High Calcium Score Research Articles

Abstract 4117834: Utility of Abdominal Aortic Calcification Assessment for the Prediction of Major Adverse Cardiovascular Events in Liver Transplant Patients

Background: Cardiovascular disease is a leading cause of postoperative morbidity and mortality following liver transplantation (LT). Presence of abdominal aortic calcification (AAC) has been linked to cardiovascular events in the general population. We investigated whether AAC on pre-transplant computed tomography (CT) predicts major adverse cardiovascular events (MACE) post-LT. Methods: Consecutive LT patients between 2010-2018 from the Victorian Liver Transplant Unit (Australia) were included. Extent of AAC was quantified in a blinded fashion, with high AAC defined as a calcium score of ≥500. MACE was defined as any recorded episodes of acute coronary syndrome (ACS), ventricular arrhythmia, decompensated heart failure, or stroke. The primary outcome was post-LT MACE at 30 days and the secondary outcome was all-cause mortality at maximal follow-up. Results: Of 461 patients undergoing LT, 350 had suitable CTs for analysis, of which 90 (25.7%) had also undergone CT coronary angiography. High AAC was identified in 98 patients (28.0%). This finding demonstrated a moderate correlation with high coronary artery calcium score (CACS) ≥400 (r=0.52, p<0.001). Fifty-eight MACE occurred in 42 patients (12.0%) within 30-days. High AAC was associated with increased risk of 30-day MACE (OR=2.68 (95%CI 1.39-5.17), p=0.004), and long-term mortality (HR=2.52 (95%CI 1.29-4.92), p=0.007) at a median follow-up of 4.0 years. In addition, high AAC predicted an increased risk of ACS (OR 3.80 (95%CI 1.18-12.27), p=0.025), heart failure (OR 3.07 (95%CI 1.21-7.80), p=0.020) and atrial fibrillation (OR 2.04 (95%CI 1.02-4.07), p=0.048), with a trend to increased prevalence of ventricular arrhythmia (OR 2.67 (95%CI 0.84-8.50), p=0.10). Following multivariate analysis, high AAC remained a strong independent predictor of MACE (OR=3.49, 95%CI 1.21-10.06, p=0.021). Addition of AAC to the revised cardiac risk index (RCRI) improved model fit for predicting MACE (net reclassification improvement of 52.7% (p<0.001)). Conclusions: This study demonstrates for the first time that high AAC on routine abdominal CT scans is associated with a 3-fold increased risk of 30-day MACE post-LT, and improves cardiovascular risk prediction compared to traditional risk scores. Quantification of AAC may offer a simple method of improving cardiovascular risk assessment and implementation of preventative strategies in liver transplant patients, using pre-existing scans without additional cost or patient risk.

Improved quantification of coronary stenosis in patients with high calcium scores using spectral reconstructions in coronary CT angiography

Abstract Background Coronary CT angiography has demonstrated reduced accuracy in patients with high calcium scores due to blooming artifacts, often resulting in overestimated stenosis. Purpose This study aimed to assess the impact of spectral reconstructions on coronary stenosis quantification in patients with high calcium scores (>500), utilizing invasive coronary angiography as the gold standard. Methods Twenty consecutive patients referred for coronary artery disease assessment underwent both coronary CT angiography and invasivecoronary angiography. Conventional 120 kV images, 100 keV virtual monoenergetic images, and iodine-no-water images were reconstructed. Two blinded operators independently reviewed the images. Lesions were qualitatively classified in both CCTA and invasive angiography as stenosis of 1-24%, 25-49%, 50-70%, and >70%. Results A total of 87 plaques were evaluated. Mean age was 72 years (SD=7.7) and 79% were male. Pre-test probability were low, medium and high in 15.8, 26.3% and 57.9% of patients respectively. Mean calcium score was 1662, with an average dose of 7.5 mSv (67.9% retrospective studies). Nitrates were administered in 89.5% of patients, and 47.4% received intravenous beta-blockers. Sensitivity, specificity, positive predictive value, and negative predictive value to detect lesions > 50% improved from 94%, 57%, 38%, 97% with conventional images to 94%, 82%, 59%, 98% with 100 keV virtual monoenergetic images. Conclusion Spectral reconstructions significantly enhance diagnostic accuracy in coronary CT angiography of severely calcified coronary arteries.

