Calcification Grade Research Articles

Papillary calcifications: a new prognostic factor in idiopathic calcium oxalate urolithiasis

Metabolic evaluation is not suitable to forecast the course of the disease in idiopathic calcium oxalate stone formation (iCaOxU). An important pathway in CaOx stone formation is the overgrowth on interstitial apatite papillary plaques. Therefore, we studied whether the extent of such plaques may be used as a prognostic factor in CaOxU. Prospectively, we studied n=100 patients with iCaOxU. For stone analysis, X-ray diffraction/polarizing microscopy was used. During flexible ureteroscopy and flexible percutaneous nephrolithotomy, all the renal papillae were inspected, counted and the severity of calcifications assessed. A calcification index (CI) was calculated: sum of the No. of papillae×calcification grade (1-3)×No. of calcified/total No. of papillae. Furthermore, the following parameters were examined in all patients: age, sex, BMI, arterial blood pressure, stone episodes, DM; blood: creatinine, glucose, uric acid, calcium, sodium and potassium; urine: pH, volume, calcium, uric acid, citrate, ammonia and urea. Using the statistic programme Prism 5 (GraphPad), summary statistics and non-parametric correlations (Spearman) and their significance were calculated. The CI correlated significantly (r=0.37; p=0.012) with the No. of stone episodes. Apart from citrate (r=0.51; p=0.002), none of the conventional metabolic parameters correlated significantly with the No. of stone episodes. Paradoxically, the citrate excretion-although citrate being an inhibitor of CaOx stone formation-positively correlated to the recurrence rate. The endoscopic assessment of papillary plaques/calcifications and the calculation of the CI are a more suitable prognostic factor in CaOx than conventional metabolic evaluation.

Value of cardiac CT in comprehensive aortic valve and root evaluation before percutaneous aortic valve replacement

Aortic stenosis (AS) is the most frequent valvular heart disease, and patients who develop AS are at a high risk of sudden death. There is no medical cure available, and aortic valve replacement is the only effective treatment for advanced disease. Preoperative evaluation is the cornerstone of therapy and is necessary for selecting the implantation technique and valve. To evaluate the role of cardiac CT in comprehensive aortic valve and aortic root evaluation before percutaneous aortic valve replacement. Thirty-four patients with severe aortic valve stenosis were evaluated by cardiac CT. The aortic valve calcification grade defined by cardiac CT was compared to the operative findings. The mean calculated aortic annulus diameter (CAAD) measured by cardiac CT was compared to the aortic annulus diameter measured by transthoracic echocardiography (TTE) as well as during the operation. The distances from the aortic valve annulus to the coronary ostia (right and left) were measured by cardiac CT and compared to the intraoperative measurements. The findings from the CT coronary angiography and conventional coronary angiography were compared. There was strong agreement (k = 0.865) between the calcification grade by cardiac CT and the intraoperative grading. There was a stronger correlation (r = 0.948) between the CAAD assessed by cardiac CT and intraoperatively compared to the correlation between the intraoperative versus TTE measurements (r = 0.660). The distances measured between the aortic annulus and the right and left coronary artery ostia by cardiac CT were strongly correlated with the distances measured intraoperatively (r = 0.966 and 0.940 in the right and left sides, respectively). Cardiac CT detected three coronary artery stenotic lesions and three patent stents. All findings were confirmed by conventional coronary angiography. Thirteen percent of the evaluated coronary artery segments were of non-diagnostic quality by cardiac CT. Cardiac CT substantially facilitates the assessment of aortic root morphology prior to aortic valve replacement.

