Coronary spiral CT

This dissertation describes the use and clinical potential of ECG gated multislice spiral computed tomography in patients with coronary artery disease. First the use of other non invasive cardiac imaging, i.e. the previously mentioned electron beam CT and magnetic resonance imaging is reviewed (chapter 2.1). Part 3 contains studies related to the characteristics of multislice spiral CT for the imaging of the heart and coronary arteries, and the diagnostic potential of ECG gated spiral CT coronary angiography to detect and visualize obstructive coronary artery disease in symptomatic patients, using conventional coronary angiography as the standard of reference. Part 4 is focussed on the feasibility and characteristics of coronary wall imaging by CT, including the assessment of non calcified atherosclerotic plaque material. The usefulness of contrast enhanced multislice spiral CT in symptomatic patients who previously underwent coronary artery bypass grafting and percutaneous coronary intervention with stent implantation is discussed in part 5. Finally, the first results with the latest generation 16 slice computed tomography scanners and patient preparation with ~ receptor blockers are described in part 6, including a review and future outlook on the continuing development and clinical use of non invasive coronary angiography with spiral computed tomography

Stress myocardial perfusion cardiac magnetic resonance imaging vs. coronary CT angiography in the diagnostic work-up of patients with stable chest pain: comparative effectiveness and costs

Background:To determine the comparative effectiveness and costs of coronary CT angiography (CCTA) and stress cardiac magnetic resonance imaging (CMR) for diagnosing coronary artery disease (CAD).Methods:A Markov micro-simulation model for 60-year-old patients with stable chest pain was developed, analyzing the perspective of the United States (US), United Kingdom (UK), and the Netherlands (NL).CCTA, CMR, and CCTA+CMR (CCTA, if positive followed by CMR) were considered and compared to direct catheter-based angiography (CAG) and no testing. The strategies were considered both as conservative strategy (patients with mildly-positive test results are not referred for CAG), and as invasive strategy (all patients with positive test results are referred for CAG). Outcome measures included lifetime costs, quality-adjusted life years (QALY), and radiation exposure.Results:Differences in effectiveness (QALYs) across diagnostic strategies were very small (range 0.001-0.016). For 60-year old men and women with a pre-test probability of 30% (and up to 70-90%, depending on the country considered), the CCTA, CMR, and CAG strategies were dominated, because the CCTA+CMR-conservative strategy was slightly more effective, and less expensive. Compared to the CCTA+CMR-conservative strategy, the CCTA+CMR-invasive strategy was slightly more costly and slightly more effective. The CCTA+CMR-invasive strategy was cost-effective for the US and NL, but not for the UK. When patients with false-negative test results were assumed to remain false-negative for 3 years, differences between strategies increased, and the CCTA-invasive strategy became cost-effective for UK and NL.Conclusions:Quality-adjusted life expectancy was similar across strategies. The CCTA+CMR strategy was cost-effective up to a pre-test probability of 70-90%, depending on the country. Above these thresholds, the CMR-strategy was cost-effective.<br/

Stress myocardial perfusion cardiac magnetic resonance imaging vs. coronary CT angiography in the diagnostic work-up of patients with stable chest pain:comparative effectiveness and costs

Background:To determine the comparative effectiveness and costs of coronary CT angiography (CCTA) and stress cardiac magnetic resonance imaging (CMR) for diagnosing coronary artery disease (CAD).Methods:A Markov micro-simulation model for 60-year-old patients with stable chest pain was developed, analyzing the perspective of the United States (US), United Kingdom (UK), and the Netherlands (NL).CCTA, CMR, and CCTA+CMR (CCTA, if positive followed by CMR) were considered and compared to direct catheter-based angiography (CAG) and no testing. The strategies were considered both as conservative strategy (patients with mildly-positive test results are not referred for CAG), and as invasive strategy (all patients with positive test results are referred for CAG). Outcome measures included lifetime costs, quality-adjusted life years (QALY), and radiation exposure.Results:Differences in effectiveness (QALYs) across diagnostic strategies were very small (range 0.001-0.016). For 60-year old men and women with a pre-test probability of 30% (and up to 70-90%, depending on the country considered), the CCTA, CMR, and CAG strategies were dominated, because the CCTA+CMR-conservative strategy was slightly more effective, and less expensive. Compared to the CCTA+CMR-conservative strategy, the CCTA+CMR-invasive strategy was slightly more costly and slightly more effective. The CCTA+CMR-invasive strategy was cost-effective for the US and NL, but not for the UK. When patients with false-negative test results were assumed to remain false-negative for 3 years, differences between strategies increased, and the CCTA-invasive strategy became cost-effective for UK and NL.Conclusions:Quality-adjusted life expectancy was similar across strategies. The CCTA+CMR strategy was cost-effective up to a pre-test probability of 70-90%, depending on the country. Above these thresholds, the CMR-strategy was cost-effective.<br/

