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Cundari G, Marchitelli L, Pambianchi G, Catapano F, Conia L, Stancanelli G, Catalano C, Galea N. Imaging biomarkers in cardiac CT: moving beyond simple coronary anatomical assessment. LA RADIOLOGIA MEDICA 2024; 129:380-400. [PMID: 38319493 PMCID: PMC10942914 DOI: 10.1007/s11547-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/03/2024] [Indexed: 02/07/2024]
Abstract
Cardiac computed tomography angiography (CCTA) is considered the standard non-invasive tool to rule-out obstructive coronary artery disease (CAD). Moreover, several imaging biomarkers have been developed on cardiac-CT imaging to assess global CAD severity and atherosclerotic burden, including coronary calcium scoring, the segment involvement score, segment stenosis score and the Leaman-score. Myocardial perfusion imaging enables the diagnosis of myocardial ischemia and microvascular damage, and the CT-based fractional flow reserve quantification allows to evaluate non-invasively hemodynamic impact of the coronary stenosis. The texture and density of the epicardial and perivascular adipose tissue, the hypodense plaque burden, the radiomic phenotyping of coronary plaques or the fat radiomic profile are novel CT imaging features emerging as biomarkers of inflammation and plaque instability, which may implement the risk stratification strategies. The ability to perform myocardial tissue characterization by extracellular volume fraction and radiomic features appears promising in predicting arrhythmogenic risk and cardiovascular events. New imaging biomarkers are expanding the potential of cardiac CT for phenotyping the individual profile of CAD involvement and opening new frontiers for the practice of more personalized medicine.
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Affiliation(s)
- Giulia Cundari
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Livia Marchitelli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Giacomo Pambianchi
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Federica Catapano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, Pieve Emanuele, 20090, Milano, Italy
- Humanitas Research Hospital IRCCS, Via Alessandro Manzoni, 56, Rozzano, 20089, Milano, Italy
| | - Luca Conia
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Giuseppe Stancanelli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Nicola Galea
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
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2
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Lyu L, Pan J, Li D, Yu D, Li X, Yang W, Dong M, Han Y, Liang Y, Zhang P, Zhang M. A stepwise strategy integrating dynamic stress CT myocardial perfusion and deep learning-based FFR CT in the work-up of stable coronary artery disease. Eur Radiol 2024:10.1007/s00330-023-10562-x. [PMID: 38214735 DOI: 10.1007/s00330-023-10562-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 09/08/2023] [Accepted: 10/29/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVES To validate a novel stepwise strategy in which computed tomography-derived fractional flow reserve (FFRCT) is restricted to intermediate stenosis on coronary computed tomography angiography (CCTA) and computed tomography myocardial perfusion imaging (CT-MPI) was reserved for vessels with gray zone FFRCT values. MATERIALS AND METHODS This retrospective study included 87 consecutive patients (age, 58 ± 10 years; 70% male) who underwent CCTA, dynamic CT-MPI, interventional coronary angiography (ICA), and fractional flow reserve (FFR) for suspected or known coronary artery disease. FFRCT was computed using a deep learning-based platform. Three stepwise strategies (CCTA + FFRCT + CT-MPI, CCTA + FFRCT, CCTA + CT-MPI) were constructed and their diagnostic performance was evaluated using ICA/FFR as the reference standard. The proportions of vessels requiring further ICA/FFR measurement based on different strategies were noted. Furthermore, the net reclassification index (NRI) was calculated to ascertain the superior model. RESULTS The CCTA + FFRCT + CT-MPI strategy yielded the lowest proportion of vessels requiring additional ICA/FFR measurement when compared to the CCTA + FFRCT and CCTA + CT-MPI strategies (12%, 22%, and 24%). The CCTA + FFRCT + CT-MPI strategy exhibited the highest accuracy for ruling-out (91%, 84%, and 85%) and ruling-in (90%, 85%, and 85%) functionally significant lesions. All strategies exhibited comparable sensitivity for ruling-out functionally significant lesions and specificity for ruling-in functionally significant lesions (p > 0.05). The NRI indicated that the CCTA + FFRCT + CT-MPI strategy outperformed the CCTA + FFRCT strategy (NRI = 0.238, p < 0.001) and the CCTA + CT-MPI strategy (NRI = 0.233%, p < 0.001). CONCLUSIONS The CCTA + FFRCT + CT-MPI stepwise strategy was superior to the CCTA + FFRCT strategy and CCTA+ CT-MPI strategy by minimizing unnecessary invasive diagnostic catheterization without compromising the agreement rate with ICA/FFR. CLINICAL RELEVANCE STATEMENT Our novel stepwise strategy facilitates greater confidence and accuracy when clinicians need to decide on interventional coronary angiography referral or deferral, reducing the burden of invasive investigations on patients. KEY POINTS • A stepwise CCTA + FFRCT + CT-MPI strategy holds promise as a viable method to reduce the need for invasive diagnostic catheterization, while maintaining a high level of agreement with ICA/FFR. • The CCTA + FFRCT + CT-MPI strategy performed better than the CCTA + FFRCT and CCTA + CT-MPI strategies. • A stepwise CCTA + FFRCT + CT-MPI strategy allows to minimize unnecessary invasive diagnostic catheterization and helps clinicians to referral or deferral for ICA/FFR with more confidence.
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Affiliation(s)
- Lijuan Lyu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Jichen Pan
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Dumin Li
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Dexin Yu
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Xinhao Li
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Wei Yang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Mei Dong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Yeming Han
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Yongfeng Liang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China
| | - Pengfei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China.
| | - Mei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People's Republic of China.
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Mehta CR, Naeem A, Patel Y. Cardiac Computed Tomography Angiography in CAD Risk Stratification and Revascularization Planning. Diagnostics (Basel) 2023; 13:2902. [PMID: 37761268 PMCID: PMC10530183 DOI: 10.3390/diagnostics13182902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/25/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
PURPOSE OF REVIEW Functional stress testing is frequently used to assess for coronary artery disease (CAD) in symptomatic, stable patients with low to intermediate pretest probability. However, patients with highly vulnerable plaque may have preserved luminal patency and, consequently, a falsely negative stress test. Cardiac computed tomography angiography (CCTA) has emerged at the forefront of primary prevention screening and has excellent agency in ruling out obstructive CAD with high negative predictive value while simultaneously characterizing nonobstructive plaque for high-risk features, which invariably alters risk-stratification and pre-procedural decision making. RECENT FINDINGS We review the literature detailing the utility of CCTA in its ability to risk-stratify patients with CAD based on calcium scoring as well as high-risk phenotypic features and to qualify the functional significance of stenotic lesions. SUMMARY Calcium scores ≥ 100 should prompt consideration of statin and aspirin therapy. Spotty calcifications < 3 mm, increased non-calcified plaque > 4 mm3 per mm of the vessel wall, low attenuation < 30 HU soft plaque and necrotic core with a rim of higher attenuation < 130 HU, and a positive remodeling index ratio > 1.1 all confer additive risk for acute plaque rupture when present. Elevations in the perivascular fat attenuation index > -70.1 HU are a strong predictor of all-cause mortality and can further the risk stratification of patients in the setting of a non-to-minimal plaque burden. Lastly, a CT-derived fractional flow reserve (FFRCT) < 0.75 or values from 0.76 to 0.80 in conjunction with additional risk factors is suggestive of flow-limiting disease that would benefit from invasive testing. The wealth of information available through CCTA can allow clinicians to risk-stratify patients at elevated risk for an acute ischemic event and engage in advanced revascularization planning.
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Affiliation(s)
- Chirag R. Mehta
- Department of Cardiology, The Warren Alpert Medical School of Brown University, Providence, RI 02903, USA (Y.P.)
