Standard Coronary Angiography Research Articles

Could Computed Tomography Coronary Angiography Replace Invasive Coronary Angiography as a First-Line Diagnostic Investigation in Suspected Acute Coronary Syndromes? A Decision-Analytic Model

The implementation of high-sensitivity cardiac troponin (hs-cTn) assays into clinical practice has resulted in the identification of a novel cohort of patients with modestly increased troponin concentrations. Subsequent increases in rates of coronary angiography have been observed, without significant increases in rates of coronary revascularisation. Computed tomography coronary angiography (CTCA) is a non-invasive investigation that offers the opportunity to decouple investigation from the impetus to revascularise, and may provide an alternative, more risk-appropriate initial investigative strategy for the cohort with low to moderate hs-cTn increases. This analysis seeks to define the threshold of pre-test probability of coronary revascularisation in patients with suspected acute coronary syndrome at which a strategy of initial CTCA is safe and a more cost-effective approach than standard invasive coronary angiography (ICA). A cost-benefit evaluation was conducted using a decision-analytic model. The primary outcome measure was the incremental cost-effectiveness ratio (ICER) of CTCA in comparison with ICA as an initial diagnostic investigation for patients with hs-cTnT levels between 5 and 100 ng/L. Secondary outcome measures of costs, patient outcomes, and quality-adjusted life years were analysed. Median base case ICER over 1,000 trials was $17,163 AUD but demonstrated large variability. Sensitivity analysis demonstrated that CTCA was cost-effective until the probability of requiring revascularisation was ∼60%, beyond which point CTCA was associated with higher costs and poorer outcomes than ICA. Computed tomography coronary angiography may be a cost-effective first-line investigation for patients with moderate hs-cTnT rises until/up to a 60% pre-test probability for receiving coronary revascularisation. To objectively assess the optimal circumstances of cost-effectiveness, prospective evaluation incorporating the estimated probability of revascularisation will be required.

Standardized angiographic projections allow evaluation of coronary artery side branches with quantitative flow ratio (QFR)

Quantitative flow ratio (QFR) is a novel, software-based noninvasive method for the quantitative evaluation of coronary physiology. QFR results correlate with invasive FFR measurements in the three main epicardial coronary arteries. However, QFR data for the evaluation of coronary side branches (SB) are scarce. The evaluation of QFR-performance of SB was retrospective and prospective. Eighty-seven patients with suspected chronic coronary syndrome, who received angiography using routine core lab projections, were retrospectively analyzed. On the second part 37 patients, who received angiography using recommended standardized coronary angiography projections, were prospectively analyzed. Quantitative analysis was performed for SB with a maximum lumen diameter proximal of ≥2 mm based on quantitative coronary angiography (QCA) by two certified experts with the software QAngio XA 3D 3.2. Using routine projections, QFR computation in 55 % of the SB were obtained (123 out of 224). Using standardized projections, 85 % of SB were computed by QFR (64 out of 75; p < 0.001 vs routine projections). The fluoroscopy time for recommended projections was not significantly different as opposed to routine projections (3.75 ± 2.2 vs. 4.58 ± 3.00 min, p = 2.6986). Using the standardized projections was associated with a higher amount of contrast medium (53.44 ± 24.23 vs. 87.95 ± 43.73 ml, p < 0.01), longer overall procedure time (23.23 ± 16.35 vs. 36.14 ± 17.21 min, p < 0.01) and a higher dose area product (1152.28 ± 576.70 vs. 2540.68 ± 1774.07 cGycm2, p < 0.01). Our study shows that the blood flow of the vast majority of coronary SB can be determined non-invasively by QFR in addition to the main epicardial coronary arteries when standardized projections are used.

Dobutamine Stress Cardiac MRI in Pediatric Patients with Suspected Coronary Artery Disease.

Following current practice, pediatric patients with treated congenital coronary malformations or acquired coronary disease undergo Cardio-Pulmonary Exercise Test (CPET), stress Echocardiography and Electrocardiography (sEcho, sEKG), and Coronary Angiography (CA). Stress cMRI can assess cardiac function, myocardial viability, and stress/rest perfusion deficit-without radiation exposure, general anesthesia, and hospitalization-in a single non-invasive exam. The aim of our pilot study is to assess the feasibility and diagnostic accuracy of Dobutamine stress cMRI compared to the current procedures (sEcho, CPET, CA). The prospective study is focused on pediatric patients, at risk for or with previously diagnosed coronary artery disease: d-looped TGA after arterial Switch, Kawasaki disease, and anomalous origin of left coronary artery from pulmonary artery (ALCAPA) after coronary artery reimplantation. We have compared the results of MRI coronary angiography, and Dobutamine stress cMRI with traditional tests. All these diagnostic exams were acquired in a timeframe of 3month, in a blinded fashion. All the 13 patients (age: 12 ± 2years, median 12,7 y) recruited, completed the study without major adverse events. The mean heart rate-pressure product was 25,120 ± 5110bpm x mm Hg. The target heart rate of 85% of the maximal theoretical was reached by 10 (77%) patients. The comparison between cardiac MRI coronarography versus the gold standard Coronary Angiography to identify the patency of the origin and the proximal pathway of the coronary arteries shows a sensitivity of 100% (confidence interval: 2,5-100%), specificity 92% (confidence interval: 64-100%). The stress test was well tolerated for the 77% of the patients and completed by the totality of patients (Table 3). Three patients (23%) had mild symptoms: nausea, vomiting, or general discomfort. In pediatric patients with a potential or definite diagnosis of coronary artery disease, stress cMRI combines an effective assessment of proximal coronary arteries anatomy with cardiac function, myocardial perfusion, and viability in a single examination. Stress cMRI can be proposed as alternative, standalone test.

