Mortality impact of low CAC density predominantly occurs in early atherosclerosis: explainable ML in the CAC consortiumOriginal TOC summary: We used SHAP, an explainable machine learning (ML) technique, to determine the risk predictive value and age interaction of coronary artery calcium (CAC) characteristics among 63,215 asymptomatic patients in the CAC consortium. The addition of CAC density and number of calcified vessels to an ML model with clinical characteristics + CAC did not improve prediction for all-cause mortality (p = 0.23), but did improve for cardiovascular mortality (p = 0.03). Lower CAC density increased mortality, particularly very low CAC density ≤0.75, which occurred predominantly in CAC1-100. Explainable ML should be applied in clinical research for transparent predictive modeling.
Higher coronary artery calcium score is associated with increased risk of atrial fibrillation recurrence after catheter ablationCoronary artery calcium score (CACS) is associated with an increased risk of atrial fibrillation (AF) development, but scarce data are available regarding the impact on AF recurrence. This study aims to assess the impact of CACS on AF recurrence following catheter ablation.
Computed tomography imaging for subclinical leaflet thrombosis following surgical and transcatheter aortic valve replacementSubclinical leaflet thrombosis (LT) may occur following surgical and transcatheter aortic valve replacement. Computed tomography (CT) has become an established imaging modality to diagnose subclinical LT following bioprosthetic aortic valve replacement. Even so, there is a limited (but growing) experience in utilizing CT imaging for this indication. This review emphasizes a systematic approach to acquiring and analysing CT imaging for subclinical LT, highlighting evidence surrounding clinical sequelae of subclinical LT and anti-thrombotic implications following diagnosis.
The effect of patient and imaging characteristics on coronary CT angiography assessed pericoronary adipose tissue attenuation and gradientCoronary CT angiography (CCTA) pericoronary adipose tissue (PCAT) markers are promising indicators of inflammation.
Implications of computed tomography reconstruction algorithms on coronary atheroma quantification: Comparison with intravascular ultrasoundAdvances in coronary computed tomography angiography (CCTA) reconstruction algorithms are expected to enhance the accuracy of CCTA plaque quantification. We aim to evaluate different CCTA reconstruction approaches in assessing vessel characteristics in coronary atheroma using intravascular ultrasound (IVUS) as the reference standard.
Association of left ventricular diastolic function with coronary artery calcium score: A Project Baseline Health StudyCoronary artery calcium (CAC) and left ventricular diastolic dysfunction (LVDD) are strong predictors of cardiovascular events and share common risk factors. However, their independent association remains unclear.
Follow-up assessment of myocardial calcification secondary to fulminant myocarditis with computed tomographyA 16-year-old man underwent venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy due to hemodynamic collapse caused by viral fulminant myocarditis. Supplementary Figure 1 presents the time course of treatment. High-density areas wtihin the myocardium were initially detected by computed tomography (CT) 10 days after admission which was not observed on admission (Fig. 1A). The CT tissue attenuation value reached 106 Hounsfield Unit (HU) in these areas 40 days after admission (Fig. 1B), with changes in the left lateral wall being more evident than other areas.
Comparison of coronary CT angiography-based and invasive coronary angiography-based quantitative flow ratio for functional assessment of coronary stenosis: A multicenter retrospective analysisThe aim of this study was to evaluate the diagnostic performance of coronary CT angiography (CTA)-based quantitative flow ratio (QFR), namely CT-QFR, and compare it with invasive coronary angiography (ICA)-based Murray law QFR (μQFR), using fractional flow reserve (FFR) as the reference standard.
Multivessel coronary artery aneurysms as a complication of chronic active Epstein-Barr virus infection: An atypical and occasional complicationCoronary artery aneurysm (CAA) is defined as a coronary artery dilatation >1.5 times the diameter of the normal adjacent segments or the diameter of the patient's largest coronary vessel. It is an uncommon disease, present in 1–4% of coronary angiography findings.1
Perivascular fat attenuation for predicting adverse cardiac events in stable patients undergoing invasive coronary angiographyInflammation surrounding the coronary arteries can be non-invasively assessed using pericoronary adipose tissue attenuation (PCAT). While PCAT holds promise for further risk stratification of patients with low coronary artery disease (CAD) prevalence, its value in higher risk populations remains unknown.