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Dell’Aversana F, Tedeschi C, Comune R, Gallo L, Ferrandino G, Basco E, Tamburrini S, Sica G, Masala S, Scaglione M, Liguori C. Advanced Cardiac Imaging and Women's Chest Pain: A Question of Gender. Diagnostics (Basel) 2023; 13:2611. [PMID: 37568974 PMCID: PMC10416986 DOI: 10.3390/diagnostics13152611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
Awareness of gender differences in cardiovascular disease (CVD) has increased: both the different impact of traditional cardiovascular risk factors on women and the existence of sex-specific risk factors have been demonstrated. Therefore, it is essential to recognize typical aspects of ischemic heart disease (IHD) in women, who usually show a lower prevalence of obstructive coronary artery disease (CAD) as a cause of acute coronary syndrome (ACS). It is also important to know how to recognize pathologies that can cause acute chest pain with a higher incidence in women, such as spontaneous coronary artery dissection (SCAD) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (CMR) gained a pivotal role in the context of cardiac emergencies. Thus, the aim of our review is to investigate the most frequent scenarios in women with acute chest pain and how advanced cardiac imaging can help in the management and diagnosis of ACS.
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Affiliation(s)
- Federica Dell’Aversana
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Napoli, Italy
| | - Carlo Tedeschi
- Operational Unit of Cardiology, Presidio Sanitario Intermedio Napoli Est, ASL-Napoli 1 Centro, 80144 Napoli, Italy;
| | - Rosita Comune
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Napoli, Italy
| | - Luigi Gallo
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Napoli, Italy
| | - Giovanni Ferrandino
- Department of Radiology, Ospedale del Mare-ASL Napoli 1, 80147 Napoli, Italy; (G.F.)
| | - Emilia Basco
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Napoli, Italy
| | - Stefania Tamburrini
- Department of Radiology, Ospedale del Mare-ASL Napoli 1, 80147 Napoli, Italy; (G.F.)
| | - Giacomo Sica
- Department of Radiology, Monaldi Hospital Azienda dei Colli, 80131 Napoli, Italy
| | - Salvatore Masala
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| | - Mariano Scaglione
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
- Department of Radiology, James Cook University Hospital, Middlesbrough TS4 3BW, UK
| | - Carlo Liguori
- Department of Radiology, Ospedale del Mare-ASL Napoli 1, 80147 Napoli, Italy; (G.F.)
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Sliwicka O, Sechopoulos I, Baggiano A, Pontone G, Nijveldt R, Habets J. Dynamic myocardial CT perfusion imaging-state of the art. Eur Radiol 2023; 33:5509-5525. [PMID: 36997751 PMCID: PMC10326111 DOI: 10.1007/s00330-023-09550-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/02/2023] [Accepted: 02/22/2023] [Indexed: 04/01/2023]
Abstract
In patients with suspected coronary artery disease (CAD), dynamic myocardial computed tomography perfusion (CTP) imaging combined with coronary CT angiography (CTA) has become a comprehensive diagnostic examination technique resulting in both anatomical and quantitative functional information on myocardial blood flow, and the presence and grading of stenosis. Recently, CTP imaging has been proven to have good diagnostic accuracy for detecting myocardial ischemia, comparable to stress magnetic resonance imaging and positron emission tomography perfusion, while being superior to single photon emission computed tomography. Dynamic CTP accompanied by coronary CTA can serve as a gatekeeper for invasive workup, as it reduces unnecessary diagnostic invasive coronary angiography. Dynamic CTP also has good prognostic value for the prediction of major adverse cardiovascular events. In this article, we will provide an overview of dynamic CTP, including the basics of coronary blood flow physiology, applications and technical aspects including protocols, image acquisition and reconstruction, future perspectives, and scientific challenges. KEY POINTS: • Stress dynamic myocardial CT perfusion combined with coronary CTA is a comprehensive diagnostic examination technique resulting in both anatomical and quantitative functional information. • Dynamic CTP imaging has good diagnostic accuracy for detecting myocardial ischemia comparable to stress MRI and PET perfusion. • Dynamic CTP accompanied by coronary CTA may serve as a gatekeeper for invasive workup and can guide treatment in obstructive coronary artery disease.
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Affiliation(s)
- Olga Sliwicka
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Ioannis Sechopoulos
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Andrea Baggiano
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gianluca Pontone
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jesse Habets
- Department of Medical Imaging, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Department of Radiology and Nuclear Medicine, Haaglanden Medical Center, The Hague, The Netherlands
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Nieman K, Chandrashekhar Y. Myocardial CT Perfusion Imaging in 2023. JACC Cardiovasc Imaging 2023; 16:1000-1002. [PMID: 37407119 DOI: 10.1016/j.jcmg.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
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Patel P, Emrich T, Schoepf UJ, Mehta V, Bayer RR, von Assen M, Giovagnoli V, Jeudy J, Varga-Szemes A, White C. Comprehensive Computed Tomography Imaging of Vessel-specific and Lesion-specific Myocardial Ischemia. J Thorac Imaging 2023; 38:212-225. [PMID: 34029280 DOI: 10.1097/rti.0000000000000592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Coronary computed tomographic angiography (CCTA) has emerged as a fast and robust tool with high sensitivity and excellent negative predictive value for the evaluation of coronary artery disease, but is unable to estimate the hemodynamic significance of a lesion. Advances in computed tomography (CT)-based diagnostic techniques, for example, CT-derived fractional flow reserve and CT perfusion, have helped transform CCTA primarily from an anatomic assessment tool to a technique that is able to provide both anatomic and functional information for a stenosis. With the results of the ISCHEMIA trial published in 2019, these advanced techniques can elevate CCTA into the role of a better gatekeeper for decision-making and can help guide referral for invasive management. In this article, we review the principles, limitations, diagnostic performance, and clinical utility of these 2 functional CT-based techniques in the evaluation of vessel-specific and lesion-specific ischemia.
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Affiliation(s)
- Pratik Patel
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
- Department of Radiology, University of Florida College of Medicine, Gainesville, FL
| | - Tilman Emrich
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - U Joseph Schoepf
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Varun Mehta
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Richard R Bayer
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Marly von Assen
- Department of Radiology and Imaging Sciences, Division of Cardiothoracic Imaging, Emory University Hospital, Atlanta, GA
| | - Vincent Giovagnoli
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Jean Jeudy
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Akos Varga-Szemes
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Charles White
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD
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Capisizu AS, Stanciu S, Cuzino D. Reliability of cardiac computed tomography examination in cardiac pathology - a case series and literature review. J Med Life 2023; 16:1140-1146. [PMID: 37900066 PMCID: PMC10600673 DOI: 10.25122/jml-2023-0268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/28/2023] [Indexed: 10/31/2023] Open
Abstract
Due to the technological progress in the last decade, the medical practice of cardiology relies more and more on the information provided by cardiac computed tomography. Current guidelines propose coronary computed angiography as a first-line anatomic investigation in patients with low and intermediate probability of coronary atherosclerosis. At the same time, anatomical information is obtained about the rest of the cardiac structures and about cardiac function. The present work aimed to present the contribution of cardiac computed tomography in the morphological and functional characterization of patients with complex cardiac pathology. Three cases are presented in which the information provided by cardiac computed tomography contributed significantly to the diagnosis. The cases were cardiac pathologies such as ventricular apical aneurysm, aortic prosthetic thrombosis, and a cardiac malformation with transposition of great arteries. In addition to highlighting the role of cardiac computed tomography in diagnosing cardiac pathology, a brief review of cardiac computed tomography indications, inclusion criteria, patient safety, basic techniques, and the main protocols and types of post-processing used in practice is provided. This article provides an overview of the applications of cardiac computed tomography, highlighting its role within clinical practice, particularly in the characterization of complex cardiac pathologies.
