Mild Calcification Research Articles

TCT-629 Balloon-Expandable Transcatheter Aortic Valve Replacement in Patients with Severe Aortic Stenosis and Mild Aortic Valve Calcification

TCT-629 Balloon-Expandable Transcatheter Aortic Valve Replacement in Patients with Severe Aortic Stenosis and Mild Aortic Valve Calcification

Risk Evaluation of Immediate Surgical Failure During Thigh Hemodialysis Graft Placement by Sonographic Screening.

The purpose of this study was to determine whether preoperative sonographic evaluation of vascular diameters and calcification identifies patients at risk for immediate technical failure of thigh hemodialysis grafts. A retrospective analysis of 143 chronic hemodialysis patients who underwent thigh graft placement was performed. All patients underwent preoperative sonography to assess arterial and venous waveforms and vascular diameters. The degree of arterial calcification was assessed retrospectively. Patient characteristics and graft outcomes were examined. Statistical analyses were performed, with P< .05 considered clinically significant. Sonography identified no or mild arterial calcification in 113 of 143 patients (79%) and moderate to severe calcification in 30 of 143 patients (21%). Primary surgical technical failure occurred in 23% of patients (7 of 30) with moderate to severe calcification, compared to 3.5% (4 of 113) of those with no or mild calcification (hazard ratio, 6.59; 95% confidence interval, 2.06-21.05; P = .002). Cumulative graft survival (time to permanent failure) was shorter in patients with moderate to severe arterial calcification (3-year graft survival, 37% versus 56%; hazard ratio, 2.32; 95% confidence interval, 1.48-6.69; P= .003) but was not significantly associated with venous (P= .82) or arterial (P = .43) diameters. Preoperative sonographic assessment of thigh vessel diameters and calcification can identify patients who may be at risk for immediate technical graft failure and decreased cumulative graft survival. The use of sonography as a screening examination may improve preoperative assessment and surgical planning of hemodialysis thigh grafts.

Perturbations in fatty acid metabolism and apoptosis are manifested in calcific coronary artery disease: An exploratory lipidomic study

BackgroundControversy exists concerning the beneficial or harmful effects of the presence of ectopic calcification in the coronary arteries. Additionally, further elucidation of the exact pathophysiological mechanism is needed. In this study, we sought to identify metabolic markers of vascular calcification that could assist in understanding the disease, monitoring its progress and generating hypotheses describing its pathophysiology. MethodsUntargeted lipid profiling and complementary modeling strategies were employed to compare serum samples from patients with different levels of calcific coronary artery disease (CCAD) based on their calcium score (CS). Subsequently, patients were divided into three groups: no calcification (NC; CS=0; n=26), mild calcification (MC; CS:1–250; n=27) and severe (SC; CS>250; n=17). ResultsPhosphatidylcholine levels were found to be significantly altered in the disease states (p=0.001–0.04). Specifically, 18-carbon fatty acyl chain (FAC) phosphatidylcholines were detected in lower levels in the SC group, while 20:4 FAC lipid species were detected in higher concentrations. A statistical trend was observed with phosphatidylcholine lipids in the MC group, showing the same tendency as with the SC group. We also observed several sphingomyelin signals present at lower intensities in SC when compared with NC or MC groups (p=0.000001–0.01). ConclusionsThis is the first lipid profiling study reported in CCAD. Our data demonstrate dysregulations of phosphatidylcholine lipid species, which suggest perturbations in fatty acid elongation/desaturation. The altered levels of the 18-carbon and 20:4 FAC lipids may be indicative of disturbed inflammation homeostasis. The marked sphingomyelin dysregulation in SC is consistent with profound apoptosis as a potential mechanism of CCAD.

Is radial artery Doppler scanning mandatory for use as coronary bypass conduit?