Severe aortic arch calcification depicted on chest radiography strongly suggests coronary artery calcification

To evaluate the association between aortic arch calcifications (AAC) on chest radiography and coronary artery calcium (CAC) score determined by CT. A total of 128 patients (75 men; 69.3 ± 14.7 years) who underwent chest radiography and CAC scoring at CT were included in this retrospective analysis. The extent of AAC on chest radiography was evaluated independently by two blinded observers using a semi-quantitative four-point scale (0-3). Intra- and interobserver agreement was assessed by weighted ĸ statistics. Amount of AAC determined on radiography was correlated with CAC and ROC analyses performed to characterise the diagnostic performance of AAC grading. Excellent intraobserver (ĸ = 0.82) and good interobserver (ĸ = 0.75) agreement of AAC grading was noted. Moderate agreement (ĸ = 0.46, 95 % CI 0.36-0.56) with a linear trend (P < 0.0001) between AAC grades and CAC scores was found. Cut-off between AAC grades 0-2 and 3 had a sensitivity of 38.6 %, specificity of 96.4 %, PPV of 85.0 %, NPV of 75.0 % and accuracy of 76.6 % for the correct identification of CAC scores greater than 400. Semi-quantitative AAC grading on chest radiography is reliable and positively associated with CAC scoring. We propose to report the extent of AAC in comprehensive radiological reports as "not present", "moderate" or "severe", as severe AAC strongly suggests coronary artery calcification. • Semi-quantitative aortic arch calcification (AAC) grading on plain chest radiography appears reliable. • AAC grading is positively associated with CT coronary artery calcium scoring. • AAC grading has a high specificity for ruling out CAC scores greater than 400. • We propose the reporting of the extent of AAC grade in chest X-ray (CXR) reports.

Prostate Calcification Worsen Lower Urinary Tract Symptoms in Middle-aged Men

To investigate the correlation between prostatic calcification and lower urinary tract symptoms (LUTS) in a sample of middle-aged men receiving health checkups. Subjects aged 40 years or older who voluntarily underwent transrectal prostate ultrasound (TRUS) and fulfilled International Prostate Symptoms Score (IPSS) as part of their medical checkup were enrolled in this study. The prostatic calcification grading and prostate volume (PV) were measured by TRUS. The medical history, demographics, and metabolic markers were also evaluated. Logistic regression was used to analyze the correlation between prostatic calcification and LUTS. A total of 604 men were enrolled as study subjects. The prostatic calcification grading was significantly associated with age and PV instead of metabolic markers. Compared to the nonprostatic calcification group, the moderate/marked prostatic calcification group had a significantly higher age-adjusted IPSS (8.69 vs 6.87, P<.01), quality of life (QOL) score (2.57 vs 2.17, P<.01), storage score (3.74 vs 3.06, P= .01), voiding score (4.95 vs 3.72, P<.01), and more maximum flow rate<15 mL/sec (40.4% vs 24.5%, P<.01). Prostatic calcification grading was positively correlated with age-adjusted IPSS, QOL, voiding, and storage scores (all P for trend<.05). Further multivariate analysis indicated that moderate/marked prostatic calcification was an independent risk factors for moderate to severe LUTS (odds ratio [OR]= 1.68, P= .02). Prostatic calcification worsened IPSS, QOL, storage, voiding symptoms, and maximum urine flow (Qmax) in middle-aged men receiving a health checkup. Moderate/marked prostatic calcification was an independent risk factor for moderate to severe LUTS.

Expression of Both Matrix Metalloproteinase-2 and Its Tissue Inhibitor-2 in Tunica Media of Radial Artery in Uremic Patients

Objective: To investigate the expression and clinical significance of both matrix metalloproteinase-2 (MMP-2) and its tissue inhibitor (tissue inhibitor of metalloproteinase-2 (TIMP-2)) in tunica media of radial artery in uremic patients. Methods: The modified radial arteries from 80 uremic patients during internal arteriovenous fistula surgery were selected and used as experimental specimens. The calcification of tunica media was observed by alizarin red staining, and the expression status of MMP-2, TIMP-2, osteoprotegerin (OPG), and osteopontin (OPN) in tunica media of radial arteries of these patients was detected by immunohistochemical method. The semiquantitative analysis and comparison were conducted based on the calcification grading and the expression of each test protein in tunica media of radial artery. Results: Of the 80 cases of radial artery specimens, 37 cases were presented with various degrees of calcification of tunica media, and the calcification rate was 46.25%; the expression of MMP-2, TIMP-2, OPG, and OPN could be detected in the calcificated tunica media of the radial artery and was positively correlated with the degree of vascular calcification (p < 0.05). Conclusion: The incidence of vascular calcification in uremic patients was high. The occurrence of calcification in tunica media of the radial artery was correlated with the expression of MMP-2 and TIMP-2.

