Coronary CT Scan Research Articles

Scanner cardiaque : intérêt dans le bilan des douleurs thoraciques, dans le dépistage cardiovasculaire et dans le bilan pré-ablation de fibrillation auriculaire

Cardiac CT-scan is recommended for sorting patients presenting with stable or acute chest pain with low to intermediate risk of coronary artery disease (CAD). Recent studies have shown its reliability for diagnosing CAD in high-risk patients, notably those with acute coronary syndrome (ACS) without ST-elevation. Coronary CT-scan also represents a great opportunity for the screening of atherosclerosis in patients at risk and allows a better prevention of coronary artery disease by introduction of preventive treatments in patients with abnormal coronary CT-scan, especially statins. It is useful for the follow-up of patients who underwent a coronary arteries revascularization with either stents or bypasses. Coronary arteries calcium scoring appears to be an independent predictive factor of cardiovascular and total mortality and its use is recommended for stratifying the cardiovascular risk. However, its interpretation remains unobvious and the patient management is poorly improved by the results. Anyway, if the score is above zero, atherosclerosis is present and therefore a lipid lowering treatment should be discussed. Cardiac CT-scan has become the Gold Standard exam before an aortic valve replacement, for the measurement of the aortic root notably, allowing the best prothesis selection. Before atrial fibrillation ablation procedure by pulmonary vein isolation, the cardiac CT-scan allows a 3-D visualization of the two atria, especially the left atrium, and rules out any suspicion of cardiac thrombus. It allows the research of an anomalous pulmonary venous connection. The 3-D support will also enable the operator to navigate in the heart during the ablation procedure.

Physics driven real-time blood flow simulations

Predictive modeling of blood flow and pressure have numerous applications ranging from non-invasive assessment of functional significance of disease to planning invasive procedures. While several such predictive modeling techniques have been proposed, their use in the clinic has been limited due in part to the significant time required to perform virtual interventions and compute the resultant changes in hemodynamic conditions. We propose a fast hemodynamic assessment method to aid in interventional planning based on first constructing an exploration space of geometries, tailored to each patient, and subsequently building a physics driven reduced order model in this space. We demonstrate that this method can predict fractional flow reserve derived from coronary computed tomography angiography in response to changes to a patient-specific lumen geometry in real time while achieving high accuracy when compared to computational fluid dynamics simulations. We validated this method on over 1300 patients that received a coronary CT scan and demonstrated a correlation coefficient of 0.98 with an error of 0.005±0.015 (95% CI: (-0.020, 0.031)) as compared to three-dimensional blood flow calculations. This technology is implemented in a product that has received clearance by the U.S. Food and Drug Administration and is being used clinically to enable physicians to predict changes in blood flow resulting from removal of coronary stenoses as might occur with percutaneous coronary interventions. This technology is also cleared for use in Japan and pending regulatory approval in Europe.

P1716 Aorto-left atrial fistula with left atrium dissection

Abstract We report a 71 year-old female with a history of rheumatic valvulopathy, who underwent St. Jude 23 and St. Jude 21 in mitral and aortic position replacement. The patient was admitted to the ER for pulmonary edema with haemoglobin level of 7.7 g/dL .No evidence of gastrointestinal bleeding. She was assessed to exclude intravascular hemolysis: bilirrubin 3.1mg/d,L direct bilirrubin 1.0 mg/dL, reticulocytes 207.000/mcL 6.8%, LDH 1.213, free plasmatic haemoglobin 9.6mg/dL, haptoglobin < 1 mg/dL, negative direct and indirect Coombs. Upon suspicion of hemolytic anemia in relation to prosthetic dysfunction, TEE was performed revealing stenotic mechanical aortic prosthesis with abundant pannus and normofunctional mitral prosthesis, no leakages were observed. A coronary CT scan showed severe calcification of the aortic root and mitral annulus without evidence of redundant tissue than hindered the opening of the aortic or mitral valves. Cardiac catheterization revealed normal coronary arteries, cardiac output preserved and mild passive predominance of PAP. Heart Team decided on aortic prosthesis valve replacement. On March 22, 2019 surgery was performed. There was a heavily calcified ascending aorta and aortic root with abundant pannus at the ventricular aspect of the aortic prosthesis. Former aortic prosthesis was resected and the root reconstructed with a pericardial patch. 18-mmATS mechanical aortic prosthesis was implanted. After 127minutes of cross-clamping time, the patient was admitted to the ICU. She presented a torpid course in the postoperative period after cardiac surgery and cardiogenic shock ensued. TEE was repeated, showing pseudoaneurysm of the mitral–aortic intervalvular fibrosa, left atrium dissection and severe paraprosthetic aortic leakage. Coronary CT scan revealed a large cavity, 7x4x3.5 cm, extending posteriorly and displacing cranially the right pulmonary artery and subsequently rejecting the cavity of left atrium; with final diagnosis of aorto-left atrial fistula with left atrium dissection. Emergent surgery was decided. During the procedure, mitral–aortic intervalvular fibrosa pseudoaneurysm was confirmed, perforation from the subaortic left ventricle into the left atrium was also appreciated at the junction of the aortic root pericardial patch with the dissected left atrium wall. Surgery was complicated with hemorrhagic shock and massive uncontrolled bleeding with severe coagulopathy and thrombocytopenia. The patient went into cardiac arrest and passed away in the operating room. Conclusion Aorto atrial fistulas are rare but important complications of many disease processes of the aorta and aortic valve. Classical clinical signs of continuous murmurs may not be present and echocardiography forms the cornerstone of diagnosis. AAF should be suspected in patients with poorly controlled heart failure and prior aortic surgery. Prompt surgical repair is usually helpful in relieving symptoms and decreasing mortality. Abstract P1716 Figure. Aortoatrial fistula