Screening of the radial artery prior to harvesting as a conduit for coronary bypass may be performed clinically by the Allen test or by Doppler ultrasound. In a developing country like ours, the use of resources for Doppler studies may be questioned when Allen tests lead to a low rate of clinical sequelae. However, the rare occurrence of hand ischemia may be devastating and could justify the routine use of Doppler screening. This study aimed to address this question. One hundred patients undergoing elective coronary artery bypass grafting were screened by the modified Allen test and Doppler ultrasound for suitability of use of a radial artery conduit. After harvesting, proximal and distal segments of the radial artery were subjected to histopathological examination. Of the 95 patients deemed suitable for radial artery grafting, 6 had mild calcification on Doppler ultrasound and 9 had calcification on histopathological examination. While Doppler showed atherosclerosis in 9 patients, only 6 had histopathological evidence of this (false-positive rate 3%). Of the 6 patients with histopathologic evidence of atherosclerosis, 2 were negative on Doppler (false-negative rate 2%). Routine preoperative Doppler screening of the radial artery in the setting of limited resources is not justified. On the other hand, the time-tested Allen test which is easy to perform, interpret, and reproduce can be safely used as the sole screening test to harvest the radial artery.

Impact of Vascular Calcifications on Arteriovenous Fistula Survival in Hemodialysis Patients: A Five-Year Follow-Up

Background/Aims: Vascular calcifications are frequently found among dialysis patients, and the calcification process may influence the patient's outcome. The aim of the present study was to determine the role that vascular calcifications may have on autologous arteriovenous fistula (AVF) survival. Methods: This study included 90 patients (49 males, mean age 62 ± 11) with a native AVF treated by chronic hemodialysis (HD) for more than one year. The overall vascular calcification scores ranged from 0-11 (Adragao score + vascular access calcification score); patients were categorized into mild (score 0-3; n = 36), moderate (score 4-7; n = 24) and severe (score 8-11; n = 30) calcification groups. AVF survival was then followed for 5 years after calcification measurement or until the patient's death/transplantation. Results: Patients with more pronounced vascular calcifications were more frequently diabetic and male. Multiple linear regression analysis showed a significant relationship between calcification score and male gender, diabetes mellitus, previous duration of AVF, low dialysis flow rate and intact parathormone (iPTH) values. After multivariate adjustment for basal differences, Cox proportional analysis revealed a graded impact of calcification scores on AVF failure: moderate scores (were associated with a hazard rate (HR) of 3.82 (95% confidence interval (CI) 1.10-13.23) and severe scores with an HR of 4.65 (CI 0.97-22.38). Conclusion: Vascular calcifications are associated with worse survival of native arteriovenous hemodialysis fistulas.

Porcelain Aorta

Calcification of the thoracic aorta is often associated with valvular and coronary calcification, reflecting an underlying atherosclerotic process.1,2 It has been found to be associated with an increased rate of mortality and cardiovascular disease.1 Porcelain aorta (PA) is extensive calcification of the ascending aorta or aortic arch that can be completely or near completely circumferential.3–5 This entity is rare in the general population, but it has an increasing incidence in older patients and in patients with coronary artery disease (CAD) or aortic stenosis (AS).6,7 The clinical relevance is based on the fact that it can complicate surgical aortic valve replacement (SAVR) for the treatment of severe AS by preventing safe access via the ascending aorta. PA is associated with increased morbidity and mortality, especially as a result of increased perioperative stroke risk.8,9 Recently, transcatheter aortic valve replacement (TAVR) has emerged as a less invasive and feasible treatment option in patients at high risk for conventional SAVR.10 In some series, ≈20% (5%–33%) of patients undergoing TAVR were diagnosed with PA.11 Inconsistencies in the definition and the use of different diagnostic modalities contribute to this wide range of PA prevalence. We reviewed the available published data to seek a consistent, clinically relevant definition based on contemporary imaging, a firm understanding of the pathogenesis and associations, and the clinical implications of this disease entity. PA has been used to address extensive circumferential or nearly circumferential calcification of the thoracic aorta such that it precludes safe cross-clamping or entry to the ascending aorta. However, there is no clear description or definition used; thus, cardiac surgeons and cardiologists use this term inconsistently. In the 1980s, Coselli and Crawford12 initially described 2 …

