Evaluating the Coronary Artery Disease Consortium Model and the Coronary Artery Calcium Score in Predicting Obstructive Coronary Artery Disease in a Symptomatic Mixed Asian Cohort

Background

The utility of a given pretest probability score in predicting obstructive coronary artery disease (CAD) is population dependent. Previous studies investigating the additive value of coronary artery calcium (CAC) on pretest probability scores were predominantly limited to Western populations. This retrospective study seeks to evaluate the CAD Consortium (CAD2) model in a mixed Asian cohort within Singapore with stable chest pain and to evaluate the incremental value of CAC in predicting obstructive CAD.

Methods and Results

Patients who underwent cardiac computed tomography and had chest pain were included. The CAD2 clinical model comprised of age, sex, symptom typicality, diabetes, hypertension, hyperlipidemia, and smoking status and was compared with the CAD2 extended model that added CAC to assess the incremental value of CAC scoring, as well as to the corresponding locally calibrated local assessment of the heart models. A total of 522 patients were analyzed (mean age 54±11 years, 43.1% female). The CAD2 clinical model obtained an area under the curve of 0.718 (95% CI, 0.668–0.767). The inclusion of CAC score improved the area under the curve to 0.896 (95% CI, 0.867–0.925) in the CAD2 models and from 0.767 (95% CI, 0.721–0.814) to 0.926 (95% CI, 0.900–0.951) in the local assessment of the heart models. The locally calibrated local assessment of the heart models showed better discriminative performance than the corresponding CAD2 models (P<0.05 for all).

Conclusions

The CAD2 model was validated in a symptomatic mixed Asian cohort and local calibration further improved performance. CAC scoring provided significant incremental value in predicting obstructive CAD.

Interoperator reliability of an on-site machine learning-based prototype to estimate CT angiography-derived fractional flow reserve

BACKGROUND

Advances in CT and machine learning have enabled on-site non-invasive assessment of fractional flow reserve (FFR_CT).

PURPOSE

To assess the interoperator and intraoperator variability of coronary CT angiography-derived FFR_CT using a machine learning-based postprocessing prototype.

MATERIALS AND METHODS

We included 60 symptomatic patients who underwent coronary CT angiography. FFR_CT was calculated by two independent operators after training using a machine learning-based on-site prototype. FFR_CT was measured 1 cm distal to the coronary plaque or in the middle of the segments if no coronary lesions were present. Intraclass correlation coefficient (ICC) and Bland-Altman analysis were used to evaluate interoperator variability effect in FFR_CT estimates. Sensitivity analysis was done by cardiac risk factors, degree of stenosis and image quality.

RESULTS

A total of 535 coronary segments in 60 patients were assessed. The overall ICC was 0.986 per patient (95% CI 0.977 to 0.992) and 0.972 per segment (95% CI 0.967 to 0.977). The absolute mean difference in FFR_CT estimates was 0.012 per patient (95% CI for limits of agreement: -0.035 to 0.039) and 0.02 per segment (95% CI for limits of agreement: -0.077 to 0.080). Tight limits of agreement were seen on Bland-Altman analysis. Distal segments had greater variability compared with proximal/mid segments (absolute mean difference 0.011 vs 0.025, p<0.001). Results were similar on sensitivity analysis.

CONCLUSION

A high degree of interoperator and intraoperator reproducibility can be achieved by on-site machine learning-based FFR_CT assessment. Future research is required to evaluate the physiological relevance and prognostic value of FFR_CT.

The Burden of Resistant Hypertension Across the World

PURPOSE OF REVIEW

Resistant hypertension (R-HTN) is related to worse cardiovascular, renal outcomes, and death compared to non R-HTN. We aimed to review the burden of R-HTN across the world, focusing on its prevalence, associated factors and outcomes, and the impact of treatment.

RECENT FINDINGS

R-HTN prevalence among hypertensive individuals varies around 10-20%, depending on the population and definition applied. R-HTN consistently relates to older age, chronic kidney disease, obesity, and obstructive sleep apnea - which are increasing in prevalence with global population aging. As such, R-HTN prevalence is also expected to rise. Infrequent use of ambulatory blood pressure monitoring to identify at higher risk individuals and poor adherence to treatment are still barriers in the approach of R-HTN. Available evidence suggests that 10-20% of patients with hypertension have R-HTN. However, the prevalence of true R-HTN using contemporaneous standardized definitions is still unknown. Novel strategies to address clinicians, patients and health system barriers to treatment inertia and adherence are fundamental to reduce the burden of R-HTN.