P640 Multimodality imaging of an asymptomatic aortic fibroelastoma successfully treated with a surgical valve-sparing technique

Abstract Papillary fibroelastoma is an uncommon cardiac tumour. It is usually attached to the chordae tendineae or to the papillary muscles, while the involvement of the valves or the LVOT is rarely seen. The diagnosis is often due to incidental finding because the tumor is often asymptomatic, even though structural cardiac damages or dramatic embolization may occur. We present the case of a 66 year old woman affected by arterial hypertension and dyslipidemia. During a routine cardiologic visit a transthoracic echocardiogram unexpectedly revealed the presence of a extremely mobile peduncolate mass (11x5mm) with a homogenous speckle pattern, apparently settled on the aortic side of the right cusp of the aortic valve. No further pathological elements were detected. A diagnosis of suspected fibroelastoma was made and the patient was transferred to the cardiac surgery department. On admission clinical examination and vital signs were unremarkable. No symptoms suggestive of TIA or amaurosis were reported by the patient, hence the tumor was considered as an asymptomatic incidental finding. Since the mass did not seem to be firmly attached, based on the high risk of embolization and the possibility of coronary ostia impingement with the manipulation of the catheters, the Heart Team decided to omit a pre-interventional coronary angiography. A coronary CT scan excluded significant coronary artery disease and the patient was offered a surgical resection of the mass. After anterior mini-sternotomy, during extracorporeal circulation, the ascending aorta was opened with a transversal incision and the aortic valve was exposed. A pedunculated tumour of 1.5x2 cm implanted in the edge of the right cusp was observed and completely excised with a valve-sparing resection. Macroscopically, the tumour looked whitish and filamentous, suggestive of fibroelastoma. At the end of the procedure transesophageal echocardiography guaranteed the competence of the aortic valve was preserved. The patient recovered successfully and was discharged one week after the intervention. The control transthoracic echocardiography excluded tumoral residual and the histological examination confirmed the diagnosis of fibroelastoma. The patient was discharged after an uneventful course. This report singularly shows a rare case of aortic location of an asymptomatic fibroelastoma treated with an early surgical approach in order to avoid embolic complications. Multimodality imaging provides clear and exemplary information about this rare entity. Nowadays, the optimal management of challenging cases requires a multidisciplinary team with a discrete familiarity with the common imaging techniques, which play a pivotal role in the diagnostic, pre-procedural and interventional setting. Abstract P640 Figure. Multimodality imaging: fibroelastoma

HDL-C to hsCRP ratio is associated with left ventricular diastolic function in absence of significant coronary atherosclerosis