D-9 | Additional Value of Instant Wave Free Ratio (iFR) on Standard Quantitative Coronary Angiography (QCA) in Cancer Patients

D-9 | Additional Value of Instant Wave Free Ratio (iFR) on Standard Quantitative Coronary Angiography (QCA) in Cancer Patients

Diagnostic Performance of CT-Derived Fractional Flow Reserve in Australian Patients Referred for Invasive Coronary Angiography

Non-invasive computed tomography (CT)-derived fractional flow reserve (FFRCT) is computed from standard coronary CT angiography (CTA) datasets and provides accurate vessel-specific ischaemia assessment of coronary artery disease (CAD). To date, the technique and its diagnostic performance has not been verified in the Australian clinical context. The aim of this study was to describe and compare the diagnostic performance of FFRCT and CTA for the detection of vessel-specific ischaemia as determined by invasive fractional flow reserve (FFR) in the Australian patient population. One-hundred-and-nine patients (219 vessels) referred for clinically mandated invasive angiography were retrospectively assessed. Each patient underwent research mandated CTA and FFRCT within 3 months of invasive angiography and invasive FFR assessment. Independent core laboratory assessments were made to determine visual CTA stenosis, FFRCT and invasive FFR values. FFRCT values were matched with the corresponding invasive FFR measurement taken at the given wire position. Visual CTA stenosis ≥50%, FFRCT values ≤0.8 and invasive FFR values ≤0.8 were considered significant for ischaemia. Per vessel accuracy, sensitivity, specificity, positive predictive value and negative predictive value of FFRCT were 80.4%, 80.0%, 80.6%, 64.9% and 90.0% respectively. Corresponding values for CTA were 75.1%, 87.1%, 69.2%, 58.1% and 91.7% respectively. In receiver operating characteristic curve analysis, FFRCT demonstrated superior area under the curve (AUC) compared with CTA in both per vessel (0.87 vs 0.77, p=0.004) and per patient analysis (0.86 vs 0.74, p=0.011). Per vessel AUC of combined CTA and FFRCT was superior to CTA alone (0.89 vs 0.77, p<0.0001). In this cohort of Australian patients, the diagnostic performance of FFRCT was found to be comparable to existing international literature, with demonstrated improvement in performance compared with CTA alone for the detection of vessel-specific ischaemia.

Implantación de un protocolo de angio-TC coronaria basado en el índice de masa corporal: reducción de dosis, calidad de imagen y rendimiento diagnóstico

ObjectivesTo evaluate the relation between the coronary calcium score and the posterior choice of kilovoltage according to radiologists’ criteria in a standard coronary CT angiography protocol to rule out coronary disease.To quantify the reduction in ionizing radiation after linking kilovoltage to patients’ body mass index in a low-dose protocol with iterative model reconstruction.To evaluate the image quality and diagnostic performance of the low-dose protocol. Material and methodsWe compared anthropometric characteristics, calcium score, kilovoltage levels, size-specific dose estimates (SSDE), and the dose-length product (DLP) between a group of 50 patients who were prospectively recruited to undergo coronary CT angiography with a low-dose protocol and a historical group of 50 patients who underwent coronary CT angiography with the standard protocol. We correlated these parameters, the number of coronary segments that could not be evaluated with and without temporal padding, the attenuation, and the signal-to-noise ratio in the ascending aorta in the low-dose protocol with excellent imaging quality according to a semiquantitative scale. To calculate the diagnostic performance per patient, we used 24-month clinical follow-up including all tests as the gold standard. ResultsIn the standard protocol, the presence of coronary calcium correlated with the selection of high kilovoltage (P=0.02); this correlation was not found in the low-dose protocol (P=0.47). Median values of SSDE and DLP were significantly (P<0.001) lower and less dispersed in the low-dose protocol [9.22 mGy (IQR 7.84-12.1 mGy) vs. 26.5 mGy (IQR 21.3-36.3 mGy) in the standard protocol] and [97mGy*cm (IQR 78-134mGy*cm) vs. 253mGy*cm (IQR 216-404mGy*cm) in the standard protocol], respectively.The overall quality of the images obtained with the low-dose protocol was considered good or excellent in 96% of the studies. The parameters associated with image quality in a multivariable model (C statistic=0.792) were heart rate (estimated coefficient, -0,12 [95% confidence interval: -0.2, -0.04]; P<0.01) and the SSDE (estimated coefficient, -0,26 [95% confidence interval: -0.51, -0.01]; P<0.05).The CAD-RADS modifier for a not fully evaluable or diagnostic study was used on two occasions (4%); the final measures for the diagnosis of coronary disease were sensitivity 100%, specificity 94%, and efficacy 94%. ConclusionsIn the standard protocol, the radiologist selects higher kilovoltage for CT angiography studies for patients whose previous calcium score indicates the presence of coronary calcium. In the low-dose protocol, linking kilovoltage with body mass index enables the dose of radiation to be reduced by 65% while obtaining excellent or good image quality in 96% of studies and excellent diagnostic performance.