Machine learning methods for perioperative anesthetic management in cardiac surgery patients: a scoping review

Background

Machine learning (ML) is developing fast with promising prospects within medicine and already has several applications in perioperative care. We conducted a scoping review to examine the extent and potential limitations of ML implementation in perioperative anesthetic care, specifically in cardiac surgery patients.

Methods

We mapped the current literature by searching three databases: MEDLINE (Ovid), EMBASE (Ovid), and Cochrane Library. Articles were eligible if they reported on perioperative ML use in the field of cardiac surgery with relevance to anesthetic practices. Data on the applicability of ML and comparability to conventional statistical methods were extracted.

Results

Forty-six articles on ML relevant to the work of the anesthesiologist in cardiac surgery were identified. Three main categories emerged: (I) event and risk prediction, (II) hemodynamic monitoring, and (III) automation of echocardiography. Prediction models based on ML tend to behave similarly to conventional statistical methods. Using dynamic hemodynamic or ultrasound data in ML models, however, shifts the potential to promising results.

Conclusions

ML in cardiac surgery is increasingly used in perioperative anesthetic management. The majority is used for prediction purposes similar to conventional clinical scores. Remarkable ML model performances are achieved when using real-time dynamic parameters. However, beneficial clinical outcomes of ML integration have yet to be determined. Nonetheless, the first steps introducing ML in perioperative anesthetic care for cardiac surgery have been taken.

Aortic Arch Variants and Anomalies: Embryology, Imaging Findings, and Clinical Considerations

There is a wide spectrum of congenital anomalies or variations of the aortic arch, ranging from non-symptomatic variations that are mostly detected incidentally to clinically symptomatic variations that cause severe respiratory distress or esophageal compression. Some of these may be accompanied by other congenital heart diseases or chromosomal anomalies. The widespread use of multidetector computed tomography (CT) in clinical practice has resulted in incidental detection of several variations of the aortic arch in adults. Thus, radiologists and clinicians should be aware of the classification of aortic arch anomalies and carefully look for imaging features associated with a high risk of clinical symptoms. Understanding the embryological development of the aortic arch aids in the classification of various subtypes of aortic arch anomalies and variants. For accurate diagnosis and precise evaluation of aortic arch anomalies, cross-sectional imaging modalities, such as multidetector CT or magnetic resonance imaging, play an important role by providing three-dimensional reconstructed images. In this review, we describe the embryological development of the thoracic aorta and discuss variations and anomalies of the aortic arch along with their clinical implications.

Renal denervation for resistant hypertension

BACKGROUND

Resistant hypertension is highly prevalent among the general hypertensive population and the clinical management of this condition remains problematic. Different approaches, including a more intensified antihypertensive therapy, lifestyle modifications or both, have largely failed to improve patients' outcomes and to reduce cardiovascular and renal risk. As renal sympathetic hyperactivity is a major driver of resistant hypertension, in the last decade renal sympathetic ablation (renal denervation) has been proposed as a possible therapeutic alternative to treat this condition.

OBJECTIVES

We sought to evaluate the short- and long-term effects of renal denervation in individuals with resistant hypertension on clinical end points, including fatal and non-fatal cardiovascular events, all-cause mortality, hospital admissions, quality of life, blood pressure control, left ventricular hypertrophy, cardiovascular and metabolic profile and kidney function, as well as the potential adverse events related to the procedure.

SEARCH METHODS

For this updated review, the Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to 3 November 2020: Cochrane Hypertension's Specialised Register, CENTRAL (2020, Issue 11), Ovid MEDLINE, and Ovid Embase. The World Health Organization International Clinical Trials Registry Platform (via CENTRAL) and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov were searched for ongoing trials. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that compared renal denervation to standard therapy or sham procedure to treat resistant hypertension, without language restriction.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study risk of bias. We summarised treatment effects on available clinical outcomes and adverse events using random-effects meta-analyses. We assessed heterogeneity in estimated treatment effects using Chi² and I² statistics. We calculated summary treatment estimates as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes, and a risk ratio (RR) for dichotomous outcomes, together with their 95% confidence intervals (CI). Certainty of evidence has been assessed using the GRADE approach.