Abstract 13022: Second-generation versus First-generation Drug-eluting Stents in Patients With Calcified Coronary Lesions: Pooled Analysis From the RESET and NEXT Trials

Background: The impact of second-generation drug-eluting stents (G2-DES) implantation as compared with first-generation drug-eluting stents (G1-DES) for calcified coronary lesion has not been yet adequately addressed. Methods: This pooled analysis compared 2-year clinical outcomes between G1- and G2-DES according to the presence or absence of coronary lesion calcification, using individual patient-level data from 2 large-scale prospective multicenter randomized trials, RESET (Randomized Evaluation of Sirolimus-Eluting Versus Everolimus-Eluting Stent Trial) and NEXT (Biodegradable Polymer Biolimus-Eluting Stent Versus Durable Polymer Everolimus-Eluting Stent). Among 4583 patients enrolled in the 2 trials, G1-DES (sirolimus-eluting stent) and G2-DES (everolimus- or biolimus-eluting stent) were used in 299 and 1033 patients, respectively, in the Calc stratum (at least 1 moderate to severe calcification), and 1208 and 3550 patients, respectively, in the Non-calc stratum (no or mild calcification). Coronary calcification was assessed by an independent angiographic core laboratory. The primary endpoint of the study was clinically driven target-lesion revascularization (TLR) at 2-year follow-up. Result: In the Calc stratum, the cumulative incidence of clinically driven TLR was significantly lower in G2-DES than in G1-DES (5.7% vs. 9.4%, P=0.03), while it was not significantly different between G1- and G2-DES in the Non-calc stratum (3.6% vs. 4.2%, P=0.35). Cumulative incidence of definite stent thrombosis was not significantly different between G1- and G2-DES in both strata (Calc stratum, 0.6% vs. 1.0%, P=0.44, and Non-calc stratum, 0.2% vs. 0.2%, P=0.98). After adjusting for confounders, the lower risk of G2-DES relative to G1-DES for clinically driven TLR remained significant in the Calc stratum (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.35-0.87; P=0.01). There was significant interaction between the generation of DES and presence or absence of calcification (P interaction=0.01). Conclusion: G2-DES as compared with G1-DES was associated with lower risk for clinically driven TLR in patients with calcified coronary lesions.

Sarcocystosis in a stillborn lamb.

Confirmed congenital sarcocystosis has been reported extremely rarely in domestic ruminants. Sarcocystosis was diagnosed in a stillborn lamb with microscopic lesions predominantly in the central nervous system and placenta. Encephalitis was characterized by multiple foci of glial nodules some with central necrosis, perivascular cuffing and vascular occlusion, while placental lesions consisted of multifocal necroses, inflammation and mild calcification. Immature and mature schizonts were found in vascular endothelium of several organs. It is suggested that the protozoa were Sarcocystis tenella based on their morphology, location and as this is the most pathogenic Sarcocystis sp. parasitizing sheep.

The use of temporalis muscle graft, fresh and cryopreserved amniotic membrane in preventing temporomandibular joint ankylosis after discectomy in rabbits

PurposeThe aim of the study was to evaluate the efficacy of temporalis muscle-fascia graft, fresh and cryopreserved human amniotic membrane as an interpositional material in preventing temporomandibular joint ankylosis in a rabbit model. Materials and methodsIn this experimental study, 21 New Zealand white rabbits were used. The condyle and the joint disc were removed to induce ankylosis in left TMJs. Reconstruction was immediately performed with temporalis muscle-fascia graft (tMFG) in group I (n = 7), fresh human amniotic membrane (fHAM) in group II (n = 7) and cryopreserved human amniotic membrane (cHAM) in group III (n = 7). All rabbits were sacrificed at 3 months after the operation. The comparison was made among three groups by means of vertical mouth opening and weight measurements, radiologic and histologic findings obtained before and after surgery. ResultsIn all rabbits, there was no statistically significant difference in the jaw movements and weight among groups at commencement and 3 months after surgery. The condylar surfaces were more irregular in HAM groups. There were mild osteophyte formations, sclerosis, fibrosis and calcification around the condyle in all groups however the joint gap was more preserved in group I. All interpositional materials were also seen to be partially present in the joint gap at 3 months. Ankylosis was not seen in the joint gap in any group. ConclusionWith the results of this study it was concluded that interpositional arthroplasty with HAM and tMFG have an almost similar effect in preventing TMJ ankylosis after discectomy in the rabbit model.