Optical Coherence Tomography-OCT for Characterization of Non-Atherosclerotic Coronary Lesions in Acute Coronary Syndromes.

Cardiovascular diseases are the main cause of death worldwide, with coronary artery disease being the predominant underlying etiology. The most prevalent coronary lesions are represented by the atherosclerotic plaques, in more than 85% of cases, but there are several other non-atherosclerotic lesions such as spontaneous coronary artery dissection and/or hematoma and spontaneous recanalization of coronary thrombus, which are less common, approximately 5% of cases, but with similar clinical manifestations as well as complications. There are insufficient data regarding the pathological mechanism, true prevalence and optimal treatment of these kind of coronary lesions. Optical coherence tomography (OCT) is an intracoronary imaging technique, developed in order to overcome the diagnostic limitations of a standard coronary angiography and has an extremely high resolution, similar to that of a usual histological evaluation of a biopsy sample, thus, OCT provides a histological-like information, but in a in vivo environment. The aim of this article is to review the current knowledge regarding non-atherosclerotic coronary lesions, with an emphasis on the importance of OCT for optimal identification, characterization of pathogenic mechanisms and optimal treatment selection.

Invasive methods for coronary reserve measurement

During the last years, following numerous trials, the need of functional assessment of stenoses before myocardial revascularization has been established. This came to replace the subjective approach based on the so-called “oculo-stenotic” reflex of the operator. Numerous methods for coronary reserve (CR) estimation as a measure of functional significance of the lesion, have been introduced in the practice. Those methods are noninvasive and invasive. A part of them are based on the measurement of coronary flow velocity before and after hyperemic medication, other are based on the difference of arterial pressure before and after the coronary stenosis. They are divided to such with or without hyperemic medication. During the last years in the diagnostic have been used methods for functional estimation of the lesions based only on standard coronary angiography or even computerized tomography (CT). The aim of this article is to present a review of modern invasive methods for coronary reserve measurement.

Virtual fractional flow reserve derived from coronary angiography – artery and lesion specific correlations

Abstract Introduction Virtual Fractional flow reserve (vFFR) from standard non-hyperaemic invasive coronary angiography (ICA) has emerged as a promising non-invasive test to assess hemodynamic severity of coronary artery disease (CAD). Purpose To investigate the difference in vFFR analysis between vessels and specific lesions. Methods Retrospective analysis of consecutive patients (pts) who underwent invasive functional assessment (iFA) in a tertiary center between 2019 and 2020. vFFR was calculated using dedicated software (CAAS Workstation 8.4) based on coronary angiograms of the acquired in ≥2 different projections, by operators blinded to iFA results. Diagnostic performance of vFFR was evaluated and correlated with iFA, according to coronary vessel, vessel diameter at stenosis, diameter stenosis and area stenosis at lesion. vFFR was considered positive when &amp;lt;0.80. FFR &amp;lt;0.8 and iFR/RFR &amp;lt;0.90 were classified as positive according to current clinical standards. Results 106 coronary arteries of 95 pts (78% male, mean age 67.8±9.7 years) underwent vFFR evaluation. ICA indications were chronic coronary syndrome in 63% or acute coronary syndrome (non-culprit lesion) in the remaining pts. VFFR accuracy was good (AUC 0.839 (p&amp;lt;0.001) and Pearson's correlation coefficient 0.533 (p&amp;lt;0.001) when vFFR was measured in the distal vessel segment. The correlation improved when vFFR were assessed at lesion site (r=0.631, p&amp;lt;0.001) or up to 1cm below the stenosis (0.610, p&amp;lt;0.001). Binary concordance of 89% were observed in RCA and LAD (Sensibility -S 68%, Specificity-Sp 96%, False positive -FP 3.8%, False negative - FN 31%, predictive positive value-PPV 87%, predictive negative value- PNV 89%), while in the circumflex coronary artery binary concordance were of 77% (S 50%; Sp 82%; FP 18%; FN 50%; PPV 33% and PNV 90%). Correlation between vFFR and iFA was higher in vessels ≥2mm (r=0.730, p&amp;lt;0.001). and in lesions in the extremes of the severity spectrum (Table 1). Conclusion vFFR has a moderate to high linear correlation to iFA, depending on the artery and type of lesion studied. The higher correlation was found when vFFR were measured at lesion site, in non-circumflex artery stenosis, in vessels ≥2mm and in vessels with mild or severe stenosis. Funding Acknowledgement Type of funding sources: None.

