. With the improvement of technical aspects of multimodality coronary imaging, clinical practice and research are increasingly shifting toward defining the clinical implication of plaque morphology and patients outcomes. There were numerous published data regarding the relationship between pre-PCI lesion subsets on multi-modality imaging and post-PCI biomarker levels. In this review, we discuss the relationship between coronary plaque morphology estimated by invasive or noninvasive coronary imaging and the occurrence of PMI. Furthermore, this review underlies that the value of the multimodality coronary imaging approach will become the gold standard for invasive or noninvasive prediction of PMI in clinical practice.
Periprocedural myocardial infarction (PMI) has been shown to be associated with worse short- and long-term clinical outcome. Clinical practice and research are increasingly shifting toward the plaque morphology and patients outcomes. This review discusses the relationship between plaque morphology estimated by coronary imaging and the occurrence of PMI. This review underlies the value of the multimodality coronary imaging approach for prediction of PMI in clinical practice.
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Affiliation(s)
- Akira Sato
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Japan
| | - Kazutaka Aonuma
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Japan
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Fujimoto S, Kondo T, Kumamaru KK, Shinozaki T, Takamura K, Kawaguchi Y, Matsumori R, Hiki M, Miyauchi K, Daida H, Rybicki FJ. Prognostic Value of Coronary Computed Tomography (CT) Angiography and Coronary Artery Calcium Score Performed Before Revascularization. J Am Heart Assoc 2015; 4:e002264. [PMID: 26296858 PMCID: PMC4599477 DOI: 10.1161/jaha.115.002264] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cardiac events after revascularization are equally attributable to recurrence at site of culprit lesions and development of nonculprit lesions. We evaluated the hypothesis that coronary computed tomography (CT) angiography and coronary artery calcium score (CACS) performed before revascularization predicts cardiac events after treatment. METHODS AND RESULTS Among 2238 consecutive patients without known coronary artery disease who underwent coronary CT angiography and CACS, 359 patients underwent revascularization within 30 days after CT; in 337 of 359 (93.9%) follow-up clinical information was available. In addition to known cardiac risk factors, CT findings were evaluated as predictors of cardiac events after revascularization: CACS and the presence of CT-verified high-risk plaque (CT-HRP). Improvement of predictive accuracy by including CT findings was evaluated from a discrimination (Harrell's C-statistics) standpoint. During the follow-up period (median: 673, interquartile range: 47 to 1529 days), a total of 98 cardiac events occurred. Cox proportional hazard model revealed that age, diabetes, triglyceride, CACS, and nonculprit CT-HRP were significant predictors of overall cardiac events. Although not statistically significant, discriminatory power was greater for the model with CACS (C-stat: 63.2%) and the model with both CACS and CT-HRP (65.8%) compared to the model including neither CACS nor CT-HRP (60.7%). CONCLUSIONS High CACS and the presence of nonculprit CT-HRP performed before revascularization are significant predictors of cardiac events after revascularization.
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Affiliation(s)
- Shinichiro Fujimoto
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan (S.F., K.T., Y.K., R.M., M.H., K.M., H.D.) Department of Cardiology, Takase Clinic, Takasaki, Japan (S.F., T.K., K.T.)
| | - Takeshi Kondo
- Department of Cardiology, Takase Clinic, Takasaki, Japan (S.F., T.K., K.T.)
| | - Kanako K Kumamaru
- Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA (K.K.K., F.J.R.)
| | - Tomohiro Shinozaki
- Department of Biostatistics, School of Public Health, The University of Tokyo, Japan (T.S.)
| | - Kazuhisa Takamura
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan (S.F., K.T., Y.K., R.M., M.H., K.M., H.D.) Department of Cardiology, Takase Clinic, Takasaki, Japan (S.F., T.K., K.T.)
| | - Yuko Kawaguchi
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan (S.F., K.T., Y.K., R.M., M.H., K.M., H.D.)
| | - Rie Matsumori
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan (S.F., K.T., Y.K., R.M., M.H., K.M., H.D.)
| | - Makoto Hiki
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan (S.F., K.T., Y.K., R.M., M.H., K.M., H.D.)
| | - Katsumi Miyauchi
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan (S.F., K.T., Y.K., R.M., M.H., K.M., H.D.)
| | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan (S.F., K.T., Y.K., R.M., M.H., K.M., H.D.)
| | - Frank J Rybicki
- Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA (K.K.K., F.J.R.)