MAIN RESULTS

We found 15 eligible studies (1416 participants). In four studies, renal denervation was compared to sham procedure; in the remaining studies, renal denervation was tested against standard or intensified antihypertensive therapy. Most studies had unclear or high risk of bias for allocation concealment and blinding.  When compared to control, there was low-certainty evidence that renal denervation had little or no effect on the risk of myocardial infarction (4 studies, 742 participants; RR 1.31, 95% CI 0.45 to 3.84), ischaemic stroke (5 studies, 892 participants; RR 0.98, 95% CI 0.33 to 2.95), unstable angina (3 studies, 270 participants; RR 0.51, 95% CI 0.09 to 2.89) or hospitalisation (3 studies, 743 participants; RR 1.24, 95% CI 0.50 to 3.11). Based on moderate-certainty evidence, renal denervation may reduce 24-hour ambulatory blood pressure monitoring (ABPM) systolic BP (9 studies, 1045 participants; MD -5.29 mmHg, 95% CI -10.46 to -0.13), ABPM diastolic BP (8 studies, 1004 participants; MD -3.75 mmHg, 95% CI -7.10 to -0.39) and office diastolic BP (8 studies, 1049 participants; MD -4.61 mmHg, 95% CI -8.23 to -0.99). Conversely, this procedure had little or no effect on office systolic BP (10 studies, 1090 participants; MD -5.92 mmHg, 95% CI -12.94 to 1.10). Moderate-certainty evidence suggested that renal denervation may not reduce serum creatinine (5 studies, 721 participants, MD 0.03 mg/dL, 95% CI -0.06 to 0.13) and may not increase the estimated glomerular filtration rate (eGFR) or creatinine clearance (6 studies, 822 participants; MD -2.56 mL/min, 95% CI -7.53 to 2.42).  AUTHORS' CONCLUSIONS: In patients with resistant hypertension, there is low-certainty evidence that renal denervation does not improve major cardiovascular outomes and renal function. Conversely, moderate-certainty evidence exists that it may improve 24h ABPM and diastolic office-measured BP. Future trials measuring patient-centred instead of surrogate outcomes, with longer follow-up periods, larger sample size and more standardised procedural methods are necessary to clarify the utility of this procedure in this population.

Prognostic Value of Computed Tomography-Derived Fractional Flow Reserve Comparison With Myocardial Perfusion Imaging

OBJECTIVES

The aim of this study was to compare the incremental prognostic value of coronary computed tomography (CT) angiography (CCTA)-derived machine learning fractional flow reserve CT (ML-FFRct) versus that of ischemia detected on single-photon emission-computed tomography (SPECT) myocardial perfusion imaging (MPI) on incident cardiovascular outcomes.

BACKGROUND

SPECT MPI and ML-FFRct are noninvasive tools that can assess the hemodynamic significance of coronary atherosclerotic disease.

METHODS

We studied a retrospective cohort of consecutive patients who underwent clinically indicated CCTA and SPECT MPI. ML-FFRct was computed using a ML prototype. The primary outcome was all-cause mortality and nonfatal myocardial infarction (D/MI), and the secondary outcome was D/MI and unplanned revascularization, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) occurring more than 90 days postimaging. Multiple nested multivariate cox regression was used to model a scenario wherein an initial anatomical assessment was followed by a functional assessment.

RESULTS

A total of 471 patients (mean age: 64 ± 13 year; 53% males) were included. Comorbidities were prevalent (78% hypertension, 66% diabetes, 81% dyslipidemia). ML-FFRct was <0.8 in at least 1 proximal/midsegment was present in 41.6% of patients, and ischemia on MPI was present in 13.8%. After a median follow-up of 18 months, 7% of patients (n = 33) experienced D/MI. On multivariate Cox proportional analysis, the presence of ischemia on MPI but not ML-FFRct significantly predicted D/MI (HR: 2.3; 95% CI: 1.0-5.0; P = 0.047; or HR: 0.7; 95% CI: 0.3-1.4; P = 0.306 respectively) when added to CCTA obstructive stenosis. Furthermore, the model with SPECT ischemia had higher global chi-square result and significantly improved reclassification. Results were similar using the secondary outcome and on several sensitivity analyses.

