Assessment of coronary sinus anatomy between normal and insufficient mitral valves by multi-slice computertomography for mitral annuloplasty device implantation

Introduction: Latest techniques enable positioning of devices into the coronary sinus (CS) for mitral valve (MV) annuloplasty. We evaluate the feasibility of non-invasive assessment to determine CS anatomy and its relation to MV annulus and coronary arteries by multi-slice CT (MSCT) in normal and insufficient MV. Methods: Fifty patients (33 males, 17 females, age 67±11 years) were studied retrospectively by 64-MSCT scans for anatomical criteria regarding CS and its relation to MV annulus and circumflex artery (CX). We included 24 patients with severe mitral insufficiency and 26 with no MV disease. Diameter of MV, of proximal and distal ostium of CS, length and volume of CS, angle between anterior interventricular vein (AIV) and CS, caliber change of CX before, under/over and after CS were analysed. Different anatomical correlations were demonstrated: distance of MV annulus to CS, CX to CS. Results: Diameter of proximal CS ostium was significantly larger in insufficient MV compared to normal MV (11±2.8mm vs 9.9±2.5mm; p<0.024). CS was significantly longer in patients with insufficient MV (125.4±17mm vs 108.9±18mm; p<0.003) with also significant differences in volume of CS (p<0.039). Significant difference in annulus diameter, 46.1±6mm (insufficient MV) versus 39.5±7.5mm, p<0.004 was observed. Angle CS-AIV was 103.5±29° (range 52°-144°) in insufficient valves versus 118.2±24.5° (range 73°-166°) in normal valves with a tendency to higher angles in normal valves (p=0.06). Distance of MV annulus to CS measured 16±4.1/14.2±3.6mm (insufficient/normal MV) without significant difference between groups. In 15 patients CX ran under CS. Eighty-four percent of these patients (13/15) show a decrease in CS caliber in the area of intersection. In 14 patients CS ran over and in one patient the diameter of the CS at intersecting region was smaller. In 16 patients no direct point of contact was visible, in five patients CX to CS positioning was not evaluable. Conclusion: There is a significant anatomic difference between normal and insufficient MV, which might be the basis for any interventional approaches through the CS. Exact measurements of all structures and its anatomic correlations are possible with MSCT, which allows pre-interventional plannin

Accuracy of dual-source computed tomography coronary angiography: evaluation with a standardised protocol for cardiac surgeons

Background: This study assesses the accuracy of the new dual-source computed tomography (DSCT) for detection of coronary artery disease (CAD) compared with invasive coronary angiography (ICA) with a specifically designed data presentation protocol for cardiac surgeons. Methods: Forty patients (30 males/10 females) underwent ICA and DSCT. Best-quality images were prepared by radiologists. Evaluation of 12 segments of significant coronary stenosis was done by two cardiac surgeons with a data presentation protocol including different coronary views in two-/three-dimensional (2D/3D) images. No beta-blockers were administered prior to DSCT. Results: ICA revealed CAD in 21 patients and valvular disease but no CAD in 19 patients. In DSCT, 20/21 patients were diagnosed with CAD (at least one significant stenosis per patient). In 11/21 patients, all 12 segments were assessed correctly; in 7/21 patients one segment and in 3/21 patients two segments were evaluated incorrectly. Of all 21 patients with CAD, 239/252 segments (95%) were correctly evaluated. In 18/19 patients without CAD, DSCT correctly ruled-out the ICA results in 226/228 segments (99%). In total, 465/480 segments were correctly assessed (97%). Of 480 segments, only six were considered not assessable. DSCT assessments of the segments showed a sensitivity of 91%, specificity of 99%, a positive predictive value of 92% and a negative predictive value of 99%. Conclusions: The accuracy of DSCT coronary angiography especially for exclusion of CAD is promising. The introduced data presentation protocol allows for the independent evaluation by cardiac surgeons after pre-arrangement from the radiologist

Is off-pump superior to conventional coronary artery bypass grafting in diabetic patients with multivessel disease?