Age stratified differences in coronary artery plaque phenotype in women and men with non-obstructive coronary artery disease

Abstract Background Development of coronary artery disease (CAD) and risk of acute cardiac events differ between women and men during the life span. The aim of this study was therefore to characterize sex differences in coronary artery plaque phenotype among patients with symptomatic non-obstructive CAD in different age groups. Methods Advanced coronary artery plaque phenotyping by coronary computed tomography angiography was performed in 606 patients (31% women) with symptomatic non-obstructive CAD from the Norwegian Registry of Invasive Cardiology. A 1:1 sex-matched study design ensured equal distribution of the sexes in the different age groups. We assessed total plaque burden adjusted for vessel volume and plaque composition consisting of dense calcium, fibrous, fibro-fatty, and necrotic core. Patients were further stratified into age groups of ≤50, 51-64, and ≥65 years to explore the relationship between age and sex on coronary artery plaque phenotype. Results In the study population, patients ≥65 years had a higher prevalence of hypertension, higher calcium score, coronary artery segment involvement score and total plaque burden, whereas the prevalence of obesity was lower compared to patients aged 51-64 and ≤50 years (all p<0.05). The prevalence of smoking, diabetes and statin treatment was similar between groups. A two-way analysis of variance demonstrated an interaction between sex and age group on total plaque burden (F [2, 600] =3.431, p=0.33), where women aged 51-64 and ≥65 years had a higher total plaque burden compared to men (p=0.002 and p<0.001, respectively, Figure 1). Plaque composition in women ≥65 years was characterized by an increased proportion of stable dense calcified plaques compared to men and younger women (all p<0.05), whereas men ≥65 years had a higher proportion of vulnerable necrotic core plaque phenotype (p<0.001). Women showed consistently lower proportions of more vulnerable fibro-fatty plaques compared to men across all age groups (all p<0.05, Figure 2). Conclusions In non-obstructive CAD, higher total plaque burden was associated with older age and female sex. Women had a lower proportion of vulnerable fibro-fatty plaques across all age groups and a higher proportion of stable dense calcified plaques at an older age compared to men. Future longitudinal studies on coronary artery plaque phenotype during the life span will increase the understanding of sex differences in CAD development and may contribute to customise risk stratification in women and men.Figure 1.Total plaque burdenFigure 2.Compositional plaque burden

Impact of ultra-high-resolution on cardiac CT assessment of coronary artery stenoses, plaque burden/composition, and pericoronary adipose tissue attenuation

Abstract Background Conventional coronary computed tomography angiography (CCTA) overestimates stenoses within stents and calcified arteries due to "blooming" artifacts. Ultra-high-resolution coronary CT (UHR-CT) may overcome this limitation because of higher spatial resolution. Purpose To investigate differences in coronary arterial lumen volume, stenosis severity, and plaque composition, between CCTA and UHRCT in patients with stents and/or high coronary calcium scores. Methods As part of a prospective pilot study, 14 patients referred for invasive coronary angiography for evaluation of obstructive CAD underwent UHRCT (Canon Precision, 160 x 0.25mm slices) prior to catheterization. Images of identical cardiac phases were reconstructed in two badges for comparison: 1) Ultra-high resolution using a 1,024 x 1,024 matrix, 0.25 mm, and 2) conventional resolution with a 524 x 524 matrix, 0.5 mm. All images were reconstructed using iterative reconstruction algorithm (AIDR 3D) and a sharp kernel (FC05). For the left main and three coronary arteries, an automated contour analysis using a dedicated software (QAngioCT RE 3.2, Medis, Netherlands) was performed to compare conventional CCTA vs. UHR-CT resolution images across common vascular and plaque metrics, including lumen and vessel volume, plaque burden/volume, plaque composition based upon predefined fixed intensity cut-off values of CT attenuation, minimal and maximal plaque thickness, pericoronary adipose tissue attenuation (PCAT), minimal lumen area and diameter, and diameter stenosis. All lumen and vessel contours were generated by the software, without manual editing. The segment model proposed by the SCCT was used as reference and the lesions classified as greater than 25% stenosis by visual assessment were recorded. The quality of the images was subjectively assessed using a 5-point Likert scale. Vessel segments with scores 1 (severe artifacts) and 2 (pronounced artifacts) were not included in the analysis. Results The mean patient age was 68.5 years (±6.8), 2 were female (14.3%), 6 patients had stents (11 stented segments) and the mean Agatston score was 947.6 (±449) among the 8 non-stented patients. A total of 56 vessels, 133 segments, and 57 lesions were analyzed. Eight segments (6%) were excluded from the analysis due to poor quality. Results on a per segment and per lesion basis were summarized in the table. The mean PCAT value was significantly lower for the UHRCT images compared to NR reconstruction in both segment (p<0.001) and lesion based (p=0.002) analyses. Plaque differentiation varied by UHRCT resulted in a lower fibrous plaque volumes but higher necrotic (low attenuation) plaque volumes. Conclusions Ultra-high-resolution CT image analysis results in significantly different coronary artery plaque volume and PCAT assessment vs. conventional resolution CCTA. These findings have implications for evaluating high-risk plaque features and perivascular inflammation in patients.Table 1

