Catheter Coronary Angiography Research Articles

An Adaptive SCG-ECG Multimodal Gating Framework for Cardiac CTA.

Cardiovascular disease (CVD) is the leading cause of death worldwide. Coronary artery disease (CAD), a prevalent form of CVD, is typically assessed using catheter coronary angiography (CCA), an invasive, costly procedure with associated risks. While cardiac computed tomography angiography (CTA) presents a less invasive alternative, it suffers from limited temporal resolution, often resulting in motion artifacts that degrade diagnostic quality. Traditional ECG-based gating methods for CTA inadequately capture cardiac mechanical motion. To address this, we propose a novel multimodal approach that enhances CTA imaging by predicting cardiac quiescent periods using seismocardiogram (SCG) and ECG data, integrated through a weighted fusion (WF) approach and artificial neural networks (ANNs). We developed a regression-based ANN framework (r-ANN WF) designed to improve prediction accuracy and reduce computational complexity, which was compared with a classification-based framework (c-ANN WF), ECG gating, and US data. Our results demonstrate that the r-ANN WF approach improved overall diastolic and systolic cardiac quiescence prediction accuracy by 52.6% compared to ECG-based predictions, using ultrasound (US) as the ground truth, with an average prediction time of 4.83 ms. Comparative evaluations based on reconstructed CTA images show that both r-ANN WF and c-ANN WF offer diagnostic quality comparable to US-based gating, underscoring their clinical potential. Additionally, the lower computational complexity of r-ANN WF makes it suitable for real-time applications. This approach could enhance CTA's diagnostic quality, offering a more accurate and efficient method for CVD diagnosis and management.

Assessment of Carotid Plaque Enhancement on Contrast-Enhanced Ultrasound as a Predictor for Severe Coronary Artery Disease.

Background and Aim Contrast-enhanced ultrasound (CEUS) can reliably identify vulnerable plaques. As atherosclerosis is a systemic disease, we evaluated whether contrast enhancement of carotid plaque (CECP) can predict severe coronary artery disease (CAD) by comparing CECP in patients who have had acute coronary syndromes (ACS) recently with asymptomatic individuals. Settings and Design This case-control study was done at a tertiary care center during 2022. Materials and Methods Fourteen participants were recruited in each group, after screening in-patients for carotid plaques and inclusion and exclusion criteria. Those who had history of ACS were enrolled as cases, while those who did not were enrolled as controls. All these patients underwent grayscale, Doppler, and CEUS examination for characterization of the carotid plaque. For cases, findings on CEUS were also compared with the severity of CAD on catheter coronary angiography. Statistical Analysis Diagnostic parameters including sensitivity, specificity, and diagnostic accuracy were calculated and proportions were compared by using Fisher's exact test. Results Eight out of 28 patients showed CECP. CECP and CAD were positively associated with p -Value of 0.033. Eighty-three percent patients with triple vessel disease and 50% patients with double vessel disease on coronary angiography showed CECP. Sensitivity and specificity of CECP for prediction of CAD were 50 and 92.9%, respectively. Conclusion CECP on CEUS can predict CAD and is a more reliable indicator of severe CAD than plaque characteristics on grayscale and Doppler imaging; making it useful for screening of patients at risk of having CAD.

Combined CT Coronary Artery Assessment and TAVI Planning.

Computed tomography angiography (CTA) of the aorta and the iliofemoral arteries is crucial for preprocedural planning of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS), because it provides details on a variety of aspects required for heart team decision-making. In addition to providing relevant diagnostic information on the degree of aortic valve calcification, CTA allows for a customized choice of the transcatheter heart valve system and the TAVI access route. Furthermore, current guidelines recommend the exclusion of relevant coronary artery disease (CAD) prior to TAVI. The feasibility of coronary artery assessment with CTA in patients scheduled for TAVI has been established previously, and accumulating data support its value. In addition, fractional flow reserve determined from CTA (CT-FFR) and machine learning-based CT-FFR were recently shown to improve its diagnostic yield for this purpose. However, the utilization of CTA for coronary artery evaluation remains limited in this specific population of patients due to the relatively high risk of CAD coexistence with severe AS. Therefore, the current diagnostic work-up prior to TAVI routinely includes invasive catheter coronary angiography at most centers. In this article, the authors address technological prerequisites and CT protocol considerations, discuss pitfalls, review the current literature regarding combined CTA coronary artery assessment and preprocedural TAVI evaluation, and provide an overview of unanswered questions and future research goals within the field.