Low-dose coronary calcium scoring CT using a dedicated reconstruction filter for kV-independent calcium measurements

In this prospective, pilot study, we tested a kV-independent coronary artery calcium scoring CT protocol, using a novel reconstruction kernel (Sa36f). From December 2018 to November 2019, we performed an additional research scan in 61 patients undergoing clinical calcium scanning. For the standard protocol (120 kVp), images were reconstructed with a standard, medium-sharp kernel (Qr36d). For the research protocol (automated kVp selection), images were reconstructed with a novel kernel (Sa36f). Research scans were sequentially performed using a higher (cohort A, n = 31) and a lower (cohort B, n = 30) dose optimizer setting within the automatic system with customizable kV selection. Agatston scores, coronary calcium volumes, and radiation exposure of the standard and research protocol were compared. A phantom study was conducted to determine inter-scan variability. There was excellent correlation for the Agatston score between the two protocols (r = 0.99); however, the standard protocol resulted in slightly higher Agatston scores (29.4 [0-139.0] vs 17.4 [0-158.2], p = 0.028). The median calcium volumes were similar (11.5 [0-109.2] vs 11.2 [0-118.0] mm(3); p = 0.176), and the number of calcified lesions was not significantly different (p = 0.092). One patient was reclassified to another risk category. The research protocol could be performed at a lower kV and resulted in a substantially lower radiation exposure, with a median volumetric CT dose index of 4.1 vs 5.2 mGy, respectively (p < 0.001). Our results showed that a consistent coronary calcium scoring can be achieved using a kV-independent protocol that lowers radiation doses compared to the standard protocol

Preventing LVAD implantation by early short-term mechanical support and prolonged inodilator therapy

Cardiogenic shock continues to be a life-threatening condition carrying a high mortality and morbidity, where the prognosis remains poor despite intensive modern treatment modalities. In recent years, mainly technical improvements have led to a more widespread use of short- and long-term mechanical circulatory support, such as veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and left ventricular assist devices (LVADs). Currently, LVADs are indispensable as 'bridge' to cardiac recovery, heart transplantation (HTX), and/or as destination therapy Importantly, both LVADs and HTX put a vast burden on financial resources, besides significant short- and long-term risks of morbidity and mortality. These considerations underscore the importance of optimal timing and appropriate patient selection for LVAD therapy, avoiding as much as possible an unfortunate and costly clinical path. In this report, we present a series of three cases with acute refractory cardiogenic shock ('crash and burn', INTERMACS profile 1) successfully treated by ECMO and early optimal medical therapy preventing a certain path towards LVAD and/or HTX, for which they were initially referred. This conservative approach in INTERMACS profile one patients warrants very early introduction of adequate medical heart failure therapy under the umbrella of a combination of short-term mechanical circulatory and inotropic support by phosphodiesterase inhibitors. Therefore, this novel combined medical-mechanical approach could have important clinical implications for this extremely challenging patient category, as it may avoid an unnecessary and costly clinical path towards LVAD and/or heart transplantation

Functional evaluation of coronary disease by CT angiography

Publisher Copyright: © 2015 American College of Cardiology Foundation.In recent years, several technical developments in the field of cardiac computed tomography (CT) have made possible the extraction of functional information from an anatomy-based examination. Several different lines have been explored and will be reviewed in the present paper, namely: 1) myocardial perfusion imaging; 2) transluminal attenuation gradients and corrected coronary opacification indexes; 3) fractional flow reserve computed from CT; and 4) extrapolation from atherosclerotic plaque characteristics. In view of these developments, cardiac CT has the potential to become in the near future a truly 2-in-1 noninvasive evaluation for coronary artery disease.publishersversionpublishe

Prognostic Value of Subclinical Coronary Artery Disease in Atrial Fibrillation Patients Identified by Coronary Computed Tomography Angiography

Identifying coronary artery disease (CAD) in atrial fibrillation (AF) patients improves risk stratification and defines clinical management. However, the value of screening for subclinical CAD with cardiac CT in AF patients is unknown. Between 2011 and 2015, 94 consecutive patients without known or suspected CAD (66 (57–73) years, 68% male), who were referred for AF evaluation, under