Objective: Diabetic patients often present with diffuse coronary disease than nondiabetic patients posing a greater surgical challenge during off-pump revascularization. In this study, the safety, feasibility, and completeness of revascularization for this subset of patients was assessed. Methods: From 2002 to 2008, 1015 diabetic patients underwent myocardial revascularization. Patients received either off-pump coronary artery bypass (OPCAB; n=540; 53%) or coronary artery bypass grafting (CABG; n=475; 47%). Data collection was performed prospectively and data analysis was done by propensity-score (PS)-adjusted regression analysis. Primary endpoints were mortality, major adverse cardiac and cerebrovascular events (MACCEs), and a composite endpoint including major noncardiac adverse events (MNCAEs) such as respiratory failure, renal failure, and rethoracotomy for bleeding was applied. An index of complete revascularization (ICOR) was defined to assess complete revascularization by dividing the total number of distal anastomoses by the number of diseased vessels. Complete revascularization was assumed when ICOR was >1. Results: OPCAB patients had a significantly lower mortality-rate (1.1% vs 3.8%; propensity-adjusted odds ratio (PAOR)=0.11; p=0.018) and displayed less frequent MACCE (8.3% vs 17.9%; PAOR=0.66; p=0.07) including myocardial infarction (1.3% vs 3.2%; PAOR=0.33; p=0.06) and stroke (0.7% vs 2.3%; PAOR=0.28; p=0.13). Similarly, a significantly lower occurrence of the noncardiac composite endpoint (MNCAE) (PAOR=0.46; confidence interval (CI) 95% 0.35-0.91; p1 was achieved clearly indicating complete revascularization (94.3% vs 93.7%; p=0.24). Conclusions: OPCAB offers a lower mortality and superior postoperative outcomes in diabetic patients with multivessel disease. Arterial grafts are used more frequently that may contribute to better long-term outcomes and the OPCAB approach does not come at the cost of less complete revascularizatio

High-pitch dual-source CT angiography of the aortic valve-aortic root complex without ECG-synchronization

Purpose: To compare image quality and radiation dose of high-pitch computed tomography angiography(CTA) of the aortic valve-aortic root complex with and without prospective ECG-gating compared to a retrospectively ECG-gated standard-pitch acquisition. Materials and Methods: 120 patients(mean age 68 ± 13years) were examined using a 128-slice dual-source CT system using prospectively ECG-gated high-pitch(group A; n = 40), non-ECG-gated high-pitch(group B; n = 40) or retrospectively ECG-gated standard-pitch(C; n = 40) acquisition techniques. Image quality of the aortic root, valve and ascending aorta including the coronary ostia was assessed by two independent readers. Image noise was measured, radiation dose estimates were calculated. Results: Interobserver agreement was good(κ = 0.64-0.78). Image quality was diagnostic in 38/40 patients(group A), 37/40(B) and 38/40(C) with no significant difference in number of patients with diagnostic image quality among all groups (p = 0.56). Significantly more patients showed excellent image quality in group A compared to groups B and C(each, p < 0.01). Average image noise was significantly different between all groups(p < 0.05). Mean radiation dose estimates in groups A and B(each; 2.4 ± 0.3mSv) were significantly lower compared to group C(17.5 ± 4.4mSv; p < 0.01). Conclusion: High-pitch dual-source CTA provides diagnostic image quality of the aortic valve-aortic root complex even without ECG-gating at 86% less radiation dose when compared to a standard-pitch ECG-gated acquisitio

Atmospheric new particle formation at the research station Melpitz, Germany : connection with gaseous precursors and meteorological parameters

