Computed Tomography Angiography Research Articles

Association of the triglyceride glucose index with myocardial ischemia in patients with minimal to moderate coronary artery disease

The triglyceride glucose (TyG) index has been suggested as a reliable substitute to indicate insulin resistance. Several studies have identified the association between the TyG index and cardiovascular disease. However, the association between the TyG index and the incidence of myocardial ischemia in patients with minimal to moderate coronary artery disease (CAD) has not been clearly assessed. We aimed to investigate the association between the TyG index and the incidence of myocardial ischemia in patients with minimal to moderate CAD. A total of 1,697 patients who underwent coronary computed tomography angiography (CTA) examinations and had minimal to moderate CAD were retrospectively included in the study. The TyG index and computed tomography–derived fractional flow reserve (CT-FFR) were used to assess insulin resistance (IR) and myocardial ischemia, respectively. Myocardial ischemia was defined as a CT-FFR value ≤ 0.80. Logistic regression models were used to explore the associations between the TyG index and myocardial ischemia. The incidence of myocardial ischemia was higher in the highest TyG index tertile (T3) group than in the lowest TyG index tertile (T1) group. After adjusting for other variables, the T3 group remained associated with a higher risk of myocardial ischemia than the T1 group did (OR, 1.43; 95% CI, 1.01–2.04; p = 0.047). A 1- standard deviation (SD) increase in the TyG index was correlated with a 19–24% elevated risk of myocardial ischemia when regarding the TyG index was considered as a continuous variable. Subgroup analysis revealed similar effects. A TyG index is associated with a higher risk of myocardial ischemia detected by CT-FFR in patients with minimal to moderate CAD.

Cardiovascular Imaging: Recent Advances in Atherosclerosis Diagnosis

Recent advancements in cardiovascular imaging have significantly enhanced the diagnosis and management of atherosclerosis, a leading cause of cardiovascular disease. Techniques such as coronary computed tomography angiography (CCTA), magnetic resonance imaging (MRI), and positron emission tomography (PET) have improved our ability to detect and quantify atherosclerotic plaques, assess their stability, and predict adverse cardiovascular events. This review explores the latest developments in imaging modalities, their clinical applications, and the implications for personalized patient care.

Correlation of Sarcopenia with Coronary Artery Disease Severity and Pericoronary Adipose Tissue Attenuation: A Coronary CT Study

Objective: To investigate the association between sarcopenia, as appraised with CT-derived muscle metrics, and cardiovascular status, as assessed via coronary CT angiography (CCTA) using the Coronary Artery Disease-Reporting and Data System (CAD-RADS) and with pericoronary adipose tissue (pCAT) metrics. Methods: A retrospective observational study conducted on patients who underwent CCTA. The cross-sectional area (CSA) and attenuation values of the paravertebral muscles at the T8 level and the pectoralis major muscles at the T6 level were measured. The patient height was employed for the normalization of the skeletal muscle CSA. The pCAT attenuation around the coronary arteries was assessed, and the CAD severity was graded using the CAD-RADS reporting system. Regression analyses were performed to assess the impact of demographics, clinical factors, and CT variables on the CAD-RADS and pCAT. Results: A total of 220 patients were included (132 males, median age 65 years). Regression analyses showed the associations of CAD with age and sex (p < 0.001). Familiarity with CAD was related to the left anterior descending artery pCAT (p = 0.002) and circumflex artery pCAT (p = 0.018), whereas age was related to the left anterior descending artery pCAT (p = 0.032). Weak positive correlations were found between the lower muscle density and lower pCAT attenuation (ρ = 0.144–0.240, p < 0.039). Conclusions: This study demonstrated weak associations between the sarcopenia indicators and the cardiovascular risk, as assessed by the CAD severity and pCAT inflammation. However, these correlations were not strong predictors of CAD severity, as age and traditional cardiovascular risk factors overshadowed the impact of sarcopenia in the cardiovascular risk assessment.

A Review of Factors Affecting Radiation Dose and Image Quality in Coronary CTA Performed with Wide-Detector CT

Compared with traditional invasive coronary angiography (ICA), coronary CT angiography (CCTA) has the advantages of being rapid, economical, and minimally invasive. The wide-detector CT, with its superior temporal resolution and robust three-dimensional reconstruction technology, thus enables CCTA in patients with high heart rates and arrhythmias, leading to a high potential for clinical application. This paper systematically summarizes wide-detector CT hardware configurations of various vendors routinely used for CCTA examinations and reviews the effects of patient heart rate and heart rate variability, scanning modality, reconstruction algorithms, tube voltage, and scanning field of view on image quality and radiation dose. In addition, novel technologies in the field of CT applied to CCTA examinations are also presented. Since this examination has a diagnostic accuracy that is highly consistent with ICA, it can be further used as a routine examination tool for coronary artery disease in clinical practice.