Correlation of Epicardial Fat Thickness with Angiographic Severity and LDL Cholesterol Level in CAD

Background: Epicardial fat is independently related to coronary artery disease (CAD). Clinical imaging research has established a robust direct correlation between epicardial fat and abdominal visceral adiposity. This study aimed to assess the association of epicardial fat thickness (EFT) with CAD in patients. Objective: To find the association between EFT, Low-density lipoprotein (LDL) cholesterol levels, and angiographic severity by SYNTAX score. Methods: This prospective observational study involved 321 patients with suspected CAD patients undergoing catheter coronary angiography. Epicardial fat thickness was measured by means of transthoracic echocardiography within 90 days after coronary angiography. The severity of coronary atherosclerotic lesions become evaluated from at least 3 projections in all of the sufferers. The angiographic characteristics of the coronary atherosclerotic lesion have been defined using the SYNTAX score. Results: 321 patients took part in this study; the sex distribution has 259 male subjects (80.7%) and 62 female subjects (19.3%). LDL cholesterol levels <100 mg/dl are present in 75.1% (241 subjects) of the study population. The categories and variables were analyzed, and they show a significant correlation between epicardial fat thickness and SYNTAX score with a p-value of <0.0001. A significant correlation has been observed between LDL cholesterol levels and the angiographic severity of CAD by the SYNTAX score. Conclusion: This study suggests that there is a significant correlation between LDL cholesterol levels, EFT and angiographic severity, and complexity of the coronary lesions by the SYNTAX score. Keywords: Body Fat; Coronary Artery Disease; Epicardial Fat Thickness; CAD

Deep learning-based end-to-end automated stenosis classification and localization on catheter coronary angiography.

Automatic coronary angiography (CAG) assessment may help in faster screening and diagnosis of stenosis in patients with atherosclerotic disease. We aimed to provide an end-to-end workflow that separates cases with normal or mild stenoses from those with higher stenosis severities to facilitate safety screening of a large volume of the CAG images. A deep learning-based end-to-end workflow was employed as follows: (1) Candidate frame selection from CAG videograms with Convolutional Neural Network (CNN) + Long Short Term Memory (LSTM) network, (2) Stenosis classification with Inception-v3 using 2 or 3 categories (<25%, >25%, and/or total occlusion) with and without redundancy training, and (3) Stenosis localization with two methods of class activation map (CAM) and anchor-based feature pyramid network (FPN). Overall 13,744 frames from 230 studies were used for the stenosis classification training and fourfold cross-validation for image-, artery-, and per-patient-level. For the stenosis localization training and fourfold cross-validation, 690 images with > 25% stenosis were used. Our model achieved an accuracy of 0.85, sensitivity of 0.96, and AUC of 0.86 in per-patient level stenosis classification. Redundancy training was effective to improve classification performance. Stenosis position localization was adequate with better quantitative results in anchor-based FPN model, achieving global-sensitivity for left coronary artery (LCA) and right coronary artery (RCA) of 0.68 and 0.70. We demonstrated a fully automatic end-to-end deep learning-based workflow that eliminates the vessel extraction and segmentation step in coronary artery stenosis classification and localization on CAG images. This tool may be useful to facilitate safety screening in high-volume centers and in clinical trial settings.

Left ventricular lead delivery system used to implant right ventricular lead via persistent left superior vena cava.

Left ventricular lead delivery system used to implant right ventricular lead via persistent left superior vena cava.

ROLE OF STRESS CARDIAC MRI IN THE EVALUATION OF SUSPECTED CORONARY ARTERY DISEASE.