The impact of novel scoring balloon and cutting balloon after orbital atherectomy on severely calcified coronary lesion as assessed by optical coherence tomography.

Debulking devices are often followed by a scoring or cutting balloon in percutaneous coronary intervention (PCI) for severely calcified lesions. However, there are limited data on balloon preparation after orbital atherectomy (OA) assessed using optical coherence tomography (OCT). We aimed to compare the effects of a novel scoring and cutting balloon on calcified coronary lesions with OCT. We retrospectively examined 38 patients (38 lesions) who underwent PCI with a scoring or a cutting balloon after OA. All patients underwent pre-PCI, preballooning, postballooning, and post-PCI OCT imaging. We divided the patients into novel scoring-balloon (group A: n = 22) and cutting-balloon (group B: n = 16) groups and compared the OCT findings, including minimum lumen area (MLA) and expansion ratio (MLA divided by mean reference lumen area). The mean patient age was 76.1 ± 8.7 years; 71.5% were male. There were no significant differences in patient background between both groups. Regarding procedural characteristics, the maximum balloon pressure was significantly higher in group A (median 23 atm, interquartile range [IQR] 18-24 vs. 12 atm [IQR: 10-12], p < 0.01). Although a calcium score of 4 was more frequently observed in group A (86.4% vs. 62.5%, p = 0.12), post-PCI MLA was comparable between both groups (3.95 mm2 [IQR: 3.27-4.41] vs. 3.43 mm2 [IQR: 2.90-4.82], p = 0.63). Furthermore, the expansion ratio was significantly greater in group A (0.83 ± 0.20 vs. 0.68 ± 0.14, p < 0.01). Despite a higher calcium score, a larger expansion ratio was achieved in patients with a novel scoring balloon than in those with a cutting balloon after OA.

Correlation Between Calcium Scoring and Abdominal Aortic Aneurysm Endovascular Repair Outcomes.

Endovascular aneurysm repair, though minimally invasive and has the benefit of relatively low perioperative complication rates, it is associated with significant long term reintervention rates related to endoleaks. Several variables have been studied to predict the outcomes of endovascular aneurysm repair, 1 of which is the calcium burden of the vasculature. This prompted us to study the association between calcium burden measured by the standardized Agatston scoring system and the outcomes of Endovascular aneurysm repair. This is a retrospective study of patients who underwent Endovascular aneurysm repair from 2008 to 2020 at our institution and who had a non-contrast computerized tomography scan preoperatively, accounting for 87 patients. The calcium burden of the vasculature was measured by the Agatston scoring system allowing for better reproducibility, and the outcome variables included mortality and endoleaks. Patients with higher median total calcium scores (≥12966.9) had significantly lesser survival (79.8% vs 52.3% (P = .002) at five years compared to patients with lower median total calcium score (<12966.9). Also, patients with type 2 endoleaks had higher calcium scores in above the aneurysm level ((1591.2 vs 688.2), P = .05)) compared to patients with no type 2 endoleaks. Calcium score assigned using a standardized Agatston scoring system can be used as a predictor of mortality risk assisting in deciding the treatment of choice for patients.

Disproportionately high aortic valve calcium scores in atrial fibrillation: implications for transcatheter aortic valve replacement.