Rasmussen's Aneurysm: A Rare Cause of Massive Hemoptysis in Pulmonary Tuberculosis

Rasmussen's aneurysm is a rare cause of hemoptysis in patients with tuberculosis. It is an under-recognised vascular complication of active pulmonary tuberculosis, with a mortality rate of over 50%. It is secondary to an aneurysmal dilatation of the pulmonary artery adjacent to tuberculous cavity. Thoracic CT angiography is the gold standard for making a positive diagnosis and precising the hemorrhagic site, with a mapping of the pulmonary artery damage. Rupture of the artery can cause massive hemoptysis, which can sometimes be devastating. It is important to remember that hemoptysis persists despite successful bronchial artery embolisation in all patients with tuberculosis.

The natural history of cerebral infundibula: A retrospective cohort study.

Debate exists regarding the true pathogenicity of cerebral infundibula (CI). Pre-aneurysmal lesions and benign anatomical variants have both been proposed. In this study, we present the largest single cohort series on the natural history of CI. Retrospective review of prospective surveillance of 420 CI was undertaken in a single tertiary cerebrovascular centre. All CI diagnosed by a neuroradiologist, diagnosed on either a Magnetic resonance angiography (MRA), Computed tomography angiography (CTA) or Digital subtraction angiography (DSA) were eligible for inclusion. Imaging and demographic characteristics were recorded at baseline. CI growth and aneurysm transformation were the outcomes of interest. Groupwise comparison was conducted via Fischer exact testing. Kaplan Meir curves and Cox proportional hazard ratios were used to assess variables of interest with respect to time on surveillance. 402 patients with 420 CI were surveyed over 2418 infundibula-years. Eleven CI (2.62%) grew on surveillance, and three (0.7%) transformed into aneurysms. Median time to growth was 85 months (36-263) and median time to aneurysm transformation was 112 months (96-142). Of the CI that grew, male sex and CI >2 mm at diagnosis were significant predictors of growth (all p<0.05). Of the CI that grew in surveillance, 2/11 (18.2%) transformed into aneurysms (p=0.001). Aneurysm transformation occurred at a rate of 1.27 per 1000 infundibula years. CI growth on surveillance (p= 0.00016) and size at diagnosis (p=0.038) remained significant predictors of aneurysm transformation on Kaplan Meir curves. The transformation of a CI to an aneurysm occurs at a low rate. A history of growth on surveillance imaging represents significant risk for aneurysm transformation.

Comparative analysis of Zero Pressure Geometry and prestress methods in cardiovascular Fluid-Structure Interaction

Background and Objective:Modelling patient-specific aortic biomechanics with advanced computational techniques, such as Fluid–Structure Interaction (FSI), can be crucial to provide effective decision-making indices to enhance current clinical practices. To effectively simulate Ascending Thoracic Aortic Aneurysms (ATAA), the stress-free configuration must be defined. The Zero Pressure Geometry (ZPG) and the Prestress Tensor (PT) are two of the main approaches to tackle this issue. However, their impact on the numerical results is yet to be analysed. Computed Tomography Angiography (CTA) and Magnetic Resonance Imaging (MRI) data were used to develop patient-specific 2-way FSI frameworks. Methods:Three models were developed considering different tissue prestressing approaches to account for the reference configuration and their numerical results were compared. The selected approaches were: (i) ZPG, (ii) PT and (iii) a combination of the PT approach with a regional mapping of material properties (PTCAL). Results:The pressure fields estimated by all models were equivalent. The estimation of Wall Shear Stress (WSS) based metrics revealed good correspondence between all models except the Relative Residence Time (RRT). Regarding ATAA wall mechanics, the proposed extension to the PT approach presented a closer agreement with the ZPG model than its counterpart. Additionally, the PT and PTCAL approaches required around 60% fewer iterations to achieve cycle-to-cycle convergence than the ZPG algorithm. Conclusion:Using a regional mapping of material properties in combination with the PT method presented a better correspondence with the ZPG approach. The outcomes of this study can pave the way for advancing the accuracy and convergence of ATAA numerical models using the PT methodology.

Characterizing Nonculprit Lesions and Perivascular Adipose Tissue of Patients Following Acute Myocardial Infarction Using Coronary Computed Tomography Angiography: A Comparative Study.

The comparison of coronary computed tomography angiography plaques and perivascular adipose tissue (PVAT) between patients with acute myocardial infarction (AMI) posttreatment and patients with stable coronary artery disease is poorly understood. Our objective was to evaluate the differences in coronary computed tomography angiography-quantified plaque and PVAT characteristics in patients post-AMI and identify signs of residual inflammation. We analyzed 205 patients (age, 59.77±9.24 years; 92.20% men) with AMI ≤1 month and matched them with 205 patients with stable coronary artery disease (age, 60.52±10.04 years; 90.24% men) based on age, sex, and cardiovascular risk factors. Coronary computed tomography angiography scans were assessed for nonculprit plaque and vessel characteristics, plaque volumes by composition, high-risk plaques, and PVAT mean attenuation. Both patient groups exhibited similar noncalcified plaque volumes (383.35±313.23 versus 378.63±426.25 mm3, P=0.899). However, multivariable analysis revealed that patients post-AMI had a greater patient-wise noncalcified plaque volume ratio (estimate, 0.089 [95% CI, 0.053-0.125], P<0.001), largely attributed to a higher fibrofatty and necrotic core volume ratio, along with higher peri-lesion PVAT mean attenuation (estimate, 3.968 [95% CI, 2.556-5.379], P<0.001). When adjusted for vessel length, patients post-AMI had more high-risk plaques (estimate, 0.417 [95% CI, 0.298-0.536], P<0.001) per patient. Patients post-AMI displayed heightened noncalcified plaque components, largely due to fibrofatty and necrotic core content, more high-risk plaques, and increased PVAT mean attenuation on a per-patient level, highlighting the necessity for refined risk assessment in patients with AMI after treatment.