Background: Cardiovascular magnetic resonance (CMR) has emerged in recent years as an essential tool in the imaging of coronary artery disease(CAD) and its preclinical detection. Our study aims at describing CMR imaging features of CAD, including CINE and perfusion imaging. We performed Stress perfusion CMR with Methods: pharmacologic stress(Adenosine) in 26patients of suspected CAD with intermediate cardiac chest pain. Results: All patients showed maintained wall thickness.The mean wall thickness of LV was 7.3mm ± 0.6 SD. 5 (6.4%) coronary territories showed regional wall motion abnormality on CINE imaging. No patient had hyperintensity on T2/STIR images. 9 patients (34.6%)showed subendocardial perfusion defect in coronary distribution on stress imaging, without matched defect on rest perfusion or LGE on delayed imaging (reversible inducible ischemia). 17 patients (73.4%) showed no perfusion defect on stress imaging. Out of 26, only 15 patients underwent catheter coronary angiography (CCA). This included all the 9 patients with stress inducible perfusion defect, of which 7(78%) showed significant CAD (&gt;70% stenosis) in the corresponding artery and 2(22%) showed no significant CAD and 6 patients without stress inducible perfusion defect of which 5(83%) patients showed no significant CAD and 1(17%) showed significant CAD. Using CCA as a gold standard, the sensitivity of stress perfusion CMR in our study was 87.5%, specificity was 71.4% and accuracy was 80%. Stress Perfusion CMR is a noninvasive technique capable of detecting obstructive C Conclusion: AD with excellent diagnostic accuracy. It has high sensitivity and moderate specificity for diagnosing significant obstructive CAD compared with CCA.

Coronary angiography causes Rumpel-Leede symptoms

BackgroundRumpel Leede sign (RLS) is a clinical presentation observed at the extremities due to pressure applied externally. The appearance ranges from scattered pin-point rashes to an entire arm covered with petechial hemorrhage depending upon the severity. This phenomenon is relatively uncommon in clinical practice.Case presentationA 64 year old female patient developed a rash in the normal skin area below the compression area on the second day of single catheter coronary angiography. The patient's rash resolved without treatment after 3 days.ConclusionsWe report a case of hypertension and hyperlipidemia with a petechial rash on the skin under the tourniquet compressed by the radial artery after coronary angiography, which is consistent with the Rumpel-Leede phenomenon. clinicians should be watchful of these symptoms.

Detection of cardiac allograft vasculopathy on dual source computed tomography in heart transplant recipients: comparison with invasive coronary angiography.

We aimed to evaluate the diagnostic accuracy (DA) of dual-source CT coronary angiography (DSCTCA) against invasive coronary angiography (ICA) in assessing stenotic cardiac allograft vasculopathy (CAV) in heart transplant (HTX) recipients. Consecutive HTX recipients(n = 38) on annual surveillance, underwent DSCTCA prior to ICA on a 192-detector 384-slice DSCT scanner. Cases were classified as no CAV (no stenosis), any CAV (any degree of stenosis) or significant CAV (>50% stenosis). Mean age was 33.66 ± 11.45 years (M:F = 27:11, median time from HTX-23.5 months). Prevalence of any CAV on DSCTCA and ICA was 44.7%(n = 17) and 39.5%(n = 15), respectively and that of significant CAV was 21.1%(n = 8) and 15.8%(n = 6), respectively. 557 (96.7%) segments were interpretable on DSCTCA. Mean radiation dose was 4.24 ± 2.15 mSv. At patient-level, the sensitivity, specificity, positive-predictive value, negative-predictive value (NPV), and DA of DSCTCA for detection of any CAV and significant CAV were 100%, 91.3%, 88.2%, 100%, 94.73% and 100%, 94%, 75%, 100%, 95% respectively. The same on segment-based analysis were 96%, 97.6%, 80%, 99.6%, 97.5% and 100%, 99.6%,86.7%,100%, 99.6%, respectively. There was excellent agreement between the two modalities for detection of any CAV and significant CAV [κ = 0.892 and 0.826 (patient-level), 0.859 and 0.927 (segment-level)]. CAC score correlated significantly with the presence of any CAV on both modalities. A diagnosis of rejection on biopsy did not correlate with any/significant CAV on DSCTCA or ICA. High sensitivity and NPV of DSCTCA in the evaluation of stenotic CAV suggests that it can be an accurate and non-invasive alternative to ICA for routine surveillance of HTX recipients. DSCTCA detects the stenotic CAV non-invasively in transplant recipients with high sensitivity, specificity and NPV when compared with catheter coronary angiography, at lower radiation doses. There is excellent agreement between CT angiography and catheter coronary angiography for detection of any CAV and significant CAV. A diagnosis of rejection on biopsy does not correlate with any/significant CAV on CT angiography or catheter angiography.

Image quality and diagnostic performance evaluation in transcatheter aortic valve implantation candidates with atrial fibrillation using a whole-heart coverage CT scanner.