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Affiliation(s)
- Adriana Sorina Capisizu
- Department of Radiology and Imagistic Medicine 1, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Silviu Stanciu
- Department of Cardiology, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Center for Cardiovascular Diseases, Laboratory of Noninvasive Cardiovascular Functional Explorations, Dr. Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
| | - Dragoș Cuzino
- Department of Radiology and Imagistic Medicine 1, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Clinical Radiology-Medical Imaging Center, Medical Imaging Radiology Laboratory II, Dr. Carol Davila Central Military Emergency University Hospital, Bucharest, Romania
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Ahn Y, Koo HJ, Hyun J, Lee SE, Jung SH, Park DW, Ahn JM, Kang DY, Park SJ, Hwang HS, Kang JW, Yang DH, Kim JJ. CT Coronary Angiography and Dynamic CT Myocardial Perfusion for Detection of Cardiac Allograft Vasculopathy. JACC Cardiovasc Imaging 2023; 16:934-947. [PMID: 37407125 DOI: 10.1016/j.jcmg.2022.12.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/23/2022] [Indexed: 07/07/2023]
Abstract
BACKGROUND Cardiac allograft vasculopathy (CAV) is a major obstacle limiting long-term graft survival. Effective noninvasive surveillance modalities reflecting both coronary artery and microvascular components of CAV are needed. OBJECTIVES The authors evaluated the diagnostic performance of dynamic computed tomography-myocardial perfusion imaging (CT-MPI) and coronary computed tomography angiography (CCTA) for CAV. METHODS A total of 63 heart transplantation patients underwent combined CT-MPI and CCTA plus invasive coronary angiography (ICA) with intravascular ultrasonography (IVUS) between December 2018 and October 2021. The median interval between CT-MPI and heart transplantation was 4.3 years. Peak myocardial blood flow (MBF) of the whole myocardium (MBFglobal) and minimum MBF (MBFmin) among the 16 segments according to the American Heart Association model, except the left ventricular apex, were calculated from CT-MPI. CCTA was assessed qualitatively, and the degree of coronary artery stenosis was recorded. CAV was diagnosed based on both ICA (ISHLT criteria) and IVUS. Patients were followed up for a median time of 2.3 years after CT-MPI and a median time of 5.7 years after transplantation. RESULTS Among the 63 recipients, 35 (55.6%) had diagnoses of CAV. The median MBFglobal and MBFmin were significantly lower in patients with CAV (128.7 vs 150.4 mL/100 mL/min; P = 0.014; and 96.9 vs 122.8 mL/100 mL/min; P < 0.001, respectively). The combined use of coronary artery stenosis on CCTA and MBFmin showed the highest diagnostic performance with an area under the curve of 0.886 (sensitivity: 74.3%, specificity: 96.4%, positive predictive value: 96.3%, and negative predictive value: 75.0%). CONCLUSIONS The combination of CT-MPI and CCTA demonstrated excellent diagnostic performance for the detection of CAV. One-stop evaluation of the coronary artery and microvascular components involved in CAV using combined CCTA and CT-MPI may be a potent noninvasive screening method for early detection of CAV.
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Affiliation(s)
- Yura Ahn
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hyun Jung Koo
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Junho Hyun
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Eun Lee
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do-Yoon Kang
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Seung-Jung Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hee Sang Hwang
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon-Won Kang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Hyun Yang
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae-Joong Kim
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Pugliese L, Ricci F, Sica G, Scaglione M, Masala S. Non-Contrast and Contrast-Enhanced Cardiac Computed Tomography Imaging in the Diagnostic and Prognostic Evaluation of Coronary Artery Disease. Diagnostics (Basel) 2023; 13:2074. [PMID: 37370969 DOI: 10.3390/diagnostics13122074] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
In recent decades, cardiac computed tomography (CT) has emerged as a powerful non-invasive tool for risk stratification, as well as the detection and characterization of coronary artery disease (CAD), which remains the main cause of morbidity and mortality in the world. Advances in technology have favored the increasing use of cardiac CT by allowing better performance with lower radiation doses. Coronary artery calcium, as assessed by non-contrast CT, is considered to be the best marker of subclinical atherosclerosis, and its use is recommended for the refinement of risk assessment in low-to-intermediate risk individuals. In addition, coronary CT angiography (CCTA) has become a gate-keeper to invasive coronary angiography (ICA) and revascularization in patients with acute chest pain by allowing the assessment not only of the extent of lumen stenosis, but also of its hemodynamic significance if combined with the measurement of fractional flow reserve or perfusion imaging. Moreover, CCTA provides a unique incremental value over functional testing and ICA by imaging the vessel wall, thus allowing the assessment of plaque burden, composition, and instability features, in addition to perivascular adipose tissue attenuation, which is a marker of vascular inflammation. There exists the potential to identify the non-obstructive lesions at high risk of progression to plaque rupture by combining all of these measures.
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Affiliation(s)
- Luca Pugliese
- Radiology Unit, Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea University Hospital, 00189 Rome, Italy
| | - Francesca Ricci
- Radiology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| | - Giacomo Sica
- Radiology Unit, Monaldi Hospital, 80131 Napoli, Italy
| | - Mariano Scaglione
- Radiology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
| | - Salvatore Masala
- Radiology Unit, Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100 Sassari, Italy
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11
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Møller MB, Hasbak P, Linde JJ, Sigvardsen PE, Køber LV, Kofoed KF. Quantification of myocardial blood flow using dynamic myocardial CT perfusion compared with 82Rb PET. J Cardiovasc Comput Tomogr 2023:S1934-5925(23)00093-X. [PMID: 37024395 DOI: 10.1016/j.jcct.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 04/08/2023]
Abstract
PURPOSE Absolute measures of myocardial blood flow (MBF) obtained with dynamic myocardial CT perfusion (DM-CTP) are underestimated when compared with reference standards. This is to some extent explained by incomplete extraction of iodinated contrast agent (iCA) to the myocardial tissue. We aimed to establish an extraction function for iCA, use the function to calculate MBFCT and to compare this with MBF measured with 82Rb positron emission tomography (PET). MATERIALS AND METHODS Healthy individuals without coronary artery disease (CAD) were examined with 82Rb PET and DM-CTP. The factors a and β of the generalized Renkin-Crone model were estimated using a non-linear least squares model. The factors providing the best fit for the data were subsequently used to calculate MBFCT. RESULTS Of consecutive 91 individuals examined, 79 were eligible for analysis. The factors a and β providing the best fit of the nonlinear least-squares model to the data were a = 0.614 and β = 0.218 (R-squared = 0.81). Conversion of the CT inflow parameter (K1) values using the derived extraction function resulted in a significant correlation between MBF measured during stress using CT and PET (P = 0.039). CONCLUSION In healthy individuals, flow estimates obtained with dynamic myocardial CT perfusion during stress were, after conversion to MBF using the extraction of iodinated CT contrast agent, correlated with absolute MBF quantified with 82Rb PET.