Improving culprit artery identification with intraprocedural cone-beam CT aortography and its clinical impact in bronchial artery embolization.

To evaluate the impact of intraprocedural cone-beam CT (CBCT) aortography on culprit artery identification and clinical outcomes in patients undergoing bronchial artery embolization (BAE). Two hundred eighty-two patients with 317 BAE procedures were retrospectively reviewed. Patients who underwent preprocedural chest CT angiography (CTA) without intraprocedural CBCT aortography were categorized as Group A (n = 177). Patients who underwent both preprocedural chest CTA and intraprocedural CBCT aortography were categorized as Group B (n = 105). Whether CBCT can provide improved culprit artery identification and whether this improvement has a clinical impact were evaluated by comparing the two Groups. In Group B, CBCT aortography detected more culprit non-bronchial systemic arteries originating from the subclavian arteries compared to chest CTA (16 vs 3, p = 0.026), and the average number of embolized vessels was significantly higher than in Group A (2.47 ± 1.61 vs 2.03 ± 1.17, p = 0.016), while the procedure time was shorter (37.4 ± 22.0 vs 43.6 ± 22.7 min, p = 0.024). The recurrent hemoptysis rate was lower in Group B (17.5% vs 8.7%, p = 0.041), and the proportion of patients requiring subsequent procedures was significantly lower (12.4% vs 4.8%, p = 0.035). The changes in estimated glomerular filtration rate before and 3 days after the procedure (0.1 ± 12.8 vs 0.3 ± 11.0 mL/min/1.73 m2, p = 0.909) and total dose area product (DAP, 6119.5 ± 5725.7 vs 6906.2 ± 5978.6 uGym2, p = 0.279) were not significantly different between the two groups. BAE with intraprocedural CBCT aortography enabled the embolization of more culprit arteries, leading to lower recurrent hemoptysis rates without increasing the risk of renal deterioration and radiation hazards when compared to procedures without it. Question Does intraprocedural CBCT aortography improve culprit artery detection and clinical outcomes in BAE for hemoptysis? Findings CBCT aortography significantly improved the detection of additional culprit arteries, especially from non-bronchial systemic arteries, increasing the number of vessels treated during BAE. Clinical relevance Using CBCT aortography during BAE results in better long-term outcomes by reducing recurrent hemoptysis and the need for additional procedures, without increasing the risk of renal impairment.

Feasibility of ultra-low volume contrast pulmonary arterial injection protocol for CTA in TAVI candidates with severe renal failure

Abstract Introduction Computer tomography angiography (CTA) has an important role in patient screening before TAVI. The high volumes of iodinated contrast media (CM) injected during the examination represents the main limitation of CTA with a dose-dependent association with contrast-induced nephropathy. Purpose Show the feasibility of an ultra-low-dose CM pulmonary arterial injection protocol for CTA in TAVI candidates in high risk patients with severe renal failure. Methods In our retrospective study seventy-seven (77) patients with CKD on stage 3b or worse (eGFR ≤ 45/min/1.73 m2) underwent pre-procedural CTA for TAVI-planning with a pulmonary arterial administration of CM. All CTA examinations were performed using a Dual Source 256-slice CT system. All enhanced CT acquisitions were performed using our dedicated biphasic injection protocol composed of two connected phases of contrast medium injection using different amount of CM (8, 10, 15 and 20 ml) according to BMI (&amp;lt;22 kg/m2; 22-24 kg/m2; 24-28 kg/m2; &amp;gt;28 kg/m2). The CM was administered directly into the pulmonary artery in all patients. For each examination was measured Intraluminal attenuation at thoraco-abdominal aorta and along the ilio-femoral vessels using the ROI (mean SD in HU) as objective image parameters (Picture 1). Serum creatinine and the eGFR were recorded pre-TAVI CT scan and after the procedures as reference of CM to renal function. Results CTA was successfully performed in all patients. Mean creatinine was 2.25 ± 0,76 mg/dL and mean GFR was 26.5± 8.1 mL/min/m2. Mean vessel attenuation was 352±164 HU at the aortic annulus, 238.1 ± 141,3 HU in the aortic arch and 266±168 in the iliac arteries (Picture 2). The mean image noise was 28.2 ± 7 HU in the aortic annulus, 24.4 ± 10,9 in the right external iliac artery, and 25. ± 12,8 HU in the left external iliac artery. After CTA examination, a total of 74 patients (96%) underwent TAVI. Mean CM dose administered during TAVI procedure was 150,6 ± 85,8. Three patients (3.9%) were abolished for TAVI. Postprocedural settings complications were recorded. A total of 31 patients (41%) had grade 1 paravalvular regurgitation, 10 patients (14%) grade 2. No cases of valve embolization or anulus rupture occured. No major vascular complications occured. No significant differences between creatine and eGFR pre and post procedures (p&amp;lt;0,001). Conclusions The use of an ultra-low-dose CM pulmonary arterial injection protocol for CTA in TAVI candidates does not affect the renal function and procedural success rate is high and the clinical outcomes after TAVI is satisfactory according to the litterature.