Systolic or diastolic CT image acquisition for transcatheter aortic valve replacement – An outcome analysisComputed tomography (CT) imaging is the standard of care before transcatheter aortic valve replacement (TAVR). The aortic annulus undergoes conformational changes during the heart cycle. Therefore, the image acquisition time point can impact prosthesis sizing and fit. Clinical outcome data are lacking. The aim of this study was to compare systolic and diastolic cardiac CT data acquisition with regard to procedural and clinical outcomes in patients undergoing TAVR for severe aortic stenosis (AS).
Coronary CTA plaque volume severity stages according to invasive coronary angiography and FFRAtherosclerotic plaque characterization by coronary computed tomography angiography (CCTA) enables quantification of coronary artery disease (CAD) burden and type, which has been demonstrated as the strongest discriminant of future risk of major adverse cardiac events (MACE). To date, there are no clinically useful thresholds to assist with understanding a patient's disease burden and guide diagnosis and management, as there exists with coronary artery calcium (CAC) scoring. The purpose of this manuscript is to establish clinically relevant plaque stages and thresholds based on evidence from invasive angiographic stenosis (ICA) and fractional flow reserve (FFR) data.
Are risk factors necessary for pretest probability assessment of coronary artery disease? A patient similarity network analysis of the PROMISE trialPretest probability (PTP) calculators utilize epidemiological-level findings to provide patient-level risk assessment of obstructive coronary artery disease (CAD). However, their limited accuracies question whether dissimilarities in risk factors necessarily result in differences in CAD. Using patient similarity network (PSN) analyses, we wished to assess the accuracy of risk factors and imaging markers to identify ≥50% luminal narrowing on coronary CT angiography (CCTA) in stable chest-pain patients.
Prognostic value of computed tomography derived fractional flow reserve for predicting cardiac events and mortality in kidney transplant candidatesCardiac screening using coronary computed tomography angiography (CCTA) in kidney transplant candidates before transplantation yields both diagnostic and prognostic information. Whether CT-derived fractional flow reserve (FFRCT) analysis provides prognostic information is unknown. This study aimed to assess the prognostic value of FFRCT for predicting major adverse cardiac events (MACE) and all-cause mortality in kidney transplant candidates.
Prospective evaluation of the learning curve and diagnostic accuracy for Pre-TAVI cardiac computed tomography analysis by cardiologists in training: The LEARN-CT studyTo investigate the learning curve and the minimum number of cases required for a cardiologist in training to acquire the skills to an accurate pre-TAVI cardiac CT (CCT) analysis using a semi-automatic software.
Diagnostic concordance and discordance between angiography-based quantitative flow ratio and fractional flow reserve derived from computed tomography in complex coronary artery diseaseBoth quantitative flow ratio (QFR) and fractional flow reserve derived from computed tomography (FFRCT) have shown significant correlations with invasive wire-based fractional flow reserve. However, the correlation between QFR and FFRCT is not fully investigated in patients with complex coronary artery disease (CAD). The aim of this study is to investigate the correlation and agreement between QFR and FFRCT in patients with de novo three-vessel disease and/or left main CAD.
Coronary volume to left ventricular mass ratio in patients with diabetes mellitusDiabetes mellitus is a major risk factor for coronary artery disease (CAD) and may provoke structural and functional changes in coronary vasculature. The coronary volume to left ventricular mass (V/M) ratio is a new anatomical parameter capable of revealing a potential physiological imbalance between coronary vasculature and myocardial mass. The aim of this study was to examine the V/M derived from coronary computed tomography angiography (CCTA) in patients with diabetes.