This paper revisits the atmospheric new particle formation (NPF) process in the polluted Central European troposphere, focusing on the connection with gas-phase precursors and meteorological parameters. Observations were made at the research station Melpitz (former East Germany) between 2008 and 2011 involving a neutral cluster and air ion spectrometer (NAIS). Particle formation events were classified by a new automated method based on the convolution integral of particle number concentration in the diameter interval 2-20 nm. To study the relevance of gaseous sulfuric acid as a precursor for nucleation, a proxy was derived on the basis of direct measurements during a 1-month campaign in May 2008. As a major result, the number concentration of freshly produced particles correlated significantly with the concentration of sulfur dioxide as the main precursor of sulfuric acid. The condensation sink, a factor potentially inhibiting NPF events, played a subordinate role only. The same held for experimentally determined ammonia concentrations. The analysis of meteorological parameters confirmed the absolute need for solar radiation to induce NPF events and demonstrated the presence of significant turbu-lence during those events. Due to its tight correlation with solar radiation, however, an independent effect of turbulence for NPF could not be established. Based on the diurnal evolution of aerosol, gas-phase, and meteorological parameters near the ground, we further conclude that the particle formation process is likely to start in elevated parts of the boundary layer rather than near ground level.Peer reviewe

Diagnostic accuracy of high-pitch dual-source CT for the assessment of coronary stenoses: first experience

Objectives: The objective was to prospectively investigate the diagnostic accuracy of high-pitch (HP) dual-source computed tomography coronary angiography (CTCA) compared with catheter coronary angiography (CCA) for the diagnosis of significant coronary stenoses. Methods: Thirty-five patients (seven women; mean age 62 ± 8years) underwent both CTCA and CCA. CTCA was performed with a second-generation dual-source CT system permitting data acquisition at an HP of 3.4. Patients with heart rates >60bpm were excluded from study enrolment. All coronary segments were evaluated by two blinded and independent observers with regard to image quality on a four-point scale (1: excellent to 4: non-diagnostic) and for the presence of significant coronary stenoses (defined as diameter narrowing exceeding 50%). CCA served as the standard of reference. Radiation dose values were calculated using the dose-length product. Results: Diagnostic image quality was found in 99% of all segments (455/459). Non-diagnostic image quality occurred in a single patient with a sudden increase in heart rate immediately before and during CTCA. Taking segments with non-evaluative image quality as positive for disease, the sensitivity, specificity and positive and negative predictive values were 94, 96, 80 and 99% per segment and 100, 91, 88 and 100% per patient. The effective radiation dose was on average 0.9 ± 0.1mSv. Conclusion: In patients with heart rates ≤60bpm, CTCA using the HP mode of the dual-source CT system is associated with high diagnostic accuracy for the assessment of coronary artery stenoses at sub-milliSievert dose

Off-pump surgery for the poor ventricle?

Severely decreased ejection-fraction is an established risk-factor for worse outcome after cardiac surgery. We compare outcomes of off-pump coronary artery bypass grafting (OPCAB) and on-pump CABG (ONCABG) in patients with severely compromised EF. From 2004 to 2009, 478 patients with a decreased EF ≤35% underwent myocardial-revascularization. Patients received either OPCAB (n=256) or ONCABG (n=222). Propensity score (PS), including 50 preoperative risk-factors, was used to balance characteristics between groups. PS adjusted logistic regression analysis was performed to assess mortality and major adverse cardiac and cerebrovascular events (MACCE). A composite endpoint for major non-cardiac complications such as respiratory failure, renal failure, rethoracotomy was applied. Complete revascularization (CR) was assumed when the number of distal anastomoses was larger than that of diseased vessels. There was no difference for mortality (2.3 vs. 4.1%; PS-adjusted odds ratio (PS-OR)=1.05; p=0.93) and MACCE (13.7 vs. 17.6%; PS-OR=1.22; p=0.50) including myocardial-infarction (1.4 vs. 4.9%; PS-OR=0.39; p=0.26), low cardiac output (2.3 vs. 4.7%; PS-OR=0.75; p=0.72) and stroke (2.3 vs. 2.7%; PS-OR=0.69; p=0.66). OPCAB patients presented with a trend to less frequent occurrence of the non-cardiac composite (12.1 vs. 22.1%; PS-OR=0.54; p=0.059) including renal dysfunction (PAOR=0.77; 95% CI 0.31-1.9; p=0.57), bleeding (PAOR=0.42; 95% CI 0.14-1.20; p=0.10) and respiratory failure (PAOR=0.39; 95% CI 0.05-3.29; p=0.39). The rate of complete revascularization was similar (92.2 vs. 92.8%; PS-OR=0.75; p=0.50). OPCAB in patients with severely decreased EF is safe and feasible. It may even benefit these patients in regard to non-cardiac complications and does not come at cost of less complete revascularizatio