Three-dimensional transthoracic vs transesophageal echocardiography vs computed tomography angiography aorta for aortic annular diameter measurement for TAVI in our hospital

Abstract Background Tans femoral transcatheter aortic valve implantation (TF-TAVI) was recently the standard treatment option in patient with severe aortic stenosis. All patients undergoing TF-TAVI needed computed tomography angiography (CTA) aorta not only to evaluate entry site but to measure the annulus size to determine the prosthesis valve size. In Siriraj hospital we have protocol to perform Three-dimensional transthoracic echocardiography (3D-TTE) and three-dimensional esophageal echocardiography (3D-TEE) prior to TF-TAVI. We aimed to evaluate the correlation between conventional CTA aorta vs 3D-TEE vs 3D-TTE aortic annulus size. Method and result We performed a cross sectional study in all patients undergone TF-TAVI in our hospital who had all 3 aortic annulus sizes measured by 3 methods: CTA aorta, 3D-TEE vs 3D-TTE during 2015-2023. For 244 patients underwent TAVI, 52 patients were excluded (22 Transapical approach, 10 valve in valve TAVI, 6 not complete annulus measurement, 6 transcarotid, 3 severe AR, etc.) One hundred sixteen patients were female (60.4%) with average age of 83.2 years old. 98% of patients had comorbid disease; hypertension 84%, dyslipidemia 79%, diabetes 47%, coronary artery disease 55% (9% CABG), 2.6% of patients were bicuspid aortic valve. 27% of patients had LVEF less than 55%, average AVA was 0.71 centimeter-square, average mean pressure gradient was 52.5 mmHg. We analyzed the co-relation between these 3 methods by Bland–Altman plot which revealed the Pearson's correlation coefficient (r) between CTA Aorta and 3D-TEE was 0.814 with average difference of 0.68 mm (95% limit of agreement –1.68 - 3.04) and r between CTA Aorta and 3D-TTE was 0.442 with average difference of 0.41 mm (95% limit of agreement –3.82 - 4.63) Conclusion 3D-TTE annulus sizing had a reasonable correlation with CTA annulus sizing (Pearson’s correlation of 0.442) while 3D-TEE annulus sizing had a very high correlation with CTA annulus sizing (Pearson’s correlation of 0.814). In patient which CTA was not available to measure annulus size 3D-TEE annulus sizing might be reasonable method to measure the annulus size for TF-TAVI. Keyword trans femoral transcatheter aortic valve implantation (TF-TAVI), annulus size, three-dimensional transthoracic echocardiography (3D-TTE), three-dimensional esophageal echocardiography (3D-TEE), computed tomography angiography (CTA) aorta

Large vessel vasculitis evaluation by CTA: impact of deep-learning reconstruction and “dark blood” technique

ObjectivesTo assess the performance of the “dark blood” (DB) technique, deep-learning reconstruction (DLR), and their combination on aortic images for large-vessel vasculitis (LVV) patients.Materials and methodsFifty patients diagnosed with LVV scheduled for aortic computed tomography angiography (CTA) were prospectively recruited in a single center. Arterial and delayed-phase images of the aorta were reconstructed using the hybrid iterative reconstruction (HIR) and DLR algorithms. HIR or DLR DB image sets were generated using corresponding arterial and delayed-phase image sets based on a “contrast-enhancement-boost” technique. Quantitative parameters of aortic wall image quality were evaluated.ResultsCompared to the arterial phase image sets, decreased image noise and increased signal-noise-ratio (SNR) and CNRouter (all p < 0.05) were obtained for the DB image sets. Compared with delayed-phase image sets, dark-blood image sets combined with the DLR algorithm revealed equivalent noise (p > 0.99) and increased SNR (p < 0.001), CNRouter (p = 0.006), and CNRinner (p < 0.001). For overall image quality, the scores of DB image sets were significantly higher than those of delayed-phase image sets (all p < 0.001). Image sets obtained using the DLR algorithm received significantly better qualitative scores (all p < 0.05) in all three phases. The image quality improvement caused by the DLR algorithm was most prominent for the DB phase image sets.ConclusionDB CTA improves image quality and provides better visualization of the aorta for the LVV aorta vessel wall. The DB technique reconstructed by the DLR algorithm achieved the best overall performance compared with the other image sequences.Critical relevance statementDeep-learning-based “dark blood” images improve vessel wall image wall quality and boundary visualization.Key PointsDark blood CTA improves image quality and provides better aortic wall visualization.Deep-learning CTA presented higher quality and subjective scores compared to HIR.Combination of dark blood and deep-learning reconstruction obtained the best overall performance.Graphical