Sleep Apnoea Syndrome as a Risk for Mortality in Elderly Inpatients

The characteristics of sleep apnoea syndrome (SAS) in the elderly, including subtype classification and association with mortality, have not been fully elucidated. This study examined these factors in an elderly Japanese inpatient population. Overnight polysomnography was used to diagnose and classify SAS in 145 elderly inpatients (mean ± age 81 ± 8 years). Clinical data, including brain computerized tomography findings, were recorded. The study population included nine inpatients with obstructive SAS, 12 with central SAS, 25 with mixed SAS and 99 controls (no SAS). Increased body mass index and grade of aortic arch calcification independently contributed to risk of all subtypes of SAS combined. There was an independent association between SAS and increased risk of mortality from all causes as well as from pneumonia and from cardiovascular disease. Only mixed SAS was independently and positively associated with increased risk of death from pneumonia. Obstructive, central and mixed SAS were associated with increased risk of cardiovascular related and all-cause mortality. Mixed SAS was associated with an increase in mortality from pneumonia. There was no relationship between mortality and severity of SAS.

Natural History of Side Branches Jailed by Drug‐Eluting Stents

Stent deployment across side branch (SB) ostium is common in daily practice. The present study investigated the natural history of SBs jailed by drug-eluting stents (DES). The thrombolysis in myocardial infarction (TIMI) flow grades of 271 consecutive SBs jailed by DES in 196 patients was assessed immediately after the procedure and at 9 months of follow-up. Patients receiving any SB intervention were excluded. Of 271 jailed SBs, occlusion occurred in 6.27% and deterioration of flow occurred in 6.27% immediately after stenting. In patients with these SB changes, periprocedural myocardial infarction was more likely than in those without (10.0% vs. 1.8%, P = 0.017), while there was no increase of cardiac death or life-threatening complications such as stent thrombosis and Q-wave myocardial infarction (Q MI) during follow-up. At 9 months, angiography showed that one-third of the initially obstructed SBs were still occluded. In contrast, flow was maintained in almost all (98.6%) SBs with early TIMI flow grade 3 and there was no delayed occlusion of these branches. Multiple regression analysis showed that lesion complexity (Medina bifurcation class, calcification, and preprocedural TIMI grade 2 flow in the SB) and technical factors (jailing by overlapping stents) were related to SB occlusion or flow deterioration. Jailed SBs showing good flow after stenting had a favorable angiographic and clinical outcome after 9 months of follow-up. However, preprocedural lesion complexity and technical factors should be considered to avoid SB occlusion/flow deterioration associated with periprocedural myocardial infarction.

Crimping May Affect the Durability of Transcatheter Valves: An Experimental Analysis

Transcatheter aortic valve implantation has gained widespread acceptance to treat elderly high-risk patients with aortic stenosis. We used a subcutaneous rat model to evaluate whether crimping may affect valve long-term durability. Standard Sapien transcatheter valves (Edwards Lifesciences, Irvine, CA) were crimped for different durations (1 hour, 1 day, 1 month) and uncrimped, and leaflet pieces as well as control tissue (Perimount Magna, Edwards) were then implanted subcutaneously in 15 male weanling Sprague-Dawley rats for 12 weeks. Grade of calcification was measured by freeze-dried mass and van Kossa staining. Histologic and electron microscopic examination were performed to investigate potential leaflet-fragmentation caused by crimping. There were no differences in calcification among the groups. The calcium carbonate concentrations in all samples ranged from 0.1 to 100 mg/g dry weight. Leaflet morphology, however, differed from no fragmentation (control group) to highly fragmented tissue (1-month crimped). These differences reached statistical significance between crimped and non-crimped leaflets (p<0.003). Transcatheter valve crimping does not necessarily affect leaflet calcification. However, the structural changes of the leaflets that were caused by crimping may have clinical significance. Duration of crimping should be as short as possible, and very tight crimping to small diameters should be avoided.