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Affiliation(s)
- Mathias B Møller
- Department of Cardiology, The Heart Centre, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Philip Hasbak
- Department of Nuclear Medicine, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Jesper J Linde
- Department of Cardiology, The Heart Centre, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Per E Sigvardsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Lars V Køber
- Department of Cardiology, The Heart Centre, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Klaus F Kofoed
- Department of Cardiology, The Heart Centre, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark; Department of Radiology, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
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12
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Lan Z, Ding X, Yu Y, Yu L, Yang W, Dai X, Ling R, Wang Y, Yang W, Zhang J. CT-derived fractional flow reserve for prediction of major adverse cardiovascular events in diabetic patients. Cardiovasc Diabetol 2023; 22:65. [PMID: 36944990 PMCID: PMC10032006 DOI: 10.1186/s12933-023-01801-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/13/2023] [Indexed: 03/23/2023] Open
Abstract
OBJECTIVES To investigate the prognostic value of computed tomography fractional flow reserve (CT-FFR) in patients with diabetes and to establish a risk stratification model for major adverse cardiac event (MACE). METHODS Diabetic patients with intermediate pre-test probability of coronary artery disease were prospectively enrolled. All patients were referred for coronary computed tomography angiography and followed up for at least 2 years. In the training cohort comprising of 957 patients, two models were developed: model1 with the inclusion of clinical and conventional imaging parameters, model2 incorporating the above parameters + CT-FFR. An internal validation cohort comprising 411 patients and an independent external test cohort of 429 patients were used to validate the proposed models. RESULTS 1797 patients (mean age: 61.0 ± 7.0 years, 1031 males) were finally included in the present study. MACE occurred in 7.18% (129/1797) of the current cohort during follow- up. Multivariate Cox regression analysis revealed that CT-FFR ≤ 0.80 (hazard ratio [HR] = 4.534, p < 0.001), HbA1c (HR = 1.142, p = 0.015) and low attenuation plaque (LAP) (HR = 3.973, p = 0.041) were the independent predictors for MACE. In the training cohort, the Log-likelihood test showed statistical significance between model1 and model2 (p < 0.001). The C-index of model2 was significantly larger than that of model1 (C-index = 0.82 [0.77-0.87] vs. 0.80 [0.75-0.85], p = 0.021). Similar findings were found in internal validation and external test cohorts. CONCLUSION CT-FFR was a strong independent predictor for MACE in diabetic cohort. The model incorporating CT-FFR, LAP and HbA1c yielded excellent performance in predicting MACE.
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Affiliation(s)
- Ziting Lan
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, #85 Wujin Rd, Shanghai, 200080, China
| | - Xiaoying Ding
- Department of Endocrinology and Metabolism, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, #85 Wujin Rd, Shanghai, China
| | - Yarong Yu
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, #85 Wujin Rd, Shanghai, 200080, China
| | - Lihua Yu
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, #85 Wujin Rd, Shanghai, 200080, China
| | - Wenli Yang
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, #85 Wujin Rd, Shanghai, 200080, China
| | - Xu Dai
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, #600, Yishan Rd, Shanghai, China
| | - Runjianya Ling
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, #600, Yishan Rd, Shanghai, China
| | - Yufan Wang
- Department of Endocrinology and Metabolism, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, #85 Wujin Rd, Shanghai, China
| | - Wenyi Yang
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, #85 Wujin Rd, Shanghai, China.
| | - Jiayin Zhang
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, #85 Wujin Rd, Shanghai, 200080, China.
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13
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Gao X, Wang R, Sun Z, Zhang H, Bo K, Xue X, Yang J, Xu L. A Novel CT Perfusion-Based Fractional Flow Reserve Algorithm for Detecting Coronary Artery Disease. J Clin Med 2023; 12:jcm12062154. [PMID: 36983156 PMCID: PMC10058085 DOI: 10.3390/jcm12062154] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/23/2023] [Accepted: 02/28/2023] [Indexed: 03/12/2023] Open
Abstract
Background: The diagnostic accuracy of fractional flow reserve (FFR) derived from coronary computed tomography angiography (CCTA) (FFR-CT) needs to be further improved despite promising results available in the literature. While an innovative myocardial computed tomographic perfusion (CTP)-derived fractional flow reserve (CTP-FFR) model has been initially established, the feasibility of CTP-FFR to detect coronary artery ischemia in patients with suspected coronary artery disease (CAD) has not been proven. Methods: This retrospective study included 93 patients (a total of 103 vessels) who received CCTA and CTP for suspected CAD. Invasive coronary angiography (ICA) was performed within 2 weeks after CCTA and CTP. CTP-FFR, CCTA (stenosis ≥ 50% and ≥70%), ICA, FFR-CT and CTP were assessed by independent laboratory experts. The diagnostic ability of the CTP-FFR grouped by quantitative coronary angiography (QCA) in mild (30–49%), moderate (50–69%) and severe stenosis (≥70%) was calculated. The effect of calcification of lesions, grouped by FFR on CTP-FFR measurements, was also assessed. Results: On the basis of per-vessel level, the AUCs for CTP-FFR, CTP, FFR-CT and CCTA were 0.953, 0.876, 0.873 and 0.830, respectively (all p < 0.001). The sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of CTP-FFR for per-vessel level were 0.87, 0.88, 0.87, 0.85 and 0.89 respectively, compared with 0.87, 0.54, 0.69, 0.61, 0.83 and 0.75, 0.73, 0.74, 0.70, 0.77 for CCTA ≥ 50% and ≥70% stenosis, respectively. On the basis of per-vessel analysis, CTP-FFR had higher specificity, accuracy and AUC compared with CCTA and also higher AUC compared with FFR-CT or CTP (all p < 0.05). The sensitivity and accuracy of CTP-FFR + CTP + FFR-CT were also improved over FFR-CT alone (both p < 0.05). It also had improved specificity compared with FFR-CT or CTP alone (p < 0.01). A strong correlation between CTP-FFR and invasive FFR values was found on per-vessel analysis (Pearson’s correlation coefficient 0.89). The specificity of CTP-FFR was higher in the severe calcification group than in the low calcification group (p < 0.001). Conclusions: A novel CTP-FFR model has promising value to detect myocardial ischemia in CAD, particularly in mild-to-moderate stenotic lesions.
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Affiliation(s)
- Xuelian Gao
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Rui Wang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Zhonghua Sun
- Discipline of Medical Radiation Science, Curtin Medical School, Curtin University, Perth 6845, Australia
| | - Hongkai Zhang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Kairui Bo
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Xiaofei Xue
- School of Biomedical Engineering, Sun Yat-sen University, Shenzhen 518107, China
| | - Junjie Yang
- Department of Cardiology, The Sixth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
- Correspondence: (J.Y.); (L.X.)
| | - Lei Xu
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- Correspondence: (J.Y.); (L.X.)
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14
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Schwarz EL, Pegolotti L, Pfaller MR, Marsden AL. Beyond CFD: Emerging methodologies for predictive simulation in cardiovascular health and disease. BIOPHYSICS REVIEWS 2023; 4:011301. [PMID: 36686891 PMCID: PMC9846834 DOI: 10.1063/5.0109400] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 12/12/2022] [Indexed: 01/15/2023]
Abstract
Physics-based computational models of the cardiovascular system are increasingly used to simulate hemodynamics, tissue mechanics, and physiology in evolving healthy and diseased states. While predictive models using computational fluid dynamics (CFD) originated primarily for use in surgical planning, their application now extends well beyond this purpose. In this review, we describe an increasingly wide range of modeling applications aimed at uncovering fundamental mechanisms of disease progression and development, performing model-guided design, and generating testable hypotheses to drive targeted experiments. Increasingly, models are incorporating multiple physical processes spanning a wide range of time and length scales in the heart and vasculature. With these expanded capabilities, clinical adoption of patient-specific modeling in congenital and acquired cardiovascular disease is also increasing, impacting clinical care and treatment decisions in complex congenital heart disease, coronary artery disease, vascular surgery, pulmonary artery disease, and medical device design. In support of these efforts, we discuss recent advances in modeling methodology, which are most impactful when driven by clinical needs. We describe pivotal recent developments in image processing, fluid-structure interaction, modeling under uncertainty, and reduced order modeling to enable simulations in clinically relevant timeframes. In all these areas, we argue that traditional CFD alone is insufficient to tackle increasingly complex clinical and biological problems across scales and systems. Rather, CFD should be coupled with appropriate multiscale biological, physical, and physiological models needed to produce comprehensive, impactful models of mechanobiological systems and complex clinical scenarios. With this perspective, we finally outline open problems and future challenges in the field.