Safe, effective and durable epicardial left atrial appendage clip occlusion in patients with atrial fibrillation undergoing cardiac surgery: first long-term results from a prospective device trial

OBJECTIVES Atrial fibrillation (AF) is a significant risk factor for embolic stroke originating from the left atrial appendage (LAA). This is the first report of long-term safety and efficacy data on LAA closure using a novel epicardial LAA clip device in patients undergoing cardiac surgery. METHODS Forty patients with AF were enrolled in this prospective ‘first-in-man' trial. The inclusion criterion was elective cardiac surgery in adult patients with AF for which a concomitant ablation procedure was planned. Intraoperative transoesophageal echocardiography (TEE) was used to exclude LAA thrombus at baseline and evaluate LAA perfusion after the procedure, while computed tomography (CT) was used for serial imagery workup at baseline, 3-, 12-, 24- and 36-month follow-up. RESULTS Early mortality was 10% due to non-device-related reasons, and thus 36 patients were included in the follow-up consisting of 1285 patient-days and mean duration of 3.5 ± 0.5 years. On CT, clips were found to be stable, showing no secondary dislocation 36 months after surgery. No intracardial thrombi were seen, none of the LAA was reperfused and in regard to LAA stump, none of the patients demonstrated a residual neck >1 cm. Apart from one unrelated transient ischaemic attack (TIA) that occurred 2 years after surgery in a patient with carotid plaque, no other strokes and/or neurological events demonstrated in any of the studied patients during follow-up. CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100% effective, safe and durable in the long term. Closure of the LAA by epicardial clipping is applicable to all-comers regardless of LAA morphology. Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation and/or catheter closure. Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention. CLINICAL TRIAL REGISTRATION The trial is registered at www.ClinicalTrials.gov, reference: NCT0056751

High-pitch dual-source CT angiography of the aortic valve-aortic root complex without ECG-synchronization.

PURPOSE: To compare image quality and radiation dose of high-pitch computed tomography angiography(CTA) of the aortic valve-aortic root complex with and without prospective ECG-gating compared to a retrospectively ECG-gated standard-pitch acquisition. MATERIALS AND METHODS: 120 patients(mean age 68 +/- 13 years) were examined using a 128-slice dual-source CT system using prospectively ECG-gated high-pitch(group A; n = 40), non-ECG-gated high-pitch(group B; n = 40) or retrospectively ECG-gated standard-pitch(C; n = 40) acquisition techniques. Image quality of the aortic root, valve and ascending aorta including the coronary ostia was assessed by two independent readers. Image noise was measured, radiation dose estimates were calculated. RESULTS: Interobserver agreement was good(kappa = 0.64-0.78). Image quality was diagnostic in 38/40 patients(group A), 37/40(B) and 38/40(C) with no significant difference in number of patients with diagnostic image quality among all groups (p = 0.56). Significantly more patients showed excellent image quality in group A compared to groups B and C(each, p < 0.01). Average image noise was significantly different between all groups(p < 0.05). Mean radiation dose estimates in groups A and B(each; 2.4 +/- 0.3 mSv) were significantly lower compared to group C(17.5 +/- 4.4 mSv; p < 0.01). CONCLUSION: High-pitch dual-source CTA provides diagnostic image quality of the aortic valve-aortic root complex even without ECG-gating at 86% less radiation dose when compared to a standard-pitch ECG-gated acquisition