The contemporary study of acute myocarditis in South Africa – CAMISA

Abstract Introduction The aetiology and estimated incidence of acute myocarditis (AM) remains undefined in Africa. Whilst cardiac magnetic resonance (CMR) provides for a provisional non-invasive diagnosis, endomyocardial biopsy (EMB), which is infrequently clinically sought, remains the gold standard. The developed world has experienced a shift in the viral epidemiology of AM and the ESC's most recent position statement on myocarditis recommends both CMR and EMB as the standard of care in suspected cases. We report on the interim results of the study. Purpose To determine the nature of presentation, underlying aetiology, and outcomes of patients presenting with AM to a single tertiary centre in South Africa. Methods A cohort of patients from a single tertiary centre in South Africa will be recruited from January 2018 to December 2022. All patients presenting or referred to the centre with clinically suspected AM that are investigated according to the ESC recommendations on myocarditis, which includes blood tests (CRP, hsTNT, HIV and Hepatitis C serology, ANA), a standard twelve-lead ECG, TTE, coronary angiography, CMR and EMB, will be included. Enrolment is ongoing. Results A total of 102 (mean age 42.2±13 years, 64.7% male) cases of clinically suspected AM were identified between January 2018 and January 2021. AM was confirmed in 41 (40.2%) cases on CMR only, while 41 (40.2%) were also confirmed on EMB. 4 cases of sarcoidosis, 1 case each of eosinophilic myocarditis, amyloidosis and primary cardiac lymphoma were diagnosed. Viral genome was isolated by PCR in 60 (59.8%) patients. PVB19 (73.5%) was the most commonly identified virus in those with confirmed AM followed by EBV (12.2%), HHV6 (4.1%) and Human Bocavirus (2%). 3 were coinfected with PVB19/EBV, and 1 with PVB19/EBV/HHV6. PVB19 was also isolated in 9 patients with no evidence of AM on CMR or EMB, but with lower median viral load compared to those with AM (198copies/ml IQR 113 – 282 vs 483copies/ml IQR 366 – 1460, p=0.005). The virus-positive patients with confirmed AM tended to be older (43.1±13.4 years vs 37.6±12.2 years, p=n/s), had higher median CRP (24mg/L vs 16mg/L, p=n/s) but lower median hsTnT (326.5ng/L vs 434.5ng/L, p=n/s) at presentation, and were more likely to be EMB positive (60% vs 37.5%, p=0.04) when compared to the virus-negative group. To date 6 patients have demised, of which 4 were related to AM. Conclusion To our knowledge, this is the first study to evaluate AM in Africa, and the biggest cohort of AM patients outside of the developed world. It demonstrates the heterogeneity in presentations and provides insight into the viral pathogens within our local setting, which appears similar to those reported in the developed world. We were also able to highlight some differences in demographic and clinical characteristics between those with virus-positive and virus-negative AM. The background prevalence and causal role of PVB19 in our setting will also need to be further explored. Funding Acknowledgement Type of funding sources: None.

Non-invasive imaging software to assess the functional significance of coronary stenoses: a systematic review and economic evaluation.