CONCLUSIONS

In a high-risk patient cohort, SPECT MPI but not ML-FFRct adds independent and incremental prognostic information to CCTA-based anatomical assessment and clinical risk factors in predicting incident outcomes.

Hybrid Procedure for Coexistence of Coarctation of the Aorta and Aberrant Right Subclavian Artery: A Case Report and Review of the Literature

Background: Coarctation of the aorta (CoA) can either present alone as an isolated condition or in association with other aortic arch or cardiac anomalies. One percent of patients with CoA have concomitant an aberrant right subclavian artery (ARSA). Purpose: We report the case of a 35-year-old woman with uncontrolled hypertension who was found to have CoA and ARSA. Results: The patient was treated successfully using a hybrid procedure comprising ARSA ligation and subclavian to carotid transposition, followed by thoracic endovascular aortic repair. Conclusions: Patients with CoA should be carefully studied, considering the possible coexistence of other congenital aortic arch defects, such as ARSA. Hybrid repair is a safe and effective approach for this condition.

Delayed presentation of massive haemoptysis from aortic aneurysm after aortic coarctation repair (a case report)

Introduction

Massive haemoptysis refers to coughing and losing a huge amount of blood in a 24-hour period. It's a life-threatening condition with high mortality rate.

Case presentation

We report a rare case of massive haemoptysis in a 60-year-old female patient who had aortic coarctation repair 30 years ago. Her Computed tomography (CT) angiography showed huge aneurysmal dilatation and dissection of the descending thoracic aorta at the site of the repair. Thoracic endovascular aortic repair (TEVAR) was done, but the patient had recurrent massive haemoptysis due to extension of the aneurysm to the aortic arch. The patient then underwent one stage surgical right to left carotid artery shunt followed by TEVAR to the aortic arch covering the left common carotid artery. The procedure was successful, and haemoptysis was controlled without any complications.

Discussion

In this case the high index of suspicion for thoracic aortic aneurysm in patients presenting with haemoptysis and prior history of coarctation repair were demonstrated.

Conclusion

massive haemoptysis in patients who had aortic coarctation repair is an alarming sign, and surgical intervention is required. TEVAR has become one of the best approaches for managing aortic aneurysm and has replaced open repair.

•

Thoracic aortic aneurysms must be ruled out in those patients who present with massive hemoptysis.

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In case of aortic coarctation repair, thoracic aortic aneurysms should be considered.

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Thoracic endovascular aortic repair (TEVAR) has become one of the best approaches for managing thoracic aortic pathology.

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In patients who present with massive hemoptysis post TEVAR, aneurysms and endoleak must be ruled out.

The cardiac surgeon's guide to artificial intelligence

PURPOSE OF REVIEW

Artificial intelligence is the ability for machines to perform intelligent tasks. Artificial intelligence is already penetrating many aspects of medicine including cardiac surgery. Here, we offer a platform introduction to artificial intelligence for cardiac surgeons to understand the implementations of this transformative tool.

RECENT FINDINGS

Artificial intelligence has contributed greatly to the automation of cardiac imaging, including echocardiography, cardiac computed tomography, cardiac MRI and most recently, in radiomics. There are also several artificial intelligence based clinical prediction tools that predict complex outcomes after cardiac surgery. Waveform analysis, specifically, automated electrocardiogram analysis, has seen significant strides with promise in wearables and remote monitoring. Experimentally, artificial intelligence has also entered the operating room in the form of augmented reality and automated robotic surgery.

SUMMARY

Artificial intelligence has many potential exciting applications in cardiac surgery. It can streamline physician workload and help make medicine more human again by placing the physician back at the bedside. Here, we offer cardiac surgeons an introduction to this transformative tool so that they may actively participate in creating clinically relevant implementations to improve our practice.

Effect of Exercise Training on Ambulatory Blood Pressure Among Patients With Resistant Hypertension: A Randomized Clinical Trial

Importance

Limited evidence suggests exercise reduces blood pressure (BP) in individuals with resistant hypertension, a clinical population with low responsiveness to drug therapy.

Objective

To determine whether an aerobic exercise training intervention reduces ambulatory BP among patients with resistant hypertension.