Thrombus attenuation predicts natural history of hypo-attenuating leaflet thickening after transcatheter aortic valve replacement

Abstract Background Hypo-attenuating leaflet thickening (HALT) after transcatheter aortic valve replacement (TAVR) occurs in up to 25% of patients and is characterized by diverse temporal dynamics. Several studies investigated the natural history of HALT in transcatheter and surgical cohorts, but little is known about the imaging features of persistent thrombus. Purpose To examine the association of quantitative HALT volume and attenuation from computed tomography angiography (CTA) with its natural history. Methods We prospectively examined patients with HALT present on CTA at 30 days after TAVR and who underwent a follow-up CTA at one year. Hypoattenuation affecting motion (HAM) was defined as the presence of HALT with at least moderately reduced (&amp;gt;50%) leaflet motion. HALT was quantified by segmenting the inner volume of the bioprosthetic frame at the level of the leaflets and extracting voxels between a threshold of -200 to 200 HU. Thrombus volume, mean thrombus attenuation and thrombus heterogeneity measured with standard deviation of attenuation were automatically calculated (Figure 1). Results A total of 37 patients (70% men, 71±7 years old) undergoing TAVR with balloon-expandable SAPIEN3 (86%) and self-expanding EVOLUT (14%) valves were evaluated. Hypoattenuation affecting motion (HAM) at 30 days after TAVR was present in 29 (74%) patients. Patients with HAM had higher thrombus volume than patients without reduced leaflet motion (0.40cm3 [IQR 0.16 – 0.61cm3] vs 0.14 [IQR 0.06 – 0.19 cm3], p=0.009) but comparable mean attenuation values (145HU [IQR 141-151HU] vs 123 [IQR 114 – 141HU], p=0.079). Only 3 patients were switched to oral anticoagulation following HALT detection. At one year, HALT resolution was observed in 18/37 (48%) and HAM resolution in 19/29 (65%). No difference in quantitative thrombus features was noted between patients with persistent and resolved HALT. Notably, patients with persistent HAM had higher mean thrombus attenuation (141HU [IQR 123-156HU] vs 123HU [IQR 110 – 138 HU), p=0.045; Figure 2) and thrombus heterogeneity (58HU [IQR 51-63HU] vs 48HU [IQR 41- 54HU], p=0.021) than resolved HAM. Mean thrombus attenuation (area under the curve of 0.732, p=0.044) and thrombus heterogeneity (area under the curve of 0.763, p=0.022) were predictive of HAM resolution at one year. The optimal cutoff values as determined by Youden index was 140HU for mean attenuation and 52HU for heterogeneity. There was an increase in the mean transvalvular gradients between measurements at 30 days and one year in patients with persistent HAM as compared to patients with HAM resolution (Δ3mmHg [IQR -3 – 11mmHg] vs Δ-1mmHg [IQR -4 – 0mmHg], p=0.049). The volume of thrombus at one year was associated with the magnitude of change in transvalvular gradients (β = 10.3, 95% CI 1.6- 19.0, p=0.025). Conclusion Quantitative evaluation of HALT by CTA may aid the identification of patients at risk of persistent thrombus.

Image quality of the non-contrast BOOST cardiac magnetic resonance sequence to visualize the pulmonary veins in patients with atrial fibrillation

Abstract Background In patients with atrial fibrillation (AF), imaging examinations have an important role in planning ablation by imaging the pulmonary veins (PV). The PV anatomy is conventionally assessed before ablation using computer tomography (CT) or 3 dimensional (3D) contrast-enhanced cardiac magnetic resonance (CMR) imaging. The new 3-dimensional, free-breathing BOOST (Bright-blood and black-blOOd phase SensiTive inversion recovery) cardiac magnetic resonance (CMR) sequence is suitable for imaging the left atrium without the addition of contrast agent. Purpose The aim of our study was to investigate the BOOST sequence for the imaging of PVs, and the effect of heart rate and rhythm on image quality. Methods Forty-seven patients underwent and BOOST CMR before ablation, 25 of them had also left atrial CT angiography (CTA). The BOOST sequence was performed using T2 preparation pre-pulse (T2prep) and magnetization transfer preparation (MTC) techniques. The image quality was analyzed using a subjective Likert scale and quantitatively by determining the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). Heart rate and rhythm were assessed by 12-lead ECG. Results MTC-BOOST images were suitable for PVs analysis in all cases, whereas the assessment of PVs on T2prep-BOOST images was inadequate in the majority of cases due to artifacts. CTA showed the same PV anatomy as assessed with BOOST CMR. Based on the operating electrophysiologists’ subjective opinion, the quality of the CTA scans was better compared with BOOST sequence. Still, they found the CMR images appropriate for procedural planning in 43 out of 47 cases (91%). SNR and CNR values of the MTC-BOOST bright-blood images were higher if patients had sinus rhythm. We found a significant or nearly significant negative correlation between heart rate and the SNR and CNR values of MTC-BOOST bright-blood images. Conclusions MTC-BOOST images are suitable for visualisation of PVs, producing diagnostic image quality in 100% of cases. In the majority of cases, MTC-BOOST images were appropriate for procedural planning before ablation. Image quality is affected by the patients' heart rate and frequency. Figure 1: MTC BOOST bright blood image of the left atrium and the right pulmonary veins (arrows)