Reproducibility of 4D cardiac computed tomography feature tracking myocardial strain and comparison against speckle-tracking echocardiography in patients with severe aortic stenosisMyocardial strain is an established parameter for the assessment of cardiac function and routinely derived from speckle tracking echocardiography (STE). Novel post-processing tools allow deformation imaging also by 4D cardiac computed tomography angiography (CCT). This retrospective study aims to analyze the reproducibility of CCT strain and compare it to that of STE.
Increased coronary pericoronary adipose tissue attenuation in diabetic patients compared to non-diabetic controls: A propensity score matching analysisPericoronary adipose tissue (PCAT) attenuation is an indicator of active inflammation of perivascular adipose tissue, which is supposed to increase in diabetic patients. We aimed to investigate the PCAT attenuation values and high-risk plaque (HRP) features in diabetic and non-diabetic subjects with different stenotic extents.
IgG4-related disease: Coronary arteritis masquerading as coronary “masses”A 64-year-old man with a history of psoriasis and latent tuberculosis presented to the emergency department with cough and dyspnea. Transthoracic echocardiogram (TTE) showed a large pericardial effusion with early echocardiographic signs of tamponade and a well circumscribed right atrioventricular groove mass extending into the pericardial space, moving with the cardiac cycle without independent mobility (Fig. 1). Pericardiocentesis drained 1 L of sanguinous fluid with a lymphocytic predominance and negative infectious and cytologic work-up.
Live integration of comprehensive cardiac CT with electroanatomical mapping in patients with refractory ventricular tachycardiaAim of the present study was to verify the feasibility and accuracy of live integration of myocardial fibrosis evaluated at CCT with EAM (electro-anatomical mapping).
Deep learning model to quantify left atrium volume on routine non-contrast chest CT and predict adverse outcomesTable of Contents Summary: We aimed to validate a deep learning model to automatically quantify left atrial (LA) volumes from routine non-contrast chest CT and evaluate prediction for cardiovascular outcomes. We evaluated 273 patients (median age 69 years, 55.5% male) who underwent a routine non-ECG gated NCCT for lung cancer screening. LA volumes were quantified by three expert cardiothoracic radiologists and a prototype AI algorithm. There was excellent correlation between AI and expert results. AI-derived LA volumes were associated with increased risk of major adverse cardiac events, heart failure hospitalization, and new-onset atrial fibrillation within five years.
Impact of computed-tomography defined sarcopenia on outcomes of older adults undergoing transcatheter aortic valve implantationThe adoption of Computed tomography (CT)-defined sarcopenia to risk stratify transcatheter aortic valve implantation (TAVI) candidates remains limited by a lack of both standardized definition and evidence of independent value over currently adopted mortality prediction tools.
The impact of hypo-attenuated leaflet thickening on haemodynamic valve deterioration following transcatheter aortic valve replacement186 patients were prospectively recruited following transcatheter aortic valve replacement (TAVR) for hypo-attenuated leaflet thickening (HALT) on computed-tomography (CT) imaging and to determine its impact on haemodynamic valve deterioration (HVD). Routine echocardiograms at discharge, one month and annually were performed. LT prevalence was 17.7% and HVD was present in 8.6% of the total cohort. HALT was the only independent predictor of HVD. Thresholds for HALT predicting HVD were a cumulative depth of 2.4 mm and cumulative area of 28 mm2. HALT is an independent predictor of HVD, which exhibits specific depth and area thresholds for HVD prediction.
Cumulative exposure amount of PM2.5 in the ambient air is associated with coronary atherosclerosis - Serial coronary CT angiography studyTOC SUMMARY: It is unclear how air pollution contributes to the development of cardiovascular disease. We investigated the change of coronary atherosclerosis using serial CCTAs in relation to the cumulative amount of PM2.5 exposure between the two CCTAs in 3,127 healthy adults. Coronary calcification progressed in 1,361 (43.5%) subjects with a positive relationship between the cumulative amount of PM2.5 exposure and CACS. The cumulative amount of PM2.5 exposure, rather than the average concentration of PM2.5, was independently associated with progression of coronary calcification and diffuse development of de novo calcified plaques, with its impact higher than any other traditional cardiovascular risk factors.