The value of computed tomography scanning for the detection of coronary artery disease in patients with idiopathic pulmonary fibrosis

Patients with idiopathic pulmonary fibrosis (IPF) have a higher prevalence of coronary artery disease and this could have an impact on their outcomes. We investigated the predictive ability of coronary artery calcification, assessed by routine CT, which may predict the presence of coronary artery disease. The study cohort consisted of patients with IPF and with left heart catheterization data plus CT scans from July 2003 to July 2008. Grades of coronary calcification on CT were compared with left heart catheterization determination of coronary artery disease. There were 57 patients in whom left heart catheterization review demonstrated significant coronary artery disease in 28.1% (16/57), mild disease in 40.3% (23/57) and none in 31.6% (18/57). The median time interval between the catheterization and the reviewed CT scan was 39 days. The sensitivity of moderate to severe calcification for significant coronary artery disease was 81%, while the specificity was 85%, with an associated odds ratio of 25.2 (4.64-166, P < 0.005). There was excellent agreement among three radiologists in the grading of coronary calcification. Coronary calcification, as assessed by routine CT of the chest, has very good performance characteristics in predicting underlying significant coronary artery disease in patients with IPF. The routine availability of this study enables the ready screening for coronary artery disease in IPF patients.

TCT-92: Complications After TAVI Depending on Grade of Aortic Valve Calcification: Results From the Prospective Multicenter German TAVI Registry

TCT-92: Complications After TAVI Depending on Grade of Aortic Valve Calcification: Results From the Prospective Multicenter German TAVI Registry

Association of severity of conjunctival and corneal calcification with all-cause 1-year mortality in maintenance haemodialysis patients

Conjunctival and corneal calcification (CCC) is the most common form of metastatic calcification in patients with chronic renal failure. The aim of this study is to investigate if severity of CCC correlates with vascular calcification and mortality in maintenance haemodialysis (MHD) patients. One hundred and nine MHD patients were recruited. CCC was evaluated by external eye photographs, and was graded and scored according to modified Porter and Crombie classification system described by Tokuyama et al. Chest X-ray examination was used to evaluate aortic arch calcification. Geographic, haematological, biochemical and dialysis-related data were obtained. The patients were analysed for traditional and non-traditional risk factors for cardiovascular disease stratified by severity of CCC. All patients were followed up for 1 year to investigate the risks for mortality. Forty-three, 35 and 31 patients had mild (scores ≤ 4), moderate and severe (scores ≥ 9) CCC at baseline, respectively. With trend estimation, patients with severe CCC had a significantly higher percentage of severe aortic arch calcification. Multiple linear regression analysis showed that hypertension, haemodialysis duration and corrected calcium level were associated with scores of CCC in MHD patients. Moreover, age, corrected calcium-phosphate level, and moderate and severe CCC were associated with grades of aortic arch calcification. At 1-year follow-up, 11 of 109 (10.1%) patients had died. Multivariate Cox proportional hazards model showed that age, corrected calcium and severe CCC were significant risk factors for all-cause 1-year mortality in MHD patients. Each increment of one score of CCC is associated with a 26.4% increased risk for all-cause mortality. Severity of CCC, which is easily obtained at bedside, acts as an independent predictor for all-cause 1-year mortality in MHD patients.