Design, Settings, and Participants

The Exercise Training in the Treatment of Resistant Hypertension (EnRicH) trial is a prospective, 2-center, single-blinded randomized clinical trial performed at 2 hospital centers in Portugal from March 2017 to December 2019. A total of 60 patients with a diagnosis of resistant hypertension aged 40 to 75 years were prospectively enrolled and observed at the hospitals' hypertension outpatient clinic.

Interventions

Patients were randomly assigned in a 1:1 ratio to a 12-week moderate-intensity aerobic exercise training program (exercise group) or a usual care control group. The exercise group performed three 40-minute supervised sessions per week in addition to usual care.

Main Outcomes and Measures

The powered primary efficacy measure was 24-hour ambulatory systolic BP change from baseline. Secondary outcomes included daytime and nighttime ambulatory BP, office BP, and cardiorespiratory fitness.

Results

A total of 53 patients completed the study, including 26 in the exercise group and 27 in the control group. Of these, 24 (45%) were women, and the mean (SD) age was 60.1 (8.7) years. Compared with the control group, among those in the exercise group, 24-hour ambulatory systolic BP was reduced by 7.1 mm Hg (95% CI, -12.8 to -1.4; P = .02). Additionally, 24-hour ambulatory diastolic BP (-5.1 mm Hg; 95% CI, -7.9 to -2.3; P = .001), daytime systolic BP (-8.4 mm Hg; 95% CI, -14.3 to -2.5; P = .006), and daytime diastolic BP (-5.7 mm Hg; 95% CI, -9.0 to -2.4; P = .001) were reduced in the exercise group compared with the control group. Office systolic BP (-10.0 mm Hg; 95% CI, -17.6 to -2.5; P = .01) and cardiorespiratory fitness (5.05 mL/kg per minute of oxygen consumption; 95% CI, 3.5 to 6.6; P < .001) also improved in the exercise group compared with the control group.

Conclusions and Relevance

A 12-week aerobic exercise program reduced 24-hour and daytime ambulatory BP as well as office systolic BP in patients with resistant hypertension. These findings provide clinicians with evidence to embrace moderate-intensity aerobic exercise as a standard coadjutant therapy targeting this patient population.

Trial Registration

ClinicalTrials.gov Identifier: NCT03090529.

Evaluation of the Fractional Flow Reserve by Computer Tomography Data: Comparison of the Calculated Parameters with the Results of Invasive Measurements

Aim      To create a three-dimensional mathematical model of coronary flow in patients with ischemic heart disease based on findings of computed tomography angiography (CTA) with subsequent calculation of the fractional flow reserve (FFRCTA) and comparison of estimated FFRCTA with FFR reference values measured by coronary angiography (CAG).Material and methods  The study included 10 patients with borderline stenosis (50-75 %) as determined by CTA performed with a 640‑slice CT-scanner. Based on CTA findings, three-dimensional mathematical models were constructed for further calculation of FFRCTA. Later, an invasive measurement of FFR (FFRINV) was performed for all patients. FFR values &lt;0.8 indicated the hemodynamic significance of stenosis.Results FFRCTA and FFRINV values differed insignificantly in most cases (n=9) and exceeded 5% in only one case. The regression analysis showed a close correlation between estimated and invasively measured FFR values.Conclusion      Preliminary results showed a good consistency of calculated and measured FFR values. Therefore, further development of the method for mathematical modeling of three-dimensional blood flow by CTA findings is promising. Noninvasive evaluation of FFR is particularly relevant for analysis of hemodynamic significance of borderline (50-75 %) coronary stenoses.

Prediction of 1-year mortality after heart transplantation using machine learning approaches: A single-center study from China

BACKGROUND

Heart transplantation (HTx) remains the gold-standard treatment for end-stage heart failure. The aim of this study was to establish a risk-prediction model for assessing prognosis of HTx using machine-learning approach.

METHODS

Consecutive recipients of orthotopic HTx at our institute between January 1st, 2015 and December 31st, 2018 were included in this study. The primary outcome was 1-year mortality. Least absolute shrinkage and selection operator method was used to select variables and seven different machine-learning approaches were employed to develop the risk-prediction model. Bootstrap method was used for model validation. Shapley Additive exPlanations (SHAP) method was used for model interpretation.