Imaging signs of carotid plaque vulnerability predict subclinical neurological events in asymptomatic patients: the carotid artery multi-modality imaging prognostic study

Abstract Background Carotid artery plaques should be considered for invasive treatment if diameter stenoses is ≥60%, in the presence of clinical and/or imaging characteristics associated with an increased risk of ipsilateral stroke, such as intraplaque haemorrhage (IPH) or lipid-rich necrotic core (LRNC). However, little is known about plaque’s characteristics in patients with &amp;lt;60% stenoses. Purpose To evaluate the prevalence and significance of imaging signs of plaque vulnerability in patients with asymptomatic &amp;lt;60% carotid artery stenoses. Methods In the Carotid Artery Multi-modality imaging Prognostic (CAMP) study (granted by Bando Ricerca Salute 2018 - Regione Toscana) we prospectively enrolled 200 patients with asymptomatic, mild/moderate (40-60%) carotid artery stenoses, as assessed at Doppler ultrasound (DUS). All patients were evaluated with multimodality imaging, including computed tomography angiography (CTA), magnetic resonance angiography (MRA) and brain magnetic resonance imaging (MRI), whenever not contraindicated. A subgroup of 75 patients underwent also a 18[F]-fluorodeoxyglucose (FDG) positron emission tomography (PET). A thorough clinical, biochemical, cardiological and neurological evaluation was performed in all patients. Results Imaging signs of plaque vulnerability were frequent (IPH and/or LRNC at MRA were found in 26.3% patients, plaque ulceration at CTA was found in 36.7% of patients). No difference in the prevalence of cardiovascular risk factors was noted in those with and without signs of vulnerability. Subclinical embolic brain infarctions at brain MRI were found in 8.8% of patients at enrollment. These patients had more frequently a LRNC at MRA than patients without subclinical embolic brain infarctions (50% vs 17%, p&amp;lt;0.05), lower estimated glomerular filtration rate (55±8 vs 73±23 mL/min/1.73mq, p&amp;lt;0.001), higher troponin HS values (16±4 vs 12±8 ng/ml, p&amp;lt;0.05). Presence of LRNC at MRA was the only predictor of embolic lesions at MRI (odds ratio 4.86, 95% confidence interval 1.08-21.8, p&amp;lt;0.05). Conclusions Imaging signs of vulnerability are highly prevalent in patients with asymptomatic intermediate carotid artery stenosis. Presence of a LRNC at MRA is associated with subclinical embolic brain infarcts. The use of non-invasive multi-imaging can better characterize carotid plaques, independent of the degree of stenosis, and help identifying a subgroup of patients at higher risk of events.

Histological assessment of the shared vascular wall in anomalous aortic origin of coronary arteries with an interarterial course

Abstract Background In anomalous aortic origin of a coronary artery (AAOCA) an intramural segment is present if the proximal AAOCA courses through the aortic wall. This is defined as a shared tunica media of the aorta and AAOCA in the ‘intramural septum’. This definition is based on autopsy studies of selected AAOCA patients who suffered sudden cardiac death and is difficult to apprehend on imaging modalities. Therefore, the aim was to identify the histological features and variants of the interarterial vascular wall in living adult patients, and correlate this to CT-angiography (CTA). Methods This prospective multicenter study included consecutive adult AAOCA patients who underwent surgical unroofing between 2021 to 2024. The excised interatrial vascular wall tissue was embedded, sectioned, and immunohistochemically stained for physiological components, e.g. smooth muscle cells and connective tissue, and pathological components such as fibrosis. Microscopic examination and quantification was performed by two independent observers and findings were correlated with CTA. Results Fifteen patients (mean age 42.9±14.0 years, 60% female) and 1 postmortem specimen were included. Fourteen (93%) had a right-AAOCA and 1 (7%) a left-AAOCA, with a mean intramural length of 8.4±4.1mm. Histopathologically, disorganized elastic lamellae with fragmentation, presence of fibrosis and loss of nuclei were observed. No vasa vasorum or nervi vasorum were identified. Post-sectioning virtual 3D reconstructions enhanced the spatial insight in correlation of histological sections with CTA. Conclusion This first study of the intramural septum in adults with AAOCA reveals the histological structure of the shared vascular wall between the aorta and AAOCA. Marked vascular wall abnormalities such as lack of vasa and nervi vasorum, fragmentation of elastic lamellae and fibrotic changes were observed. These findings support a propensity to local vascular wall pathology in patients with AAOCA. 3D reconstruction supported the translation of histological data to clinical imaging techniques.Central Figure