Intracranial Internal Carotid Artery Calcification: A Representative for Cerebral Artery Calcification and Association with White Matter Hyperintensities

Background: Our aim was to investigate the distribution pattern of cerebral artery calcification and its association with white matter hyperintensities (WMH). Methods: We identified 159 consecutive patients with acute ischemic stroke. Calcifications of cerebral arteries and WMH were graded. Results: Cerebral artery calcification was found in 137 patients (86.2%). The intracranial internal carotid artery (I-ICA) was the most frequently affected artery with calcification (76.7%) and moderate-to-severe calcification (38.1%). Spearman’s rank test revealed that the grade of I-ICA calcification was correlated with those of periventricular WMH (r = 0.417, p < 0.001) and deep WMH (r = 0.388, p < 0.001). The adjusted ORs of I-ICA were 2.62 (p <0.05) for periventricular WMH and 3.25 (p <0.05) for deep WMH. Conclusions: Cerebral artery calcification is common in patients with ischemic stroke. I-ICA is the most frequently and most severely affected cerebral artery and its calcification is associated with WMH.

Predictors of invasion in needle core biopsies of the breast with ductal carcinoma in situ

A significant proportion of ductal carcinomas in situ (DCISs) of the breast diagnosed on core biopsies had invasion upon excision. An assessment of various invasion predictors in the biopsies yielded conflicting results. A cohort of 157 cases with needle core biopsy diagnosed with DCISs (including 109 histologically proven DCISs, and 48 cases with invasion upon excision) were evaluated for the numbers of positive and total cores, the percentage of positivity, lobular cancerization, tumor nuclear grade, necrosis, calcification, predominate histological pattern, lymphocytic infiltrate and excisional tumor size. The mean positive core percentage and excisional tumor size were 76% and 2.8 cm for invasive and 66% and 1.9 cm for noninvasive groups. In the biopsy of the invasive group, cancerization of lobules was present in 52%, and nuclear grades 1, 2 and 3 were present in 31, 31 and 38%, respectively. Large comedo and small noncomedo necroses were present in 48 and 10%, whereas large and small calcifications were present in 16 and 21%. Solid, cribriform and papillary patterns were observed in 88, 38 and 21%, respectively. Moderate to marked lymphoid infiltrate was present in 31%. In the biopsy of the noninvasive group, cancerization of lobules was present in 69%, and the nuclear grades 1, 2 and 3 were present in 23, 48 and 29%, respectively. Large comedo and small noncomedo necroses were present in 35 and 11%, whereas large and small calcifications were present in 33 and 23%. Solid, cribriform and papillary patterns were observed in 85, 39 and 9%, respectively. Moderate to marked lymphoid infiltrate was present in 36%. Comparing these groups, a higher positive core percentage, papillary pattern and less cancerization of lobules in the cores and larger excisional tumor size were associated with a higher chance of invasion. Calcification, necrosis and nuclear grade were not significant invasion predictors.

Efficacy of everolimus eluting stent implantation in patients with calcified coronary culprit lesions: Two‐year angiographic and three‐year clinical results from the SPIRIT II study

Little is known about the impact of treatment with drug-eluting stents (DES) on calcified coronary lesions. This analysis sought to assess the safety and efficacy of the XIENCE V everolimus-eluting stent (EES) in patients with calcified or noncalcified culprit lesions. The study population consisted of 212 patients with 247 lesions, who were treated with EES alone. Target lesions were angiographically classified as none/mild, moderate, or severe grades of calcification. The population was divided into two groups: those with at least one target lesion moderately or severely calcified (the calcified group: 68 patients with 75 calcified lesions) and those with all target lesions having mild or no calcification (the noncalcified group: 144 patients). Six-month and 2-year angiographic follow-up and clinical follow-up up to 3 years were completed. The baseline characteristics were not significantly different between both groups. When compared with the noncalcified group, the calcified group had significantly higher rates of 6-month in-stent angiographic binary restenosis (ABR, 4.3% vs. 0%, P = 0.03) and ischemia-driven target lesion revascularization (ID-TLR, 5.9% vs. 0%, P = 0.01), resulting in numerically higher major cardiac adverse events (MACE, 5.9% vs. 1.4%, P = 0.09). At 2 years, when compared with the noncalcified group, the calcified group presented higher in-stent ABR (7.4% vs. 0%, P = 0.08) and ID-TLR (7.8% vs. 1.5%, P = 0.03), resulting in numerically higher MACE (10.9% vs. 4.4%, P = 0.12). At 3 years, ID-TLR tended to be higher in the calcified group than in the noncalcified group (8.6% vs. 2.4%, P = 0.11), resulting in numerically higher MACE (12.1% vs. 4.7%, P = 0.12). The MACE rates in patients treated with EES for calcified lesions were higher than in those for noncalcified lesions, but remained lower than the results of previously reported stent studies. EES implantation in patients with calcified culprit lesions was safe and associated with favorable reduction of restenosis and repeat revascularization. © 2010 Wiley-Liss, Inc.

