Assessment of intermediate severity coronary lesions in the catheterization laboratory

Increased basal coronary blood flow as a cause of reduced coronary flow reserve in diabetic patients

A reduced coronary flow reserve (CFR) has been demonstrated in diabetes, but the underlying mechanisms are unknown. We assessed thermodilution-derived CFR after 5-min intravenous adenosine infusion through a pressure-temperature sensor-tipped wire in 30 coronary arteries without significant lumen reduction in 30 patients: 13 with and 17 without a history of diabetes. We determined CFR as the ratio of basal and hyperemic mean transit times (Tmn); fractional flow reserve (FFR) as the ratio of distal and proximal pressures at maximal hyperemia to exclude local macrovascular disease; and an index of microvascular resistance (IMR) as the distal coronary pressure at maximal hyperemia divided by the inverse of the hyperemic Tmn. We also assessed insulin resistance by the homeostasis model assessment (HOMA) index. FFR was normal in all investigated arteries. CFR was significantly lower in diabetic vs. nondiabetic patients [median (interquartile range): 2.2 (1.4–3.2) vs. 4.1 (2.7–4.4); P = 0.02]. Basal Tmn was lower in diabetic vs. nondiabetic subjects [median (interquartile range): 0.53 (0.25–0.71) vs. 0.64 (0.50–1.17); P = 0.04], while hyperemic Tmn and IMR were similar. We found significant correlations at linear regression analysis between logCFR and the HOMA index ( r2 = 0.35; P = 0.0005) and between basal Tmn and the HOMA index ( r2 = 0.44; P < 0.0001). In conclusion, compared with nondiabetic subjects, CFR is lower in patients with diabetes and epicardial coronary arteries free of severe stenosis, because of increased basal coronary flow, while hyperemic coronary flow is similar. Basal coronary flow relates to insulin resistance, suggesting a key role of cellular metabolism in the regulation of coronary blood flow.

Early bare-metal stent thrombosis presenting with cardiogenic shock: a case report

Introduction

Although stents have improved the safety and efficacy of percutaneous coronary interventions, coronary stent thrombosis remains a serious complication.

Case presentation

We present the case of a 64-year-old Caucasian man from Greece, with symptoms and electrocardiographic findings suggestive of acute inferior myocardial infarction, who complained of chest pain and rapidly developed cardiogenic shock 48 hours after primary percutaneous coronary intervention.

Conclusion

The most common cause of early bare-metal stent thrombosis is stent malapposition. Intravascular ultrasound is the preferred method to recognize predictors of coronary events that are not detected by angiography.

Pressure-wire based assessment of microvascular resistance using calibrated upstream balloon obstruction: a predictor of myocardial viability

OBJECTIVES

We assess microvascular integrity as a marker of myocardial viability after coronary stenting, using only a pressure guidewire.

BACKGROUND

Microvascular integrity generally is not assessed using pressure-only guidewires because the transducer lies upstream of microvasculature. We partially inflate a balloon inside a coronary stent to achieve a specific normalized pressure drop at rest (distal coronary/aortic pressure = 0.8) and then infuse a vasodilator, to render the wire sensitive to microvascular function. We hypothesize that the further decline in pressure (ΔFFR(0.8) ) predicts MRI myocardial viability.

METHODS

We studied 29 subjects with acute coronary syndrome including myocardial infarction. After successful culprit stenting, the resting coronary/aortic pressure was set to 0.8 using temporary balloon obstruction. ΔFFR(0.8) was defined as 0.8-(distal coronary/aortic pressures) during adenosine-induced hyperemia. The average transmural extent of infarction was defined as the average area of MRI late gadolinium enhancement (after 2.8 ± 1.5 days) divided by the corresponding full thickness of the gadolinium enhanced sector in short axis slices, and was compared with ΔFFR(0.8) .

RESULTS

ΔFFR(0.8) corresponded inversely and linearly with the average transmural extent of infarction (r(2) = 0.65, P < 0.001). We found that a transmural extent of infarction of 0.50 corresponded to a ΔFFR(0.8) threshold of 0.1, and had high sensitivity and specificity (100% and 94.4%, respectively).

CONCLUSIONS

Using only an upstream pressure-sensitive guidewire and a partially obstructing balloon during pharmacologic hyperemia, we were able to predict MRI myocardial viability with high accuracy after relief of epicardial stenosis. With further validation, this may prove a useful clinical prognostic tool after percutaneous intervention.