Correlation of coronary and carotid atheroma volume in patients with severe and familial hypercholesterolemia (VOCCA-3D HF)

Abstract Background Stratifying the risk of CV event of familial hypercholesterolemia (FH) patients is not always simple, as they usually are excluded from CV disease risk estimation scores. It has become increasingly clear over the last several years that the heterogeneity in risk among patients with FH is far greater than previously appreciated. To that end, not all patients with FH will require the use of PCSK9 inhibitors. Aim We described the type of coronary artery disease (CAD) in patients with severe and familial hypercholesterolemia and without known atherosclerotic cardiovascular disease and searched for the best determinants of CAD. We searched for correlation between epicardial adipose tissue and CAD. Methods We evaluated the atherosclerosis burden with a combination of calcium score (CAC), computed tomography angiography, and the quantification of coronary atheroma volume and the analysis of the composition of the plaques, alongside with the use of ultrasonography of supra-aortic trunks with 3D quantification of atheroma volume. We also evaluated epicardial adipose tissue volume with CT. Results We analyzed 89 individuals with LDL-c &amp;gt; 190 mg/dL, with a mean age of 56,7 years. LDL-c burden was high (maximal LDL-c level across life of 2.77 g/L in mean, duration of hypercholesterolemia of 21.5 years in mean). Forty percent of the individuals had a CAC score of zero, and only one patient had non-calcified atheroma despite a CAC score of zero. Among patients with CAD, 50% had a CAC &amp;gt; 100 AU, 9% had a stenosis &amp;gt; 50%. Coronary atheroma volume amounted to a median of 50.9 mm3 in patients with CAD, representing 4% of the analyzed coronary lumen volume, and was mainly made of calcified and non-calcified fibrous plaques. At-risk plaques were not frequent (9% of low-attenuation plaques, 15.2% of positive remodeling and 2% of napkin-ring sign) in patients with CAD. Fifty percent of the individuals had no carotid plaque. Among various clinical and biological risk factors (LDL-year-score, age, blood pressure, smoking, familial history, diabetes), the carotid atheroma volume was the only variable to be independently correlated with both CAC (t=3.1, p=0.006) and coronary atheroma volume (t=4.9, p&amp;lt;0.001). Epicardial adipose tissue was not associated with CAD. Conclusion A significant part of the patients with severe and familial hypercholesterolemia has no CAD, however half of the patients with CAD have an important atherosclerosis burden, which can be well predicted by the carotid atheroma volume. Such a screening could help identify the individuals who would benefit the most from intensive cholesterol-lowering drugs.CAC categoriesType of coronary plaques

Plasma protein profile associated with a family history of early-onset coronary heart disease

Abstract Introduction Although family history of coronary heart disease (CHD) is an established risk factor for subsequent CHD, its relation to the circulating proteome is unknown. Proteins linked to coronary atherosclerosis in subjects with a family history could uncover new pathophysiological mechanisms of heritable CHD. Purpose Firstly, we aimed to study the protein profile associated with a family history of early-onset CHD. Secondly, we aimed to identify proteins among which family history was an effect modifier for the association between each protein and coronary atherosclerosis. Methods Plasma levels of proteins were assessed with Olink panels CVD-II and -III in the population-based Swedish CArdioPulmonary bioImage Study (SCAPIS) cohort. The coronary segment involvement score (SIS) was assessed from computed tomography angiography. Subjects without known CHD were cross-referenced with national registers to identify records of myocardial infarction or coronary revascularization in any parent before 55 or 65 years of age in males and females, respectively. The associations between a family history of CHD and each protein were studied with linear regression adjusted for age, sex and study site, using a False Discovery Rate (FDR) of 5%. Associations were subsequently adjusted for cardiovascular risk factors. Similarly, associations between each protein and SIS were modelled linearly with an FDR of 5%. For significant proteins, the statistical interactions between each protein and family history for the association between proteins and SIS were studied. Results Of 4,251 subjects, 9.5% had a family history CHD. 43 proteins were significantly associated with family history, and when adjusted for risk factors 29 protein associations remained significant (p&amp;lt;0,05) [Figure 1]. The strongest associations were observed for cathepsin D, paraoxonase 3, interleukin-1 receptor antagonist protein and renin. 79 proteins were associated with SIS at FDR&amp;lt;5%, and family history was a significant effect modifier 18 for proteins [Figure 2]. The strongest modifying effects were observed for transferrin receptor protein 1 (β 0.64, 95% CI 0.25–1.04 for those with family history vs β -0.04, 95% CI -0.14–0.06 in those without, p for interaction=0.001), LDL-receptor (β 0.68, 95% CI 0.36–1.00 vs β 0.18, 95% CI 0.08–0.26) and tissue-type plasminogen activator (β 0.45, 95% CI 0.19–0.70 vs β 0.13, 95% CI 0.05–0.21). Conclusion We found that 43 proteins, with biological features of inflammation and vascular function, were associated with a family history of early-onset CHD. Most were also linked to the coronary atherosclerosis burden. Notably, 18 biomarkers, among them transferrin receptor protein 1, LDL-receptor and tissue-type plasminogen activator, exhibited strong statistical interactions with family history in the association with SIS, indicating that they are of particular importance for the genetic susceptibility and the pathophysiology of heritable CHD.