Socioeconomic Status and Subclinical Coronary Disease in the Whitehall II Epidemiological Study

BackgroundThere are pronounced socioeconomic disparities in coronary heart disease, but the extent to which these primarily reflect gradients in underlying coronary artery disease severity or in the clinical manifestation of advanced disease is uncertain. We measured the relationship between socioeconomic status (SES) as indexed by grade of employment and coronary artery calcification (CAC) in the Whitehall II epidemiological cohort, and tested the contribution of lifestyle, biological and psychosocial factors in accounting for this association.Methods and FindingsCAC was assessed in 528 asymptomatic men and women aged 53–76 years, stratified into higher, intermediate and lower by grade of employment groups. Lifestyle (smoking, body mass index, alcohol consumption, physical activity), biological (blood pressure, lipids, fasting glucose, inflammatory markers) and psychosocial factors (work stress, financial strain, social support, depression, hostility, optimism) were also measured. Detectable CAC was present in 293 participants (55.5%). The presence of calcification was related to lifestyle and biological risk factors, but not to grade of employment. But among individuals with detectable calcification, the severity of CAC was inversely associated with grade of employment (p = 0.010), and this relationship remained after controlling for demographic, lifestyle, biological and psychosocial factors. Compared with the higher grade group, there was a mean increase in log Agatston scores of 0.783 (95% C.I. 0.265–1.302, p = 0.003) in the intermediate and 0.941 (C.I. 0.226–1.657, p = 0.010) in the lower grade of employment groups, after adjustment for demographic, lifestyle, biological and psychosocial factors.ConclusionsLow grade of employment did not predict the presence of calcification in this cohort, but was related to the severity of CAC. These findings suggest that lower SES may be particularly relevant at advanced stages of subclinical coronary artery disease, when calcification has developed.

Abstract 5205: Aortic Arch Calcification Detectable on Chest X-ray is a Strong Independent Predictor of Cardiovascular Events Beyond Traditional Risk Factors

Background: Aortic stiffness resulting from calcification makes management of hemodynamic status more difficult. Some reports have previously shown that simple assessment of aortic calcification in aortic arch and abdominal aorta using plain radiography can predict cardiovascular (CV) events. However, these studies simply assessed whether aortic calcification detectable on X-ray was present or absent, without considering the grade of calcification. In this study, we evaluated the validity and usefulness of grading aortic arch calcification (AAC) to predict new CV events, and compared it to traditional atherosclerotic risk factors. Methods and Results: This study enrolled 239 asymptomatic outpatients (mean age 61±14 years) without previous CV events. We divided the extent of AAC into four grades (from 0 to 3) by reviewing a postero-anterior plain chest X-ray. AAC grade was 0, 1, 2, and 3 in 46%, 22%, 29%, and 4% of the subjects, respectively. AAC grade was positively related to age, prevalence of diabetes and chronic kidney disease (CKD), and showed a significant association with clustering of traditional risk factors. In addition, impairment of endothelial function, as determined by flow-mediated dilation (FMD), was also associated with increasing AAC grade. Thirty two new CV events in total occurred during a mean follow-up period of 40±19 months. With multivariate adjustment, Kaplan-Meier analysis showed that the new incidence of CV events was significantly higher in patients with high AAC grade (grades 2 and 3) than in those with grade 0 or 1 (p&lt;0.01, log-rank test). Multivariate Cox-proportional hazards analysis showed that the predictive value of AAC grade for CV events was significantly stronger (hazard ratio, 1.8; 95% confidence interval, 1.2–2.8; p &lt;0.01) than that of FMD, HbA1c, and estimated GFR. In addition, predictive usefulness was found even in patients without CKD. Conclusion: AAC detectable on chest X-ray is a strong independent predictor of CV events. Beyond traditional risk factors including endothelial dysfunction, risk stratification by assessment of AAC may provide important information for primary preventive management of atherosclerotic disease.