QAngio® XA 3D/QFR® (three-dimensional/quantitative flow ratio) imaging software (Medis Medical Imaging Systems BV, Leiden, the Netherlands) and CAAS® vFFR® (vessel fractional flow reserve) imaging software (Pie Medical Imaging BV, Maastricht, the Netherlands) are non-invasive technologies to assess the functional significance of coronary stenoses, which can be alternatives to invasive fractional flow reserve assessment. The objectives were to determine the clinical effectiveness and cost-effectiveness of QAngio XA 3D/QFR and CAAS vFFR. We performed a systematic review of all evidence on QAngio XA 3D/QFR and CAAS vFFR, including diagnostic accuracy, clinical effectiveness, implementation and economic analyses. We searched MEDLINE and other databases to January 2020 for studies where either technology was used and compared with fractional flow reserve in patients with intermediate stenosis. The risk of bias was assessed with quality assessment of diagnostic accuracy studies. Meta-analyses of diagnostic accuracy were performed. Clinical and implementation outcomes were synthesised narratively. A simulation study investigated the clinical impact of using QAngio XA 3D/QFR. We developed a de novo decision-analytic model to estimate the cost-effectiveness of QAngio XA 3D/QFR and CAAS vFFR relative to invasive fractional flow reserve or invasive coronary angiography alone. Scenario analyses were undertaken to explore the robustness of the results to variation in the sources of data used to populate the model and alternative assumptions. Thirty-nine studies (5440 patients) of QAngio XA 3D/QFR and three studies (500 patients) of CAAS vFFR were included. QAngio XA 3D/QFR had good diagnostic accuracy to predict functionally significant fractional flow reserve (≤ 0.80 cut-off point); contrast-flow quantitative flow ratio had a sensitivity of 85% (95% confidence interval 78% to 90%) and a specificity of 91% (95% confidence interval 85% to 95%). A total of 95% of quantitative flow ratio measurements were within 0.14 of the fractional flow reserve. Data on the diagnostic accuracy of CAAS vFFR were limited and a full meta-analysis was not feasible. There were very few data on clinical and implementation outcomes. The simulation found that quantitative flow ratio slightly increased the revascularisation rate when compared with fractional flow reserve, from 40.2% to 42.0%. Quantitative flow ratio and fractional flow reserve resulted in similar numbers of subsequent coronary events. The base-case cost-effectiveness results showed that the test strategy with the highest net benefit was invasive coronary angiography with confirmatory fractional flow reserve. The next best strategies were QAngio XA 3D/QFR and CAAS vFFR (without fractional flow reserve). However, the difference in net benefit between this best strategy and the next best was small, ranging from 0.007 to 0.012 quality-adjusted life-years (or equivalently £140-240) per patient diagnosed at a cost-effectiveness threshold of £20,000 per quality-adjusted life-year. Diagnostic accuracy evidence on CAAS vFFR, and evidence on the clinical impact of QAngio XA 3D/QFR, were limited. Quantitative flow ratio as measured by QAngio XA 3D/QFR has good agreement and diagnostic accuracy compared with fractional flow reserve and is preferable to standard invasive coronary angiography alone. It appears to have very similar cost-effectiveness to fractional flow reserve and, therefore, pending further evidence on general clinical benefits and specific subgroups, could be a reasonable alternative. The clinical effectiveness and cost-effectiveness of CAAS vFFR are uncertain. Randomised controlled trial evidence evaluating the effect of quantitative flow ratio on clinical and patient-centred outcomes is needed. Studies are required to assess the diagnostic accuracy and clinical feasibility of CAAS vFFR. Large ongoing randomised trials will hopefully inform the clinical value of QAngio XA 3D/QFR. This study is registered as PROSPERO CRD42019154575. This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 25, No. 56. See the NIHR Journals Library website for further project information.

Post-stenting fractional flow reserve vs coronary angiography for optimization of percutaneous coronary intervention (TARGET-FFR).

Aims A fractional flow reserve (FFR) value ≥0.90 after percutaneous coronary intervention (PCI) is associated with a reduced risk of adverse cardiovascular events. TARGET-FFR is an investigator-initiated, single-centre, randomized controlled trial to determine the feasibility and efficacy of a post-PCI FFR-guided optimization strategy vs. standard coronary angiography in achieving final post-PCI FFR values ≥0.90.Methods and results After angiographically guided PCI, patients were randomized 1:1 to receive a physiology-guided incremental optimization strategy (PIOS) or a blinded coronary physiology assessment (control group). The primary outcome was the proportion of patients with a final post-PCI FFR ≥0.90. Final FFR ≤0.80 was a prioritized secondary outcome. A total of 260 patients were randomized (131 to PIOS, 129 to control) and 68.1% of patients had an initial post-PCI FFR <0.90. In the PIOS group, 30.5% underwent further intervention (stent post-dilation and/or additional stenting). There was no significant difference in the primary endpoint of the proportion of patients with final post-PCI FFR ≥0.90 between groups (PIOS minus control 10%, 95% confidence interval −1.84 to 21.91, P = 0.099). The proportion of patients with a final FFR ≤0.80 was significantly reduced when compared with the angiography-guided control group (−11.2%, 95% confidence interval −21.87 to −0.35], P = 0.045).Conclusion Over two-thirds of patients had a physiologically suboptimal result after angiography-guided PCI. An FFR-guided optimization strategy did not significantly increase the proportion of patients with a final FFR ≥0.90, but did reduce the proportion of patients with a final FFR ≤0.80.

Coronary computed tomography versus coronary angiography for preoperative coronary assessment before valve surgery