To evaluate the image quality and diagnostic performance for obstructive coronary artery disease of transcatheter aortic valve implantation (TAVI) patients with atrial fibrillation (AF) during TAVI planning CT using a whole-heart coverage CT scanner. Eighty-eight consecutive TAVI candidates with AF (50 men, 74 ± 6 years) who underwent both TAVI planning CT and invasive coronary catheter angiography (ICA) were retrospectively analyzed. With ICA results as the reference standard, the accuracy of TAVI planning CT for lesion detection on a per-vessel and per-patient level was calculated. Meanwhile, image quality, contrast volume, and effective dose (ED) were evaluated. A 5-point visual scale (1-5) was used to assess the subjective image quality. The CT value and signal-to-noise ratio were measured for the left main coronary artery (LM), left anterior descending (LAD), left circumflex (LCX), and right coronary arteries (RCA). The ED for CCTA was 3.25 ± 1.39 mSv and contrast volume was 58.14 ± 12.34 mL. A total of 1371 (1371/1408 = 97.4%) segments with diameter > 1.5 mm were analyzed. For the subjective evaluation, the mean score was 3.99 ± 0.96 for overall image quality. The mean CT values in LM, RCA, LCX, and LAD were all above 400 HU. For the detection of > 50% stenosis, TAVI planning CT provided on the per-vessel and per-patient basis 97.06% and 100% in sensitivity, 96.23% and 89.06% in specificity, 99.7% and 100% in negative predictive value, and 73.3% and 77.4% in positive predictive value, respectively. TAVI planning CT with whole-heart coverage demonstrates good CCTA image quality and a high sensitivity and NPV in excluding obstructive CAD in TAVI candidates with AF. • Transcatheter aortic valve implantation planning (TAVI) CT with whole-heart coverage enables good image quality of CCTA in TAVI candidates with atrial fibrillation. • Obstructive coronary artery disease may be excluded with high accuracy in transcatheter aortic valve implantation (TAVI) candidates with atrial fibrillation with the usage of whole-heart coverage TAVI planning CT.

Ultrasound‐gated computed tomography coronary angiography: Development of ultrasound transducers with improved computed tomography compatibility

Cardiovascular disease (CVD) is a leading cause of death worldwide, with coronary artery disease (CAD) accounting for nearly half of all CVD deaths. The current gold standard for CAD diagnosis is catheter coronary angiography (CCA), an invasive, expensive procedure. Computed tomography coronary angiography (CTCA) represents an attractive non-invasive alternative to CCA, however, CTCA requires gated acquisition of CT data during periods of minimal cardiac motion (quiescent periods) to avoid non-diagnostic scans. Current gating methods either expose patients to high levels of radiation (retrospective gating) or lead to high rates of non-diagnostic scans (prospective gating) due to the challenge of predicting cardiac quiescence based on ECG alone. Alternatively, ultrasound (US) imaging has been demonstrated as an effective indicator of cardiac quiescence, however, ultrasound transducers produce prominent streak artifacts that disrupt CTCA scans. In this study, a proof-of-concept array transducer with improved CT-compatibility was developed for utilization in an integrated US-CTCA system. Alternative materials were tested radiographically and acoustically to replace the radiopaque acoustic backings utilized in low frequency (1-4MHz) cardiac US transducers. The results of this testing were used to develop alternative acoustic backings consisting of varying concentrations of aluminum oxide in an epoxy matrix via simulations. On the basis of these simulations, single element test transducers designed to operate at 2.5MHz were fabricated, and the performance of these devices was characterized via acoustic and radiographic testing with micro-computed tomography (micro-CT). Finally, a first proof-of-concept cardiac phased array transducer was developed and its US imaging performance was evaluated. Micro-CT images of the developed US array with improved CT-compatibility were compared with those of a conventional array. Materials testing with micro-CT identified an acoustic backing with a measured radiopacity of 1008 HU, more than an order of magnitude lower than that of the acoustic backing (24,000 HU) typically used in cardiac transducers operating in the 1-4MHz range. When utilized in a simulated transducer design, this acoustic backing yielded a -6-dB fractional bandwidth of 57%, similar to the 54% bandwidth of the transducer with the radiopaque acoustic backing. The developed 2.5MHz, single element transducer based on these simulations exhibited a fractional bandwidth of 51% and signal-to-noise ratio (SNR) of 14.7dB. Finally, the array transducer developed with the acoustic backing having decreased radiopacity exhibited a 56% fractional bandwidth and 10.4dB single channel SNR, with penetration depth >10cm in phantom and in vivo imaging using the full array. The first attempt at developing a CT-compatible ultrasound transducer is described. The developed CT-compatible transducer exhibits improved radiographic compatibility relative to conventional cardiac array transducers with similar SNR, bandwidth, and penetration depth for US imaging, according to phantom and in vivo cardiac imaging. A CT-compatible US transducer might be used to identify cardiac quiescence and prospectively gate CTCA acquisition, reducing challenges associated with current gating approaches, specifically relatively high rates of non-diagnostic scans for prospective ECG gating and high radiation dose for retrospective gating.