RESULTS

381 recipients were included with average age of 43.783 years old. Albumin, recipient age and left atrium diameter ranked top three most important variables that affected the 1-year mortality of HTx. Other important variables included red blood cell, hemoglobin, lymphocyte%, smoking history, use of lyophilized rhBNP, use of Levosimendan, hypertension, cardiac surgery history, malignancy and endotracheal intubation history. Random Forest (RF) model achieved the best area under curves (AUC) of 0.801 and gradient boosting machine (GBM) showed the best sensitivity of 0.271. SHAP method was introduced to display the RF model's predicting processes of "survival" or "death" in individual level.

CONCLUSIONS

We established the risk-prediction model for postoperative prognosis of HTx patients by using machine learning method and demonstrated that the RF model performed the highest discrimination with the largest AUC when validated. This prediction model could help to recognize high-risk HTx recipients, provide personalized therapy plan and reduce organ wastage.

Current Status and Future Perspectives of Renal Denervation

Despite the availability of numerous antihypertensive medications, hypertension treatment and control rates remain low, and uncontrolled hypertension is well-known to be one of the most important cardiovascular risk factors. Endovascular catheter-based renal denervation (RDN) has been developed to be a complementary or alternative treatment option for patients who cannot take medication, poor adherence, or have resistant hypertension despite the use of maximal doses of medications. Recently, several randomized trials for evaluating the efficacy and safety of second-generation RDN devices consistently show solid evidence for their blood pressure-lowering efficacy. This review summarizes the current evidence and future perspectives of RDN.

Catheter-based renal denervation (RDN) therapy, a new procedure that uses radiofrequency ablation to interrupt efferent and afferent renal sympathetic nerve fibers, is a complementary or alternative treatment to antihypertensive medications for optimal control of blood pressure (BP). Although several single-arm early proof-of-concept studies showed significant BP reduction, the largest sham-controlled study using the first-generation RDN device (SYMPLICITY HTN-3) failed to significantly reduce BP in patients with resistant hypertension who were taking the guideline-based combination of antihypertensive medications. Since then, new devices and techniques have been developed to improve the efficacy and safety of RDN procedures. Sham-controlled trials using second-generation RDN devices (radiofrequency- and ultrasound-based) have provided solid evidence for their BP-lowering efficacy with and without the use of concomitant antihypertensive medication. Moreover, the safety profile of RDN in several registries and clinical trials appears to be excellent. This review summarizes the current evidence for RDN and discusses its current issues, future trials, Asian perspectives, and potential roles in both hypertension and other morbidities.

Diagnostic performance of computed tomography-based fraction flow reserve in identifying myocardial ischemia caused by coronary artery stenosis: A meta-analysis

BACKGROUND

As a new noninvasive diagnostic technique, computed tomography (CT)-based fraction flow reserve (FFR) has been used to identify hemodynamically significant coronary artery stenosis. This meta-analysis used invasive FFR as the standard to evaluate the diagnostic performance of FFRCT.

METHODS

We searched the PubMed, Cochrane library, and EMBASE for articles published between January 2009 and January 2021. The synthesized sensitivity and specificity of invasive FFR and FFRCT were analyzed at both the patient and vessel levels. We generated a summary receiver operating characteristic curve (SROC) and then calculated the area under the curve (AUC).

RESULTS

We included a total of 23 studies, including 2,178 patients and 3,029 vessels or lesions. Analysis at each patient level demonstrated a synthesized sensitivity of 88%, specificity of 79%, LR+ of 4.16, LR-of 0.15, and AUC of 0.89 for FFRCT. Analysis at the level of each vessel or lesion showed a synthesized sensitivity of 85%, specificity of 81%, LR+ of 4.44, LR-of 0.19, and AUC of 0.87 for FFRCT.

CONCLUSION

Our research reveals that FFRCT has high diagnostic performance in patients with coronary artery stenosis, regardless of whether it is at the patient level or the vessel level.