Feasibility and safety of percutaneous coronary intervention in patients with end-stage liver disease referred for liver transplantation

Percutaneous coronary intervention (PCI) has traditionally not been an option for patients with end-stage liver disease (ESLD) and coronary artery disease (CAD). This retrospective study was designed to demonstrate the feasibility and safety of PCI in liver transplant candidates. Patients with ESLD and hemodynamically significant CAD who were otherwise deemed to be acceptable candidates for liver transplantation underwent PCI. The procedural success rates, mortality and myocardial infarction rates, and bleeding outcomes were examined. Sixteen patients with ESLD underwent PCI: 15 with bare-metal stents (1.3 stents per patient on average) and 1 with balloon angioplasty alone. The median diameter stenosis per lesion was 80%, the median platelet count was 68 × 10(9) /L, the median international normalized ratio was 1.3, and the median Model for End-Stage Liver Disease score was 13. PCI was successful in 94% of the patients. One patient had a suboptimal residual stenosis of 50% after stenting. There were no in-hospital or 30-day deaths or myocardial infarctions, and no patients developed hematomas. One patient required a 1-U platelet transfusion, and another required 1 U of packed red blood cells. All patients remained clinically stable 1 month after PCI. Nine of the 16 patients were listed for liver transplantation, and 3 patients underwent liver transplantation. In conclusion, we have demonstrated the safety and feasibility of PCI in a small cohort of patients with ESLD and hemodynamically significant CAD, the majority of whom had significant thrombocytopenia. Larger studies are required to determine whether PCI is an effective treatment strategy for patients with ESLD and hemodynamically significant CAD who otherwise would not be candidates for liver transplantation.

Can differences in corrected coronary opacification measured with computed tomography predict resting coronary artery flow?

OBJECTIVES

A proof-of-concept study was undertaken to determine whether differences in corrected coronary opacification (CCO) within coronary lumen can identify arteries with abnormal resting coronary flow.

BACKGROUND

Although computed tomographic coronary angiography can be used for the detection of obstructive coronary artery disease, it cannot reliably differentiate between anatomical and functional stenoses.

METHODS

Computed tomographic coronary angiography patients (without history of revascularization, cardiac transplantation, and congenital heart disease) who underwent invasive coronary angiography were enrolled. Attenuation values of coronary lumen were measured before and after stenoses and normalized to the aorta. Changes in CCO were calculated, and CCO differences were compared with severity of coronary stenosis and Thrombolysis In Myocardial Infarction (TIMI) flow at the time of invasive coronary angiography.

RESULTS

One hundred four coronary arteries (n = 52, mean age = 60.0 ± 9.5 years; men = 71.2%) were assessed. Compared with normal arteries, the CCO differences were greater in arteries with computed tomographic coronary angiography diameter stenoses ≥ 50%. Similarly, CCO differences were greater in arteries with TIMI flow grade < 3 (0.406 ± 0.226) compared with those with normal flow (TIMI flow grade 3) (0.078 ± 0.078, p < 0.001). With CCO differences, abnormal coronary flow (TIMI flow grade < 3) was identified with a sensitivity and specificity, positive predictive value, and negative predictive value of 83.3% (95% confidence interval [CI]: 57.7 to 95.6%), 91.2% (95% CI: 75.2% to 97.7%), 83.3% (95% CI: 57.7% to 95.6%), and 91.2% (95% CI: 75.2% to 97.7%), respectively. Accuracy of this method was 88.5% with very good agreement (kappa = 0.75, 95% CI: 0.55 to 0.94).

CONCLUSIONS

Changes in CCO across coronary stenoses seem to predict abnormal (TIMI flow grade < 3) resting coronary blood flow. Further studies are needed to understand its incremental diagnostic value and its potential to measure stress coronary blood flow.

Intravascular imaging tools in the cardiac catheterization laboratory: comprehensive assessment of anatomy and physiology

Intravascular imaging modalities have an imperative role in contemporary cardiovascular research. Currently, there are several invasive imaging modalities available in the cardiac catheterization laboratory and new technologies are under development. In the current review, we aimed to provide an update on the research applications of contemporary intravascular imaging tools in the cardiac catheterization laboratory. For the purpose of this review, we separately discuss imaging tools for assessment of epicardial disease (fractional flow reserve and hyperemic stenosis resistance), microvascular function (coronary flow reserve, hyperemic microvascular resistance, and index of microcirculatory resistance), endothelial function, atherosclerotic plaque and vascular remodeling (intravascular ultrasound, optical coherence tomography, angioscopy, and near-infrared spectroscopy), and finally the emerging modalities (palpography and wall shear stress profiling).