Doppler mean gradient (MG) can underestimate aortic stenosis (AS) severity in patients with atrial fibrillation (AF) compared with patients with sinus rhythm (SR), potentially delaying intervention in AF. This study compared outcomes in patients with AF and SR following transcatheter aortic valve replacement (TAVR) and investigated delay in TAVR based on computed tomography aortic valve calcium score (AVCS). Patients who underwent TAVR from 2013 to 2017 for native valve severe AS were identified from an institutional database. Baseline characteristics and overall survival were compared between those with SR and AF. There were 820 patients (mean age 81 years; 41.6% females) included in this study. AF was present in 356 patients. Patients with AF were older (82.2 vs. 80.5, P = 0.003) and had a lower MG compared with patients with SR (42.0 vs. 44.9, P = 0.002) with similar indexed aortic valve area (0.4 vs. 0.4, P = 0.17). Median AVCS was higher in AF (males: AF 2850.0 vs. SR 2561.0, P = 0.044; females: AF 1942.0 vs. SR 1610.5, P = 0.025). Projected AVCS, assuming the same age of diagnosis, was similar between AF and SR. Median survival post-TAVR was worse in AF compared with SR (3.2 vs. 5.4 years, log rank P < 0.001). AF, lower MG, higher right ventricular systolic pressure, dialysis, diabetes, and significant tricuspid regurgitation were associated with higher mortality (P < 0.05 for all). Older age and higher AVCS in patients with AF compared with those with SR suggest that AS was both underestimated and more advanced at TAVR referral.

Influence of graft anastomosis and graft morphology on long-term patency of the saphenous vein after aortocoronary bypass.

Several factors are involved in the preservation of graft function after surgical myocardial revascularization. This follow-up study aimed to evaluate the effects of vein graft anastomosis and graft morphology on long-term graft patency a minimum of 10 years after aortocoronary bypass grafting.Setting and Cohorts. This was a sub-analysis of a study that enrolled patients after isolated bypass surgery at the University Hospital Ostrava in order to evaluate the long-term graft patency of the saphenous vein after endoscopic harvest, a minimum of 10 years after aortocoronary bypass grafting. Fifty angiograms, with a total of 90 grafts, after isolated myocardial revascularization were visualized using coronary computed tomography angiography, with 50% luminal stenosis or greater considered significant. The overall graft patency rate was 72.3%. The differences in occlusion rates between sequential and individual grafts were not statistically significant (P=0.156). All y-grafts were totally occluded. Graft and target artery diameters had a statistically significant influence on patency (P=1.000 and 0.381, respectively). Longer graft length and higher calcium scores were associated with statistically significant graft occlusion (P=0.033 and 0.005, respectively). Sequential grafts can be constructed safely, especially when the goal is complete myocardial revascularization.

Prosthesis Infolding Incidence and Short-Term Outcomes in Transcatheter Aortic Valve Implantation Using Evolut Self-Expandable Device: A Multicenter Study

Transcatheter aortic valve implantation (TAVI) is an established treatment strategy in aortic valve disease. Infolding, as a nonuniform expansion of the prosthesis leading to introflection of part of the device circumference, is a complication specific to self-expandable prostheses. The aim of the study is to determine incidence, predictors, treatment strategy, and outcomes of infolding during Medtronic Evolut TAVI (Minneapolis, MN, US). Between January 2018 and March 2022, all patients treated with Evolut TAVI were included in a multicenter observational retrospective study. According to the occurrence of infolding, the enrolled cohort was divided into 2 groups; periprocedural characteristics and 30-day outcomes were compared. A total of 1,470 patients were included; 23 infolding cases (1.6%) were detected. Preprocedural imaging showed larger aortic anatomy and greater calcium burden in the infolding group. Infolding occurred mostly with Evolut Pro+ and size 34 mm and was diagnosed before full prosthesis release in 78.3%. The rate of moderate-to-severe paravalvular regurgitation was higher in the infolding group (21.7% vs 1.9%, p <0.001). Short-term follow-up showed greater all-cause and cardiovascular mortality (respectively, 4.3% vs 0.7% and 4.3% vs 0.6%, p <0.05) and higher rate of pacemaker implantation (33.3% vs 15.7%, p = 0.042) in case of infolding. High right cusp calcium score and resheathing maneuvers were independent predictors of infolding. In conclusion, prosthesis infolding is a TAVI complication burdened by worse cardiovascular outcomes. Prompt intraprocedural infolding diagnosis is pivotal, especially in case of great native valve calcium burden and resheathing maneuvers, to safely overcome this complication by prosthesis recapture or postdilation.