Late Complications After Previous Surgical Repair for Coarctation With Extra-Anatomic Bypass Graft: Report on Two Cases

Surgical correction of aortic coarctation (CoA) has been the standard treatment in infants and adolescents to prevent late consequences related to obstruction and distal hypoperfusion. Several surgical techniques for CoA repair have traditionally been applied. However, late complications, including re-CoA and pseudoaneurysm formation, are not uncommon. The incidence of complications is highly related to the type of initial surgery. Here, we are reporting two cases of late complications related to an infrequently used surgical technique, the extra-anatomical aortic bypass graft (EABG). The first case presented with pseudoaneurysm at the distal anastomosis site with the descending aorta and treated by endovascular stent graft. The second case presented with stenosis at the proximal anastomosis site with the left subclavian artery (LSCA) and treated medically upon the request of the patient.

Optimizing Precision of Hypertension Care to Maximize Blood Pressure Control: A Pilot Study Utilizing a Smartphone App to Incorporate Plasma Renin Activity Testing

Only half of patients with hypertension (HTN) respond to any given antihypertensive medication. Heterogeneity in pathophysiologic pathways underlying HTN is a major contributor. Personalizing antihypertensive therapy could improve blood pressure (BP) reduction. The objective of this study was to assess the effect of pragmatic implementation of a personalized plasma renin activity (PRA)‐based smartphone app on improving BP reduction. Patients with untreated or treated but uncontrolled HTN were recruited. BP and PRA were measured at baseline with final BP measured at 6 months. Patient’s information was entered into the app and treatment recommendations were returned. Clinicians were at liberty to follow or disregard the app’s recommendations. BP levels and percent BP control among patients whose clinicians did and did not follow the app’s recommendations were compared using independent t‐test and Fisher’s exact test, respectively. Twenty‐nine European American patients were included (38% women) with mean age of 52 ± 9 years and median PRA of 1.3 ng/mL/hr (interquartile range 0.5–3.1 ng/mL/hr). Participants whose clinicians followed the app’s recommendations (n = 16, 55%) as compared with those whose clinicians did not (n = 13, 45%), had a greater reduction in 6‐month systolic BP (−15 ± 21 vs. −3 ± 21 mm Hg; adjusted‐P = 0.1) and diastolic BP (−8 ± 8 vs. −1 ± 8 mm Hg; adjusted‐P = 0.04). BP control at 6 months tended to be greater among patients whose clinicians accepted the app’s recommendations vs. those whose clinicians did not (63% vs. 23%, P = 0.06). This pilot study demonstrates that acceptance of the app’s recommendations was associated with a greater BP reduction. Future studies to confirm these pilot findings are warranted.

FFR-CT strengthens multi-disciplinary reporting of CT coronary angiography

The utility of computed tomography (CT) coronary angiography (CTCA) is underpinned by its excellent sensitivity and negative-predictive value for coronary artery disease (CAD), although it lacks specificity. Invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR), are gold-standard investigations for coronary artery disease, however, they are resource intensive and associated with a small risk of serious complications. FFR-CT has been shown to have comparable performance to FFR measurements and has the potential to reduce unnecessary ICAs. The aim of this study is to briefly review FFR-CT, as an investigational modality for stable angina, and to share 'real-world' UK data, in consecutive patients, following the initial adoption of FFR-CT in our district general hospital in 2016. A retrospective analysis was performed of a previously published consecutive series of 157 patients referred for CTCA by our group in a single, non-interventional, district general hospital. Our multi-disciplinary team (MDT) recorded the likely definitive outcome following CTCA, namely intervention or optimised medical management. FFR-CT analysis was performed on 24 consecutive patients where the MDT recommendation was for ICA. The CTCA + MDT findings, FFR-CT and ICA ± FFR were correlated along with the definitive outcome. In comparing CTCA + MDT, FFR-CT and definitive outcome, in terms of whether a percutaneous coronary intervention was performed, FFR-CT was significantly correlated with definitive outcome (r=0.471, p=0.036) as opposed to CTCA + MDT (r=0.378, p=0.07). In five cases (21%, 5/24), FFR-CT could have altered the management plan by reclassification of coronary stenosis. FFR-CT of 60 coronary artery vessels (83%, 60/72) (mean FFR-CT ratio 0.82 ± 0.10) compared well with FFR performed on 18 coronary vessels (mean 0.80 ± 0.11) (r=0.758, p=0.0013). In conclusion, FFR-CT potentially adds value to MDT outcome of CTCA, increasing the specificity and predictive accuracy of CTCA. FFR-CT may be best utilised to investigate CTCAs where there is potentially prognostically significant moderate disease or severe disease to maximise cost-effectiveness. These data could be used by other NHS trusts to best incorporate FFR-CT into their diagnostic pathways for the investigation of stable chest pain.