BackgroundHigh-density lipoprotein cholesterol (HDL-C) is considered as a protective marker of coronary atherosclerotic disease (CAD). It is still not clear if HDL-C is associated with left ventricular (LV) diastolic function in an inflammation-related manner in absence of significant coronary atherosclerosis.Methods392 patients who complained of chest pain and were suspected of CAD without heart failure were enrolled in this study. Coronary angiography or coronary artery CT scan was performed to detect coronary atherosclerosis. Transthoracic echocardiography was performed to evaluate cardiac function. Plasma level of HDL-C and high-sensitive C-reactive protein (hsCRP) were determined in each subject. Relationship between HDL-C/hsCRP ratio and LV diastolic function in subjects without significant coronary atherosclerosis was investigated.Results204 subjects without significant coronary plaques were analyzed finally, including 84 males and 120 females whose ages ranged from 30 to 84 years old. When divided into HDL-C/hsCRP quartiles, those in the fourth quartile demonstrated the best diastolic function (E/e’ 10.14 ± 2.87, P = 0.02 ). HDL-C/hsCRP was the most significant factor correlated with E/e’ in univariate regression analysis (r = − 0.232, P < 0.001) and multiple regression analysis adjusted by other factors (standardized β = − 0.258 , P < 0.0005 ). In logistic regression, HDL-C/hsCRP was proved to be a protective factor of LV diastolic dysfunction E/e’ > 14 (OR = 0.649, 95%CI 0.444–0.948,P = 0.025 ). The sensitivity and specificity of using HDL-C/hsCRP < 0.98 to predict LV diastolic dysfunction were 64.3% and 56.2%, respectively. HDL-C/hsCRP ratio presented a reduced trend as increasing rate of CV risk factors.ConclusionsHDL-C/hsCRP ratio strongly correlates with LV diastolic function in absence of significant coronary atherosclerosis. Low HDL-C/hsCRP ratio tends to relate with LV diastolic dysfunction.

P3555Lower native T1, extracellular volume and T2 on cardiac magnetic resonance imaging is related to more left ventricular reverse remodeling in nonischemic dilated cardiomyopathy

Abstract Introduction Guideline-directed medical therapy can induce left ventricular reverse remodeling (LVRR) in nonischemic dilated cardiomyopathy (NIDCM). Some predictors for LVRR have been reported but, there were few studies about the relationship between cardiac magnetic resonance imaging (CMR) parameters and LVRR in NIDCM on optimal GDMT. Methods We retrospectively analyzed echocardiogram and CMR data of newly diagnosed 142 NIDCM patients (age: 57±16 years old, 71.8% male) in a single center from Jan 2012 to Dec 2017. NIDCM was defined as left ventricular ejection fraction (LVEF) &lt;45% and the ischemic etiology was excluded by CMR, coronary angiography or coronary CT or SPECT scan. LVRR was defined as improvement in LVEF ≥10% during follow-up period (median 403 days). Results Baseline LVEF and LV end diastolic dimension (LVEDD) were 27±8% and 64±8 mm. There were 87 patients (61.3%) of LVRR in our cohort. In LVRR group, native T1 value was significantly lower (1326±66 for LVRR vs 1369±72ms, p&lt;0.001), extracellular volume (ECV) was significantly lower (28.3±3.6 for LVRR vs 32.4±4.4%, p&lt;0.001), and T2 value was significantly lower (49.6±4.6 for LVRR vs 52.1±5.4ms, p=0.004) compared with non-LVRR group. ECV was an independent predictor for LVRR after adjusting current LVRR predictors such as age, sex, LVEF, LVEDD, systolic blood pressure, heart rate and QRS duration (Odd ratio 0.706, 95% confidence interval 0.616–0.809, p&lt;0.001). Conclusion Lower native T1, ECV and T2 on CMR is related to higher incidence of LVRR in NIDCM. Further larger prospective study should be warranted to confirm the relationship between CMR parameters and LVRR in NIDCM.

A New 3D CT Method to Analyze Bronchial Stenosis after Lung Transplantation

Purpose The diagnosis of bronchial stenosis after lung transplantation relies on bronchoscopic findings of airway narrowing. However, it is an invasive method and the degree of stenosis is based on the relation between its lumen and the diameter of the fiberscope. We propose a non nvasive method based on 3D CT to evaluate bronchial stenosis. Methods All cases of bronchial stenosis after lung transplantation at our institution were analyzed. Chest CT scan from these patients at the moment of diagnosis were collected. Using a specific software Terarecon, which is used to analyse coronary CT scans, the airways were reconstructed and the area of the stenosis/anastomosis site were calculated. Two more areas were calculated 5mm before and 5mm after the stenosis site. We define the relation between the stenosis area and the average of the areas before and after as Anastomosis Index (AI). Another 10 patients without stenosis were paired as control group and similar technique were applied. Results In a normal airway after lung transplantation, the expectation is an AI close to 1. In the control group we obtained a mean AI of 0.842+/-0.091, whereas in the stenosis group the mean AI was 0.387+/-0.151 (p Conclusion The Anastomosis Index can be useful to diagnose bronchial stenosis after lung transplantation. It is harmless and subsequently may help as a basis for new studies involving management of bronchial stenosis. Further investigation is needed to establish a minimum value of AI to define bronchial stenosis.