Abstract T P93: Cerebral Artery Calcification is Associated with Deep Cerebral Microbleed

BACKGROUND: Cerebral arterial calcification has been reported to be associated with lacunar infarction and white matter hyperintensities. The aim of the present study was to determine the association between arterial calcification and cerebral microbleed (CMB) which is a small hemorrhagic lesion in the brain and is known to be associated with small vessel disease (SVD). METHODS: We identified 834 consecutive patients with acute ischemic stroke who visited a tertiary university hospital within 7 days of symptom onset and underwent both CT angiography and brain MR imaging. Calcifications in the intracranial internal carotid artery (ICA) were graded on CT angiography. CMBs were counted relative to their location on susceptibility-weighted imaging. The association between ICA calcification and CMB was tested using logistic regression analysis. RESULTS: The patients ranged in age from 26 to 111 years (67 ± 12.7 years, mean ± standard deviation). ICA calcification and CMB were found in 660 patients (79.1%) and 335 patients (40.2%), respectively. On multivariable analysis, ICA calcification was associated with CMB of any location (odds ratio (OR) 1.76, 95% confidence interval (CI) 1.31 - 2.36 for mild calcification; OR 2.86, 95% CI 2.01 - 4.08 for severe calcification, respectively). More robust association was found between calcification and CMB in the basal ganglia, thalamus, or brainstem (odds ratio (OR) 1.76, 95% confidence interval (CI) 1.27 - 2.44 for mild calcification; OR 3.51, 95% CI 2.39 - 5.14 for severe calcification, respectively). However, ICA calcification was not associated with CMB strictly located in the lobar area. CONCLUSIONS: ICA calcification is an independent predictor for deep CMB but not for a strictly lobar CMB. Our findings add evidence to the hypothesis that cerebral arterial calcification is associated with SVD and might contribute to the elucidation of the pathogenesis of SVD.

Ganglion Cyst in the Tarsal Tunnel

The patient was a 35-year-old man who worked as a pipe fitter. He was referred to a physical therapist by an orthopaedic surgeon for a chief complaint of progressively worsening pain in the medial aspect of the right distal Achilles tendon and heel that began insidiously 12 months earlier, which was consistent with a diagnosis of insertional Achilles tendonitis. Prior radiographs revealed mild calcification at the insertion of the Achilles tendon. Despite physical therapist intervention for 8 weeks, the patient did not improve. Subsequent magnetic resonance imaging revealed a large multiloculated ganglion cyst in the tarsal tunnel.

Aortic Annulus Rupture During Transcatheter Aortic Valve Implantation (TAVI): One Ounce of Prevention is Worth One Pound of Cure

An 87 year-old female presented with severe aortic stenosis (AS). Aortic valve replacement by conventional surgery was considered at high risk by a multidisciplinary team. Therefore, she was considered for transcatheter aortic valve implantation (TAVI). Aortic valve area (AVA) was 0.3 cm/m, mean gradient was 57 mmHg and left ventricular ejection fraction was 74% on transthoracic echocardiography (TTE). Femoral and iliac arteries evaluated by angiography and multislice computed tomography were straight with mild calcification and had adequate internal diameters. TTE showed heavily calcified aortic annulus with a nodule of calcium at the bottom of left sinus of valsalva. There was discrepancy in the aortic annulus sizing between the TTE (20 mm) (Fig. 1A), the multislice computed tomography (22 mm) (Fig. 1 BC Abbott Vascular, Redwood City, CA). During TAVI, aortic valvuloplasty was performed with a 23 mm balloon to aid aortic annulus sizing and to