Safety and feasibility of frequency domain optical coherence tomography to guide decision making in percutaneous coronary intervention

AIMS

The purpose of this single centre registry is to assess safety and feasibility of the frequency domain optical coherence tomography (FD-OCT) system during coronary interventions.

METHODS AND RESULTS

Ninety patients with unstable or stable coronary artery disease were included in this study. OCT imaging was performed in a first group of 40 patients (group 1), to evaluate ambiguous/intermediate lesions (24 patients in group 1 had OCT also done post-PCI, for assessment of stent deployment); and in a second group of 50 patients (group 2), to address the adequacy of stent deployment. Therefore, 74 patients underwent FD-OCT after stent implantation. A complex-lesion population was studied (B2 type lesion=72.2% and C type lesion=20.3%). The mean time of a FD-OCT pull-back (from the set up to the completion of the pull back) was 2.1 min and in all but one (99.1%) the procedure was successful. No patients experienced major complications in terms of death, myocardial infarction, emergency revascularisation, embolisation, life-threatening arrhythmia, coronary dissection, prolonged and severe vessel spasm and contrast induced nephropathy. In the ambiguous lesion group, 60% of patients were treated with PCI, whilst in the others, PCI were deferred. In total, 113 deployed stents (33,6% chromium cobalt stent, 66,4% drug eluting stent) were imaged with OCT. OCT findings led to additional interventions in 24 out of 74 patients (32%): 15 had further balloon inflations, nine had additional stent deployment whilst two had both treatments. At clinical follow-up, (4.6 ± 3.,2 months), there were no death, acute myocardial infarctions and cases of stent thrombosis, whilst two patients underwent revascularisation for recurrence of angina.

CONCLUSIONS

The present registry shows that FD-OCT is a feasible and safe technique for guidance of coronary interventions. Randomised studies will confirm whether the use of FD-OCT will improve the clinical outcome.

Virtual histology: a window to the heart of atherosclerosis

Intravascular ultrasound has done much to improve our understanding of atherosclerosis and the impact of percutaneous intervention on the coronary artery. However, subjectivity in interpreting the acoustic reflection of the ultrasound signal has spawned the development of other progressive technologies. Virtual histology intravascular ultrasound (VHIVUS) utilises the ultrasound backscatter signal in order to colour code plaque into four pre-specified subtypes based on their histological composition. We review the background behind traditional grey scale intravascular ultrasound (IVUS) and examine the current evidence for VHIVUS and its potential for use in clinical interventional practice.

MRI and CT in the diagnosis of coronary artery disease: indications and applications

In recent years, technical advances and improvements in cardiac computed tomography (CT) and cardiac magnetic resonance imaging (MRI) have provoked increasing interest in the potential clinical role of these techniques in the non-invasive work-up of patients with suspected coronary artery disease (CAD) and correct patient selection for these emerging imaging techniques. In the primary detection or exclusion of significant CAD, e.g. in the patient with unspecific thoracic complaints, and also in patients with known CAD or advanced stages of CAD, both CT and MRI yield specific advantages. In this review, the major aspects of non-invasive MR and CT imaging in the diagnosis of CAD will be discussed. The first part describes the clinical value of contrast-enhanced non-invasive CT coronary angiography (CTCA), including the diagnostic accuracy of CTCA for the exclusion or detection of significant CAD with coronary artery stenoses that may require angioplastic intervention, as well as potentially valuable information on the coronary artery vessel wall. In the second section, the potential of CT for the imaging of myocardial viability and perfusion will be highlighted. In the third and final part, the range of applications of cardiac MRI in CAD patients will be outlined.