Recommendations for cardiovascular evaluation in athletes – a viewpoint

Traditionally, cardiovascular screening has been recommended mostly for competitive athletes younger than 35 years. The perception that only young competitive athletes at top level are at increased risk, has changed in the last years. Theoretically, we advocate a voluntary cardiovascular screening for all athletes who exercise vigorously, independent of their competitive status, and age. Although, this should be based on an individual estimation of the athlete’s risk. Physical examination, medical history and an ECG should be the baseline investigations for all athletes. Ideally, an echocardiography should be performed once at the beginning of the athletic career to rule out congenital coronary and valvular abnormalities-although addition of an echocardiography has not yet been established routinely due to lacking evidence. We advocate to repeat the ECG every 1–2 years in athletes &lt; 30–35 years. For older athletes, we recommend to assess their individual CV risk profile (particularly with inclusion of lipid profile) and their previous training history. Depending on the assessment, further investigations should be implemented such as an exercise stress test and/or Coronary CT scan.

Impact of coronary artery disease and percutaneous coronary intervention in women undergoing transcatheter aortic valve replacement: From the WIN-TAVI registry.

To evaluate the impact of coronary artery disease (CAD) with or without recent (≤ 30 days) percutaneous coronary intervention (PCI) in women undergoing transcatheter aortic valve replacement (TAVR). Although women display a specific risk-profile for both PCI and TAVR, the impact of CAD and PCI in the setting of TAVR in women is unclear. The multinational Women's International Transcatheter Aortic Valve implantation registry enrolled consecutive female patients undergoing contemporary TAVR in 19 centers between 2013 and 2015. Patients with available coronary angiography or CT scan in the pre-operative assessment of TAVR were categorized as without CAD, with CAD but no recent PCI and CAD and recent PCI (≤30 days). All events were adjudicated according to the VARC-2 criteria. A total of 787 patients were included in this analysis, among whom 459 (58.3%) had no CAD, 247 (31.4%) had CAD without recent PCI and 81 (10.3%) underwent recent PCI (≤ 30 days before TAVR). After multivariable adjustment, both groups of CAD patients, without and with recent PCI, presented with higher risk of death, myocardial infarction or stroke, compared with patients without CAD (adj HR 1.56, 95%CI 1.03-2.39, P = 0.038 and adj HR 1.96, 95% CI 1.1-3.5, P = .021, respectively). Patients with recent PCI had increased risk of all-cause death (adj HR 1.89, 95% CI 1.0-3.5, P = 0.04) and stroke (adj HR 3.7, 95% CI 1.0-13.5, P = 0.046) compared with patients without CAD. The presence of CAD in women undergoing TAVR, with or without recent PCI, was associated with long-term poorer outcomes.

Heart transplantation as rescue treatment of left main stem occlusion by a recurrent aortic pseudoaneurysm

A 58 year-old man was admitted in our ICU for cardiogenic shock and electrical storm. His medical history was marked by a triple redo valvular surgery complicated by a recurrent aortic pseudoaneurysm of the ascending aorta. Coronary angiogram and heart CT scan diagnosed an extensive anterior myocardial infarction related to an extrinsic compression of the left main stem by this massive and calcified pseudoaneurysm. Angioplasty or new cardiac surgery options were rejected by the heart team. Despite an unusual indication, the patient was registered on the heart transplant list, and underwent it successfully.