Positive Association of Coronary Calcium Detected by Computed Tomography Coronary Angiography with Periprocedural Myocardial Infarction

BackgroundPeriprocedural myocardial infarction (PMI) may occur in approximately 5% to 30% of patients undergoing percutaneous coronary intervention. Whether the morphology of coronary plaque calcium affects the occurrence of PMI is unknown.Materials and MethodsA total of 616 subjects with stable angina and normal baseline cardiac troponin I levels who had undergone computed tomography angiography (CTA) were referred to elective percutaneous coronary intervention. The morphology of coronary calcium was determined by CTA analysis. PMI was defined as an elevation in 24-h post-procedural cardiac troponin I levels of > 5 times the upper limit of normal with either symptoms of myocardial ischemia, new ischemic electrocardiographic changes, or documented complications during the procedure. Logistic regression was performed to identify the effect of the morphology of coronary calcium on the occurrence of PMI.ResultsAccording to the presence or morphology of coronary calcium as shown by CTA, 210 subjects were grouped in the heavy calcification group, 258 in the mild calcification group, 40 in the spotty calcification group and 108 in the control group. The dissection rate was significantly higher in the heavy calcification group than in the control group (7.1 % vs. 1.9%, p = 0.03). The occurrence of PMI in the heavy calcification group was significantly higher than that in the control group (OR 4.38, 95% CI 1.80–10.65, p = 0.001). After multivariate adjustment, the risk of PMI still remained significantly higher in the heavy calcification group than in the control group (OR 4.04, 95% CI 1.50–10.89, p = 0.003).ConclusionsThe morphology of coronary calcium determined by CTA may help to predict the subsequent occurrence of PMI. A large amount of coronary calcium may be predictive of PMI.

Lanthanum carbonate prevents accelerated medial calcification in uremic rats: role of osteoclast-like activity

BackgroundArterial medial calcification (AMC) is frequent prevalence in patients with end stage renal disease. Evidence about hyperphosphatemia induced anabolic crosstalk between osteoblast and osteoclast in AMC of uremia is rare. Lanthanum carbonate as an orally administered phosphate-binding agent to reduce phosphate load and ameliorate AMC, but direct evidence is missing.MethodsDetailed time-course studies were conducted of Sprague–Dawley rats fed with adenine and high phosphate diet to imitate the onset and progression of AMC of uremia. Calcification in great arteries was evaluated by VonKossa’s and Masson's trichrome staining. Osteoblast (Runx2, Osteocalcin) and osteoclast (RANKL, Cathepsin K, TRAP) related genes were analyzed by Immunohistochemistry and qRT-PCR. Serum PTH, RANKL and OPG levels were detected by ELISA kit.ResultsSerum phosphate was markedly increased in CRF group (6.94 ± 0.97 mmol/L) and 2%La group (5.12 ± 0.84 mmol/L) at week 4, while the latter group diminished significantly (2.92 ± 0.73 mmol/L vs CRF Group 3.48 ± 0.69, p < 0.01) at week 10. The rats that did not receive 2%La treatment had extensive von kossa staining for medial calcification in CRF group. In contrast, the rats in 2%La group just exhibit mild medial calcification. Inhibitory effect on progression of AMC was reflected by down regulated osteogenic genes and altered osteoclast-like genes. RANKL/OPG ratio in local calcification area was declined in 2%La group (vs CRF group, p <0.01), whereas marginal difference in serum among the three groups. In contrast to the robust expression of cathepsinK in calcified area, TRAP expression was not found.ConclusionsAbnormal phosphate homeostasis, induction of osteogenic conversion and osteoclast suppression were contributed to the current mechanisms of uremia associated arterial medial calcification based on our studies. Beneficial effects of Lanthanum carbonate could be mainly due to the decreased phosphate retention and cross-talk between osteoblast and osteoclast-like cell, both of which can be the therapeutic target for uremia associated with AMC.