Relevance of BEST-CLI trial endpoints in a tertiary care limb preservation program

ObjectiveMajor adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial represented a highly selected subgroup of patients seen in clinical practice; thus, we examined the endpoint of MALE-FS in an all-comers tertiary care practice setting. MethodsThis is a single-center retrospective study of consecutive, unique patients who underwent technically successful infrainguinal revascularization for chronic limb-threatening ischemia (2011-2021). MALE was major amputation (transtibial or above) or major reintervention (new bypass, open bypass revision, thrombectomy, or thrombolysis). ResultsAmong 469 subjects, the mean age was 70 years, and 34% were female. Characteristics included diabetes (68%), end-stage renal disease (ESRD) (16%), Wound, Ischemia, and foot Infection (WIfI) stage 4 (44%), Global Limb Anatomic Staging System (GLASS) stage 3 (62%), and high pedal artery calcium score (pMAC) (22%). Index revascularization was autogenous vein bypass (AVB) (30%), non-autogenous bypass (NAB) (13%), or endovascular (ENDO) (57%). The composite endpoint of MALE or death occurred in 237 patients (51%) at a median time of 189 days from index revascularization. In an adjusted Cox model, factors independently associated with MALE or death included younger age, ESRD, WIfI stage 4, higher GLASS stage, and moderate-severe pMAC, whereas AVB was associated with improved MALE-FS. Freedom from MALE-FS, MALE, and major amputation at 30 days were 90%, 92%, and 95%; and at 1 year were 63%, 70%, and 83%, respectively. MALE occurred in 144 patients (31%) and was associated with ESRD, WIfI stage, GLASS stage, pMAC score, and index revascularization approach. AVB had superior durability, with adjusted 2-year freedom from MALE of 72%, compared with 66% for ENDO and 51% for NAB. Within the AVB group, spliced vein conduit had higher MALE compared with single-segment vein (hazard ratio, 1.8; 95% confidence interval, 0.9-3.7; P = .008 after inverse propensity weighting), but there was no statistically significant difference in major amputation. Of the 144 patients with any MALE, the first MALE was major reintervention in 47% and major amputation in 53%. Major amputation as first MALE was associated with non-AVB index approach. Indications for major reintervention were symptomatic stenosis/occlusion (54%), lack of clinical improvement (28%), asymptomatic graft stenosis (16%), and iatrogenic events (3%). Conversion to bypass occurred after 6% of ENDO cases, two-thirds of which involved distal bypass targets at the ankle or foot. ConclusionsIn this consecutive, all-comers cohort, disease complexity was associated with procedural selection and MALE-FS. AVB independently provided the greatest MALE-FS and freedom from MALE and major amputation. Compared with the BEST-CLI randomized trial, MALE after ENDO in this series was more frequently major amputation, with relatively few conversions to open bypass.

The Value of Coronary Computed Tomography Angiography in Patients with a High Calcium Score.

We aimed to assess the agreement between coronary computed tomography angiography (CCTA) and invasive coronary angiography (ICA) to determine whether patients with a high coronary artery calcium score (CS) would benefit from CCTA. This cross-sectional study was conducted on patients suspected of having coronary artery disease. The patients underwent calcium scoring. The total CS and the number of calcified foci were determined. The calcium score index (CSI) was defined, and coronary arteries were evaluated by CCTA. ICA was performed, and reports of ICA were extracted. All the abovementioned variables were compared. For data analysis, the κ coefficient and the ROC curve were used. The study population consisted of 195 patients: 124 men (63.6%) and 71 women (36.4%). The median (IQR) value of CS was 529 (229-1042), ranging from 17 to 4717. In all 195 patients, the concordance between the final impression of CCTA and ICA was 90.2%, while the number and type of involved territories were similar at 57.9%. The highest agreement was seen in the left main and right coronary arteries, whereas the lowest agreement was detected in the left anterior descending and the left circumflex artery. The patients were categorized into different CS groups, and in those with a high CS (>1000), the agreement between CCTA and ICA concerning final impression and involved territories was similar to the whole group of patients. CCTA in patients with a high CS, even exceeding 1000, remains beneficial as the noninvasive available method.