Functional assessment of coronary artery flow using adenosine stress dual-energy CT: a preliminary study

We attempted to assess coronary artery flow using adenosine-stress and dual-energy mode with dual-source CT (DE-CT). Data of 18 patients with suspected coronary arteries disease who had undergone cardiac DE-CT were retrospectively analyzed. The patients were divided into two groups: 10 patients who performed adenosine stress CT, and 8 patients who performed rest CT as controls. We reconstructed an iodine map and composite images at 120 kV (120 kV images) using raw data with scan parameters of 100 and 140 kV. We measured mean attenuation in the coronary artery proximal to the distal portion on both the iodine map and 120 kV images. Coronary enhancement ratio (CER) was calculated by dividing mean attenuation in the coronary artery by attenuation in the aortic root, and was used as an estimate of coronary enhancement. Coronary stenosis was identified as a reduction in diameter of >50% on CT angiogram, and myocardial ischemia was diagnosed by adenosine-stress myocardial perfusion scintigraphy. The iodine map showed that CER was significantly lower for ischemic territories (0.76 ± 0.06) or stenosed coronary arteries (0.77 ± 0.06) than for non-ischemic territories (0.95 ± 0.21, P = 0.02) or non-stenosed coronary arteries (1.07 ± 0.33, P < 0.001). The 120 kV images showed no difference in CER between these two groups. Use of CER on the iodine map separated ischemic territories from non-ischemic territories with a sensitivity of 86% and a specificity of 75%. Our quantification is the first non-invasive analytical technique for assessment of coronary artery flow using cardiac CT. CER on the iodine map is a candidate method for demonstration of alteration in coronary artery flow under adenosine stress, which is related to the physiological significance of coronary artery disease.

CT angiography: current technology and clinical use

Since 1958, catheter angiography has assumed the role of gold standard for vascular imaging, despite the invasive nature of the procedure. Less invasive techniques for vascular imaging, such as computed tomographic angiography (CTA), have been developed and have matured in conjunction with developments in catheter arteriography. In a few cases, such as imaging, the aorta and the pulmonary arteries, CTA has supplanted catheter angiography as the gold standard. The expanding role of CTA emphasizes the need for deep, broad-based understanding of physical principles. This review describes CT hardware and associated software for angiography. The fundamentals of CTA physics are complemented with several clinical examples.

Usefulness of the fractional flow reserve derived by intracoronary pressure wire for evaluating angiographically intermediate lesions in acute coronary syndrome

INTRODUCTION AND OBJECTIVES

In contrast to findings in stable ischemic heart disease, in acute coronary syndrome (ACS), measurement of the fractional flow reserve (FFR) using an intracoronary pressure wire has not been shown to be useful for evaluating angiographically equivocal coronary lesions. The aim of this study was to analyze outcomes at 1 year in ACS patients with lesions that were classed as intermediate on coronary angiography and which were not nonrevascularized because of the FFR value determined by intracoronary pressure wire.

METHODS

The observational study involved a cohort of patients admitted for ACS who had intermediate lesions on coronary angiography that were not revascularized because the FFR was >0.75. Functional studies were not carried out if there was angiographic evidence of instability. All-cause mortality, non-fatal myocardial infarction, revascularization of the target lesion and readmission for cardiac causes in the first year of the study were recorded.

RESULTS

The study included 106 patients with 127 lesions that were not revascularized because the FFR was >0.75. Their mean age was 69.9+/-10 years, 92 (86.8%) had non-ST-elevation ACS, the mean angiographic stenosis was 40.5+/-7.8%, and the mean FFR was 0.88+/-0.06. There were no complications during the procedure. The follow-up rate at 1 year was 95.1%. Events observed at 1 year were: 2 deaths (total mortality 1.9%), 0 fatal acute myocardial infarctions, 1 (0.9%) target lesion revascularization and 5 (4.7%) readmissions for cardiac causes.

CONCLUSIONS

Once lesions with clear angiographic signs of instability are excluded, intracoronary pressure wire measurement could be useful in ACS patients for avoiding unnecessary revascularization of angiographically intermediate coronary lesions.

New set of intravascular ultrasound-derived anatomic criteria for defining functionally significant stenoses in small coronary arteries (results from Intravascular Ultrasound Diagnostic Evaluation of Atherosclerosis in Singapore [IDEAS] study)