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Affiliation(s)
- Erica L. Schwarz
- Departments of Pediatrics and Bioengineering, Stanford University, Stanford, California 94305, USA
| | - Luca Pegolotti
- Departments of Pediatrics and Bioengineering, Stanford University, Stanford, California 94305, USA
| | - Martin R. Pfaller
- Departments of Pediatrics and Bioengineering, Stanford University, Stanford, California 94305, USA
| | - Alison L. Marsden
- Departments of Pediatrics and Bioengineering, Stanford University, Stanford, California 94305, USA
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15
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Xie Z, Wu T, Mu J, Zhang P, Wang X, Liang T, Weng Y, Luo J, Yu H. Influence of Left Ventricular Diastolic Dysfunction on the Diagnostic Performance of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve. J Clin Med 2023; 12:jcm12051724. [PMID: 36902511 PMCID: PMC10003343 DOI: 10.3390/jcm12051724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/05/2023] [Accepted: 02/19/2023] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVES Our study aimed to demonstrate the influence of left ventricular (LV) diastolic dysfunction on the diagnostic performance of coronary computed tomography angiography-derived fractional flow reserve (CT-FFR). METHODS One hundred vessels from 90 patients were retrospectively analyzed. All patients underwent echocardiography, coronary computed tomography angiography (CCTA), CT-FFR, invasive coronary angiography (ICA), and fractional flow reserve (FFR). The study population was divided into normal and dysfunction groups according to the LV diastolic function, and the diagnostic performance in both groups was assessed. RESULTS There was a good correlation between CT-FFR and FFR (R = 0.768 p < 0.001) on a per-vessel basis. The sensitivity, specificity, and accuracy were 82.3%, 81.8%, and 82%, respectively. The sensitivity, specificity, and accuracy were 84.6%, 88.5%, and 87.2% in the normal group and 81%, 77.5%, and 78.7% in the dysfunction group, respectively. CT-FFR showed no statistically significant difference in the AUC in the normal group vs. the dysfunction group (AUC: 0.920 [95% CI 0.787-0.983] vs. 0.871 [95% CI 0.761-0.943], Z = 0.772 p = 0.440). However, there was still a good correlation between CT-FFR and FFR in the normal group (R = 0.767, p < 0.001) and dysfunction group (R = 0.767 p < 0.001). CONCLUSIONS LV diastolic dysfunction had no effect on the diagnostic accuracy of CT-FFR. CT-FFR has good diagnostic performance in both LV diastolic dysfunction and the normal group and can be used as an effective tool for finding lesion-specific ischemia while screening for arterial disease in patients.
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Affiliation(s)
- Zhixin Xie
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
- Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
- Guangdong Cardiovascular Institute, Guangzhou 510080, China
| | - Tianlong Wu
- Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
- Guangdong Cardiovascular Institute, Guangzhou 510080, China
| | - Jing Mu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
- Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
- Guangdong Cardiovascular Institute, Guangzhou 510080, China
| | - Ping Zhang
- Department of Cardiology, Shenzhen Hospital, Southern Medical University, Shenzhen 518000, China
| | - Xuan Wang
- Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
- School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Tao Liang
- Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
- School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Yihan Weng
- Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
- Guangdong Cardiovascular Institute, Guangzhou 510080, China
- Shantou University Medical College, Shantou 515041, China
| | - Jianfang Luo
- Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
- Guangdong Cardiovascular Institute, Guangzhou 510080, China
| | - Huimin Yu
- Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
- Guangdong Cardiovascular Institute, Guangzhou 510080, China
- Department of Cardiology, Guangdong Provincial People’s Hospital’s Nanhai Hospital, Foshan 528000, China
- Correspondence:
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16
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A deep learning-based fully automatic and clinical-ready framework for regional myocardial segmentation and myocardial ischemia evaluation. Med Biol Eng Comput 2023; 61:1507-1520. [PMID: 36773119 DOI: 10.1007/s11517-023-02798-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 01/31/2023] [Indexed: 02/12/2023]
Abstract
Myocardial ischemia diagnosis with CT perfusion imaging (CTP) is important in coronary artery disease management. Traditional analysis procedure is time-consuming and error-prone due to the semi-manual and operator-dependent nature. To improve the diagnostic performance, a deep learning-based, fully automatic, and clinical-ready framework was developed. Two collaborating deep learning networks including a 3D U-Net for left ventricle segmentation and a CNN for anatomical landmarks detection were trained on 276 subjects. With our processing framework, the 17-segment left ventricular model was automatically generated conformed to the clinical standard. Myocardial blood flow computed by commercial software was extracted within each segment and visualized against the bull's eye plot. The performance was validated on another 45 subjects. Coronary angiography and invasive fractional flow reserve measurements were also performed in these patients to serve as the gold standard for myocardial ischemia diagnosis. As a result, the diagnostic accuracy for our method was 81.08%, much higher than that for commercially available CTP analysis software (56.75%), and our method demonstrated a higher consistency (Kappa coefficient 0.759 vs. 0.585). Besides, the average processing time of our method was much lower (30 ± 10.5 s/subject vs. over 30 min/subject). In conclusion, the proposed deep learning-based framework could be a promising tool for assisting CTP analysis.
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17
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Sharifkazemi M, Hooshanginezhad Z, Zoroufian A, Shamsa K. Is it the Time to Move Towards Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve Guided Percutaneous Coronary Intervention? The Pros and Cons. Curr Cardiol Rev 2023; 19:e190123212887. [PMID: 36658709 PMCID: PMC10494271 DOI: 10.2174/1573403x19666230119115228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 11/08/2022] [Accepted: 11/21/2022] [Indexed: 01/21/2023] Open
Abstract
Coronary artery disease is the leading cause of mortality worldwide. Diagnosis is conventionally performed by direct visualization of the arteries by invasive coronary angiography (ICA), which has inherent limitations and risks. Measurement of fractional flow reserve (FFR) has been suggested for a more accurate assessment of ischemia in the coronary artery with high accuracy for determining the severity and decision on the necessity of intervention. Nevertheless, invasive coronary angiography-derived fractional flow reserve (ICA-FFR) is currently used in less than one-third of clinical practices because of the invasive nature of ICA and the need for additional equipment and experience, as well as the cost and extra time needed for the procedure. Recent technical advances have moved towards non-invasive high-quality imaging modalities, such as magnetic resonance, single-photon emission computed tomography, and coronary computed tomography (CT) scan; however, none had a definitive modality to confirm hemodynamically significant coronary artery stenosis. Coronary computed tomography angiography (CCTA) can provide accurate anatomic and hemodynamic data about the coronary lesion, especially calculating fractional flow reserve derived from CCTA (CCTA-FFR). Although growing evidence has been published regarding CCTA-FFR results being comparable to ICA-FFR, CCTA-FFR has not yet replaced the invasive conventional angiography, pending additional studies to validate the advantages and disadvantages of each diagnostic method. Furthermore, it has to be identified whether revascularization of a stenotic lesion is plausible based on CCTA-FFR and if the therapeutic plan can be determined safely and accurately without confirmation from invasive methods. Therefore, in the present review, we will outline the pros and cons of using CCTA-FFR vs. ICA-FFR regarding diagnostic accuracy and treatment decision-making.