Association of Segment-Specific Pulse Wave Velocity With Vascular Calcification: The ARIC (Atherosclerosis Risk in Communities) Study.

Pulse wave velocity (PWV) is a noninvasive measure of arterial stiffness and predictor of cardiovascular disease. However, the association between PWV and vascular calcification across different vascular beds has not been fully investigated. This study aimed to quantify the association between PWV and multiterritory calcification and to explore whether PWV can identify individuals with vascular calcification beyond traditional risk factors. Among 1351 older adults (mean age, 79.2 years [SD, 4.1]) from the ARIC (Atherosclerosis Risk in Communities) study, we measured segment-specific PWVs: heart-carotid, heart-femoral, carotid-femoral, heart-ankle, brachial-ankle, and femoral-ankle. Dependent variables were high calcium score (≥75th percentile of Agatston score) across different vascular beds: coronary arteries, aortic valve ring, aortic valve, mitral valve, ascending aorta, and descending aorta. Quartiles of carotid-femoral, heart-femoral, heart-ankle, and brachial-ankle PWV were significantly associated with coronary artery calcium (eg, adjusted odds ratio [OR] for the highest versus lowest quartile of carotid-femoral PWV, 1.84 [95% CI, 1.24-2.74]). Overall, PWVs were most strongly associated with descending aorta calcification, with significant results for carotid-femoral, heart-femoral, heart-ankle, and brachial-ankle PWV (eg, adjusted OR for the highest versus lowest quartile of carotid-femoral PWV, 3.99 [95% CI, 2.61-6.17]). In contrast, femoral-ankle PWV was inversely associated with descending aorta calcification. Some PWVs improved the discrimination of coronary artery calcium and descending aorta calcification beyond traditional risk factors. The associations of PWV with vascular calcification varied substantially across segments, with descending aorta calcification most closely linked to PWVs. Our study suggests that some PWVs, especially carotid-femoral PWV, are helpful to identify individuals with coronary artery calcium and descending aorta calcification.

Assessment of Coronary Stenosis Using Coronary CT Angiography in Patients with High Calcium Scores: Current Limitations and Future Perspectives

Coronary CT angiography (CCTA) is recognized for its role as a gatekeeper for invasive coronary angiography in patients suspected of coronary artery disease because it can detect significant coronary stenosis with high accuracy. However, heavy plaque in the coronary artery makes it difficult to visualize the lumen, which can lead to errors in the interpretation of the CCTA results. This is primarily due to the limited spatial resolution of CT scanners, resulting in blooming artifacts caused by calcium. However, coronary stenosis with high calcium scores often requires evaluation using CCTA. Technological methods to overcome these limitations include the introduction of high-resolution CT scanners, the development of reconstruction techniques, and the subtraction technique. Methods to improve reading ability, such as the setting of appropriate window width and height, and evaluation of the position of calcified plaque and residual visibility of the lumen in cross-sectional images, are also recommended.

A High Coronary Calcium Score And Increased Epicardial Fat Assessed By Ccta Are Associated With Atrial Fibrillation Recurrence Following Catheter Ablation

A High Coronary Calcium Score And Increased Epicardial Fat Assessed By Ccta Are Associated With Atrial Fibrillation Recurrence Following Catheter Ablation

Contemporary experience with the Commando procedure for anterior mitral anular calcification

ObjectiveAnterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements. MethodsFrom January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs). ResultsBetween balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47). ConclusionsThe Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.

Prediction of high coronary artery calcium (CAC) scores from aortic arch calcification: An efficient tool for selection of non-optimal candidates for coronary CTA?