We sought to determine the intravascular ultrasound-derived anatomic criteria for functionally significant lesions in small coronary arteries with a reference segment diameter <3 mm. A fractional flow reserve (FFR) of <0.75, as determined by pressure wire using high-dose (100 to 150 microg) intracoronary adenosine, was used as the reference standard for functional significance. For the 94 patients/lesions involved in the present study, the average reference vessel diameter was 2.72 mm. The FFR was <0.75 in 38 patients (40.4%) and > or =0.75 in 56 patients (59.6%). Logistic regression analysis identified the minimal lumen area, plaque burden, and lesion length as the 3 most important determinants of the FFR. Using classification and regression tree analysis, the best cutoff values for these determinants to discriminate a FFR of <0.75 versus > or =0.75 were a minimal lumen area of < or =2.0 mm(2) (sensitivity 82.35%, specificity 80.77%), plaque burden of > or =80% (sensitivity 87.9%, specificity 78.9%), and lesion length of > or =20 mm (sensitivity 63.6%, specificity 78.9%). A significant increase was found in the area under the receiver operating characteristic curve of the combined parameters (minimal lumen area plus plaque burden plus lesion length) compared to the plaque burden (p = 0.014) and other individual parameters (p <0.001). In conclusion, we found that intravascular ultrasound-derived anatomic criteria are able to predict the functional significance of intermediate lesions in small coronary arteries. A minimal lumen area of < or =2.0 mm(2), plaque burden of > or =80%, and lesion length of > or =20 mm predicted a FFR of <0.75 with good sensitivity and specificity.

Correlation between coronary computed tomographic angiography and fractional flow reserve

BACKGROUND

Coronary CT angiography (CCTA) has become an important modality to evaluate the presence of coronary artery disease. Coronary artery stenosis of intermediate severity remains a therapeutic dilemma. Measurement of fractional flow reserve (FFR) during coronary angiography is the most established technique to determine the hemodynamic severity of a coronary artery lesion. The aim of this study was to compare CCTA with FFR.

METHODS

In 56 coronary artery stenoses (42 patients) we performed CCTA, quantitative coronary angiography and FFR. CCTA measurements included diameter stenosis (DS, %), area stenosis (AS, %), minimal lumen diameter (MLD, mm), minimal lumen area (MLA, mm(2)), lesion length (LL, mm), plaque volume (mm(3)) and burden (%).

RESULTS

FFR averaged 0.81±0.14, and 10 lesions had an abnormal FFR (<0.75). We found significant correlations between FFR and DS (r=-0.67, p<0.001), AS (r=-0.68, p<0.001), MLD (r=0.58, p<0.001), MLA (r=0.53, p<0.001), LL (r=-0.36, p=0.02), plaque volume (r=-0.36, p=0.02) and plaque burden (r=-0.59, p<0.001). By multivariate regression analysis AS and LL were the strongest determinants of an abnormal FFR. The optimal cut-off value for AS was >73% (sensitivity 90%, specificity 80%, negative predictive value 97%, and positive predictive value 50%) and for LL >10 mm (sensitivity 60% and specificity 49%).

CONCLUSION

This study demonstrates that quantitative CCTA is correlated to FFR. Using our CCTA criteria of abnormality, significant coronary artery stenoses can be ruled out with a high negative predictive value.

Three-dimensional coronary imaging for the ostium of the left anterior descending artery

Conventional coronary angiography is subject to a significant foreshortening of the proximal left anterior descending artery and overlapping of the left anterior descending artery and the circumflex artery that limits the accurate identification of the ostium of the left anterior descending artery. The aim of this study was to determine whether the three-dimensional (3D) reconstruction of traditional coronary angiography could optimize the projection angle to clearly show the ostium of the left anterior descending artery. The left main bifurcations of 18 consecutive patients were analyzed. A 3D image of the bifurcation was reconstructed from two conventional images and the optimal projection angle was chosen to clearly identify the ostium of the left anterior descending artery. The optimal angle was the right anterior oblique 18.8 +/- 20.9 degrees-caudal 26.9 +/- 32.3 degrees. The length from the left main trunk to the proximal left anterior descending artery on the optimal views was significantly longer than that on the routine views (25.0 +/- 6.1 vs. 22.4 +/- 5.3 mm, P = 0.011). The angles of the left main bifurcations were not substantially different between the optimal and the routine views. The optimal views selected using the 3D system provided clearer images of the ostium of the left anterior descending artery with less overlapping and foreshortening.

Impact of In-Stent Minimal Lumen Area at 9 Months Poststent Implantation on 3-Year Target Lesion Revascularization–Free Survival

Background— Intravascular ultrasound (IVUS) is used to assess intermediate lesions in native coronary arteries; minimum lumen area (MLA) <4.0 mm 2 is accepted as a cutoff for a significant stenosis. We evaluated the IVUS in-stent MLA at 9-month follow-up that best predicted subsequent target lesion revascularization (TLR)–free survival in patients from the TAXUS IV, V, and VI studies.