BackgroundConventional coronary angiography (CAG) is currently the gold standard technique for the assessment of coronary arteries prior to cardiac valve surgery. Although CAG is a relatively safe procedure, however, it is still an invasive procedure, and it has potential hazards and complications. Coronary computed tomography angiography (CCTA) is a non-invasive technique that has emerged robustly as an excellent and attractive tool for delineating coronary anatomy. Therefore, we sought to evaluate the accuracy of CCTA when compared with the gold standard CAG in the evaluation of coronary arteries before valve surgery. We screened 111 consecutive patients with VHD undergoing a routine cardiac catheterization for preoperative evaluation of CAD. Fifty patients were eligible and underwent both CAG and CCTA. Significant coronary stenosis was defined as a luminal diameter decrease of ≥ 50%. Additionally, ectasia, calcifications, and congenital coronary anomalies were analyzed. Also, we compared both techniques regarding radiation dose, contrast volume, and complications. Non-evaluable segments were excluded from all levels of analysis. Sixty-one patients were excluded from the study due to various reasons.ResultsAmong the 50 patients of the study population, 27 (54%) were males. The prevalence of significant CAD in the study population was 19.6% according to the patient-based analysis, and CAG could have been avoided in 80.4% of patients with a true-negative CCTA result. Diagnostic accuracy of CCTA for detection of significant stenosis was evaluated regarding sensitivity and specificity, positive predictive value, negative predictive value, and overall accuracy of CCTA, which was 87.5%, 99.6%,87.5%, 99.6%, and 99.2%, respectively, for segmental-based analysis; 86%, 100%, 100%, 99%, and 99%, respectively, for vessel-based analysis; and 77.8%,100%,100%, 94.9%, and 95.7%, respectively, for patient-based analysis. Fewer rates of complications were encountered with CCTA. Additional information obtained like calcifications and congenital anomalies was diagnosed better with CCTA than CAG.ConclusionOwing mainly to its high negative predictive value, a well-performed CCTA exam is an excellent method to rule out coronary artery disease, specially in patients who are not at high risk of atherosclerosis.

Myocardial perfusion imaging using computed tomography: Current status, clinical value and prognostic implications

AbstractCombined anatomical and functional evaluation of coronary artery disease (CAD) using computed tomography (CT) has recently emerged as an accurate, robust, and non-invasive tool for the evaluation of ischemic heart disease. Cardiac CT has become a one-stop-shop imaging modality that allows the simultaneous depiction, characterization, and quantification of coronary atherosclerosis and the assessment of myocardial ischemia. Advancements in scanner technology (improvements in spatial and temporal resolution, dual-energy imaging, wide detector panels) and the implementation of iterative reconstruction algorithms enables the detection of myocardial ischemia in both qualitative and quantitative fashion using low-dose scanning protocols. The addition of CT perfusion (CTP) to standard coronary CT angiography is a reliable tool to improve diagnostic accuracy. CTP using static first-pass imaging enables qualitative assessment of the myocardial tissue, whereas dynamic perfusion imaging can also provide quantitative information on myocardial blood flow. Myocardial tissue assessment by CTP holds the potential to refine risk in stable chest pain or microvascular dysfunction. CTP can aid the detection of residual ischemia after coronary intervention. Comprehensive evaluation of CAD using CTP might therefore improve the selection of patients for aggressive secondary prevention therapy or coronary revascularization with high diagnostic certainty. In addition, prognostic information provided by perfusion CT imaging could improve patient outcomes by quantifying the ischemic burden of the left ventricle. The current review focuses on the clinical value of myocardial perfusion imaging by CT, current status of CTP imaging and the use of myocardial CTP in various patient populations for the diagnosis of ischemic heart disease.

TERMINATION OF ANTIPLATELET AND ANTICOAGULANT THERAPY BEFORE CORONARY ARTERY BYPASS GRAFTING

The aim of the study is to analyze the peculiarities of the timing of discontinuation of antiplatelet and anticoagulant therapy before coronary artery bypass grafting. The study is based on a retrospective analysis of 194 patients who were discharged after coronary artery bypass surgery from M. Amosov National Institute of Cardiovascular Surgery, National Academy of Sciences of Ukraine for the period of 2009 - 2019. The average age of the patients was 64.2±8.9 years. All the patients underwent standard laboratory tests, coronary angiography and coronary artery bypass grafting. The analysis of the regimen of antiplatelet and anticoagulant therapy showed that 44 (22.6%) patients discontinued this medication 1 day before surgery. 86 (44.3%) patients were recommended to discontinue the medication within 2-5 days before coronary artery bypass grafting, 40 (20.6%) patients discontinued antithrombotic drugs 6-10 days before the operation. 11 (5.6%) patients did not received anticoagulants and antiplatelet agents before the operation. The majority of patients (67.01%) terminated antiplatelet therapy 1-5 days before the operation; intraoperative blood loss in average was 334.7±89.7ml. A correlation analysis between the regimen of antiplatelet / anticoagulant therapy and intraoperative blood loss revealed a negative relationship (r = -, 0.85). The patients who were on triple therapy before coronary artery bypass grafting underwent hemotransfusion in 75% of cases; among the patients who received dual antiplatelet therapy, blood transfusion was performed in 26.04% of cases, and patients who were on monotherapy with acetylsalicylic acid, blood products were transfused in 22,8% of cases. Conclusions: earlier withdrawal of antiplatelet agents before coronary bypass grafting is associated with fewer blood transfusions - when antithrombotic therapy was terminated 1 day before coronary artery bypass grafting, the frequency of blood transfusions was 36.3%, and among the patients who did not receive antiplatelet therapy before surgery, blood transfusion was performed in 18.1% of cases.

