CT Coronary angiography in clinical practice

__Abstract__ Stable angina is a common and disabling disease with coronary artery disease (CAD) accounting for 68% of heart related deaths (I). Common risk factors for CAD 1nclude hypertension, h1gh cholesterol levels, cigarette smoking, obesity, and a family history of heart disease. Traditionally ischemic testing include exercise ECG and stress myocardial perfusion imaging (SPECT) for the non-invasive detection of inducible ischemia. Invasive coronary angiography (ICA)

Effect of minimally invasive autopsy and ethnic background on acceptance of clinical postmortem investigation in adults

Objectives Autopsy rates worldwide have dropped significantly over the last five decades. Imaging based autopsies are increasingly used as alternatives to conventional autopsy (CA). The aim of this study was to investigate the effect of the introduction of minimally invasive autopsy, consisting of CT, MRI and tissue biopsies on the overall autopsy rate (of CA and minimally invasive autopsy) and the autopsy rate among different ethnicities. Methods We performed a prospective single center before-after study. The intervention was the introduction of m

Post-mortem tissue biopsies obtained at minimally invasive autopsy: An RNA-quality analysis

Introduction: Bereaved relatives often refuse to give consent for post-mortem investigation of deceased cancer patients, mainly because of the mutilation due to conventional au

Hospital implementation of minimally invasive autopsy: A prospective cohort study of clinical performance and costs

Objectives Autopsy rates worldwide have dropped significantly over the last decades and imaging-based autopsies are increasingly used as an alternative to conventional autopsy. Our aim was to evaluate the clinical performance and cost of minimally invasive autopsy. Methods This study was part of a prospective cohort study evaluating a newly implemented minimally invasive autopsy consisting of MRI, CT, and biopsies. We calculated diagnostic yield and clinical utility—defined as the percentage successfully answered clinical questions—of minimally invasive autopsy. We performed minimally invasive autopsy in 46 deceased (30 men, 16 women; mean age 62.9±17.5, min-max: 18–91). Results Ninety-six major diagnoses were found with the minimally invasive autopsy of which 47/96 (49.0%) were new diagnoses. CT found 65/96 (67.7%) major diagnoses and MRI found 82/ 96 (85.4%) major diagnoses. Eighty-four clinical questions were asked in all cases. Seventy-one (84.5%) of these questions could be answered with minimally invasive autopsy. CT successfully answered 34/84 (40.5%) clinical questions; in 23/84 (27.4%) without the need for biopsies, and in 11/84 (13.0%) a biopsy was required. MRI successfully answered 60/84 (71.4%) clinical questions, in 27/84 (32.1%) without the need for biopsies, and in 33/ 84 (39.8%) a biopsy was required. The mean cost of a minimally invasive autopsy was €1296 including brain biopsies and €1087 without brain biopsies. Mean cost of CT was €187 and of MRI €284. Conclusions A minimally invasive autopsy, consisting of CT, MRI and CT-guided biopsies, performs well in answering clinical questions and detecting major diagnoses. However, the diagnostic yield and clinical utility were quite low for postmortem CT and MRI as standalone modalities

Diagnostic performance of exercise bicycle testing and single-photon emission computed tomography: Comparison with 64-slice computed tomography coronary angiography

To conduct a comparison of the diagnostic performance of exercise bicycle testing and singlephoton emission computed tomography (SPECT) with computed tomography coronary angiography (CTCA) for the detection of obstructive coronary artery disease (CAD) in patients with stable angina. 376 symptomatic patients (254 men, 122 women, mean age 60.4 ± 10.0 years) referred for noninvasive stress testing (exercise bicycle test and/or SPECT) and invasive coronary angiography were included. All patients underwent additional 64-slice CTCA. The diagnostic performance of exercise bicycle testing (ST segment depression), SPECT (reversible perfusion defect) and CTCA (≥50% lumen diameter reduction) was presented as sensitivity, specificity, positive and negative predictive value (PPV and NPV) to detect or rule out obstructive CAD with quantitative coronary angiography as reference standard. Comparisons of exercise bicycle testing versus CTCA (n = 334), and SPECT versus CTCA (n = 61) were performed. The diagnostic performance of exercise bicycle testing was significantly (P value0.05): 77% (95% CI, 50-92) vs. 82% (95% CI, 56-95). We observed a PPV of 91% (95% CI, 77-97) vs. 93% (95% CI, 81-98); andNPVof 72% (95%, 46-89) vs. 93% (95%, 66-100). SPECT and CTCA yielded higher diagnostic performance compared to traditional exercise bicycle testing for the detection and rule out of obstructive CAD in patients with stable angina

Computed tomography coronary angiography accuracy in women and men at low to intermediate risk of coronary artery disease

Objectives To investigate the diagnostic accuracy of CT coronary angiography (CTCA) in women at low to intermediate pre-test probability of coronary artery disease (CAD) compared with men. Methods In this retrospective study we included symptomatic patients with low to intermediate risk who underwent both invasive coronary angiography and CTCA. Exclusion criteria were previous revascularisation or myocardial infarction. The pre-test probability of CAD was estimated using the Duke risk score. Thresholds of less than 30 % and 30-90 % were used for determining low and intermediate risk, respectively. The diagnostic accuracy of CTCA in detecting obstructive CAD (≥50 % lumen diameter narrowing) was calculated on patient level. P<0.05 was considered significant. Results A total of 570 patients (46 % women [262/570]) were included and stratified as low (women 73 % [80/109]) and intermediate risk (women 39 % [182/461]). Sensitivity, specificity, PPV and NPV were not significantly different in and between women and men at low and intermediate risk. For women vs. me

How should I treat acute valve regurgitation?