Right ventricular dysfunction by computed tomography associates with outcomes in severe aortic stenosis patients undergoing transcatheter aortic valve replacementTOC summary: This study evaluated the presence of right ventricular dysfunction (RVD) by functional cardiac computed tomography angiography (CCTA) in 502 patients undergoing routine evaluation for transcatheter aortic valve replacement. CCTA-RVD was defined as right ventricular ejection fraction <50%, and was tested for its prognostic value beyond conventional risk factors and echocardiography. In our study, 25% of patients have RVD on CT that was not present on 2D echocardiography. CT-RVD provides independent prognostic value that is incremental to conventional clinical and echocardiographic characteristics, and therefore should be considered in routine risk stratification of patients with severe AS.
Prognostic impact of identifying etiology of prosthetic valve dysfunction with CTIn 132 patients with suspected PVD, an etiology was diagnosed on CT in 60.6% and on echocardiography in 34.1% patients. On adjusted multivariable analyses, CT diagnosis of structural valve degeneration was significantly associated with the composite outcome of reoperation or death whereas echocardiography diagnosis was not. CT assessment of PVD had prognostic significance for hard outcomes and should be considered in the diagnostic evaluation of patients with suspected PVD.
Clinical outcomes following transcatheter aortic valve implantation in patients with porcelain aortaCurrent guidelines favor transcatheter aortic valve implantation (TAVI) over surgical aortic valve replacement in patients with porcelain aorta (PAo). The clinical relevance of PAo in patients undergoing TAVI is however incompletely understood. The purpose of this study is to evaluate clinical outcome of patients with PAo undergoing TAVI.
Detection of small coronary calcifications in patients with Agatston coronary artery calcium score of zeroThe conventional Agatston coronary artery calcium score (CACS) method may fail to detect very small or less dense calcified plaques; smaller than 3 continuous pixels (1 mm2) or with a density lower than 130 Hounsfield Units (HU). A significant proportion of patients classified as CACS = 0, could potentially be reclassified as >0 by altering these thresholds. The increased sensitivity with lower HU threshold comes at a cost of reduced specificity by introducing false positive (noise) cases. Modifying the threshold to <1 mm 2 and HU > 120, allows 12.1% of patients with CACS = 0 to be reclassified as CACS> 0 while introducing only 0.9% of noise.
Budd-Chiari syndrome: A rare association of Scimitar syndromeA 3-year-old asymptomatic girl was noted to have a heart murmur. Chest X-ray showed a curvilinear shadow along the right heart border (Fig. 1A) characteristic of the Scimitar sign. Echocardiography revealed a Scimitar vein (SV) draining the entire right lung to the inferior vena cava (IVC) which was stenosed at the junction with SV (Fig. 1B; arrow). CT angiography and hepatic venography revealed a 1.5 cm-long segment of stenosis in the IVC proximal to the insertion of the SV, resulting in outflow obstruction of short hepatic veins (HVs) with resultant intrahepatic veno-venous collaterals which coursed to the IVC above the level of stenosis (Fig. 2).
Comparison of coronary atherosclerotic plaque progression in East Asians and Caucasians by serial coronary computed tomographic angiography: A PARADIGM substudyTo investigate potential differences in plaque progression (PP) between in East Asians and Caucasians as well as to determine clinical predictors of PP in East Asians.
Trans-lesional fractional flow reserve gradient as derived from coronary CT improves patient management: ADVANCE registryThe role of change in fractional flow reserve derived from CT (FFRCT) across coronary stenoses (ΔFFRCT) in guiding downstream testing in patients with stable coronary artery disease (CAD) is unknown.
Left ventricular assist device pseudo-thrombosis due to use of metal artifact reduction algorithm on cardiac CTProjection-based metal artifact reduction (p-MAR) is a CT technique in which projection data corrupted by metallic artifact is replaced by ‘estimated’ corrected values. This technique has shown promise with its ability to improve image quality in patients with metallic hardware or implants. p-MAR is becoming increasingly popular, as it can be used after image acquisition and does not lead to increase in the radiation dose to the patient.1 While the advantage of p-MAR for metal artifact reduction is well established, it may induce artifact in high-attenuation cardiovascular structures with attenuation characteristics similar to metal.