Methods and Results— In the combined TAXUS IV, V, and VI randomized trials, 9-month IVUS was available in 635 patients (331 treated with paclitaxel-eluting stents [PES] and 304 treated with bare-metal stents [BMS]) who did not require TLR in the first 9 months postintervention and who were followed for 3 years. The in-stent MLA that best predicted 3-year TLR-free survival was determined. At 9-months follow-up, IVUS-measured in-stent MLA was 5.7�2.3 mm 2 in the PES group and 4.8�2.3 mm 2 in the BMS group. Between 9 months and 3 years, TLR was required in 4.9% of patients who were treated with PES and 6.7% of patients who were treated with BMS. Multivariate analysis identified MLA at 9 months as a significant predictor of late TLR (hazard ratio, 0.63 [0.43–0.93]; P =0.02). The ability of MLA to predict late TLR was further assessed using receiver operating characteristic analysis. MLA was found to be an acceptable discriminator for both PES (c=0.7448) and BMS (c=0.7329). Finally, the optimal thresholds of MLA that best predicted subsequent TLR-free survival were determined to be 4.2 mm 2 for PES and 4.0 mm 2 for BMS.

Conclusion— In the combined IVUS analysis of TAXUS IV, V, and VI, patients who did not require TLR within the first 9 months had a high subsequent TLR-free survival rate whether treated with PES or BMS. MLA measured by IVUS at 9 months predicted subsequent TLR with a cutoff similar to intermediate, de novo lesions in native coronary arteries.

Comprehensive assessment of coronary artery stenoses: computed tomography coronary angiography versus conventional coronary angiography and correlation with fractional flow reserve in patients with stable angina

OBJECTIVES

We sought to determine the diagnostic accuracy of noninvasive visual (computed tomography coronary angiography [CTCA]) and quantitative computed tomography coronary angiography (QCT) to predict the hemodynamic significance of a coronary stenosis, using intracoronary fractional flow reserve (FFR) as the reference standard.

BACKGROUND

It has been demonstrated that CTCA provides excellent diagnostic sensitivity for identifying coronary stenoses, but may lack accurate delineation of the hemodynamic significance.

METHODS

We investigated 79 patients with stable angina pectoris who underwent both 64-slice or dual-source CTCA and FFR measurement of discrete coronary stenoses. CTCA and conventional coronary angiography (CCA), and QCT and quantitative coronary angiography (QCA), were performed to determine the severity of a stenosis that was compared with FFR measurements. A significant anatomical or functional stenosis was defined as >/=50% diameter stenosis or an FFR <0.75. Stented segments and bypass grafts were not included in the analysis.

RESULTS

A total of 89 stenoses were evaluated of which 18% (16 of 89) had an FFR <0.75. The diagnostic accuracy of CTCA, QCT, CCA, and QCA to detect a hemodynamically significant coronary lesion was 49%, 71%, 61%, and 67%, respectively. Correlation between QCT and QCA with FFR measurement was weak (R values of -0.32 and -0.30, respectively). Correlation between QCT and QCA was significant, but only moderate (R = 0.53; p < 0.0001).

CONCLUSIONS

The anatomical assessment of the hemodynamic significance of coronary stenoses determined by visual CTCA, CCA, or QCT or QCA does not correlate well with the functional assessment of FFR. Determining the hemodynamic significance of an angiographically intermediate stenosis remains relevant before referral for revascularization treatment.

Applications of multislice coronary computed tomographic angiography to percutaneous coronary intervention: how did we ever do without it?

By providing data previously available only by intravascular ultrasound, 64-slice multidetector computed tomographic angiography (CTA) will impact percutaneous coronary intervention (PCI) in multiple areas: (1) pre-PCI patient selection; (2) identification of significant lesions; (3) in-stent restenosis; (4) procedure planning: stent sizing, choice of intervention, and equipment, chronic total occlusions, 3D-CTA in the catheterization laboratory; (5) plaque evaluation and identification of high-risk lesions; (6) postcatheterization decisions, and (7) structural heart disease. The likely outcome is transformation of the catheterization laboratory into a streamlined interventional suite, utilizing on-line CTA data in an interactive format.