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Affiliation(s)
| | - Zahra Hooshanginezhad
- Division of Cardiology, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arezou Zoroufian
- Division of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Shamsa
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA
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18
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Andreini D, Collet C, Leipsic J, Nieman K, Bittencurt M, De Mey J, Buls N, Onuma Y, Mushtaq S, Conte E, Bartorelli AL, Stefanini G, Sonck J, Knaapen P, Ghoshhajra B, Serruys PW. Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography. EUROINTERVENTION 2022; 18:e872-e887. [PMID: 35994043 PMCID: PMC9743242 DOI: 10.4244/eij-e-22-00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/05/2022] [Indexed: 12/12/2022]
Abstract
Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.
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Affiliation(s)
- Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | | | - Jonathon Leipsic
- St Paul's Hospital & University of British Columbia, Vancouver, British Columbia Vancouver, Canada
| | - Koen Nieman
- Stanford University School of Medicine, Departments of Medicine and Radiology, USA
| | - Marcio Bittencurt
- Division of Internal Medicine, University Hospital, University of São Paulo, São Paulo, Brazil
- DASA, São Paulo, Brazil
- Division of Cardiology and the Heart and Vascular Institute, University of Pittsburgh Medical Center
| | - Johan De Mey
- Department of Radiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
| | - Nico Buls
- Department of Radiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
| | - Yoshinobu Onuma
- Clinical Science Institute, National University of Ireland, Galway, Ireland
| | | | - Edoardo Conte
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Antonio L Bartorelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLVZ Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples, Federico II, Naples, Italy
| | - Paul Knaapen
- Vrije Universiteit Medical Center, Amsterdam, Netherlands
| | - Brian Ghoshhajra
- Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Patrick W Serruys
- Clinical Science Institute, National University of Ireland, Galway, Ireland
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19
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Canan A, Barbosa MF, Nomura CH, Abbara S, Kay FU. Cardiac CT Perfusion Imaging. CURRENT RADIOLOGY REPORTS 2022. [DOI: 10.1007/s40134-022-00406-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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20
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Andreini D, Collet C, Leipsic J, Nieman K, Bittencurt M, De Mey J, Buls N, Onuma Y, Mushtaq S, Conte E, Bartorelli AL, Stefanini G, Sonck J, Knaapen P, Ghoshhajra B, Serruys P. Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2022; 16:558-572. [PMID: 36008263 DOI: 10.1016/j.jcct.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 06/07/2022] [Accepted: 08/05/2022] [Indexed: 10/15/2022]
Abstract
Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.
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Affiliation(s)
- Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy.
| | | | - Jonathon Leipsic
- St Paul's Hospital & University of British Columbia, Vancouver, British Columbia, Vancouver, Canada
| | - Koen Nieman
- Stanford University School of Medicine, Departments of Medicine and Radiology, USA
| | - Marcio Bittencurt
- Division of Internal Medicine, University Hospital, University of São Paulo, São Paulo, Brazil; DASA, São Paulo, Brazil; Division of Cardiology and the Heart and Vascular Institute, University of Pittsburgh Medical Center, USA
| | - Johan De Mey
- Department of Radiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
| | - Nico Buls
- Department of Radiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
| | - Yoshinobu Onuma
- Clinical Science Institute, National University of Ireland, Galway, Ireland
| | | | - Edoardo Conte
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Antonio L Bartorelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Milan, Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLVZ Aalst, Belgium; Department of Advanced Biomedical Sciences, University of Naples, Federico II, Naples, Italy
| | - Paul Knaapen
- Vrije Universiteit Medical Center, Amsterdam, Netherlands
| | - Brian Ghoshhajra
- Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Patrick Serruys
- Clinical Science Institute, National University of Ireland, Galway, Ireland
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21
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Morrone D, Gentile F, Aimo A, Cameli M, Barison A, Picoi ME, Guglielmo M, Villano A, DeVita A, Mandoli GE, Pastore MC, Barillà F, Mancone M, Pedrinelli R, Indolfi C, Filardi PP, Muscoli S, Tritto I, Pizzi C, Camici PG, Marzilli M, Crea F, Caterina RD, Pontone G, Neglia D, Lanza G. Perspectives in noninvasive imaging for chronic coronary syndromes. Int J Cardiol 2022; 365:19-29. [PMID: 35901907 DOI: 10.1016/j.ijcard.2022.07.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/05/2022] [Accepted: 07/21/2022] [Indexed: 11/26/2022]
Abstract
Both the latest European guidelines on chronic coronary syndromes and the American guidelines on chest pain have underlined the importance of noninvasive imaging to select patients to be referred to invasive angiography. Nevertheless, although coronary stenosis has long been considered the main determinant of inducible ischemia and symptoms, growing evidence has demonstrated the importance of other underlying mechanisms (e.g., vasospasm, microvascular disease, energetic inefficiency). The search for a pathophysiology-driven treatment of these patients has therefore emerged as an important objective of multimodality imaging, integrating "anatomical" and "functional" information. We here provide an up-to-date guide for the choice and the interpretation of the currently available noninvasive anatomical and/or functional tests, focusing on emerging techniques (e.g., coronary flow velocity reserve, stress-cardiac magnetic resonance, hybrid imaging, functional-coronary computed tomography angiography, etc.), which could provide deeper pathophysiological insights to refine diagnostic and therapeutic pathways in the next future.
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Affiliation(s)
- Doralisa Morrone
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy.
| | - Francesco Gentile
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Alberto Aimo
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | | | - Maria Elena Picoi
- Azienda Tutela Salute Sardegna, Ospedale Giovanni Paolo II, Unità di terapia intensiva Cardiologica, Olbia, Sardegna, Italy
| | - Marco Guglielmo
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan 20138, Italy
| | - Angelo Villano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio DeVita
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesco Barillà
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Policlinico Umberto I, Roma, Italy
| | - Massimo Mancone
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Policlinico Umberto I, Roma, Italy
| | - Roberto Pedrinelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Ciro Indolfi
- Istituto di Cardiologia, Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi "Magna Graecia", Catanzaro - Mediterranea Cardiocentro, Napoli, Italy
| | - Pasquale Perrone Filardi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy, Mediterranea Cardiocentro, Naples, Italy
| | - Saverio Muscoli
- U.O.C. Cardiologia, Fondazione Policlinico "Tor Vergata", Roma, Italy
| | - Isabella Tritto
- Università di Perugia, Dipartimento di Medicina, Sezione di Cardiologia e Fisiopatologia Cardiovascolare, Perugia, Italy
| | - Carmine Pizzi
- Università di Bologna, Alma Mater Studiorum, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Bologna, Italy
| | - Paolo G Camici
- Vita-Salute University and IRCCS San Raffaele Hospital, Milan, Italy
| | - Mario Marzilli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Filippo Crea
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan 20138, Italy
| | - Raffaele De Caterina
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Gianluca Pontone
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan 20138, Italy
| | | | - Gaetano Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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22
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Antonopoulos AS, Angelopoulos A, Tsioufis K, Antoniades C, Tousoulis D. Cardiovascular risk stratification by coronary computed tomography angiography imaging: current state-of-the-art. Eur J Prev Cardiol 2022; 29:608-624. [PMID: 33930129 DOI: 10.1093/eurjpc/zwab067] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/25/2021] [Accepted: 04/07/2021] [Indexed: 12/21/2022]
Abstract
Current cardiovascular risk stratification by use of clinical risk score systems or plasma biomarkers is good but less than satisfactory in identifying patients at residual risk for coronary events. Recent clinical evidence puts now further emphasis on the role of coronary anatomy assessment by coronary computed tomography angiography (CCTA) for the management of patients with stable ischaemic heart disease. Available computed tomography (CT) technology allows the quantification of plaque burden, identification of high-risk plaques, or the functional assessment of coronary lesions for ischaemia detection and revascularization for refractory angina symptoms. The current CT armamentum is also further enhanced by perivascular Fat Attenuation Index (FAI), a non-invasive metric of coronary inflammation, which allows for the first time the direct quantification of the residual vascular inflammatory burden. Machine learning and radiomic features' extraction and spectral CT for tissue characterization are also expected to maximize the diagnostic and prognostic yield of CCTA. The combination of anatomical, functional, and biological information on coronary circulation by CCTA offers a unique toolkit for the risk stratification of patients, and patient selection for targeted aggressive prevention strategies. We hereby provide a review of the current state-of-the art in the field and discuss how integrating the full capacities of CCTA into clinical care pathways opens new opportunities for the tailored management of coronary artery disease.