Aortic Valve Area on 64-MDCT Correlates with Transesophageal Echocardiography in Aortic Stenosis

The purpose of our study was to compare aortic valve area and calcification between CT and echocardiography. We performed retrospective evaluation of 80 consecutive patients with aortic stenosis (AS) who underwent ECG-gated 64-MDCT and transesophageal echocardiography (TEE). Valve planimetry was feasible in 80 patients with CT and in 63 patients with TEE; valve area by transthoracic echocardiography was available in 46 patients. Valve calcification grade on CT was compared with TEE. One cardiologist (echocardiography) and two radiologists (CT) independently and blindly reviewed the studies. Pearson's correlations, Spearman's rank correlations, paired Student's t tests, and weighted kappa tests were used. The median valve area on TEE was 0.7 +/- 0.9 cm(2). There was excellent correlation (n = 80; r = 0.91, p < 0.001) and no difference (0.06 +/- 0.26 cm(2), p = 0.06) between CT readers. There was strong correlation (n = 63; r = 0.84, p < 0.001) and no difference (-0.06 +/- 0.48 cm(2), p = 0.33) in valve area between CT and TEE, with a strong correlation (n = 46; r = 0.83, p < 0.001) and small overestimation (0.17 +/- 0.33 cm(2), p < 0.001) in valve area with CT versus transthoracic echocardiography. The sensitivity and specificity of CT to detect severe aortic stenosis compared with TEE were 92.1% (35/38) and 89.5% (17/19), respectively. Calcification grade had fair agreement between CT readers and TEE (kappa = 0.34 and 0.37, respectively). Aortic valve area on CT strongly correlates with echocardiography and has excellent sensitivity and specificity to detect severe stenosis. Valve calcification has fair agreement between studies. Valve area and calcification should be reported on CT angiography in patients with AS.

Angiography Underestimates Peripheral Atherosclerosis:Lumenography Revisited

To compare angiograms, considered the gold standard for diagnostic imaging of peripheral arterial disease (PAD), to the corresponding histological sections of popliteal and tibial vessels obtained after amputation to determine if angiography fails to define atheroma burden in "normal appearing" arteries in patients with PAD. Between 2004 and 2006, 69 patients underwent amputation of a lower extremity for severe tissue loss, gangrene, or pedal sepsis precluding limb salvage. Popliteal and tibial vessels were harvested, perfusion-fixed, and analyzed histologically. Thirty-four of these patients had pre-amputation angiography during attempted salvage procedures. Angiograms with patent or minimally diseased vessel segments (n = 19) were assessed for stenoses, diameter, and calcification by 3 vascular surgeons (n = 72 evaluations). These results were compared to corresponding cross-sectional histological slides (n = 66) in a blinded manner. Angiograms performed prior to above-knee (n = 9) or below-knee (n = 10) amputation revealed 24 stenoses with a mean (+/-SD) diameter-reducing stenosis of 19.5%+/-15.2%. Corresponding histological cross sections revealed greater linear stenoses measured via boundaries of the internal elastic lamina (IEL stenosis, 28.9%+/-20.2%, p = 0.003 versus angiography) or via boundaries of the external elastic membrane (vessel stenosis, 43.1%+/-15.2%, p<0.0001). Stenosis calculated by area methods (IEL area) were greater and measured 39.2%+/-24.2% (p<0.0001) and 60.9%+/-15.2% (vessel area, p<0.0001). Popliteal arteries had greater discrepancy in stenosis measurement than tibial arteries (18.5%+/-14.6% versus 34.9%+/-21.0%, p = 0.0005). However, evaluations of tibial arteries for concentricity of plaque (44% versus 69%, p = 0.08) and calcification grade (1.6 versus 2.2, p = 0.002) by angiography were discordant with histological analyses. Measurement of arterial diameter by histology for popliteal arteries (6.2+/-0.9 mm) and tibial arteries (3.1+/-0.7 mm) was greater than angiographic diameter determination (p<0.001). Angiography provides information on luminal characteristics of peripheral arteries but severely underestimates the extent of atherosclerosis in patients with PAD even in "normal appearing" vessels.