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Hoshi T, Sato A, Akiyama D, Hiraya D, Sakai S, Shindo M, Mori K, Minami M, Aonuma K. Coronary high-intensity plaque on T1-weighted magnetic resonance imaging and its association with myocardial injury after percutaneous coronary intervention. Eur Heart J 2015; 36:1913-22. [PMID: 26033978 DOI: 10.1093/eurheartj/ehv187] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 04/28/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Non-contrast T1-weighted imaging (T1WI) has emerged as a novel non-invasive imaging for vulnerable coronary plaque showing a high-intensity plaque (HIP). However, the association between HIP and percutaneous coronary intervention (PCI) has not been evaluated. We investigated the association between the presence of HIP and the incidence of myocardial injury after PCI. METHODS AND RESULTS A total of 77 patients with stable angina were imaged with non-contrast T1WI by using a 1.5 T magnetic resonance system (HIP and non-HIP group, N = 31 and 46 patients, respectively). We defined HIP as a coronary plaque to myocardium signal intensity ratio (PMR) of ≥1.4. High-sensitive cardiac troponin-T (hs-cTnT) was measured at baseline and 24 h after PCI. Percutaneous coronary intervention-related myocardial injury (PMI) was defined as an elevation of hs-cTnT >5× 99th percentile upper reference limit. High-intensity plaque was associated with the characteristics of ultrasound attenuation and positive remodelling on intravascular ultrasound. Although baseline hs-cTnT was similar between the groups, increase in hs-cTnT was significantly greater in the HIP vs. non-HIP group (0.065 [0.023-0.304] vs. 0.017 [0.005-0.026], P < 0.001). Percutaneous coronary intervention-related myocardial injury occurred more frequently in the HIP than non-HIP group (58.1 vs. 10.9%, P < 0.001), and the cut-off value of PMR found to be 1.44 for predicting PMI (sensitivity 78.3% and specificity 81.5%). In multivariate analysis, a PMR of ≥1.4 was a significant predictor of PMI (odds ratio 5.63, 95% confidence interval 1.28-24.7, P = 0.022). CONCLUSION High-intensity plaque on non-contrast T1WI was characterized as vulnerable coronary plaque on IVUS and was associated with higher incidence of PMI.
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Affiliation(s)
- Tomoya Hoshi
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Akira Sato
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Daiki Akiyama
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Daigo Hiraya
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Shunsuke Sakai
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Masashi Shindo
- Department of Radiology, University of Tsukuba Hospital, Tsukuba, Japan
| | - Kensaku Mori
- Department of Radiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Manabu Minami
- Department of Radiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kazutaka Aonuma
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
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Kini AS, Motoyama S, Vengrenyuk Y, Feig JE, Pena J, Baber U, Bhat AM, Moreno P, Kovacic JC, Narula J, Sharma SK. Multimodality Intravascular Imaging to Predict Periprocedural Myocardial Infarction During Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2015; 8:937-45. [DOI: 10.1016/j.jcin.2015.03.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/24/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022]
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Abstract
Cardiac multidetector computed tomography (MDCT) has become a useful noninvasive modality for anatomical imaging of coronary artery disease (CAD). Currently, the main clinical advantage of coronary computed tomography angiography (CCTA) appears to be related to its high negative predictive value at low or intermediate pretest probability for CAD. With the development of technical aspects of MDCT, clinical practice and research are increasingly shifting toward defining the clinical implication of plaque morphology, myocardial perfusion, and patient outcomes. The presence of positive vessel remodeling, low-attenuation plaques, napkin-ring sign, or spotty calcification on CCTA could be useful information on high-risk vulnerable plaques. The napkin-ring sign, especially, showed higher accuracy for the detection of thin-cap fibroatheroma. Recently, it was reported that cardiac 3D single-photon emission tomography/CT fusion imaging, noninvasive fractional flow reserve computed from CT, and integrated CCTA and CT myocardial perfusion were associated with improved diagnostic accuracy for the detection of hemodynamically significant CAD. Furthermore, several randomized, large clinical trials have evaluated the clinical value of CCTA for chest pain triage in the emergency department or long-term reduction in death, myocardial infarction, or hospitalization for unstable angina. In this review we discuss the role of cardiac MDCT beyond coronary angiography, including a comparison with other currently available imaging modalities used to examine atherosclerotic plaque and myocardial perfusion.