Diagnostic accuracy of computed tomography angiography compared with catheter angiography in coronary artery disease

Objectives To assess the diagnostic accuracy of the computed tomography-coronary angiography (CT-CA) in detecting coronary artery disease compared with catheter coronary angiography (CCA). Background CT-CA is now considered an alternative tool of accurate and safe detection of coronary artery disease as it is rapid and noninvasive. Patients and methods This prospective study was conducted during the period between January 2017 and October 2018, including 121 patients (74 male and 47 female; mean age, 57.5 + 10.5 years) complaining of chest pain referred from cardiology outpatient clinics, Menoufia University Hospitals, for CT-CA. Patients were classified into two groups: group A underwent both CT-CA and CCA and included 41 patients (24 without previous coronary intervention, 11 had undergone previous coronary artery bypass graft, and six with previous coronary stenting), and group B included 80 patients and underwent only CT-CA, as another cause of chest pain was diagnosed or coronary significant stenosis was excluded, so patients were not candidates for CCA. Results Compared with CCA, CT-CA demonstrated sensitivity, specificity, and accuracy for detecting significant stenosis in coronary arteries of 97.1, 96.8, and 96.8%, respectively. The included 33 grafts CT-CA confirm the patency of additional five (15%) grafts that failed to be cannulation by CCA. The included nine stents showed six patents and three occluded by both CCA and CT-CA. CT-CA visualized extracoronary findings were not visualized by CCA. Conclusion CT-CA is a reliable coronary artery stenosis evaluation tool for assessment of grafts and stent patency, as well as detection of extracoronary pathology; it can reduce the number of invasive CCA studies for those patients.

Diagnostic Accuracy of 128-Slice Dual Source CT Coronary Angiography with Invasive Catheter Coronary Angiography in a Tertiary Care Teaching Hospital

Background: Coronary artery disease (CAD) morbidity and mortality increasing day by day in India as well as worldwide. Coronary arteries visualization by using invasive catheterization angiography is still using as a front-line diagnostic tool to evaluate the patients with CAD. 128 slice dual source CT improves the cardiac imaging such as high scanning speed, good temporal resolution and low radiation dose. Objective: To assess the diagnostic accuracy of 128-slice dual source CT cardiac angiography with conventional catheter angiography to find common arteries involved in CAD. Methods: This is a prospective, comparative, cross sectional study conducted at cardiology OPD. Patients with complaint of chest pain and suspected CAD were evaluated by CT and conventional coronary angiography and results were compared. Serum creatinine and ECG status were analyzed before the angiography. SIEMENS 128-slice Dual Source Flash Definition CT Scanner was used as a CT coronary angiography. Severity distribution of coronary artery disease, artery wise distribution of non-significant, significant lesions and coronary artery dominance pattern were analyzed and compared. Results: A total of 70 suspected CAD patients were selected and analyzed. American Heart Association (AHA) model of 17-segment was used to assess the coronary arteries. Normal angiograms reported in 15.71% patients and 58.57% had significant disease. A total of 356 lesions were identified from 690 out of 720 segments. Right coronary artery (RCA) is the most common location of significant lesions which contributes 33.5% (n=55/164). Coronary circulation of right-sided dominance was most commonly reported (70.0%). CT angiography showed 96.13% of an overall sensitivity, 96.28% specificity, 89.72% positive predictive value and 98.49% negative predictive value. Conclusion: 128-slice dual source CT scanner has showed high accuracy and act as non-invasive assessment of coronary arteries in patients with CAD Keywords: Cardiac angiography, Catheter coronary angiography, CT coronary angiography, 128-slice MDCT, Conventional angiography

Myopericarditis in children and adolescent: is the elevated troponin and chest pain as alarming as we thought?