Prevalence and Clinical Importance of Aortic Valve Calcification Detected Incidentally on CT Scans: Comparison with Echocardiography

To evaluate retrospectively the prevalence and grade of aortic valve calcification incidentally detected on chest multi-detector row computed tomographic (CT) scans and to compare the grade of calcification with the severity of aortic valve disease as assessed with echocardiography. Patient informed consent was waived by the institutional board on medical ethics that approved this study. The authors identified 402 patients (231 men and 171 women; mean age, 62.5 years +/- 12.1) of 1820 patients who underwent chest multi-detector row CT between July 2001 and August 2004 and also underwent echocardiography. Aortic valve calcification at multi-detector row CT was visually graded on a scale ranging from 0 to 4 (0 = no calcification, 4 = severe calcification). CT findings were correlated with hemodynamic data obtained at echocardiography. Patients without aortic stenosis were compared with patients with aortic stenosis. The Student t test, Spearman correlation coefficient, chi(2) analysis, and an unweighted kappa test were used to compare results. Aortic valve calcification was noted on multi-detector row CT scans in 72 of the 402 patients (18%). Twelve of 20 patients (60%) with grade 3 or grade 4 calcification on CT scans had aortic stenosis at echocardiography, compared with only nine of 382 patients (2.4%) with grade 0-2 calcification (P < .001). Significant correlations were observed between the grade of aortic valve calcification and the echocardiographically determined mean (r = 0.45, P = .03) and peak transvalvular gradient (r = 0.47, P = .03). There was substantial agreement between the grade of valve calcification at multi-detector row CT and the severity of aortic valve disease at echocardiography (kappa = 0.67). Aortic valve calcification was an incidental finding on 18% of multi-detector row CT scans. The grade of aortic valve calcification is correlated with the hemodynamic severity of aortic valve disease as determined with echocardiography.

Right Bundle Branch Block: A New Parameter Revealing the Progression Rate of Mitral Stenosis

Background: Mitral stenosis has a generally slow but often variable clinical course. However, the factors that influence the rate of stenosis progression have not been completely identified. The aim of this study was to evaluate whether right bundle branch block (RBBB) may be related to the rapid progression of pure mitral stenosis besides echocardiographic parameters. Methods: Four hundred and thirty-six patients (300 females) were reviewed retrospectively. The patients were classified according to RBBB existence in electrocardiography: group A included 83 patients with RBBB existence, and group B contained 353 patients without RBBB. The patients were further classified as subjects who had an echocardiographic valve score ≤8 (325 patients, group 1) and those with a valve score >8 (111 patients, group 2). Results: The mean age of the patients was similar in groups A and B. In group A, the mean mitral valve gradient was higher (12.63 ± 4.43 vs. 10.58 ± 3.37 mm Hg; p < 0.0001), the mitral valve area smaller (1.05 ± 0.2 vs. 1.14 ± 0.52 cm²; p = 0.011), and the systolic pulmonary artery pressure higher (53.5 ± 16.2 vs. 46.9 ± 13.2 mm Hg; p = 0.001) than in group B. The mean age and mitral valve area were similar in groups 1 and 2. The mean mitral valve gradient (10.5 ± 3.7 vs. 12.3 ± 3.0 mm Hg; p < 0.0001) and systolic pulmonary artery pressure were higher in group 2 (46.7 ± 13.3 vs. 52.5 ± 15 mm Hg; p < 0.0001). Conclusion: These findings indicate that RBBB existence correlates with the severity of the disease and the grade of valve calcification in moderate and severe pure mitral stenosis.