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Affiliation(s)
- Akira Sato
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba
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Impact of metabolic syndrome on myocardial injury and clinical outcome after percutaneous coronary intervention. Herz 2014; 40:129-35. [PMID: 24962253 DOI: 10.1007/s00059-014-4103-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 03/11/2014] [Accepted: 04/06/2014] [Indexed: 10/25/2022]
Abstract
AIMS This study tested the associations between metabolic syndrome, postprocedural myocardial injury, and clinical outcome after percutaneous coronary intervention. PATIENTS AND METHODS We evaluated 204 patients who fulfilled the study criteria and were scheduled for elective percutaneous coronary intervention. The patients were divided into a metabolic syndrome group and a control group according to the definition of metabolic syndrome. Creatine kinase-MB and troponin I levels were measured at baseline, at 8 h, and 24 h after the procedure, while clinical outcomes were followed up for 1 year. RESULTS The incidence of postprocedural myocardial injury was significantly higher in the metabolic syndrome group than in the control group as indicated by either blood creatine kinase-MB elevation (32.9 % vs. 17.2 %, p = 0.010) or troponin I elevation (34.2 % vs. 17.2 %, p = 0.006). Postprocedural peak values of creatine kinase-MB (5.724 ± 7.678 ng/ml vs. 3.097 ± 5.317 ng/ml, p < 0.001) and troponin I (0.066 ± 0.093 ng/ml vs. 0.038 ± 0.079 ng/ml, p < 0.001) were also significantly higher in the metabolic syndrome group than in the control group. On multiple regression analysis, metabolic syndrome was independently associated with troponin I elevation (odds ratio 2.24, 95 % confidence interval, CI, 1.04-4.80, p = 0.039). During the 1-year follow-up, cardiac events occurred in 28.9 % of patients with metabolic syndrome and 17.9 % of controls, and there was a trend toward increased adverse outcomes in the metabolic syndrome group (hazard ratio 1.67, 95 % CI 0.93-3.00, p = 0.071, log rank test). CONCLUSION The results of this study demonstrate that metabolic syndrome is associated with postprocedural myocardial injury and with increased cardiac events.
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Sato A. Coronary plaque imaging by coronary computed tomography angiography. World J Radiol 2014; 6:148-159. [PMID: 24876919 PMCID: PMC4037541 DOI: 10.4329/wjr.v6.i5.148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 02/09/2014] [Accepted: 04/17/2014] [Indexed: 02/06/2023] Open
Abstract
Coronary computed tomography angiography (CTA) has become the useful noninvasive imaging modality alternative to the invasive coronary angiography for detecting coronary artery stenoses in patients with suspected coronary artery disease (CAD). With the development of technical aspects of coronary CTA, clinical practice and research are increasingly shifting toward defining the clinical implication of plaque morphology and patients outcomes by coronary CTA. In this review we discuss the coronary plaque morphology estimated by CTA beyond coronary angiography including the comparison to the currently available other imaging modalities used to examine morphological characteristics of the atherosclerotic plaque. Furthermore, this review underlies the value of a combined assessment of coronary anatomy and myocardial perfusion in patients with CAD, and adds to an increasing body of evidence suggesting an added diagnostic value when combining both modalities. We hope that an integrated, multi-modality imaging approach will become the gold standard for noninvasive evaluation of coronary plaque morphology and outcome data in clinical practice.
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Dey D, Schuhbaeck A, Min JK, Berman DS, Achenbach S. Non-invasive measurement of coronary plaque from coronary CT angiography and its clinical implications. Expert Rev Cardiovasc Ther 2014; 11:1067-77. [DOI: 10.1586/14779072.2013.823707] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Positive association of coronary calcium detected by computed tomography coronary angiography with periprocedural myocardial infarction. PLoS One 2013; 8:e82835. [PMID: 24358229 PMCID: PMC3866265 DOI: 10.1371/journal.pone.0082835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 10/29/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Periprocedural myocardial infarction (PMI) may occur in approximately 5% to 30% of patients undergoing percutaneous coronary intervention. Whether the morphology of coronary plaque calcium affects the occurrence of PMI is unknown. MATERIALS AND METHODS A total of 616 subjects with stable angina and normal baseline cardiac troponin I levels who had undergone computed tomography angiography (CTA) were referred to elective percutaneous coronary intervention. The morphology of coronary calcium was determined by CTA analysis. PMI was defined as an elevation in 24-h post-procedural cardiac troponin I levels of > 5 times the upper limit of normal with either symptoms of myocardial ischemia, new ischemic electrocardiographic changes, or documented complications during the procedure. Logistic regression was performed to identify the effect of the morphology of coronary calcium on the occurrence of PMI. RESULTS According to the presence or morphology of coronary calcium as shown by CTA, 210 subjects were grouped in the heavy calcification group, 258 in the mild calcification group, 40 in the spotty calcification group and 108 in the control group. The dissection rate was significantly higher in the heavy calcification group than in the control group (7.1 % vs. 1.9%, p = 0.03). The occurrence of PMI in the heavy calcification group was significantly higher than that in the control group (OR 4.38, 95% CI 1.80-10.65, p = 0.001). After multivariate adjustment, the risk of PMI still remained significantly higher in the heavy calcification group than in the control group (OR 4.04, 95% CI 1.50-10.89, p = 0.003). CONCLUSIONS The morphology of coronary calcium determined by CTA may help to predict the subsequent occurrence of PMI. A large amount of coronary calcium may be predictive of PMI.