PurposeOverutilization of healthcare resources is causing a high socioeconomic burden. Patients with high coronary artery calcium (CAC) scores > 1000AU are not optimal candidates for coronary CTA and better suited for other diagnostic strategies. Therefore, our objective was to evaluate whether a 4-scale aortic arch calcification severity (AoArCa) score from CT and X-Ray predicts high-CAC scores. MethodsPatients referred to coronary/aortic CT-Angiography were enrolled. The severity of aortic arch calcification (AoArCa) was scored as grade: 0 = absent, 1 = minimal (<25 % of circumference), 2 = mild (25–50 %), 3 = moderate (50–75 %) and 4 = severe (75–100 %) on both thoracic CT and X-ray. ResultsIn 130 patients, the absence of AoArCa by CT was highly accurate to rule out CAC > 1000AU (sens. 100 %). No or minimal AoArCa had a high NPV of 95.6 % to rule out CAC > 1000 and grade 0,1 + 2 a NPV of 86.96 %.The AUC of AoArCa by CT for predicting high CAC > 1000 was c = 0.84 (p < 0.001; 95 %CI: 0.771––0.91). For moderate-to-severe AoArCa, accuracy was c = 0.792 (p < 0.001).The intermodality agreement between CT and X-Ray based AoArCa Scores was good (r = 0.824, p < 0.001); ICC = 0.902. For X-ray, AUC was c = 0.715 to predict CAC > 1000 (p < 0.001).In regression models, only moderate-or-severe AoArCa, but not the other CVRF predicted CAC > 1000 (p < 0.001), and there was an association of the number of CVRF. ConclusionsPatients with moderate-to-severe aortic arch calcification have a high probability of CAC > 1000AU, but not those with no, minimal and mild. The absence of AoArCa rules out CAC > 1000AU. AoArCa severity may serve as valuable tool for selecting the diagnostic strategy.

In 2023 PET myocardial perfusion imaging is preferred to invasive coronary angiography for the initial work-up of a symptomatic patient with a high coronary artery calcium score.

In 2023 PET myocardial perfusion imaging is preferred to invasive coronary angiography for the initial work-up of a symptomatic patient with a high coronary artery calcium score.

Lipid core burden in relation to the severity of calcium burden assessed by computed tomographic coronary angiography in patients with chronic coronary syndrome

Abstract Background Coronary calcium scores (CACS) obtained by computed tomographic coronary angiography (CTCA) enables a noninvasive assessment of coronary calcium burden both in a single vessel and in whole coronary tree. Although higher CACS in coronary tree is known as an atherosclerotic cardiovascular disease risk marker, coronary calcification is also known as a sign of plaque stabilization. Exploring the relationship between coronary calcification and lipid core burden may help understanding a role of calcium in coronary tree. Purpose We aimed to examine the relevance of lipid components assessed by near-infrared spectroscopy (NIRS) in accordance with different degrees of CACS assessed by preprocedural CTCA imaging. Methods We investigated consecutive patients who underwent elective percutaneous coronary intervention (PCI) and pre-PCI CTCA imaged within 3 months before PCI. Patients who had stents in target vessels and who required plaque modification before NIRS imaging were excluded. Target vessels were divided into tertiles based on target vessel CACS (CACSv) and total amount of 3-vessel CACS (CACSt), respectively. Lipid components of the target vessel were evaluated by maximum lipid core burden index in 4mm (maxLCBI4mm). MaxLCBI4mm was compared among the tertiles of CACSv and CACSt. Results A total of 95 target vessels in 95 patients were evaluated for the final dataset. CACSv categories were defined as follows: 1st tertile (CACSv &amp;lt;66), 2nd tertile (CACSv &amp;gt;66 and &amp;lt;250), and 3rd tertile (CACSv &amp;gt;250). CACSt categories were defined as showing CACSt &amp;lt;190 (1st tertile), CACSt &amp;gt;190 and &amp;lt;700 (2nd tertile), and CACSt &amp;gt;700 (3rd tertile). MaxLCBI4mm increased in proportion to an extent of CACv tertiles (306 [129-463], 280 [125-460], and 444 [345-587], Ptrend &amp;lt;0.01) and an extent of CACt tertiles (265 [99-488], 356 [202-458], and 448 [318-574], Ptrend &amp;lt;0.01). Conclusions In patients who underwent elective PCI, higher maxLCBI4mm in the PCI target vessel was associated with both higher CACS in the target vessel and total amount of 3-vessel CACS.