Optical coherent tomography for the diagnostic of non-obstructive coronary artery myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. The widespread use of coronary angiography (CAG) in patients with acute coronary syndrome led to the understanding that in some patients myocardial infarction (MI) occurs against angiographically unchanged or slightly modified coronary arteries (CA). In such cases, the so-called "type 2 IM" is diagnosed in some patients, however, to determine the true cause of MI, a modern method of investigation such as optical coherence tomography (OCT) is needed to visualize the intima of the CA and detect a minimal atherosclerotic process. The purpose of the study was to establish the etiology of MI without obstructive coronary artery disease (MINOCA) using OCT. Materials and methods 160 conclusions of the OCT were analyzed. In 9 (6%) cases, the study was conducted in patients who underwent proven MI (mean age 43,1 ± 13,2, 8 males, 1 female) who had no hemodynamically significant CA stenosis according to CAG data. Results in 2 cases (22%) patients had ST-elevation MI, thrombotic occlusion of the CA (in one case, thrombaspiration was performed). In both patients, spontaneous dissection of the intima of the unmodified CA was detected in the OCT. The remaining 7 patients had non-ST-elevation MI, and in 2 cases, a diagnosis of type 2 MI was established: in both patients, the atherosclerotic plaque was visualized, narrowing the lumen of the CA less than 50%, in one case MI developed against a background of the hypertensive crisis, in another - against a background of spasm of CA. In the remaining 5 patients, OCT revealed subintimal atheromatous, with elements of local dissection of the intima. Thus, in 78% of patients atherosclerosis of CA of different severity (from the subintimal deposition of lipids to the development of atherosclerotic plaque, narrowing the clearance of the SC by less than 50%) was diagnosed. In the analysis of risk factors for coronary heart disease (CHD), 57% of patients with atheromatous CA had more than 2 risk factors for CHD: 3 (42%) smoked, 5 (71%) - obesity, 4 (57% ) - had arterial hypertension, 3 (42%) had dyslipidemia, 1 (14%) had type 2 diabetes. In the group of patients with spontaneous intima dissection of the CA, 1 patient (woman) did not have CHD risk factors, the 2-nd suffered from obesity and hypertension. For all patients a lifestyle correction was recommended; statins, antiplatelets were prescribed, patients with spontaneous dissection of CA had the recommendation of examination in the medical-genetic center. Conclusion Based on the results of the study, in most cases, the cause of IMBOC development was an atherosclerotic lesion of the coronary arteries, which is not always visualized with standard coronary angiography. Basically, the patients were young and middle-aged. Most patients had different risk factors for coronary heart disease.

Using of optical coherent tomography in the determination of the causes of non-obstructive coronary artery myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. The widespread use of coronary angiography (CAG) in patients with acute coronary syndrome led to the understanding that in some patients myocardial infarction (MI) occurs against angiographically unchanged or slightly modified coronary arteries (CA). In such cases, the so-called "type 2 IM" is diagnosed in some patients, however, to determine the true cause of MI, a modern method of investigation such as optical coherence tomography (OCT) is needed to visualize the intima of the CA and detect a minimal atherosclerotic process. The purpose of the study was to establish the etiology of MI without obstructive coronary artery disease (MINOCA) using OCT. Materials and methods 160 conclusions of the OCT were analyzed. In 9 (6%) cases, the study was conducted in patients who underwent proven MI (mean age 43,1 ± 13,2, 8 males, 1 female) who had no hemodynamically significant CA stenosis according to CAG data. Results in 2 cases (22%) patients had ST elevation MI, thrombotic occlusion of the CA (in one case, thrombaspiration was performed). In both patients, spontaneous dissection of the intima of the unmodified CA was detected in the OCT. The remaining 7 patients had non ST elevation MI, and in 2 cases, a diagnosis of type 2 MI was established: in both patients, atherosclerotic plaque was visualized, narrowing the lumen of the CA less than 50%, in one case MI developed against a background of hypertonic crisis, in another - against a background of spasm of CA. In the remaining 5 patients, OCT revealed subintimal atheromatosis, with elements of local dissection of the intima. Thus, in 78% of patients atherosclerosis of CA of different severity (from the subintimal deposition of lipids to the development of atherosclerotic plaque, narrowing the clearance of the SC by less than 50%) was diagnosed. In the analysis of risk factors for coronary heart disease (CHD), 57% of patients with atheromatous CA had more than 2 risk factors for CHD: 3 (42%) smoked, 5 (71%) - obesity, 4 (57% ) - had arterial hypertension, 3 (42%) had dyslipidemia, 1 (14%) had type 2 diabetes. In the group of patients with spontaneous intima dissection of the CA, 1 patient (woman) did not have CHD risk factors, the 2-nd suffered from obesity and hypertension. For all patients a lifestyle correction was recommended; statins, disaggregants were prescribed, patients with spontaneous dissection of CA had recommendation of examination in the medical-genetic center. Conclusion Based on the results of the study, in most cases, the cause of IMBOC development was atherosclerotic lesion of the coronary arteries, which is not always visualized with standard coronary angiography. Basically, the patients were young and middle-aged. Most patients had different risk factors for coronary heart disease.