When encountering adolescents with chest pain and a high troponin level but with no underlying coronary artery illness, it is advisable to consider myopericarditis. Though myopericarditis is a self-limiting, benign condition, it nevertheless causes anxiety in the patient and the family. Thirty-nine patients diagnosed with myopericarditis were included. We retrospectively analysed the demographic and clinical features, laboratory tests, echocardiography, electrocardiograms, MRI findings, coronary CT angiography, and conventional angiography findings in these patients. Of the 39 patients (female/male = 4/35) aged 7-17 years, 66.6% had viral infection in the 2 weeks preceding presentation. Eleven patients were tested for high-sensitivity cardiac troponin I, 28 for high-sensitivity cardiac troponin T, and 10 patients were tested for both biomarkers. The median hs-TnI and hs-TnT values were 6.3 (0.05-29.9)ng/mL and 586 (51-9398)ng/L, respectively. Twenty-three patients showed ST changes on electrocardiography, of whom 11 had ST-elevation in the leads supporting left ventricular involvement. Coronary CT angiography and catheter angiography evaluations performed for differential diagnosis of coronary anomaly and acute coronary syndrome were normal. Cardiac MRI was conducted on 28 patients, and the results in 10 (35.7%) were suggestive of myopericarditis. Myopericarditis is common in the adolescent age group and is generally benign but should be carefully monitored for differential diagnosis and possible complications. Cardiac MRI, which has been used more frequently in recent years, has an important role in differential diagnosis and the follow-up of patients.

Prevalence and Pattern of Congenital Coronary Artery Anomalies in Patients Undergoing Coronary Angiography at a Tertiary Care Hospital of Northern India.

Objectives: To evaluate the prevalence and pattern of congenital coronary artery anomalies (CAAs) in the adult population undergoing catheter coronary angiography.Methods: The coronary angiograms done between October 2015 and September 2020 were reviewed for the presence of coronary anomalies based upon Angelini's classification. The medical record of patients with anomalies was reviewed for symptomatology and indication of angiography.Results: CAAs were found in 129 (87 males and 42 females) of 6,258 patients giving a prevalence of 2.06%. The mean age was 57.8 ± 11.8 (range 32-81) years. Among these, the anomalous origin and course of the coronaries were the most common anomaly seen in 81 (1.29%) patients, followed by intrinsic anomalies of the coronary arterial system in 44 (0.7%) patients and anomalies of coronary termination and anomalous anastomotic vessels in 2 (0.03%) patients each. Overall, the absence of the left main trunk with a separate origin of the left anterior descending (LAD) and the circumflex artery was the commonest anomaly seen in 46 (0.74%) patients, followed by dual LAD in 35 (0.56%) patients. The anomalous origin of the right coronary artery (RCA) from the left sinus was seen in 14 patients (0.22%) and that of the circumflex artery from the right sinus or right coronary artery was seen in 11 patients (0.17%). The origin of the left main and RCA from ascending aorta was found in eight (0.13%) patients. One (0.02%) patient had a single coronary artery, and another one (0.02%) had all the three coronary arteries arising from the right sinus; however, with separate ostia. The split RCA was seen in nine (0.14%) patients and there were two (0.03%) patients each of coronary artery fistulae, and of anomalous anastomotic vessels.Conclusions: The prevalence of congenital coronary anomalies in this study was 2.06%. The commonest anomaly was that of origin and courses of the vessels, however, the pattern of anomalies is different from previous studies.

Safety of mapping in the sinus of valsalva region under intracardiac echocardiography guidance without angiography.

BackgroundRadiofrequency ablation at the region of the sinus of Valsalva carries a risk to the ostia of the coronary arteries. Coronary angiography is usually utilized to document a safe distance for mapping and ablation.ObjectiveTo show that catheter ablation in the aortic root could be guided by phased-array intra cardiac echocardiography (ICE) and electro anatomic mapping without the need for coronary angiography.MethodsWe reviewed all patients referred to our lab that underwent mapping and/or ablation in the sinus of Valsalva region. Procedures were carried out by operators that are skilled in the use of ICE. The need for angiography was documented, also the rate of success along with the immediate and 30-day complications rate.ResultsSeventy patients (average age 48.7 ± 13.8 years; 64.3% males) were referred for ablation of ventricular and atrial arrhythmias. PVC constituted 95.7% of the cases. All patients underwent mapping and/or ablation at the sinus of Valsalva region without the need for coronary angiography to visualize the coronary ostia. Acute and effective ablation was achieved in 57 out of 70 (81.4%) patients partially effective ablation was achieved in 10 (14.3%) patients, and failure to ablate in the remaining 3 patients (4.3%). There was no occurrence of any adverse events, neither immediately or at day 30 after the procedure.ConclusionIn the hands of experienced operators, mapping and radiofrequency ablation in the sinus of Valsalva can be safely and reliably performed using intracardiac echocardiography alone without the need for supplementary catheter coronary angiography.