Prognostic value of myocardial perfusion imaging after first-line coronary computed tomography angiography: A multi-center cohort studyFurther diagnostic testing may be required after a coronary computed tomography angiography (CTA) showing suspected coronary stenosis. Whether myocardial perfusion imaging (MPI) provides further prognostic information post-CTA remains debated. We evaluated the prognosis for patients completing CTA stratified for post-CTA diagnostic work-up using real-world data.
Value of semiquantitative assessment of high-risk plaque features on coronary CT angiography over stenosis in selection of studies for FFRctThe degree of stenosis on coronary CT angiography (CCTA) guides referral for CT-derived flow reserve (FFRct). We sought to assess whether semiquantitative assessment of high-risk plaque (HRP) features on CCTA improves selection of studies for FFRct over stenosis assessment alone.
CT Evaluation by Artificial Intelligence for Atherosclerosis, Stenosis and Vascular Morphology (CLARIFY): A Multi-center, international studyAtherosclerosis evaluation by coronary computed tomography angiography (CCTA) is promising for coronary artery disease (CAD) risk stratification, but time consuming and requires high expertise. Artificial Intelligence (AI) applied to CCTA for comprehensive CAD assessment may overcome these limitations. We hypothesized AI aided analysis allows for rapid, accurate evaluation of vessel morphology and stenosis.
Smoking and obesity predict high-risk plaque by coronary CTA in low coronary artery calcium score (CACS)The AHA recommends statins in patients with CACS>100 AU. However in patients with low CACS (1–99 AU), no clear statement is provided, leaving the clinician in a grey-zone. High-risk plaque (HRP) criteria by coronary CTA are novel imaging biomarkers indicating a higher a-priori cardiovascular (CV) risk, which could help for decision-making. Therefore the objective of our study was to identify which CV-risk factors predict HRP in patients with low CACS 1–99.
Pericoronary adipose tissue CT attenuation and its association with serum levels of atherosclerosis-relevant inflammatory mediators, coronary calcification and major adverse cardiac eventsIncreased attenuation of pericoronary adipose tissue (PCAT) around the right coronary artery (RCA) derived from coronary CTA might detect coronary inflammation. We investigated a potential association between RCA PCAT attenuation and serum levels of atherosclerosis-relevant cytokines and MACE (coronary revascularization, myocardial infarction and/or cardiac death).
CTA pulmonary artery enlargement in patients with severe aortic stenosis: Prognostic impact after TAVRTAVR is highly effective at reducing mortality of patients with severe aortic stenosis. However, despite the high rates of procedural success, some patients do not achieve a functional benefit or die within a short time period after the procedure. Pulmonary hypertension is a known predictor of poor outcome in patients undergoing TAVR and correlates strongly with PA enlargement measured on CT. Our study shows that MPA enlargement, defined as area-MPA ≥7.40 cm2 on pre-procedural CTA, is an independent predictor of 1-year mortality after TAVR. This imaging marker could be relevant in improving individual risk classification in TAVR candidates.
The accuracy of coronary CT angiography in patients with coronary calcium score above 1000 Agatston Units: Comparison with quantitative coronary angiographyHigh amounts of coronary artery calcium (CAC) pose challenges in interpretation of coronary CT angiography (CCTA). The accuracy of stenosis assessment by CCTA in patients with very extensive CAC is uncertain.
Coronary and total thoracic calcium scores predict mortality and provides pathophysiologic insights in COVID-19 patientsCoronavirus disease 2019 (COVID-19) has spread worldwide determining dramatic impacts on healthcare systems. Early identification of high-risk parameters is required in order to provide the best therapeutic approach. Coronary, thoracic aorta and aortic valve calcium can be measured from a non-gated chest computer tomography (CT) and are validated predictors of cardiovascular events and all-cause mortality. However, their prognostic role in acute systemic inflammatory diseases, such as COVID-19, has not been investigated.