TCTAP C-200 Chronic Left Main and Left Anterior Descending Dissection in a Young Woman: Optical Coherence Tomography Role to Indicate Optimal Treatment

### Patient Initials or Identifier Number LMR ### Relevant Clinical History and Physical Exam 49 years, female cardiovascular risk factors: former smoker comorbidities: multifactorial anemia 2014: NSTEMI → PCI +DES in obtuse marginal 2017: aspecific thoracic pain → coronary CT scan →

Effect of sodium thiosulfate on coronary artery calcification in maintenance hemodialysis patients

Objective: To investigate the factors correlated to coronary artery calcification (CAC)in maintenance hemodialysis (MHD) patients and observe the effect of sodium thiosulfate (STS) on the progression of vascular calcification and its safety. Methods: Thirty-eight subjects from Fuzhou Genernal Hospital who underwent coronary artery CT scan using Philip's spiral CT were enrolled and the calcification degree was evaluated by CAC scores from December 2013 to December 2014. The hemodialysis patients were divided into CAC group (CAC scores>10, 27 cases) and non-CAC group (CAC scores≤10, 11 cases)according to the CT scan results.The differences of age, duration of dialysis, blood pressure and other hematological indices between the two groups were analyzed to investigate the factors correlated to CAC. Next, those with CAC (CAC scores≥50) received intravenous 0.18 g/kg STS (dissolved in 100 ml saline) in 30 minutes after each dialysis for 3 months (n=17, only 15 patients completed STS treatment) or received conventional treatment (n=10). Baseline data between the two groups before treatment had no significant statistical difference. All examination indices were evaluated before and after the treatment course. The changes of vascular calcification imaging, CAC scores, biochemical indices and bone mineral density were compared between two groups before and after the treatment. Besides, adverse reactions were observed during the treatment of STS. This study was approved by the Ethics Committee of Fuzhou General Hospital(2013No1). Results: Twenty-seven out of 38 patients (71.05%) had CAC, and the patients with CAC had significantly higher age, phosphate, the product of calcium and phosphate, intact parathyroid hormone (hPTH), hypersensitive C-reactive protein (hsCRP), and longer duration of dialysis (P=0.017, 0.038, 0.037, 0.012, 0.002, 0.037) and lower serum albumin (P=0.026) than patients without CAC.There was no significant statistical difference in the baseline characteristics. CAC score did not change significantly before and after treatment in the STS treatment group[1 045(47-12 734) vs 797(50-14 094), P=0.053], but increased significantly in the conventional treatment group[221(59-3 843) vs 174(50-3 369), P=0.021]. Difference of CAC score parameters before and after treatment showed statistically significant difference between the two groups[-67.5(-474-8) vs 52(-248-1 361) , P=0.004]. After STS treatment, level of hsCRP and HCO3- decreased (P=0.016 and P=0.020, respectively), and level of serum calcium increased (P=0.005). There was no significant statistical difference observed in iPTH, 25(OH)D, bone alkaline phosphatase (bALP), fibroblast growth factor 23 (FGF23) after STS treatment. Conclusion: STS treatment seems to be feasible, safe and may delay the rate of progression of vascular calcification, reduce inflammation in maintenance hemodialysis patients, but the adverse reactions needs further study.

PP.16.10] WHICH MEASUREMENT OF BLOOD PRESSURE IS MORE ASSOCIATED WITH ATHEROSCLEROTIC CARDIOVASCULAR DISEASE WITHOUT HYPERTENSION

Objective: Peripheral systolic blood pressure (pSBP) has been used to predict atherosclerotic cardiovascular disease (ASCVD). However, the assessment of superiority between pSBP and central SBP (SBP2) to predict ASCVD in patients without hypertension (HTN) has not been fully established. Design and method: Nine hundred and eighteen patients (male:female ratio 700:218, mean age 54.7 ± 13.7 years) without HTN were enrolled from subjects who received non-invasively semiautomated radial artery applanation tonometry (using an Omron HEM-9000AI) in the Department of Internal Medicine, St. Vincent's Hospital, from July 2011 to May 2015. Moreover, the area under the receiver operating characteristic curve (AUC) of SBP2 was compared with that of SBP to identify ASCVD. Results: Two hundred and eighteen subjects (male:female ratio 131:82, mean age 61.7 ± 11.1 years) were diagnosed as ASCVD according to coronary angiography or coronary CT scan. Interestingly, ASCVD patients had significantly lower pSBP (124 ± 18 mmHg vs 128 ± 17 mmHg) and SBP2 (114 ± 18 mmHg vs 118 ± 18 mmHg) than the patients without ASCVD. However, ASCVD patients had significantly higher pulse pressure (52 ± 13 mmHg vs 50 ± 12 mmHg) than the patients without ASCVD. After multivariate analysis after adjusted for age, gender, body mass index, fasting plasma glucose, diabetes, lipid profiles, antihypertensive medication and lipid-lowering medication, SBP2 (β = 0.231, 95% CI 1.036 to 1.289, p = 0.010) or pSBP (β = 0.887, 95% CI 0.800 to 0.982, p = 0.021) were associated with ASCVD. In addition, AUC of pSBP was significantly greater than that of SBP2 to identify ASCVD (P = 0.035). Conclusions: Central blood pressure is superior to pSBP in identifying ASCVD, although both peripheral and central SBP are associated with ASCVD in patients without hypertension.