Abstract 225: Relationship Between Blood Pressure Lowering Medication Profiles and Coronary Artery Disease in Patients With Acute Chest Pain

Introduction Whether use of blood pressure lowering medications (BPLMs) is associated with presence and severity of coronary artery disease (CAD) is unknown. The aim of this study was to examine the relationship between BPLMs and coronary artery calcium score (CACS) as a marker of CAD in patients with acute chest pain. Methods In this cross-sectional study, 1030 consecutive patients without reported history of CAD who presented with acute chest pain were included. CACS by non-contrast multi-detector computed tomography scan, BPLMs profiles prior to the visit were collected. Patients were categorized by presence and severity of CACS, number and classes of BPLMs used. Results The population with mean age of 54±13 years consisted of 60.6% (624 of 1030) patients with zero CACS, 21.7%(223 of 1030) with mild calcification(0&lt;CACS&lt;100) and 17.8%(183 of 1030) with moderate-to-severe calcification(CACS≥100). Patients with single BPLM and multiple BPLMs are accounted for 24% and 24% of all the patients respectively. Compared to non-BPLM group, BPLMs group had more patients with presence of CACS and moderate-to-severe calcification (238 of 494; 48.2% vs 168 of 536; 31.3% p&lt;0.001; for CACS&gt;0 and 118 of 494; 23.9% vs 65 of 536;12.1% p&lt;0.001;for CACS≥100). Compared to single BPLM group, multiple BPLMs group had no significant difference in numbers of patients with presence of CACS and moderate-to-severe calcification (p=0.106 and p=0.345 respectively). Most BPLMs classes are associated with CACS as shown in table1. Conclusion Use of blood pressure lowering medications is associated with presence and severity of coronary artery disease in patients with acute chest pain.

Abstract 224: Obesity Paradox in Coronary Artery Disease in Patients With Acute Chest Pain

Introduction Obesity has been inconsistently linked with coronary artery calcium score (CACS) as a surrogate of coronary artery disease (CAD) in asymptomatic subjects. Our aim was to examine whether there is relationship between obesity defined by BMI≥30kg/m 2 and presence and severity of CAD defined by CACS in patients with acute chest pain. Methods In this cross-sectional study, 1030 consecutive patients without reported history of coronary artery disease who presented with acute chest pain were included. CACS by non-contrast CT scan and BMI were collected. Patients were categorized by CACS classifications and BMI. Results The population with mean age of 54±13 years, 33% (338 of 1030) of patients being overweight and 46% (477 of 1030) being obese consisted of 60.6% (624 of 1030) patients with zero CACS, 21.7% (223 of 1030) with mild calcification (0&lt;CACS&lt;100) and 17.8% (183 of 1030) with moderate-to-severe calcification (CACS≥100). Compared to non-overweight/non-obese group, obese group had less patients with moderate-to-severe calcification (69 of 477; 14.5% VS 50 of 215; 22.6% p-value=0.016) despite more patients with hypertension (311 of 477; 65.2% VS 98 of 215; 45.6% p-value&lt;0.001), diabetes (98 of 477; 20.5% VS 11 of 215; 5.1% p-value&lt;0.001) and hyperlipidemia(174 of 477; 36.5% VS 57 of 215; 26.5% p-value=0.010). Obesity is INVERSELY associated with presence of CACS and moderate-to-severe calcification in multivariable logistic regression analysis (table 1). Conclusion Obesity defined by body mass index ≥ 30kg/m 2 is INVERSELY associated with presence and severity of coronary artery disease defined by coronary artery calcium score in patients with acute chest pain.