Cardiac computed tomography in the contemporary evaluation of infective endocarditisIncreasing data have accumulated on the role of Cardiac Computed Tomography (CCT) in infective endocarditis (IE) with high accuracy for large vegetations, perivalvular complications and for exclusion of coronary artery disease to avoid invasive angiography. CCT can further help to clarify the etiology of infective prosthetic valve dysfunction (e.g. malposition, abscess, leak, vegetation or mass). Structural interventions have increased the relevance of CCT in valvular heart disease and have amplified its use.
Multi-modality imaging and operative findings of a post-TAVR ventricular septal defectMichael Morris: Consultant for Edwards Lifesciences. Educational training for Medtronic.
Prosthesis-patient mismatch defined by cardiac computed tomography versus echocardiography after transcatheter aortic valve replacementEvaluation of prosthesis-patient mismatch (P-PM) after transcatheter aortic valve replacement (TAVR) by transthoracic echocardiography (TTE) has provided conflicting results regarding its impact on outcomes. Whether post-TAVR computed tomography angiography (CTA) evaluation of P-PM can improve our understanding is unknown. We aimed to evaluate the inter-modality (TTE vs. CTA) agreement, inter-valve platform (balloon-expanding valve [BEV] vs. self-expandable valve [SEV]) differences in P-PM severity, and outcomes related to P-PM after TAVR.
CT assessment of the left atrial appendage post-transcatheter occlusion – A systematic review and meta analysisTransesophageal echocardiography (TEE) is the standard imaging modality used to assess the left atrial appendage (LAA) after transcatheter device occlusion. Cardiac computed tomography angiography (CCTA) offers an alternative non-invasive modality in these patients. We aimed to conduct a comparison of the two modalities.
Multiphase TAVR CT identifies unexpected sticky situation (Mechanical mitral valve leaflet dysfunction and bicuspid aortic valve)60-year-old female with history of 33mm ATS mechanical mitral valve replacement 16 years ago for rheumatic mitral valve disease and permanent Atrial Fibrillation (AF) presented with one-year history of worsening exertional dyspnoea as well as symptom of pre-syncope. She was on warfarin for AF as well as mechanical mitral valve replacement (MVR) with therapeutic anticoagulation in the recent time. Her transthoracic echocardiogram was technically difficult as MVR leaflet motion and aortic valve morphology was not well visualised because of artefact from mechanical mitral valve (Panel 1 A: 4chamber still echo image showing reverberation artefact from mechanical mitral valve leaflets)) and aortic valve calcification.
Diagnostic performance of cardiac computed tomography versus transesophageal echocardiography in infective endocarditis: A contemporary comparative meta-analysisCondensed abstract Data regarding the comparison of diagnostic accuracy of TEE and CCT for diagnosing IE are limited. The present meta-analysis compares the diagnostic performance of the two imaging modalities for a variety of complications of IE in the same patient populations. Our results show that both TEE and CCT have good diagnostic accuracy, with TEE showing superiority in detecting leaflet defects and CCT performing better in prosthetic valve endocarditis. CCT also showed a trend towards higher sensitivity than TEE for detection of periannular complications. These findings suggest that CCT is a useful adjunct to TEE for IE, whenever appropriate use of complementary imaging modalities is warranted.
Coronary sinus to left atrium fistula on computed tomography angiography: Differentiation from unroofed coronary sinus with literature reviewAtrial septal defect
Clinical impact of mitral calcium volume in patients undergoing transcatheter aortic valve implantationMitral annular calcification (MAC) has been associated with mitral valve (MV) disease and cardiovascular events in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to investigate the incidence and impact of mitral calcium volume (MCV) quantified by multidetector computed tomography (MDCT) on MV function and clinical outcomes after TAVI.
The clinical utility of FFRCT stratified by ageCT coronary angiography (CTA) with Fractional Flow Reserve as determined by CT (FFRCT) is a safe alternative to invasive coronary angiography. A negative FFRCT has been shown to have low cardiac event rates compared to those with a positive FFRCT. However, the clinical utility of FFRCT according to age is not known.