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The 12th Annual Scientific Meeting of the SCCT, held from July 6 to July 9 in Washington, DC, was one of the largest to date with 724 attendants from 34 countries, 130 invited talks, 4 “Read with the Experts” sessions, 42 oral abstracts presented, 20 rapid fire posters and 164 poster presentations with the abstracts of all of these published in the JCCT. This article summarises the many themes and topics of presentation and discussion in this meeting, and the many technical advances that are likely to impact future clinical practice and feature in future meetings.
“Beavers build houses; but they build them in nowise differently, or better now, than they did, five thousand years ago. Ants, and honey-bees, provide food for winter; but just in the same way they did, when Solomon referred the sluggard to them as patterns of prudence. Man is not the only animal who labors; but he is the only one who improves his workmanship”Abraham Lincoln
Ten years ago the members of the Society of Cardiovascular Computed Tomography (SCCT) congregated within Washington DC from July 6–8, 2007 to take part in the second Annual Scientific Meeting (ASM). On the backdrop of Apple having just released its first edition of the iPhone and the announcement that Barack Obama was to run for president, 750 registrants made the trip to hear about cutting-edge advances in CT. They heard the announcement that CT-STAT – the first randomized control trial comparing coronary computed tomography angiography (coronary CTA) to myocardial perfusion imaging in patients with acute chest pain in the emergency department – was to begin recruitment; proof of the concept that myocardial perfusion could be measured using changes in myocardial contrast attenuation following the administration of adenosine; that significant dose reduction could be achieved in coronary CTA by using a tube current of 100 kV rather than 120 kV; and that prospective step-and-shoot scan modes could significantly reduce dose compared with retrospective spiral acquisitions.
10 years on we are still competing with the draw of the iPhone (now into its 8th iteration), and people are still talking about the White House Residents. However the scientific evidence supporting cardiac CT could not have changed more. Since CT-STAT first demonstrated that coronary CTA could reduce cost and length of stay in the emergency department in 2011,
it has been joined by an ever-growing number of randomized controlled trials, including ROMICAT II, ACRIN-PA, CAPP, CRESCENT, PROMISE and SCOT-HEART, each contributing to the scientific evidence base supporting coronary CTA (See Fig. 1). Based on this wealth of evidence, coronary CTA is now an established part of routine clinical care in many countries and in some countries, most notably the UK following the recent NICE guideline revision,
coronary CTA is recommended as the first-line imaging modality in the assessment of patients presenting with new onset stable chest pain.
Fig. 1Diagram of the growth of coronary CTA randomized clinical trials (top, blue) and coronary CTA registries (bottom, orange). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)
The 12th Annual Scientific Meeting of the SCCT, held from July 6 to July 9 in Washington, DC, was one of the largest to date with 724 attendants from 34 countries, with 130 invited talks, 4 “Read with the Experts” sessions, 42 oral abstracts presented, 20 rapid fire posters and 164 poster presentations with the abstracts of all these published in the JCCT.
It also introduced specialty-based hands-on workshops in four separate tracks and a pre-program focusing on coronary CTA in the Emergency Department and Advocacy.
The volume of work and breadth of applications of cardiac CT discussed and exhibited at the meeting was staggering and a testament to the talent and drive of the international SCCT community. To try and summarize this exciting and varied meeting in a cohesive manner is challenging. Here we summarize Dr Ed Nicol's closing talk at the 2017 ASM and examine the 5 key themes that he, Dr Nieman and Dr Ferencik highlighted:
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Coronary Artery Disease
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Structural Heart Disease
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Congenital Heart Disease
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Disruptive technology
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Radiation
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Advocacy
2. Coronary artery disease
With cardiovascular disease now the single leading cause of death, in not only the developed world, but also in the developing world,
it is perhaps unsurprising that CAD assessment formed a central theme throughout the conference. As Professor Leslee Shaw, the now immediate past-president of the SCCT, demonstrated in her opening speech, the evidence base underpinning the use of cardiovascular CT has grown exponentially in the last decade with the number of randomized control trials, multicenter registries and multimodality registries now too numerous to easily reel off. One of the most powerful demonstrations of the value of coronary CTA is the reduction in cardiovascular mortality evidenced in a landmark analysis of SCOT-HEART.