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Affiliation(s)
- Alexios S Antonopoulos
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 114 Vas. Sofias Avenue, 11527, Athens, Greece
- RDM Division of Cardiovascular Medicine, Oxford Academic CT Programme, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU Oxford, UK
| | - Andreas Angelopoulos
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 114 Vas. Sofias Avenue, 11527, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 114 Vas. Sofias Avenue, 11527, Athens, Greece
| | - Charalambos Antoniades
- RDM Division of Cardiovascular Medicine, Oxford Academic CT Programme, University of Oxford, John Radcliffe Hospital, Headley Way, OX3 9DU Oxford, UK
| | - Dimitris Tousoulis
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 114 Vas. Sofias Avenue, 11527, Athens, Greece
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23
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Aleksandric S, Banovic M, Beleslin B. Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis. Front Cardiovasc Med 2022; 9:849032. [PMID: 35360024 PMCID: PMC8961810 DOI: 10.3389/fcvm.2022.849032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/16/2022] [Indexed: 01/10/2023] Open
Abstract
More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.
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Affiliation(s)
- Srdjan Aleksandric
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- *Correspondence: Srdjan Aleksandric
| | - Marko Banovic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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24
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Rajiah P, Cummings KW, Williamson E, Young PM. CT Fractional Flow Reserve: A Practical Guide to Application, Interpretation, and Problem Solving. Radiographics 2022; 42:340-358. [PMID: 35119968 DOI: 10.1148/rg.210097] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CT fractional flow reserve (FFRCT) is a physiologic simulation technique that models coronary flow from routine coronary CT angiography (CTA). To evaluate lesion-specific ischemia, FFRCT is measured 2 cm distal to a stenotic lesion. FFRCT greater than 0.8 is normal, 0.76-0.8 is borderline, and 0.75 or less is abnormal. FFRCT should always be interpreted in correlation with clinical and anatomic coronary CTA findings. FFRCT increases the specificity of coronary CTA in the evaluation of coronary artery disease, decreases the prevalence of nonobstructive disease in invasive coronary angiography (ICA), and helps with revascularization decisions and planning. Patients with intermediate-risk coronary anatomy at CTA and abnormal FFRCT can undergo ICA and revascularization, whereas those with normal FFRCT can be safely deferred from ICA. In borderline FFRCT values, management is decided in the context of the clinical scenario, but many cases could be safely managed with medical treatment. There are some limitations and pitfalls of FFRCT. Abnormal FFRCT values can be seen in mild stenosis, and normal FFRCTvalues can be seen in severe stenosis. Gradually decreasing or abnormal low FFRCT values at the distal vessel without a proximal focal lesion could be due to diffuse atherosclerosis. Coronary stents, bypass grafts, coronary anomalies, coronary dissection, transcatheter aortic valve replacement, unstable angina, and acute or recent myocardial infarction are situations in which FFRCT has not been validated and should not be used at this time. The authors provide a practical guide to the applications and interpretation of FFRCT, focusing on common pitfalls and challenges. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Prabhakar Rajiah
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
| | - Kristopher W Cummings
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
| | - Eric Williamson
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
| | - Phillip M Young
- From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905 (P.R., E.W., P.M.Y.); and Department of Radiology, Mayo Clinic, Phoenix, Ariz (K.W.C.)
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25
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Pontone G, Rossi A, Guglielmo M, Dweck MR, Gaemperli O, Nieman K, Pugliese F, Maurovich-Horvat P, Gimelli A, Cosyns B, Achenbach S. Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part II. Eur Heart J Cardiovasc Imaging 2022; 23:e136-e161. [PMID: 35175348 PMCID: PMC8944330 DOI: 10.1093/ehjci/jeab292] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/28/2021] [Indexed: 11/12/2022] Open
Abstract
Cardiac computed tomography (CT) was initially developed as a non-invasive diagnostic tool to detect and quantify coronary stenosis. Thanks to the rapid technological development, cardiac CT has become a comprehensive imaging modality which offers anatomical and functional information to guide patient management. This is the second of two complementary documents endorsed by the European Association of Cardiovascular Imaging aiming to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. In this article, emerging CT technologies and biomarkers, such as CT-derived fractional flow reserve, perfusion imaging, and pericoronary adipose tissue attenuation, are described. In addition, the role of cardiac CT in the evaluation of atherosclerotic plaque, cardiomyopathies, structural heart disease, and congenital heart disease is revised.
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Affiliation(s)
- Gianluca Pontone
- Corresponding author. Tel: +39 02 58002574; Fax: +39 02 58002231. E-mail:
| | | | - Marco Guglielmo
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Marc R Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Koen Nieman
- Department of Radiology and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francesca Pugliese
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Alessia Gimelli
- Fondazione CNR/Regione Toscana “Gabriele Monasterio”, Pisa, Italy
| | - Bernard Cosyns
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair ziekenhuis Brussel, Brussel, Belgium
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-University of Erlangen, Erlangen, Germany
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26
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Lyu L, Pan J, Li D, Li X, Yang W, Dong M, Guo C, Lin P, Han Y, Liang Y, Sun J, Yu D, Zhang P, Zhang M. Knowledge of Hyperemic Myocardial Blood Flow in Healthy Subjects Helps Identify Myocardial Ischemia in Patients With Coronary Artery Disease. Front Cardiovasc Med 2022; 9:817911. [PMID: 35187130 PMCID: PMC8850642 DOI: 10.3389/fcvm.2022.817911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/14/2022] [Indexed: 11/27/2022] Open
Abstract
Backgrounds Dynamic CT myocardial perfusion imaging (CT-MPI) allows absolute quantification of myocardial blood flow (MBF). Although appealing, CT-MPI has not yet been widely applied in clinical practice, partly due to our relatively limited knowledge of CT-MPI. Knowledge of distribution and variability of MBF in healthy subjects helps in recognition of physiological and pathological states of coronary artery disease (CAD). Objectives To describe the distribution and normal range of hyperemic MBF in healthy subjects obtained by dynamic CT-MPI and validate whether it can accurately identify functional myocardial ischemia when the cut-off value of hyperemia MBF is set to the lower limit of the normal range. Materials and Methods Fifty-one healthy volunteers (age, 38 ± 12 years; 15 men) were prospectively recruited. Eighty patients (age, 58 ± 10 years; 55 men) with suspected or known CAD who underwent interventional coronary angiography (ICA) examinations were retrospectively recruited. Comprehensive CCTA + dynamic CT-MPI protocol was performed by the third – generation dual-source CT scanner. Invasive fractional flow reserve (FFR) measurements were performed in vessels with 30–90% diameter reduction. ICA/FFR was used as the reference standard for diagnosing functional ischemia. The normal range for the hyperemic MBF were defined as the mean ± 1.96 SD. The cut-off value of hyperemic MBF was set to the lower limit of the normal range. Results The global hyperemic MBF were 164 ± 24 ml/100 ml/min and 123 ± 26 ml/100 ml/min for healthy participants and patients. The normal range of the hyperemic MBF was 116–211 ml/100 ml/min. Of vessels with an ICA/FFR result (n = 198), 67 (34%) were functionally significant. In the per-vessel analysis, an MBF cutoff value of <116 ml/100 ml/min can identify myocardial ischemia with a diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 85.9% (170/198), 91.0% (61/67), 83.2 % (109/131), 73.5% (61/83), and 94.8% (109/115). CT-MPI showed good consistency with ICA/FFR in diagnosing functional ischemia, with a Cohen's kappa statistic of 0.7016 (95%CI, 0.6009 – 0.8023). Conclusion Recognizing hyperemic MBF in healthy subjects helps better understand myocardial ischemia in CAD patients.