Effects of a comprehensive intervention on hypertension control in Chinese employees working in universities based on mixed models

We conducted a comprehensive intensive intervention for hypertension patients working in universities or colleges. From July 2015 to March in 2016, 220 hypertension subjects were recruited, with 165 cases in intensive intervention group and 55 in standard intervention group. After 24 months of intervention, 208 ones including of 157 in intensive intervention group and 51 in standard intervention group were included in the final analysis. The patients in standard intervention group were given routine intervention, which mainly including of drug treatment and health education. The patients in intervention group were given comprehensive intensive intervention in addition to routine intervention, including follow-up management of hypertension, emotional, lifestyle intervention and else. The study and experimental protocols were approved by institutional review board of Zhejiang Hospital and Fu Wai Hospital and registered (ChiCTR-ECS-14004641, date of registration: May 8, 2014). After 2 years, compared with the standard intervention group, SBP/DBP in the intensive intervention group decreased by 3.7/4 mmHg and BP control rate increased by 8.9%, and the unhealthy behaviors and life quality including tension and pressure were also improved in the intensive intervention group. We used mixed effect model to analyze the intervention effect which could solve the problems of missing values and correlation. The intensive intervention of hypertension control including follow-up management, emotional and lifestyle intervention in occupational places could promote the development of the prevention, treatment and control of hypertension among staff in colleges and universities.

Diagnostic Performance of On-Site Coronary CT Angiography-derived Fractional Flow Reserve Based on Patient-specific Lumped Parameter Models

Purpose

To evaluate the diagnostic performance of a prototype on-site coronary CT angiography-derived fractional flow reserve (CT FFR) algorithm, based on patient-specific lumped parameter models, for the detection of functionally significant stenosis defined by invasive FFR, and to compare the performance to anatomic evaluation of stenosis degree.

Materials and Methods

In this retrospective feasibility study, 77 vessels in 57 patients (42 of 57 [74%]) men; mean age, 58.5 years ± 9.2 [standard deviation]) who underwent clinically indicated coronary CT angiography within 60 days prior to an invasive FFR measurement were analyzed. Invasive FFR less than or equal to 0.80 was used to indicate a functionally significant stenosis. Diagnostic performance of CT FFR was evaluated and compared with evaluation of stenosis degree. Analysis was performed on a per-vessel basis.

Results

Invasive FFR revealed functionally significant stenoses in 37 vessels (48%). CT FFR showed a significantly increased ability to indicate functionally significant stenosis (area under the receiver operating characteristic curve [AUC], 0.87) compared with degree of stenosis at coronary CT angiography (AUC, 0.70; ΔAUC 0.17; P < .01). Using a cutoff of less than or equal to 0.80 for CT FFR and greater than or equal to 50% degree of stenosis at coronary CT angiography to indicate a significant stenosis, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 33 of 37 (89.2%), 31 of 40 (77.5%), 33 of 42 (78.6%), 31 of 35 (88.6%), and 64 of 77 (83.1%), respectively, for CT FFR, and 33 of 37 (89.2%), 17 of 40 (42.5%), 33 of 56 (58.9%), 17 of 21 (81.0%), and 50 of 77 (64.9%), respectively, for degree of stenosis at coronary CT angiography.

Conclusion

Diagnostic performance of on-site CT FFR was superior to stenosis evaluation at coronary CT angiography for identification of functionally significant coronary artery stenosis in patients suspected of having or known to have coronary artery disease.© RSNA, 2019See also commentary by Schoepf et al.

Is renal denervation still a treatment option in cardiovascular disease?

The role of renal sympathetic denervation (RDN) has been the topic of ongoing debate ever since the impressive initial results. The rationale of RDN is strong and supported by non-clinical studies, which lies in uncoupling the autonomic nervous crosstalk between the kidneys and the central nervous system. Since we know that cardiovascular diseases, such as hypertension, atrial, ventricular arrhythmias and heart failure (HF) are related to sympathetic (over)activity, modulation of the renal nerve activity appears to be a reasonable and attractive therapeutic target in these patients. This review will focus on the existing evidence and potential future perspectives for RDN as treatment option in cardiovascular disease.