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Patel VG, Brayton KM, Mintz GS, Maehara A, Banerjee S, Brilakis ES. Intracoronary and Noninvasive Imaging for Prediction of Distal Embolization and Periprocedural Myocardial Infarction During Native Coronary Artery Percutaneous Intervention. Circ Cardiovasc Imaging 2013; 6:1102-14. [DOI: 10.1161/circimaging.113.000448] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Vishal G. Patel
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
| | - Kimberly M. Brayton
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
| | - Gary S. Mintz
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
| | - Akiko Maehara
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
| | - Subhash Banerjee
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
| | - Emmanouil S. Brilakis
- From VA North Texas Healthcare System and University of Texas Southwestern Medical Center, Dallas, TX (V.G.P., S.B., E.S.B.); Stanford University, Stanford, CA (K.M.B.); and Cardiovascular Research Foundation, New York, NY (G.S.M., A.M.)
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35
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Uetani T, Amano T, Harada K, Kitagawa K, Kunimura A, Shimbo Y, Harada K, Yoshida T, Kato B, Kato M, Marui N, Nanki M, Hotta N, Ishii H, Matsubara T, Murohara T. Impact of insulin resistance on post-procedural myocardial injury and clinical outcomes in patients who underwent elective coronary interventions with drug-eluting stents. JACC Cardiovasc Interv 2013; 5:1159-67. [PMID: 23174640 DOI: 10.1016/j.jcin.2012.07.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 05/09/2012] [Accepted: 07/04/2012] [Indexed: 12/14/2022]
Abstract
OBJECTIVES This study sought to evaluate the associations between homeostatic indexes of insulin resistance (HOMA-IR) and post-procedural myocardial injury and clinical outcome after a percutaneous coronary intervention (PCI) with a drug-eluting stent. BACKGROUND Insulin resistance increases the risk of cardiovascular events. However, the association between insulin resistance and clinical outcome after coronary intervention is unclear. METHODS We evaluated 516 consecutive patients who underwent elective PCI with drug-eluting stents. Blood samples were collected from venous blood after overnight fasting, and fasting plasma glucose and insulin levels were measured. HOMA-IR was calculated according to the homeostasis model assessment. Post-procedural myocardial injury was evaluated by analysis of troponin T and creatine kinase-myocardial band isozyme levels hours after PCI. Cardiac event was defined as the composite endpoint of cardiovascular death, myocardial infarction, and any revascularization. RESULTS With increasing tertiles of HOMA-IR, post-procedural troponin T and creatine kinase-myocardial band levels increased. In the multiple regression analysis, HOMA-IR was independently associated with troponin T elevation. During a median follow-up of 623 days, patients with the highest tertiles of HOMA-IR had the highest risk of cardiovascular events. The Cox proportional hazard models identified HOMA-IR as independently associated with worse clinical outcome after adjustment for clinical and procedural factors. CONCLUSIONS These results indicated the impact of insulin resistance on post-procedural myocardial injury and clinical outcome after elective PCI with drug-eluting stent deployment. Evaluation of insulin resistance may provide useful information for predicting clinical outcomes after elective PCI.
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Affiliation(s)
- Tadayuki Uetani
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, Japan.