These results were echoed in a Danish national registry study - one of the top 10 papers of the year selected by Professor Stephan Achenbach in his opening talk - which demonstrated that, compared with functional testing, coronary CTA increased utilization of statins and aspirin, as well as appropriate invasive catheterisation rates, the combination of which resulted in a downstream reduction of non-fatal acute myocardial infarction in those who underwent coronary CTA as their investigation for chest pain.
CAD-RADs - one of the chief movements towards a standardization of coronary CT reporting developed and pioneered by the SCCT in conjunction with the American College of Radiology and North American Society of Cardiovascular Imaging
CAD-RADS(TM) coronary artery disease - reporting and data system. An expert consensus document of the society of cardiovascular computed tomography (SCCT), the American College of Radiology (ACR) and the North American society for cardiovascular imaging.
- was a recurrent theme in presentations. This scoring system seeks to simplify the complex information from coronary CTA into a single number based on the most severe stenosis from CAD-RADs 0 indicating no coronary artery disease through to CAD RADs 5 when obstruction is present with a proposed management strategy based on this score. To examine the utility of this score, multiple groups analyzed existing data such as in the CONFIRM registry and the SCOT-HEART trial, with both showing powerful prognostic discrimination between CAD-RAD groups with publications expected to follow in the next year. As yet unpublished, CAC-RADS was also introduced to the SCCT ASM community by Dr Harvey Hecht, and similar validation of this new proposed model will undoubtedly follow at SCCT's next Annual Scientific Meeting 2018 in Dallas, TX.
One of the most interesting, if counterintuitive, moments came up in the discussion of the recently announced results of the PACIFIC trial.
These show that while two heads may indeed be better than one, two tests are not. When analyzing the combination of coronary CTA with single positron emission computed tomography (SPECT) or positron emission tomography (PET) it was shown that combining these tests with coronary CTA simply added noise without improving accuracy. In contrast, Dr Adriaan Coenen et al. demonstrated that combining coronary CTA, point of care CT-derived fractional flow reserve (CT-FFR, See Fig. 2) and CT perfusion (CTP) in a stepwise manner may significantly improve diagnostic accuracy.
Further analysis of the CORE-320 multicentre registry data, demonstrated that results from CTA and CTP were similarly predictive of major adverse cardiac events to those of combined invasive coronary angiography and SPECT findings.
Prognostic value of combined CT angiography and myocardial perfusion imaging versus invasive coronary angiography and nuclear stress perfusion imaging in the prediction of major adverse cardiovascular events: the CORE320 multicenter study.
These studies combined with a recent meta-analysis showing largely equivocal sensitivity and specificities between PET, CMR and CTP, and with all three outperforming SPECT,
Fig. 2CT-based fractional flow reserve in a patient with diffuse, hemodynamically significant coronary disease in the LAD, and a hemodynamically non-significant lesion in the RCA.
While we embrace the successes of CTA research in the ASM, the “Gladiators Arena: Great debates on imaging” provided an entertaining, but crucial, reminder of the challenges facing the field. Professor Peter WF Wilson - this year's winner of the Arthur S. Agatston Cardiovascular Disease Prevention Award - argued passionately that risk scores were all that were required for cardiovascular prevention. On a related theme, Professor Rita Redberg highlighted what she perceives as a paucity of high quality evidence supporting use for coronary calcium or coronary CTA in stratifying and directing preventative therapy in those with non-obstructive coronary artery disease, with the one randomized clinical trial to date in diabetics showing no significant benefit.
In favor of image guided therapy, Professor Matthew Budoff clearly demonstrated the significant benefit of coronary calcium scanning in successfully reclassifying those with low-intermediate risk, and the downstream benefit of this, potentially reducing the number needed to treat for the prevention of myocardial infarction with statin therapy to just 34.
Dr. Min nicely articulated the importance that coronary atherosclerotic burden and plaque morphology should play in modifying preventive therapies in patients who undergo coronary CGTA.
3. Structural Heart Disease
The past year has been an exciting one in structural heart disease assessment, and this was reflected in multiple sessions throughout the meeting. CT has played a central role in transcutaneous aortic valve replacement (TAVR) planning for several years, with previous work showing improved surgical outcomes with cardiac CT-based sizing as compared with echocardiography.