Effectiveness of Cerebral Embolic Protection in Transcatheter Aortic Valve Replacement with High Aortic Valve Calcium Burden

Abstract Background The use of a cerebral embolic protection device (CEPD) during transcatheter aortic valve replacement (TAVR) has not been shown to be effective in preventing stroke in the PROTECTED-TAVR randomized controlled trial. However, whether CEPD may specifically benefit patients with high aortic valve calcium burden has not been studied. Purpose This study aimed to determine the effectiveness of CEPD in preventing cerebrovascular events during TAVR in patients with high aortic valve calcium scores (AVCS) (&amp;gt;2000 AU in men and &amp;gt;1300 AU in women) detected on baseline computed tomography. Methods We retrospectively analyzed 3505 patients who underwent transfemoral TAVR at a single center between 2016-2020 (Figure 1a). Baseline demographic, clinical, and procedural characteristics were stratified by CEPD use and AVCS (high vs. low). We performed Cox Proportional Hazards regression analysis to examine whether the use of CEPD in patients with high AVCS was associated with a lower rate of cerebrovascular events (stroke or transient ischemic attack) within 30 days (primary outcome) after adjusting for baseline characteristics. Results We stratified our study cohort into four subgroups: low AVCS without CEPD (n=1163), low AVCS with CEPD (n=633), high AVCS without CEPD (n=1081), and high AVCS with CEPD (n=628). Patients for whom CEPD was used in high AVCS group had lower prevalence of peripheral arterial disease compared with no CEPD use. Otherwise, there were no significant differences in the baseline characteristics between patients with and without CEPD in either the low or high AVCS subgroups (Table). In adjusted analysis, CEPD use (HR 1.30 [95% CI, 0.64-2.65)] or high AVCS (HR 1.16 [95% CI, 0.64-2.02)] were not associated with a decreased rate of primary outcome (Figure 1b). Conclusion This study indicates that CEPD use is not associated with lower cerebrovascular events after TAVR, even in patients with a high aortic valve calcium burden. Further research is needed to identify effective stroke prevention strategies for this patient population.Study design and Cox regression analysesBaseline Characteristics and Outcomes

Computed tomographic predictors of a lipid-rich plaque identified by near-infrared spectroscopy

Abstract Background In a phase of primary prevention, individuals with high coronary calcium scores (CACS) assessed by computed tomographic coronary angiography (CTCA) are known to be associated with higher risk of atherosclerotic cardiovascular disease. However, clinical significance of CACS in patients requiring revascularization and its relevance to lipid core burden remains unknown. Purpose This study aimed to examine the relationship between lipid components assessed by near-infrared spectroscopy (NIRS) and coronary artery calcium score (CACS) assessed by preprocedural CTCA imaging. We also aimed to investigate CTCA-derived predictors of target vessels with high lipid core burden. Methods Consecutive patients who underwent preprocedural CTCA imaged within 3 months before elective NIRS-intravascular ultrasound-guided percutaneous coronary intervention (PCI) for de novo lesions in 1 coronary artery were included. Patients who had undergone stent deployment before inclusion were excluded. Target vessels requiring lesion modification such as balloon inflation or debulking before NIRS imaging were also excluded. Lipid rich plaque (LRP) was defined as a target lesion with maximum LCBI in 4 mm (maxLCBI4mm) &amp;gt;500. Clinical demographics, angiographic, and CTCA-derived morphological findings were compared between target vessels with and without LRP. Results A total of 95 target vessels in 95 patients were evaluated for the final dataset. NIRS identified 25 LRP and 70 non-LRP. Clinical demographics and angiographic findings showed no significant differences between vessels with versus without LRP. On CTCA, prevalence of high-risk plaque (HRP) that contains two or more of napkin-ring sign, positive remodeling, low attenuation plaque and spotty calcification at the target vessel was significantly higher in LRP group (56.0 % vs. 25.7 %, P=0.01). Target vessel CACS and total amount of 3-vessel CACS tended to be higher in patients with LRP than those without LRP (282 [124-479] vs. 114 [25-248], P=0.01; 882 [233-1501] vs. 308 [99-753], P=0.01, respectively). Multivariate logistic regression analyses to predict LRP at the target vessel revealed that the presence of HRP (odds ratio [OR] 3.52, 95% confidence interval [CI] 1.28-9.69, P=0.01) and higher 3-vessel CACS (per 100, OR 1.09, 95% CI 1.03-1.16, P &amp;lt;0.01) were independently predictive of LRP. Conclusions Preprocedural CTCA-derived high-risk plaque and total amount of 3-vessel CACS were independent predictors of LRP defined by NIRS.