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Relation between coronary plaque calcium deposits as described by computed tomography coronary angiography and acute results of stent deployment as assessed by intravascular ultrasound. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2013; 9:115-20. [PMID: 24570702 PMCID: PMC3915965 DOI: 10.5114/pwki.2013.35444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/25/2013] [Accepted: 05/09/2013] [Indexed: 01/09/2023] Open
Abstract
Introduction The findings from intravascular ultrasound studies on the impact of calcium deposits on the results of stent implantation are conflicting. Aim To evaluate whether calcium deposits as assessed by (CTCA) influence results of stent deployment. Material and methods The study population comprised 60 patients (43 male; age 64.2 ±8.6 years) who underwent CTCA before stent implantation. Lesion calcium score, total calcium length, and maximal area and maximal thickness of calcium deposits within the lesion segment were assessed. Plaques were divided into those with calcium score ≥ median (group 1), calcium score < median (group 2), and without calcium (group 3). Intravascular ultrasound (IVUS) was performed after attainment of optimal angiographic results of the stent procedure. Focal and diffuse stent expansion was defined as either minimum stent area (MSA) or mean stent area over the length of the stent divided by reference lumen area. Results The proximal reference segments of lesions with higher calcium score contained a larger plaque burden (47 ±12% vs. 41 ±9% vs. 34 ±18%, p = 0.02) – respectively for groups 1, 2, and 3. Positive correlation was observed between lesion calcium score and frequency of post-dilation (R = 0.28, p = 0.03). There was no difference in focal stent expansion (71 ±14% vs. 65 ±15% vs.71 ±15%, p = 0.3) or diffuse stent expansion (92 ±30% vs. 85 ±30% vs. 93 ±38%, p = 0.7) comparing groups 1, 2, and 3. Lesion calcium score, total length of calcium, and maximum area and thickness of calcium deposits did not correlate with focal or diffuse stent expansion. Conclusions Lesions with a higher CTCA calcium score had larger reference plaque burden after stent implantation and more likely required post-dilation, but final stent expansion as assessed by IVUS was not affected by the amount of CTCA calcium provided an angiographically optimal result was achieved.
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Schlett CL, Ferencik M, Celeng C, Maurovich-Horvat P, Scheffel H, Stolzmann P, Do S, Kauczor HU, Alkadhi H, Bamberg F, Hoffmann U. How to assess non-calcified plaque in CT angiography: delineation methods affect diagnostic accuracy of low-attenuation plaque by CT for lipid-core plaque in histology. Eur Heart J Cardiovasc Imaging 2013; 14:1099-105. [PMID: 23671211 DOI: 10.1093/ehjci/jet030] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS To compare the accuracy of two plaque delineation methods for coronary computed tomographic angiography (CTA) to identify lipid-core plaque (LCP) using histology as the reference standard. METHODS AND RESULTS Five ex vivo hearts were analysed by CTA and histology. LCP was defined by histology as fibroatheroma with core diameter/circumference >200 μm/>60° and cap thickness <450 μm. In CTA, plaque was manually delineated either as the difference between the inner and outer vessel walls (Method A) or as a direct tracing of plaque (Method B). Low-attenuation plaque was defined as an area with <90 Hounsfield units. Of 446 co-registered cross-sections, 55 (12%) contained LCP. In CTA, low-attenuation plaque area was larger as assessed with Method A compared with Method B (difference: 120 ± 60%). Although low-attenuation plaque was associated with the presence of LCP, the delineation Method B yielded higher diagnostic accuracy than Method A [area under the curve (AUC): 0.831 vs. 0.780, respectively, P = 0.005]. After excluding 'normal' cross-sections by CTA (n = 117), AUC for detecting LCP became similar between both methods (0.767 vs. 0.729, P = 0.07, respectively). CONCLUSION Low-attenuation plaque in CTA is a diagnostic tool for LCP but prone to error if plaque is defined as the area between the inner and outer vessel walls and normal cross-sections are included in the assessment.
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Affiliation(s)
- Christopher L Schlett
- Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Otaki Y, Berman DS, Min JK. Prognostic utility of coronary computed tomographic angiography. Indian Heart J 2013; 65:300-10. [PMID: 23809386 DOI: 10.1016/j.ihj.2013.04.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Revised: 04/08/2013] [Accepted: 04/08/2013] [Indexed: 01/11/2023] Open
Abstract
Coronary computed tomographic angiography (CCTA) employing CT scanners of 64-detector rows or greater represents a noninvasive method that enables accurate detection and exclusion of anatomically obstructive coronary artery disease (CAD), providing excellent diagnostic information when compared to invasive angiography. There are numerous potential advantages of CCTA beyond simply luminal stenosis assessment including quantification of atherosclerotic plaque volume as well as assessment of plaque composition, extent, location and distribution. In recent years, an array of studies has evaluated the prognostic utility of CCTA findings of CAD for the prediction of major adverse cardiac events, all-cause death and plaque instability. This prognostic information enhances risk stratification and, if properly acted upon, may improve medical therapy and/or behavioral changes that may enhance event-free survival. The goal of the present article is to summarize the current status of the prognostic utility of CCTA findings of CAD.