The impact of integration of a multidetector computed tomography annulus area sizing algorithm on outcomes of transcatheter aortic valve replacement: a prospective, multicenter, controlled trial.
the demand for pre-procedural assessment is likely to increase further. Thus, it is no surprise that the pre-course specialty hands-on workshops on Structural Heart and Advanced Structural Heart disease was well attended by those keen to get up-to-date with the techniques for pre-TAVR assessment, as well as get a head start on valve-in-valve assessment and learn the techniques and measures required for Transcutaneous Mitral Valve Insertion (TMVI) work-up.
Increasing utilization of CT in the pre and post-operative period has also led to unforeseen findings, namely the new entity of hypoattenuating leaflet thickening (HALT), which has been described in two large multicentre registries and is generally resolved after initiation of oral anticoagulation.
Of note, the 2017 update of the American College of Cardiology valvular heart disease guideline now considers the use of oral anticoagulation using vitamin-K antagonists for at least 3 months post-TAVR in patients at low bleeding risk as a IIa (may be considered) recommendation.
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
However with conflicting results about the clinical implications of HALT in these two registries - one showing no increased stroke hazard, and the other showing an increased risk of transient ischaemic attacks - the next couple of years are key as the imaging community expands its understanding of post-TAVR thrombotic complications. One such study is the RETORIC (Rule out Transcatheter Aortic Valve Thrombosis with Post Implantation Computed Tomography) study, the design and status of which was presented by Dr Karady from Budapest at the Annual Scientific Meeting, which will involve routine post procedural cardiac CT, transthoracic echocardiography, brain MRI and then randomisation to oral anticoagulant or standard care, the combination of which will provide many key insights into this new entity.
Traditionally, assessment of congenital heart disease, particularly in a paediatric population, has been the remit of invasive angiography and cardiac MRI. However with falling radiation doses, and increased temporal and spatial resolution, there is a rapid growth in demand for the use of CT. The SCCT has recently released consensus statements on the indications and technical requirements to guide appropriate use of cardiovascular CT in this complex population.
Computed tomography imaging in patients with congenital heart disease Part I: rationale and utility. An expert consensus document of the society of cardiovascular computed tomography (SCCT).
Computed tomography imaging in patients with congenital heart disease, Part 2: technical recommendations. An expert consensus document of the society of cardiovascular computed tomography (SCCT): endorsed by the society of pediatric Radiology (SPR) and th.
Several of the lead authors of this position statement, including Dr. Kelly Han, participated in a pre-course on ‘Congenital Heart Disease and Cardiovascular CT.’ This workshop covered the use of CT among those with congenital heart disease of all ages and was maximally attended. Topics included coronary anomalies, optimal visualisation of arterial and venous structures, dealing with complex Fontan patients and their variable flow rates and convoluted vascular connections using a two-, or for the adventurous, 3-phase contrast injection technique. Abstract submission in this growing area of cardiovascular CT was high and required its own poster presentation session, where post-operative assessment of the right ventricular outflow tract in Tetralogy of Fallot, multicentre reports on coronary anomaly assessment, and a glimpse to the future using CT to design novel stents for aortic coarctation treatment, were presented.
At the SCCT Annual Scientific Meeting in Washington 10 years ago, 256 slice CT scanners and CT perfusion imaging were considered the disruptive incoming technologies. Indeed, in 2007, cardiac CT itself was considered disruptive technology in the clinical sphere where SPECT and invasive coronary angiography held hegemony. For a glimpse into the next 10 years and a sight of this decade's disruptive technology one had to look no further than the “Cutting Edge Cardiovascular CT” session, as well as the multitude of abstracts presented on innovative and disruptive technology, throughout the meeting. Focusing on just a few of these; Professor David Bluemke presented on spectral CT and its ability to blend and extract different energies to best detect the pathology of interest. He discussed how such an approach markedly increased the contrast to noise ratio of infarct imaging – currently challenging in the clinical realm.
The utility of this was further reported by Dr Yasutoshi Ohta in the scientific abstract sessions where, using single-source dual-energy CT, iodine mapping and virtual monochromatic images were far superior to standard imaging for scar detection in patients with heart failure, with area under the receiver operating curve (AUC) of 0.97 and 0.95 achieved as compared with late gadolinium enhancement sequences on MRI.