Ultrasound Measurement of Carotid Intima–Media Thickness and Plaques in Predicting Coronary Artery Disease

Ultrasound measurement of carotid intima-media thickness (CIMT) and plaque thickness (PT) may be an additional tool for risk stratification of patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). The aim of this study was to evaluate the correlation of CIMT and PT with coronary artery disease (CAD) in risk stratification tests.This prospective observational study was conducted in an academic tertiary care ED. Carotid ultrasound measurements were obtained for emergency patients with suspected ACS. Carotid measurements included PT, mean CIMT and maximum CIMT. The correlations between carotid ultrasound and the results of coronary catheter angiography (CA), coronary computed tomography angiography (CCTA) and stress tests were identified. The convenience sample included 58 patients comprising 39 men and 19 women with a mean age of 60 ± 12 y. Twenty-two percent (13/58) of patients were positive for CAD, as indicated by results of the cardiac risk stratification tests. Presence of plaque correlated with CCTA findings, with a high specificity (92.8%) for a positive test. Max CIMT predicted abnormal CCTA (area under the curve [AUC] = 0.93, 95% confidence interval: 0.80-1). The correlations with stress test (0.78, 0.46-1) and CA (0.55, 0.28-0.82) were weaker. Presence of carotid plaque correlated significantly with findings of CAD on all risk stratification tests, but especially with CCTA. Carotid ultrasound could have a role in risk stratification in the ED, though more research is needed.

Cardiac magnetic resonance for asymptomatic patients with type 2 diabetes and cardiovascular high risk (CATCH): a pilot study

BackgroundStress cardiovascular magnetic resonance (CMR) to screen for silent myocardial ischaemia in asymptomatic high risk patients with type 2 diabetes mellitus (DM) has never been performed, and its effectiveness is unknown. Our aim was to determine the feasibility of a screening programme using stress CMR by obtaining preliminary data on the prevalence of silent ischaemia caused by obstructive coronary artery disease (CAD) and quantify myocardial perfusion in asymptomatic high risk patients with type 2 diabetes.MethodsIn this prospective cohort study, we recruited 63 asymptomatic DM patients (mean age 66 years ± 4.4 years; 77.8% male); with Framingham risk score ≥ 20% from 3 sites from June 2017 to August 2018. Normal volunteers were recruited to determine normal global myocardial perfusion reserve index (MPRI). Adenosine stress CMR and global MPRI was performed and measured in all subjects. Positive stress CMR cases were referred for catheter coronary angiography (CCA) with/without fractional flow reserve (FFR) measurements. Positive CCA was defined as an FFR ≤ 0.8 or coronary narrowing ≥ 70%. Patients were followed up for major adverse cardiovascular events. Prevalence is presented as patient numbers and percentage. Mann–Whitney U test was used to compare global MPRI between patients and normal volunteers.Results13 patients had positive stress CMR with positive CCA (20.6% of patient population), while 9 patients with positive stress CMR examinations had a negative CCA. 5 patients (7.9%) had infarcts detected of which 2 patients had no stress perfusion defects. 12 patients had coronary artery stents inserted, whilst 1 patient declined stent placement. DM patients had lower global MPRI than normal volunteers (n = 7) (1.43 ± 0.27 vs 1.83 ± 0.31 respectively; p < 0.01). After a median follow-up of 653 days, there was no death, heart failure, acute coronary syndrome hospitalisation or stroke.Conclusion20.6% of asymptomatic DM patients (with Framingham risk ≥ 20%) had silent obstructive CAD. Furthermore, asymptomatic patients have reduced global MPRI than normal volunteers.Trial Registration: ClinicalTrials.gov Registration Number: NCT03263728 on 28th August 2017; https://clinicaltrials.gov/ct2/show/NCT03263728.