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Affiliation(s)
- Yuka Otaki
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Nakanishi R, Min JK. Coronary CT Angiographic Measures of Adverse Atherosclerotic Plaque Features. CURRENT CARDIOVASCULAR RISK REPORTS 2013. [DOI: 10.1007/s12170-013-0299-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Fujihara K, Suzuki H, Sato A, Kodama S, Heianza Y, Saito K, Iwasaki H, Kobayashi K, Yatoh S, Takahashi A, Yamada N, Sone H, Shimano H. Carotid artery plaque and LDL-to-HDL cholesterol ratio predict atherosclerotic status in coronary arteries in asymptomatic patients with type 2 diabetes mellitus. J Atheroscler Thromb 2013; 20:452-64. [PMID: 23363982 DOI: 10.5551/jat.14977] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS To investigate the clinical predictors of coronary atherosclerosis and to assess the utility of maximum-IMT for predicting coronary atherosclerosis in asymptomatic type 2 diabetic patients. METHODS One hundred one Japanese patients with type 2 diabetes underwent computed tomography coronary angiography. Definitions of coronary artery stenosis and vulnerable coronary plaque were luminal narrowing of ≥50% and any coronary plaque with positive vessel remodeling and low attenuation, respectively. Carotid intima-media thickness (IMT) was assessed using B-mode ultrasound. RESULTS Of the 101 patients, 40 had coronary artery stenosis without vulnerable coronary plaque, 7 had vulnerable coronary plaque without coronary artery stenosis, and 23 had coronary artery stenosis with vulnerable coronary plaque. Male sex (p=0.031), duration of diabetes (p=0.024), systolic blood pressure (SBP) (p=0.039), and the LDL/HDL ratio (LDL/HDL) (p=0.013) were independent predictors of coronary artery stenosis and the LDL/HDL (p=0.042) independently predicted vulnerable coronary plaque by logistic regression analyses. Areas under the curves in receiver operating characteristic curve analysis of the maximum-IMT, LDL/HDL, and these two parameters combined were 0.711 (95% CI 0.601-0.820), 0.618 (0.508-0.728), and 0.732 (0.632-0.831), respectively, for predicting coronary artery stenosis and 0.655 (0.537-0.773), 0.629 (0.504-0.754), and 0.710 (0.601-0.818), respectively, for predicting vulnerable coronary plaque. CONCLUSIONS Male sex, duration of diabetes, elevated SBP, and LDL/HDL were independent predictors of coronary artery stenosis. LDL/HDL was an independent predictor of vulnerable coronary plaque. Maximum-IMT predicted both coronary stenosis and vulnerable coronary plaque. Adding LDL/HDL improved the prediction of coronary artery stenosis and vulnerable coronary plaque.
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Affiliation(s)
- Kazuya Fujihara
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
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Roleder T, Suh W, Sharma R, Hecht H, Kovacic JC, Narula J, Kini AS. Plaques with high lipid burden: keeping the fat out of the fire. Heart 2013; 99:977-8. [PMID: 23349347 DOI: 10.1136/heartjnl-2012-303421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Yoshitaka Goto Y, Kawasaki T, Koga N, Tanaka H, Koga H, Orita Y, Ikeda S, Shintani Y, Kajiwara M, Fukuyama T. Plaque distribution patterns in left main trunk bifurcations: prediction of branch vessel compromise by multidetector row computed topography after percutaneous coronary intervention. EUROINTERVENTION 2012; 8:708-16. [DOI: 10.4244/eijv8i6a110] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Zynda TK, Thompson CD, Hoang KC, Seto AH, Glovaci D, Wong ND, Patel PM, Kern MJ. Disparity between angiographic coronary lesion complexity and lipid core plaques assessed by near-infrared spectroscopy. Catheter Cardiovasc Interv 2012; 81:529-37. [PMID: 22532512 DOI: 10.1002/ccd.24470] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 03/22/2012] [Accepted: 04/21/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to determine if there was a relationship between angiographic lesion complexity and the extent of lipid core plaque (LCP) identified by catheter-based near-infrared spectroscopy (NIRS). BACKGROUND The angiographic complexity of coronary artery disease (CAD) is used to predict outcomes in patients undergoing percutaneous coronary intervention (PCI). The SYNTAX score, an angiographic tool quantifying the complexity of CAD, is associated with PCI outcomes. Recently, a novel catheter-based imaging technique using NIRS can identify LCP, which also is associated with PCI periprocedural myocardial infarction (MI). However, it is unknown whether these events are related to distinct adverse event prone pathobiology, such as a LCP within a complex angiographic lesion. Thus, we hypothesized that LCP