Absolute coronary artery calcium score is the best predictor of non-calcified plaque involvement in patients with low calcium scores (1–100)

ObjectiveWe sought to identify the predictors of non-calcified plaque (NCP) burden in patients with low coronary artery calcium (CAC) scores of 1–100. MethodsWe studied 920 consecutive patients clinically referred for coronary CT angiography (CCTA) with concomitant CAC scoring. The 276 patients with CAC 1–100 were divided into four groups based on the CAC score: CAC = 0, 1–10, 11–50, and 51–100. Univariate and multivariate linear regression analyses were performed for the demographic, risk factor, and CAC score predictors of number of coronary segments with NCP. ResultsMean age was 55 ± 11 years and 56% were women. Demographics and risk factors failed to identify NCP involvement in univariate models. The lone predictor of NCP burden was the absolute CAC score, which was persistently associated with NCP in multivariable models (CAC 51–100 vs. CAC 1–10, β-coefficient 0.35, p = 0.03). ConclusionsAbsolute CAC score is the lone robust predictor of NCP burden when CAC is 1–100. Risk within this mild coronary calcification group is likely heterogeneous, driven by the absolute CAC score.

SAT0230 Atherosclerosis of coronary arteries and coronary heart disease in patients with systemic lupus erythematosus (autopsy and intravital findings)

ObjectivesTo study frequency and character of atherosclerotic damage of coronary arteries (CA) and associated coronary heart disease (CHD) in patients (pts) with systemic lupus erythematosus (SLE); to suggest a rational...

Patterns of coronary arterial lesion calcification by a novel, cross-sectional CT angiographic assessment

To investigate the patterns and diagnostic implications of coronary arterial lesion calcification by CT angiography (CTA) using a novel, cross-sectional grading method, we studied 371 patients enrolled in the CorE-64 study who underwent CTA and invasive angiography for detecting coronary artery stenoses by quantitative coronary angiography (QCA). The number of quadrants involving calcium on a cross-sectional view for ≥ 30 and ≥ 50 % lesions in 4,511 arterial segments was assessed by CTA according to: noncalcified, mild (one-quadrant), moderate (two-quadrant), severe (three-quadrant) and very severe (four-quadrant calcium). Area under the receiver operating characteristic curve (AUC) were used to evaluate CTA diagnostic accuracy and agreement versus. QCA for plaque types. Only 4 % of ≥ 50 % stenoses by QCA were very severely calcified while 43 % were noncalcified. AUC for CTA to detect ≥ 50 % stenoses by QCA for non-calcified, mildly, moderately, severely, and very severely calcified plaques were 0.90, 0.88, 0.83, 0.76 and 0.89, respectively (P < 0.05). In 198 lesions with severe calcification, the presence or absence of a visible residual lumen by CTA was associated with ≥ 50 % stenosis by QCA in 20.3 and 76.9 %, respectively. Kappa was 0.93 for interobserver variability in evaluating plaque calcification. We conclude that calcification of individual coronary artery lesions can be reliably graded using CTA. Most ≥ 50 % coronary artery stenoses are not or only mildly calcified. If no residual lumen is seen on CTA, calcified lesions are predictive of ≥ 50 % stenoses and vice versa. CTA diagnostic accuracy for detecting ≥ 50 % stenoses is reduced in lesions with more than mild calcification due to lower specificity.

Nonvalvular right atrial papillary fibroelastoma

We present the case of a 61-year-old woman with a previous history of hypertension and diabetes mellitus. The patient was admitted for acute cholecystitis, which was confirmed radiologically by a computed tomography scan with contrast that also showed an incidental right atrial filling defect. A transthoracic echocardiogram showed a 20 3 22-mm spheric echogenic mass in the right atrium with mild mitral annular calcification. Surgical resection was planned using preoperative coronary angiography, which showed no evidence of coronary artery disease. She underwent surgical resection through a right atriotomy and a cardiopulmonary bypass without any adverse events. Grossly, the tumor was a 4 3 3-cm, cauliflower-shaped, purple-colored mass attached to the interatrial septum (Figure 1). A bovine pericardial patch was used to repair the resultant defect. Histopathology showed numerous papillae with endocardial lining and cores containing myocytes as well as scattered elastic fibers (Figure 2). The postoperative period was complicated by an atypical atrial flutter that was treated medically.