Efficacy and Comparison of 256-Slice Dual Source CT Angiography with Catheter Coronary Angiography at Different Heart Rates without using Beta Blockers

Introduction: Coronary Artery Disease (CAD) is a leading cause of morbidity and mortality in India as well as worldwide. CT angiography is an excellent imaging modality for evaluation of CAD. Previous studies with 64 or lesser slice CT scanner have failed to show consistent and optimal Image Quality (IQ) at Heart Rate (HR) more than 70 bpm and required beta blockers. Aim: To evaluate the diagnostic accuracy of 256-slice Dual Source CT Angiography (DSCTA) in comparison with Catheter Coronary Angiography (CCA) in evaluation of Coronary Arteries (CA) in patients with clinical suspicion of CAD and to study its effectiveness at higher HR without using beta blockers. Materials and Methods: This cross-sectional study was conducted on patients (n=46) with suspected CAD using ECG triggered 256-slice Dual Source Computed Tomography (DSCT) over a period of nine months. Patients were sub grouped according to HR (Group I: 50-70 (18 patients), Group II: 71-90 (24 patients) and Group III ≥91 (8 patients). A total of 48% patients had HR of 71-90 bpm while 16% had HR ≥91 bpm. Scan protocols included prospective ECG triggering (HR &lt;75 bpm) and retrospective spiral scan protocols (HR &gt;75 bpm). CA segments were analysed for IQ on a 4 point scale (1 is worst while 4 is best) by two independent readers who were blinded to the patient details. Accuracy to detect significant luminal stenosis was correlated with CCA (gold standard). Statistical significance of the study was established by Chi-square test (p&lt;0.05). Results: The mean HR and Standard Deviation (SD) in the study was 76±13.7 bpm (range 54-105). Out of 675 CA segments analysed mean IQ score and SD in medium (71-90 bpm) and high HR (≥91 bpm) groups were 3.55±0.62 and 3.25±0.62 which were comparable to IQ in low HR group (3.84±0.36). This indicates excellent IQ even at HR of ≥91 bpm (p&lt;0.05). The mean IQ score of entire study group was 3.88±0.33. Right Coronary artery (RCA) showed best IQ score in each category followed by Left Anterior Descending (LAD) and Left Circumflex (LCX). Inter-observer agreement analysis was performed using Kappa analysis to determine agreement between DSCTA readers. Kappa values for low, medium and high HR groups were 0.866, 0.842 and 0.836. The sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and accuracy for detecting significant stenosis in medium and high HR groups were 95%, 99.2%, 98.4%, 98.7%, 98.9% and 94.3%, 98.9%, 96.9%, 97.6%, 97.9%, respectively. Conclusion: 256-slice DSCTA is a reliable technique with high sensitivity, specificity, PPV and NPV for assessment of CA even at higher HR without using beta blockers.

275 A Novel Method for Detecting Coronary Artery Dissection Using Computed Tomography Coronary Angiography

Spontaneous coronary artery dissection (SCAD) is an uncommon and underdiagnosed condition, which is increasingly recognised as an important cause of myocardial infarction. Computed tomography coronary angiography (CTCA) is an emerging non-invasive tool for assessment of SCAD, not yet recommended as first-line imaging due to its lower temporal and spatial resolution compared to catheter coronary angiography. A 34-year-old female with no medical history presented with chest pain and inferolateral ST-segment elevation on electrocardiogram (ECG). Catheter coronary angiography revealed coronary artery dissection involving the left main, left anterior descending and circumflex arteries. Computed tomography angiogram revealed multifocal carotid and vertebral artery dissection, with renal artery beading, suggesting fibromuscular dysplasia. A follow-up CTCA was performed using a prospective ECG-gated dual source high-pitch helical scanner (Siemens, High Definition Flash, Forchheim, Germany). The scan was repeated 13 seconds later without further contrast. This “double-scan” had the unique effect of showing contrast “staining” in the false lumen of the dissection, occurring as a result of residual contrast not yet washed out from the first scan. The findings of this “double-scan” technique appears analogous to the contrast staining of the false lumen observed on catheter coronary angiography. Depending on the type of scanner and mode of use, obtaining more than two scans following the contrast bolus may be possible. However, the timing of repeat scans may need to vary depending on the flow characteristics of false lumen filling and haemodynamics. Further research is required to determine how to best apply this novel utility.