identified by NIRS would be associated with high SYNTAX score. METHODS Seventy-eight patients who underwent coronary angiography and target-vessel NIRS were selected from the Chemometric Observations of Lipid Core Containing Plaques of Interest in Native Coronary Arteries Registry, an industry sponsored registry to collate clinical findings in all patients undergoing NIRS evaluation. A lipid core burden index (LCBI) was obtained from the scan of the proximal 50 mm of the target vessel. Three vessel SYNTAX (total, tSYN) and target single vessel (only NIRS-interrogated vessel) SYNTAX (1vSYN) scores were calculated and compared to LCBI. High LCBI was defined as (>110) and was compared to tertile scores for 1vSYN score (low 0-5, intermediate 6-10, high ≥11) and previously established tertiles for tSYN score (low 0-22, intermediate 23-32, high ≥33). RESULTS Patients had mean age of 63 years with prevalence of females (10%), diabetes mellitus (28%), hypertension (88%), and smoking history (72%); 1vSYN and tSYN scores correlated poorly with LCBI [(r(2) = 0.25; P = 0.02; n = 78) and (r(2) = 0.24; P = 0.04; n = 78), respectively]. Mean LCBI did not differ significantly across all tertiles of 1vSYN or tSYN scores. CONCLUSIONS Angiographic SYNTAX score only weakly correlated with LCBI. It is of interest as well that high LCBI was also present in cases of low SYNTAX scores. The disparity between the degree of angiographic complexity and the amount of LCP supports postulated mechanisms of the adverse event propensity even in patients who demonstrate low angiographic complexity. Future studies are necessary to address the clinical significance of high LCBI in patients with low-to-intermediate angiographic complexity and their potential for PCI-related complications.
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Affiliation(s)
- Todd K Zynda
- Department of Medicine, University of California, Orange, CA, USA
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Malpeso J, Budoff MJ. Predicting periprocedural myocardial infarction: target-lesion plaque characterization with coronary computed tomography angiography. J Am Coll Cardiol 2012; 59:1889-90. [PMID: 22595408 DOI: 10.1016/j.jacc.2012.01.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 01/03/2012] [Indexed: 11/20/2022]
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Impact of Coronary Plaque Composition on Cardiac Troponin Elevation After Percutaneous Coronary Intervention in Stable Angina Pectoris. J Am Coll Cardiol 2012; 59:1881-8. [DOI: 10.1016/j.jacc.2012.01.051] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 12/01/2011] [Accepted: 01/03/2012] [Indexed: 01/23/2023]
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Li M, Sun G, Ding J, Li L, Peng ZH, Jiang XS. Risk factors for non-calcified plaques in asymptomatic population. Acad Radiol 2012; 19:548-53. [PMID: 22285399 DOI: 10.1016/j.acra.2011.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 12/21/2011] [Accepted: 12/22/2011] [Indexed: 11/18/2022]
Abstract
RATIONALE AND OBJECTIVES The aims of this study were to assess the prevalence of noncalcified coronary plaques in asymptomatic patients and to investigate the risk factors. MATERIALS AND METHODS In this study, 584 patients were recruited prospectively. Patients were classified as having low, intermediate, or high pretest likelihoods of coronary artery disease according to the Morise score. Coronary computed tomographic angiography was performed in all patients using a 320-detector row dynamic-volume computed tomographic scanner. Imaging reconstruction was performed, and the postprocessed data were analyzed. Logistic regression analysis was used to evaluate the relationship between risk factors and the presence of noncalcified plaque. RESULTS Coronary computed tomographic angiography revealed noncalcified plaques in 38.3% of all patients (224 of 584). The prevalence of noncalcified plaques was significantly higher in patients with calcium scores > 0 (P < .001). Significant differences were found between the degrees of luminal stenosis among patients with low, intermediate, and high pretest likelihoods of coronary artery disease (P = .001), while the prevalence of noncalcified plaques did not differ with the Morise score (P = .08). Noncalcified plaque was associated with hypercholesterolemia (P = .02) and diabetes mellitus (P = .002). Age (P = .47), gender (P = .58), estrogen status (P = .55), smoking (P = .22), hypertension (P = .27), and family history (P = .09) did not differ between patients with and those without noncalcified plaques. CONCLUSIONS Hypercholesterolemia and diabetes mellitus are high risk factors for the prevalence of noncalcified plaques for asymptomatic patients.