PS 05-01 WHICH MEASUREMENT OF BLOOD PRESSURE IS MORE ASSOCIATED WITH ATHEROSCLEROTIC CARDIOVASCULAR DISEASE IN PATIENTS WITHOUT HYPERTENSION

Objective: Peripheral systolic blood pressure (SBP) has been used to predict atherosclerotic cardiovascular disease (ASCVD). However, the assessment of superiority between peripheral SBP and central SBP to predict ASCVD in asymptomatic patients without hypertension (HTN) has not been fully established. Design and method: Nine hundred and eighteen patients (male:female ratio 700:218, mean age 54.7 ± 13.7 years) without HTN were enrolled from subjects who received non-invasively semiautomated radial artery applanation tonometry (using an Omron HEM-9000AI) in the Department of Internal Medicine, St. Vincent's Hospital, from July 2011 to May 2015. Results: Two hundred and eighteen subjects (male:female ratio 149:69, mean age 61.7 ± 11.1 years) were diagnosed as ASCVD according to coronary angiography or coronary CT scan. Interestingly, ASCVD patients had significantly lower pSBP (124 ± 18 mmHg vs 128 ± 17 mmHg) and SBP2 (114 ± 18 mmHg vs 118 ± 18 mmHg) than the patients without ASCVD. However, ASCVD patients had significantly higher pulse pressure (52 ± 13 mmHg vs 50 ± 12 mmHg) than the patients without ASCVD. After multivariate analysis after adjusted for age, gender, body mass index, fasting plasma glucose, diabetes, lipid profiles, antihypertensive medication and lipid-lowering medication, SBP2 (β = 0.231, 95% CI 1.036 to 1.289, p = 0.010) or pSBP (β = 0.887, 95% CI 0.800 to 0.982, p = 0.021) were associated with ASCVD. In addition, AUC of pSBP was significantly greater than that of SBP2 to identify ASCVD (P = 0.035). Conclusions: Central blood pressure is superior to pSBP in identifying ASCVD, although both peripheral and central SBP are associated with ASCVD in patients without hypertension.

Impact of blood pressure control on coronary flow reserve in hypertensive patients

To investigate the impacts of blood pressure control on coronary flow reserve (CFR) in hypertensive patients. A total of 236 patients without significant coronary stenosis (defined as <50% luminal narrowing which was confirmed by coronary angiography or coronary artery CT scan) between January 2011 to July 2015 were retrospectively enrolled in this study. CFR was measured in the left anterior descending coronary artery (LAD) during adenosine triphosphate-induced hyperemia by transthoracic Doppler echocardiography. Patients were divided into hypertension group (n=173) and non-hypertension group (n=63). The hypertension patients were further divided into ideally controlled (n=31, defined as SBP <120 mmHg (1 mmHg=0.133 kPa) and DBP <80 mmHg), controlled (n=82, defined as SBP 120 to 139 mmHg and DBP <90 mmHg) and uncontrolled groups (n=60, defined as SBP≥140 mmHg and/or diastolic DBP≥90 mmHg) based on their blood pressure after systematic antihypertensive therapy and CFR values were compared among the 4 groups. Multivariate regression analyses were performed to identify the independent determinants of CFR in patients with hypertension. Compared with non-hypertension group, the CFR was significantly lower in controlled (3.27±0.71 vs. 2.87±0.56, P<0.001) and uncontrolled groups (3.27±0.71 vs. 2.61±0.71, P<0.001), but was similar in ideally controlled group (3.27±0.71 vs. 3.21±0.85, P=0.68). Furthermore, the CFR was significantly lower in uncontrolled group than that of the other two hypertension groups and was significantly lower in controlled group than that of ideally controlled group. Higher blood pressure (β=-0.17, P=0.03) and age(β=-0.02, P=0.03) were independent predictors of lower CFR in patients with hypertension. Higher blood pressure is an independent predictor of decreased CFR in patients with hypertension. Hypertensive patients with ideally controlled blood pressure have similar CFR level as patients without hypertension.