Coronary bypass surgery guided by multislice computed tomography angiography in a low surgical risk population

Abstract Background In patients with three-vessel disease and/or left main disease, selecting revascularization strategies based on coronary computed tomography angiography (CCTA) has a high level of virtual agreement with treatment decisions based on invasive coronary angiography(ICA).(1) Purpose The FASTTRACK CABG trial aims to assess the feasibility and safety of using CCTA and FFRCT as guidance for planning and performing CABG in patients with 3VD and/or LMCAD. Methods In this multicentre study, coronary artery bypass grafts (CABG) were planned and performed based on CCTA without knowledge of ICA. CABG strategy was recommended by a central Core laboratory assessing the anatomy and functionality of the coronary circulation. The primary feasibility endpoint was the percentage of operations performed without access to the ICA. The primary safety endpoint was graft patency on 30-day follow-up CCTA. Secondary endpoints included topographical adequacy of grafting, major adverse cardiac and cerebrovascular events (MACCE), and major bleeding events at 30 days. The study was considered positive if the lower boundary of confidence intervals(CI) for feasibility ≥75%.(2) Results The study enrolled 114 patients with a mean (standard deviation) anatomical SYNTAX Score and Society of Thoracic Surgery score of 43.6 (15.3) and 0.81 (0.63), respectively. Three patients did not undergo CABG due to the patient’s preference for percutaneous treatment (n=1) or lack of graft material. Unblinding ICA was required in one case, yielding a feasibility of 99.1% (95%CI: 95.2%-100%). The concordance and agreement in revascularization planning between the ICA- and CCTA-Heart Team was 82.9% with a moderate kappa of 0.58 (95%CI:0.50-0.66). The concordance and agreement in revascularization planning between the CCTA-Heart Team and actual treatment was 83.7% with a substantial kappa of 0.61 (95%CI:0.53-0.68). The 30-day follow-up CCTA was performed in 102 (91.9%) of the 111 operated patients, which showed an anastomosis patency rate of 92.6%. At 30 days, the incidence of MACCE was 7.2% whereas major bleeding was 2.7%. Conclusions CABG guided by CCTA is feasible and has an acceptable safety profile in a selected population of complex coronary artery disease.

Association of vasospastic angina with myocardial bridging and pericoronary adipose tissue attenuation on computed tomography angiography

Abstract Background Recent studies have suggested that vasospastic angina (VSA) is associated with myocardial bridging (MB). The relationship between VSA and pericoronary adipose tissue (PCAT) inflammation has also been reported but still remains to be determined. Purpose We investigated clinical and coronary computed tomography angiographic (CCTA) features in patients with VSA diagnosed by spasm provocation test (SPT). Methods We retrospectively studied patients with clinically suspected VSA who underwent both SPT with intracoronary acetylcholine administration and CCTA within three months before SPT at Tsuchiura Kyodo General Hospital. PCAT inflammation was evaluated on CCTA images by fat attenuation index (FAI) which has been recently used as a novel biomarker of coronary inflammation. In FAI analysis, we measured FAI of the proximal segments not only for 4mm (FAI4mm) but also for the inner and thinner 2mm pericoronary adipose tissue layer from the vessel wall (FAI2mm), since FAI2mm has been reported to provide better discriminating efficacy for VSA diagnosis than FAI4mm. We also evaluated the presence or absence of MB and its features including length, depth and location on CCTA images. Results A total of 172 patients were studied and VSA was diagnosed in 39.0% (67/172) of patients by SPT according to the latest guideline. Male (74.6% vs 49.5%, P=0.001), smoking history (74.6% vs 48.6%, P=0.001) were more frequent, and prevalence of CCTA-defined MB (47.8% vs 34.3%, P=0.082) and RCA-FAI2mm (-68.73 HU vs -73.35 HU, P&amp;lt;0.001) were higher in patients with versus without VSA. In multivariable analysis, presence of CCTA-defined MB (odds ratio [OR] 2.56, 95% confidence interval [CI] 1.26-5.19, P=0.0095), RCA-FAI2mm (OR 1.05, 95% CI 1.01-1.09, P=0.025), and smoking (OR 3.40, 95% CI 1.57-7.36, P=0.0019) were independently associated with VSA. A combination of high RCA-FAI2mm (≥-68.93HU, the best cut-off obtained by ROC analysis with AUC of 0.64, 95% CI 0.551 - 0.728), smoking history and existence of MB could predict VSA with 73.7% of probability, while an absence of all 3 covariates could exclude VSA with 85.3% of probability. Conclusion CCTA-defined MB, high RCA-FAI2mm and smoking were independently predictive of VSA.