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Affiliation(s)
- Min Li
- Department of Medical Imaging, Jinan Military General Hospital, No 25, Shifan Road, Jinan 250031, Shandong Province, China
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Brilakis ES, Abdel-Karim ARR, Papayannis AC, Michael TT, Rangan BV, Johnson JL, Banerjee S. Embolic protection device utilization during stenting of native coronary artery lesions with large lipid core plaques as detected by near-infrared spectroscopy. Catheter Cardiovasc Interv 2012; 80:1157-62. [DOI: 10.1002/ccd.23507] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 10/29/2011] [Indexed: 11/09/2022]
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The Prognostic Value of Coronary CT Angiography. CURRENT CARDIOVASCULAR IMAGING REPORTS 2011. [DOI: 10.1007/s12410-011-9107-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Sung J, Chang JH, Chung WJ, Jung JY, Na SY, Lee HH, Sung YM, Moon CI, Hwang YH, Chung W, Kim S. Association between renal dysfunction and the mixed plaque of coronary artery on computed tomographic angiography. TOHOKU J EXP MED 2011; 225:171-7. [PMID: 21971304 DOI: 10.1620/tjem.225.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Coronary artery plaque is related to development of coronary artery disease (CAD), and chronic kidney disease is associated with CAD. However, the association of renal dysfunction (RD) with coronary artery plaque characteristics has not been fully elucidated. We evaluated the association between RD and coronary artery plaque characteristics in patients with suspected CAD, who underwent multislice computed tomographic angiography (CTA). A total of 918 patients were classified into 4 groups: group with no plaque (NP) (48.9%), group with calcified plaque (CP) (16.0%), group with noncalcified plaque (NCP) (22.4%), and group with mixed plaque (MP) (12.7%). NCP is considered as rupture-prone soft plaque, and CP as more stable lesion. The mean of estimated glomerular filtration rate (eGFR) was 82.5 ± 15.4 mL/min/1.73 m(2), and the prevalence of RD (defined as eGFR < 60 mL/min/1.73 m(2)) was 6.3%. The prevalence of RD was 3.3% in the NP group, 10.2% in the CP group, 5.3% in the NCP group, and 14.5% in the MP group (P < 0.001 by ANOVA tests). The adjusted odds ratio for RD was 3.38 (95% confidence interval, 1.27-9.04) for the MP group, compared with the NP group. The presence of RD showed an independent association with the MP counts (r = 0.155, P < 0.001); however, there was no association between RD and other plaque characteristics. In conclusion, RD is associated with MP rather than CP or NCP, compared with NP, which may reflect one of the developmental processes of CAD in patients with RD.
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Affiliation(s)
- Jiyoon Sung
- Department of Internal Medicine, Gachon University School of Medicine, Incheon, Korea
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Goldstein JA, Maini B, Dixon SR, Brilakis ES, Grines CL, Rizik DG, Powers ER, Steinberg DH, Shunk KA, Weisz G, Moreno PR, Kini A, Sharma SK, Hendricks MJ, Sum ST, Madden SP, Muller JE, Stone GW, Kern MJ. Detection of Lipid-Core Plaques by Intracoronary Near-Infrared Spectroscopy Identifies High Risk of Periprocedural Myocardial Infarction. Circ Cardiovasc Interv 2011; 4:429-37. [DOI: 10.1161/circinterventions.111.963264] [Citation(s) in RCA: 172] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- James A. Goldstein
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Brijeshwar Maini
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Simon R. Dixon
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Emmanouil S. Brilakis
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Cindy L. Grines
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - David G. Rizik
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Eric R. Powers
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Daniel H. Steinberg
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Kendrick A. Shunk
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Giora Weisz
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Pedro R. Moreno
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Annapoorna Kini
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Samin K. Sharma
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Michael J. Hendricks
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Steve T. Sum
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Sean P. Madden
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - James E. Muller
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Gregg W. Stone
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
| | - Morton J. Kern
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI (J.A.G., S.R.D., C.L.G.); Pinnacle Health, Moffitt Heart and Vascular Group, Wormleysburg, PA (B.M.); Veterans Affairs North Texas Healthcare System and University of Texas Southwestern Medical Center at Dallas, Dallas, TX (E.B.); Scottsdale Heart Group, Scottsdale Healthcare Hospital, Scottsdale, AZ (D.G.R.); Heart and Vascular Center, Medical University of South Carolina, Charleston, SC (E.R.P., D.H.S.); the
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