Dr Suhny Abbara illuminated the audience on spectral CT whereby the energies of the arriving photons can be extracted by the detector allowing quantification of the photoelectric and Compton effect interactions, thus allowing tissue finger printing using CT (see Fig. 3). The combination of these two technologies hold the potential to markedly improve tissue characterization, reduce image noise, and contrast and radiation dose in the future.
Fig. 3Spectral Detector CT (SDCT) with CT Fingerprinting. A) composite figure of cardiac CTA acquired with SDCT shows conventional 120kVp image (top left), Material Attenuation Decomposition (MAD) plot showing compton vs photoelectric contribution of all voxels within the entire CT acquisition (top right), which is known as CT fingerprinting. SDCT derived Compton (bottom left) and Photoelectric effect (bottom right) contribution images. B) shows utilization of the MAD plot to identify voxels with certain properties by circling regions of interest in the fingerprint (bottom) resulting in identification and color coding of these voxels in the image domain (top). (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)
Computational flow dynamics (CFD) was shown to be extending well beyond coronary assessment with CT-derived FFR. The results of the EMERALD study and the value of shear-stress simulations are still awaited,
though presentations throughout the ASM showed utilization of CFD in structural heart disease (TAVI, TMVI and left atrial assessment), congenital heart disease and valvular heart disease. Whilst most literature is still to be found in physics and engineering journals, this technology may soon break into the clinical research arena.
But what debate on disruptive technologies would be complete without discussing machine learning (ML)? In another paper included in Dr Achenbach's summary of top articles of the last year we heard that ML applied to the CONFIRM registry improved the AUC to 0.79 for the prediction of 5 year all cause mortality.
Machine learning for prediction of all-cause mortality in patients with suspected coronary artery disease: a 5-year multicentre prospective registry analysis.
Machine Learning appears to be penetrating all aspects of data and image analysis at the conference. Dr Commandeur presented a deep learning algorithm for the extraction of epicardial and thoracic fat with a high correlation with expert contouring (0.95 and 0.93 for thoracic and epicardial fat respectively). From others we learned that ML could be used to predict the coronary calcium score, the presence of coronary atherosclerosis, transform data from low dose CT scans into an image quality comparable to that of standard dose scans, and could generate accurate FFR estimations.
Dr Marton Kolossvary (winner of the Seimens Outstanding Academic Research Award) presented on the use of radiomics, a process of extracting numerous quantitative features from images to create large data sets in which each abnormality is described by hundreds of parameters.
Using this process in coronary plaque analysis they extracted 4784 radiomic parameters, and demonstrate superior detection of plaques with a napkin ring sign compared with conventional plaque analysis. Whilst complex to understand, ML, radiomics, CFD and other computer empowered techniques are likely to transform our understanding and clinical practice of cardiovascular CT in the next decade.
6. Radiation
The hot topic of discussion in the field of radiation exposure at the current meeting focussed on the recently published paper suggesting that the use of the chest conversion factor for calculation of cardiac CTA dose (k = 0.014 mSv·mGy−1cm−1) underappreciates the impact of radiation in the soft tissue volume encapsulating the heart with a new average k-factor of 0.026 mSv·mGy−1cm−1.
The results of the UK nationwide dose audit were presented and discussed. This showed that using real world data and an even more severe k-factor of 0.028, a median dose of 5.9 mSv was observed across 50 centres.
That this would equate to 2.95 mSv using the historic conversion factor truly shows that significant advances are being made in translating the theoretical dose reduction derived from reduced coverage, reduced kV and iterative reconstruction produced in the academic literature out into routine clinical practice. With the presented results from multiple posters at the meeting demonstrating the ability of third generation scanners to reduce dose without impacting calcium scoring, plaque analysis or image quality, this is only likely to continue to fall.
In both the pre-programme and in the closing sessions of the ASM we heard the fruitful results of the continued advocacy efforts of Dr Ahmad Slim and others in highlighting the benefits of coronary CTA, with year on year increases in coverage for an increasing range of indications, for patients in the USA. Greater information both on coverage and how the SCCT can help impact local reimbursement policies can be found on the ‘SCCT advocacy’ section of the SCCT website. However, this is not just a North American issue, as demonstrated through talks by Dr Giles Roditi, President of the British Society of Cardiovascular Computed Tomography (BSCCT), and Dr Ed Nicol (immediate past President of BSCCT), we heard about the advocacy efforts that are ongoing in the UK in the wake of recent NICE chest pain guidelines, which if they are to be met in full will require a staggering 800% increase in national coronary CTA capacity.