The Association between Serum Heme Oxygenase-1 Levels and Coronary SYNTAX Score

Aim: The relationship between heme oxygenase-1 (HO-1) levels and atherosclerosis was investigated in multiple studies. The aim of this study was to establish the relationship between HO-1 levels and coronary SYNergy between percutaneous coronary intervention with TAXus and Cardiac Surgery (SYNTAX) score in patients with stable coronary artery disease (CAD). Methods: Patients who had been planned to undergo invasive coronary angiography due to a suspected CAD, between the dates of September and December 2019, were included in the study. Serum HO-1 levels were measured from peripheral venous blood. The SYNTAX score was calculated using standard coronary angiography images. Regression analysis was performed to establish the relationship between HO-1 levels and the SYNTAX score. Results: In total, 137 patients were included. The median age was 63 years (IQR: 15), and most of the patients were male (75.2%). The median HO-1 level was 1.44 (IQR: 0.88) ng/mL, and the median SYNTAX score was 6 (IQR: 13). Regression analysis showed that HO-1 is the single most important variable associated with the SYNTAX score (HO-1 levels from 1.01 to 1.87 ng/mL, OR: 6.77, 95% confidence interval 5.18–8.36, p < 0.0001). Conclusion: In this study, serum HO-1 levels were significantly associated with the coronary SYNTAX score.

Coronary Angiogram using Distal Radial Access: A Retrospective Observational Study

Introduction: Transradial access has become gold standard for percutaneous coronary catheterisation procedures. As the learning curve overcomes, safe alternative access sites such as Distal Radial Artery (DRA), ulnar artery have been tried. Aim: The aim of this study was to generate best evidence for using right DRA for coronary angiography. Materials and Methods: In this retrospective study, a novel route in addition to radial artery was studied. A total of 150 cases who underwent the angiogram by the DRA technique were included in the study, preserving the radial artery for various procedures. DRA was punctured in anatomical snuffbox by standard techniques and coronary angiography was performed. The evaluated parameters included the characteristics of patients (gender and age distribution), blood pressure (systolic and diastolic), mean arterial pressure, flouro time, puncture time, Dose Area Product (DAP) and cumulative air kerma. Fisher’s-exact test was used to find out the association between the gender, hypertension, diabetes and the success of puncture. Results: There was 93.4% successful puncture rate for distal radial access. There was no influence of age on the success of puncture. The association of success of puncture with gender, hypertension and diabetes was not statistically significant. Conclusion: This study presents that the distal radial approach is feasible and relatively safe. Further randomised controlled trials may be required to establish this relatively new approach as the standard care.

Coronary Blood Flow Measurement in Conventional Coronary Angiograms by a New Method Based on Contrast Density Detection. A Physiological Insight.

ResumoFundamento O grau de fluxo TIMI e a contagem quadro a quadro TIMI corrigida (CTFC) são métodos amplamente utilizados para avaliar o fluxo sanguíneo coronariano angiográfico. A medição do fluxo sanguíneo coronariano (FSC) na coronariografia (CAG) padrão despertou grande interesse recentemente, tentando combinar o conceito de CTFC com novos métodos para pós-angioplastia e avaliação da síndrome cardíaca X. Além disso, o fluxo coronariano lento é considerado um critério importante para a angina microvascular.Objetivo Explorar uma nova abordagem de medição angiográfica quantitativa do FSC com base na detecção densitométrica de contraste na CAG offline, usando um software acessível para obter uma avaliação mais precisa e confiável do FSC.Métodos Trinta pacientes foram estudados e divididos em 2 grupos: fluxo sanguíneo coronariano normal (FN) e fluxo sanguíneo coronariano lento (FL), de acordo com a definição da CTFC. O MD foi aplicado à amostra do estudo para diferenciar entre FN e FL. A estatística não paramétrica foi usada para avaliar diferenças entre os grupos com p<0,05.Resultados O valor de referência normal do MD obtido para o fluxo sanguíneo coronariano foi de 9 [5–10] quadros. Os grupos FN vs. FL foi comparado e expresso como mediana [intervalo interquartil], para a artéria descendente anterior esquerda: 10 [7–11] vs. 21 [8–33]; p=0,016; artéria circunflexa: 9 [4–13] vs. 14 [11–30]; p=0,012 e artéria coronária direita: 5 [3–11] vs. 13 [8–26]; p=0,009.Conclusão O MD mostrou a viabilidade de medir o fluxo sanguíneo coronariano com precisão, consistência e reprodutibilidade em um angiograma coronariano padrão, mostrando a capacidade adicional de diferenciar FN de FL em pacientes com dor precordial e artérias coronárias normais. (Arq Bras Cardiol. 2020; 115(3):503-512)