BACKGROUND: An 81-year-old male with symptoms of angina and dyspnoea (NYHA 3), a history of coronary bypass surgery, a transaortic peak gradient of 109 mmHg on transthoracic echocardiography and a logistic Euro-SCORE of 21.6 was deemed suboptimal for surgery by a multidisciplinary team and was accepted for TAVI. INVESTIGATION: Preprocedural diameter of the native aortic root was 24.4 mm on transthoracic echocardiography (TTE), 26.9 mm on contrast angiography and 26.8 mm by 30.2 mm on multislice computed tomography (MSCT). DIAGNOSIS: Heavy calcification of the aortic root and coronary arteries by MSCT. TREATMENT: Transcatheter aortic valve replacement with an 29 mm CoreValve prosthesis

Optimal electrocardiographic pulsing windows and heart rate: Effect on image quality and radiation exposure at dual-source coronary CT angiography

Purpose: To determine the optimal width and timing of the electrocardiographic (ECG) pulsing window within the cardiac cycle in relation to heart rate (HR), image quality, and radiation exposure in patients who are suspected of having coronary artery disease. Materials and Methods: The institutional review board approved the study, and all patients gave informed consent. Dual-source computed tomography (CT) was performed in 301 patients (mean HR, 70.1 beats per minute ± 13.3 [standard deviation]; range, 43-112 beats per minute) by using a wide ECG pulsing window (25%-70% of the R-R interval). Data sets were reconstructed in 5% steps from 20%-75% of R-R interval. Image quality was assessed by two observers on a per-segment level and was classified as good or impaired. High-quality data sets w

Non-invasive diagnostic workup of patients with suspected stable angina by combined computed tomography coronary angiography and magnetic resonance perfusion imaging

Background: To evaluate additional adenosine magnetic resonance perfusion (MRP) imaging in the diagnostic workup of patients with suspected stable angina with computed tomography coronary angiography (CTCA) as first-line diagnostic modality. Methods and Results: Two hundred and thirty symptomatic patients (male, 52%; age, 56 year) with suspected stable angina underwent CTCA. In patients with a stenosis of >50% as visually assessed, MRP was performed and the quantitative myocardial perfusion reserve index (MPRI) was calculated. Coronary flow reserve (CFR) using invasive coronary flow measurements served as the standard of reference. CTCA showed non-significant CAD in 151/230 (66%) patients and significant CAD in 79/230 patients (34%), of whom 50 subsequently underwent MRP and CFR. MRP showed reduced perfusion in 32 patients (64%), which was confirmed by CFR in 27 (84%). All 18 cases of normal MRP (36%) were confirmed by CFR. The positive likelihood ratio of MRP for the presence of functional significant disease in patients with a lesion on CTCA was 4.49 (95% confidence interval [CI] 2.12-9.99). The negative likelihood ratio was 0.05 (95%CI 0.01-0.34). Conclusions: CTCA as first-line diagnostic modality excluded coronary artery disease in a high percentage of patients referred for diagnostic workup of suspected stable angina. MRP made a significant contribution to the detectio

Diagnostic performance of coronary CT angiography by using different generations of multisection scanners: Single-center experience

Purpose: To retrospectively compare sensitivity and specificity of four generations of multidetector computed tomographic (CT) scanners for diagnosing significant (≥50%) coronary artery stenosis, with quantitative conventional coronary angiography as reference standard. Materials and Methods: The institutional review board approved this study. All patients consented to undergo CT studies prior to conventional coronary angiography, after they were informed of the additional radiation dose, and to the use of their data for future retrospective research. Two hundred four patients (157 men, 47 women; mean age, 58 years ± 11 [standard deviation]), classified in four groups of 51 patients each, underwent coronary CT angiography with four-section, first- and second-generation 16-section, and 64-section CT scanners. Patients in sinus rhythm scheduled for conventional coronary angiography (stable angina, atypical chest pain) were included. Patients with bypass grafts and stents were excluded. Two readers unaware of results of conventional coronary angiography evaluated CT scans. Coronary artery segments of 2 mm or larger in diameter were included for comparative evaluation with quantitative coronary angiography. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for detection of significant stenoses (≥50% luminal diameter reduction) were calculated. Results: Image quality was rated poor for the following percentages of coronary artery segments: 33.1% at four-section CT, 14.4% at first-generation 16-section CT, 6.3% at second-generation 16-section CT, and 2.6% at 64-section CT. Sensitivity, specificity, PPV, and NPV, respectively, were as follows: 57%, 91%, 60%, and 90% at four-section CT; 90%, 93%, 65%, and 99% at first-generation 16-section CT; 97%, 98%, 87%, and 100% at second-generation 16-section CT; and 99%, 96%, 80%, and 100% at 64-section CT. Diagnostic performance of four-section CT was significantly poorer than that of second-generation 16-section CT (odds ratio = 4.57) and 64-section CT (odds ratio = 2.89). Conclusion: Diagnostic performance of coronary CT angiography varies among scanners of different generations. Earlier-generation scanners (four sections) had significantly poorer performance; performance of 16- compared with 64-section CT scanners showed progressive, although not significant, improvement