No matter how successful a society is, its future success rests on the generation it trains and inspires to continue its work into the future. It was therefore truly heartening to witness the incredible work going on by the many trainee members of the SCCT. Best abstract awards were presented to: Dr. Mhairi Doris, a UK trainee working in Cedar Sinai, for her presentation showing high risk plaque causes a reduction in CT-derived FFR even in the absence of significant stenosis; Dr Alexia Rossi for her presentation on the comparison of dynamic myocardial computed tomography, MRI perfusion and invasive fractional flow reserve; Dr Frances Wang for his presentation on gender differences in age-adjusted percentiles of the number of calcified coronary plaques in asymptomatic patients undergoing coronary calcium scanning; Dr Gowtham R. Grandhi, on the distribution of the newly described CAD-RADS classification among patients presenting to emergency department with acute chest pain; and Dr Anthony Kueh for his presentation on utilization of CT for the segmentation of the tricuspid valve. Dr Márton Kolossváry won the Seimens Outstanding Academic Research award - awarded to the best abstract from a researcher within 5 years of obtaining their MD – for his presented abstract on Radiomics assessment of high risk plaque, while Dr Balaji Tamarappoo was the runner up for his work showing a reduction of high risk plaque and no change in calcified plaque following statin initiation. Dr Evangelos Oikonomou won the Toshiba Young Investigator Award – awarded to the best abstract presented by a trainee or fellow – for his presentation showing that perivascular fat attenuation could be used to detect active plaque inflammation, with Dr Abdul Rahman Ihdayhid being awarded the runner up for his presentation of using reduced order modeling CT-FFR for the detection of hemodynamically significant coronary stenosis.
Finally Dr Rachel Forsyth won the award for the best abstract from the ‘UK presents’ session for her presentation showing that 18F-Sodium Fluoride PET-CT can predict abdominal aortic aneurysm growth and need for repair. Dr Robin Brusen won the Case of the Year Award. All should be lauded publically given the stiff competition they were up against and we look forward to seeing further results of their careers at future meetings. Also to be congratulated are Dr James Lee and the rest of the Fellows and Residents in SCCT (FiRST) committee in assisting in the boot camp training sessions, the CT jeopardy session; and their constant social media presence at the annual meeting was phenomenal. Engagement with trainees has been given a massive boost this year through the sponsorship of SCCT membership by GE and Toshiba for all Cardiology and Radiology Residents and any and all trainees reading this should make use of this incredible opportunity.
We look forward to welcoming you to the next SCCT Annual Scientific Meeting to be held in Texas, from July 12th-15th 2018.
Competing interests
The authors declare no relevant competing interests.
Funding
No relevant sources to declare.
References
Berman D.S.
Achenbach S.
Taylor A.J.
Weigold G.
Poon M.
Highlights of the Second Annual Scientific Meeting of the Society of Cardiovascular Computed Tomography.
CAD-RADS(TM) coronary artery disease - reporting and data system. An expert consensus document of the society of cardiovascular computed tomography (SCCT), the American College of Radiology (ACR) and the North American society for cardiovascular imaging.
Prognostic value of combined CT angiography and myocardial perfusion imaging versus invasive coronary angiography and nuclear stress perfusion imaging in the prediction of major adverse cardiovascular events: the CORE320 multicenter study.
The impact of integration of a multidetector computed tomography annulus area sizing algorithm on outcomes of transcatheter aortic valve replacement: a prospective, multicenter, controlled trial.
2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
Computed tomography imaging in patients with congenital heart disease Part I: rationale and utility. An expert consensus document of the society of cardiovascular computed tomography (SCCT).
Computed tomography imaging in patients with congenital heart disease, Part 2: technical recommendations. An expert consensus document of the society of cardiovascular computed tomography (SCCT): endorsed by the society of pediatric Radiology (SPR) and th.
Machine learning for prediction of all-cause mortality in patients with suspected coronary artery disease: a 5-year multicentre prospective registry analysis.
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