Effects of Iterative Reconstruction on the Diagnostic Assessment of Coronary Calcium Scores

Coronary Artery Calcium (CAC) score is a widely used indicator to determine disease severity and predict the risk of severe cardiac events. However, radiation dose associated with coronary CT scanning for CAC scoring raises concerns, especially for asymptomatic patients. Iterative Reconstruction (IR) technique represents a recently developed image processing approach for reduction of image noise and radiation dose, while improving diagnostic image quality. Despite these advantages over conventional filtered back projection technique, effects of IR techniques on CAC scores remain unclear. This review article aims to provide an overview of clinical applications of IR techniques in coronary CT angiography with a focus on the effects of different IR techniques on CAC score assessment.

Reproducibility and Impact of CT-Scanning on Pulse Wave Velocity Measurement for Cardiovascular Risk Stratification in an Asymptomatic Population

Objective: Pulse wave velocity (PWV) measurements for aortic arterial stiffness and coronary CT angiography (CCTA) may help improve cardiovascular risk assessment in asymptomatic people. On the CT-table PWV measurement is an efficient addition to the CT workflow. This study evaluated if on CT-table PWV measurements are influenced by CT anticipation stress and if the PWV measurements are reproducible. Methods: Aortic PWV measurement reproducibility was assessed in 41 asymptomatic male sportsmen (aged 56.5 ± 6.7 years) who underwent CCTA as part of a sports medical evaluation. Three consecutive measurements were performed, two outside the CT-room for intra-observer variability followed by one on the CT-table. Pearson correlation coefficients were assessed for agreement between measurements outside the CT-room and on the CT-table. Bland-Altman analysis of limits of agreement was assessed to evaluate intra-observer variability outside the CT-room. Results: Aortic PWV and systolic blood pressure (SBP) on the CT-table were significantly higher (+0.61 m/s, P = 0.004 and + 7 mmHg, P = 0.003 respectively), with acceptable correlation (Pearson’s correlation 0.8, R² 0.6). The Pearson’s correlation coefficients of PWV measurements outside the CT-room showed good intra-observer agreement, (Pearson’s correlation 0.9, R² 0.8) The mean re-test difference and the 95% limits of agreement outside the CT-room were fair: 0.25 m/s, 95%CI -0.99–1.51 m/s. Conclusion: On the CT-table PWV measurements, although higher due to anticipation stress causing higher SBP, are comparable to off-table measurements at rest. The reproducibility of PWV measurements is good when done prior to a coronary CT-scan and the limits of agreement are acceptable.

Abstract 12912: Impact of Graft Configuration of The Right Internal Mammary Artery in Coronary Artery Bypass Grafting: In-situ Versus Y Composite versus Aorto-coronary Bypass

Background: Right internal mammary artery (RIMA) has been used as second graft with various configurations. The aim of this study was to compare the patency of RIMA with using either aorto-coronary bypass (AC) or Y composite grafting proximally anastomosing to left internal mammary artery (LIMA) or in-situ grafting. Methods: Between January 1996 and June 2013, 324 patients underwent isolated coronary artery bypass grafting (CABG) using RIMA in addition to LIMA-left anterior descending artery (LAD) bypass. Target vessel of RIMA was either diagonal or circumflex branch with significant stenosis. Those patients were divided into 3 groups according to the proximal anastomosis site of RIMA. Group I contained 247 cases with in-situ RIMA grafting. Group A contained 33 cases with AC bypass with proximal anastomosis of RIMA to ascending aorta. Group Y contained 43 cases with Y composite grafting with proximal anastomosis to LIMA. Patients were evaluated by coronary angiography or CT scan postoperatively at discharge and during follow up. Graft patency and risk factors influencing IMA patency were statistically investigated. Results: RIMA patency at discharge were 97.6% in group I and 97.0% in group A, 93.0% in group Y, respectively (p=0.695). RIMA patency in 5 years were 90.5% in Group I, 100% in group A, 88.4% in group Y, respectively (Logrank P=0.309). LIMA patency at discharge were 99.2% in group I and 97.0% in group A, 97.7% in group Y, respectively (p=0.438). LIMA patency in 5 years were 100% in group A, 96.0% in group I, 76.2% in group Y (Logrank P= 0.009). Survival rate in 5 years were 89.7% in group I, 86.6% in group A, 60.7% in group Y (Logrank P= 0.011). Multivariate analysis showed Y composite grafting as risk factor in late LIMA occlusion (p=0.024, Hazard ratio (HR) 6.867, 95% Confidence Interval (CI) 1.29-36.5) and late death (p&lt;0.001 HR 2.99, 95% CI 1.70-5.27). Conclusion: In our study, the patency of RIMA was not significantly different between the groups, but LIMA patency was inferior when used as the inflow of Y composite grafting with RIMA. Y composite grafting may impact on the patency of LIMA and furthermore late survival.

Abstract P229: Pericardial Fat Density is Associated With Insulin Resistance in Treated HIV Infection: The SATURN-HIV Trial

Objective: To examine associations of pericardial fat (PCF) volume and density with baseline and changes in insulin resistance among HIV+ subjects participating in a trial of statin therapy. Methods: SATURN-HIV was a 96-week double-blind, randomized trial of 10 mg daily rosuvastatin versus placebo among 147 HIV+ subjects on stable antiretroviral therapy with LDL-c ≤130mg/dL and evidence of heightened T-cell activation or increased inflammation (high sensitivity C-reactive protein ≥2mg/L). PCF volume (ml) and density (mean Hounsfield Units) were measured from coronary calcium CT scans at entry. Homeostatic model of insulin resistance (HOMA-IR) was calculated from insulin and glucose at entry, 24, 48, and 96 weeks. Pearson correlations and linear mixed modeling were used to explore relationships between PCF and insulin resistance. Results: Median (Q1, Q3) age was 46 (40, 53) years; 78% were male and 68% African American; 49% were on a protease inhibitor. Median HOMA-IR was 1.84 (1.06, 3.33) at baseline, and participants randomized to statin had larger 0-96 week mean percentage increase in HOMA-IR (+73% vs +33%, statin vs placebo, p=0.009). PCF density did not correlate with measures of total body adiposity (BMI r=0.057 and total body fat r=-0.034, both p&gt;0.4), but was negatively correlated to waist-hip ratio (-0.337, p&lt;0.001). In a linear mixed model, PCF density was associated with baseline HOMA-IR independent of PCF volume, BMI, metabolic syndrome, and biomarkers of immune activation and systemic inflammation; however, PCF density was not associated with longitudinal changes in HOMA-IR (see Table). Conclusions: Coronary calcium scans are widely used to assess cardiovascular risk and appropriateness of statin therapy. In this HIV+ population, PCF density, a simple measure obtained from these scans, appears to be a novel marker of insulin resistance that is independent of PCF volume. Larger, adequately powered studies are needed to determine if PCF density predicts development of insulin resistance on statin.

0026: Uselessness of high-sensitivity cardiac troponins to improve diagnostic accuracy of dobutamine stress echocardiography in high-risk diabetic patients

Dobutamine stress echocardiography (DSE) is a well-established noninvasive stress modality for the detection and evaluation of coronary artery disease in diabetic patients. High-sensitivity cardiac troponin T recently emerged as a highly sensitive dosage for the detection of ischemia. The aim of the study was to examine whether high-sensitivity cardiac troponin T may improve the diagnostic accuracy of silent ischemia by DSE in high-risk diabetic patients. 21 patients with long-standing (>10 years) and/or complicated type II DM but no established CAD were included. In addition to DSE, venous blood samples for measurement of hs-cTnT and were collected prior to DSE, 6H and 24 hours after the test. Troponins were deemed positive if >1.5 upper limit for normality. Patients with positive troponins underwent coronary angiography or CT scan regardless of the result of DSE. Among the 21 patients, 7 had positive troponins measured 6 hours after stress, (mean peak troponin=44.5). DSE were negative in all of them. Mean age was 64 years significantly higher than patients with negative troponins. No differences were noted between the groups in terms of epidemiological, clinical or echocardiographic characteristics. Patients with positive cardiac troponins were evaluated for the presence of coronary lesions but none of them had significant disease. After a 18 month mean follow-up, no adverse cardiac events were noted in either groups. In high risk diabetic patients, the measurement of hs-cTnT during DSE does not improve the sensitivity at least in those with negative DSE tests