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Affiliation(s)
- Lijuan Lyu
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jichen Pan
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dumin Li
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xinhao Li
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Yang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Mei Dong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chenghu Guo
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Peixin Lin
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yeming Han
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yongfeng Liang
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Junyan Sun
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dexin Yu
- Department of Radiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Pengfei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Pengfei Zhang
| | - Mei Zhang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- *Correspondence: Mei Zhang
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27
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Static CT myocardial perfusion imaging: image quality, artifacts including distribution and diagnostic performance compared to 82Rb PET. Eur J Hybrid Imaging 2022; 6:1. [PMID: 34981241 PMCID: PMC8724508 DOI: 10.1186/s41824-021-00118-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 11/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Rubidium-82 positron emission tomography (82Rb PET) MPI is considered a noninvasive reference standard for the assessment of myocardial perfusion in coronary artery disease (CAD) patients. Our main goal was to compare the diagnostic performance of static rest/ vasodilator stress CT myocardial perfusion imaging (CT-MPI) to stress/ rest 82Rb PET-MPI for the identification of myocardial ischemia.
Methods Forty-four patients with suspected or diagnosed CAD underwent both static CT-MPI and 82Rb PET-MPI at rest and during pharmacological stress. The extent and severity of perfusion defects on PET-MPI were assessed to obtain summed stress score, summed rest score, and summed difference score. The extent and severity of perfusion defects on CT-MPI was visually assessed using the same grading scale. CT-MPI was compared with PET-MPI as the gold standard on a per-territory and a per-patient basis.
Results On a per-patient basis, there was moderate agreement between CT-MPI and PET-MPI with a weighted 0.49 for detection of stress induced perfusion abnormalities. Using PET-MPI as a reference, static CT-MPI had 89% sensitivity (SS), 58% specificity (SP), 71% accuracy (AC), 88% negative predictive value (NPV), and 59% positive predictive value (PPV) to diagnose stress-rest perfusion deficits on a per-patient basis. On a per-territory analysis, CT-MPI had 73% SS, 65% SP, 67% AC, 90.8% NPV, and 34% PPV to diagnose perfusion deficits. Conclusions CT-MPI has high sensitivity and good overall accuracy for the diagnosis of functionally significant CAD using 82Rb PET-MPI as the reference standard. CT-MPI may play an important role in assessing the functional significance of CAD especially in combination with CCTA.
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28
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Paving the Way for Clinical Implementation of Dynamic CT Perfusion. JACC. CARDIOVASCULAR IMAGING 2022; 15:88-90. [PMID: 34991895 DOI: 10.1016/j.jcmg.2021.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/15/2021] [Indexed: 11/22/2022]
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29
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Jain P, Udelson JE, Kimmelstiel C. Physiologic Guidance for Percutaneous Coronary Intervention: State of the Evidence. Trends Cardiovasc Med 2022:S1050-1738(22)00014-7. [DOI: 10.1016/j.tcm.2022.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/10/2022] [Accepted: 01/25/2022] [Indexed: 01/10/2023]
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30
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Kim MY, Yang DH, Choo KS, Lee W. Beyond Coronary CT Angiography: CT Fractional Flow Reserve and Perfusion. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2022; 83:3-27. [PMID: 36237355 PMCID: PMC9238199 DOI: 10.3348/jksr.2021.0177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/15/2021] [Accepted: 12/27/2021] [Indexed: 11/30/2022]
Abstract
심장 전산화단층촬영은 비약적인 기술발전과 다양한 연구 결과를 바탕으로 심혈관위험 계층화와 치료 결정을 위한 관상동맥 질환의 진단과 예후 평가성능이 입증되었다. 전산화단층촬영 관상동맥조영술은 폐쇄성 관상동맥 질환에 대한 음성 예측도가 높아서 침습적 혈관조영술의 빈도를 줄일 수 있는 관상동맥 질환 관련 검사의 관문으로 부상했지만, 진단특이도가 상대적으로 낮다. 하지만 심장 전산화단층촬영을 이용한 분획혈류예비력과 심근관류를 분석하여 관상동맥 질환의 혈역학적 유의성을 확인하는 기능적 평가를 통해 그 한계를 극복할 수 있다. 최근에는 이를 보다 객관적이고 재현 가능하도록 인공지능을 접목하는 연구들이 활발히 진행되고 있다. 본 종설에서는 심장 전산화단층촬영의 기능적 영상화 기법들에 대해 알아보고자 한다.
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Affiliation(s)
- Moon Young Kim
- Department of Radiology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Dong Hyun Yang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki Seok Choo
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Whal Lee
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Peper J, Schaap J, Rensing BJWM, Kelder JC, Swaans MJ. Diagnostic accuracy of on-site coronary computed tomography-derived fractional flow reserve in the diagnosis of stable coronary artery disease. Neth Heart J 2021; 30:160-171. [PMID: 34910279 PMCID: PMC8881589 DOI: 10.1007/s12471-021-01647-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2021] [Indexed: 10/30/2022] Open
Abstract
PURPOSE Invasive fractional flow reserve (FFR), the reference standard for identifying significant coronary artery disease (CAD), can be estimated non-invasively by computed tomography-derived fractional flow reserve (CT-FFR). Commercially available off-site CT-FFR showed improved diagnostic accuracy compared to coronary computed tomography angiography (CCTA) alone. However, the diagnostic performance of this lumped-parameter on-site method is unknown. The aim of this cross-sectional study was to determine the diagnostic accuracy of on-site CT-FFR in patients with suspected CAD. METHODS A total of 61 patients underwent CCTA and invasive coronary angiography with FFR measured in 88 vessels. Significant CAD was defined as FFR and CT-FFR below 0.80. CCTA with stenosis above 50% was regarded as significant CAD. The diagnostic performance of both CT-FFR and CCTA was assessed using invasive FFR as the reference standard. RESULTS Of the 88 vessels included in the analysis, 34 had an FFR of ≤ 0.80. On a per-vessel basis, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 91.2%, 81.4%, 93.6%, 75.6% and 85.2% for CT-FFR and were 94.1%, 68.5%, 94.9%, 65.3% and 78.4% for CCTA. The area under the receiver operating characteristic curve was 0.91 and 0.85 for CT-FFR and CCTA, respectively, on a per-vessel basis. CONCLUSION On-site non-invasive FFR derived from CCTA improves diagnostic accuracy compared to CCTA without additional testing and has the potential to be integrated in the current clinical work-up for diagnosing stable CAD.
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Affiliation(s)
- J Peper
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands. .,Department of Radiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - J Schaap
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - B J W M Rensing
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J C Kelder
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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Freitas SA, Nienow D, da Costa CA, Ramos GDO. Functional Coronary Artery Assessment: a Systematic Literature Review. Wien Klin Wochenschr 2021; 134:302-318. [PMID: 34870740 DOI: 10.1007/s00508-021-01970-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/11/2021] [Indexed: 11/28/2022]
Abstract
Cardiovascular diseases represent the number one cause of death in the world, including the most common disorders in the heart's health, namely coronary artery disease (CAD). CAD is mainly caused by fat accumulated in the arteries' internal walls, creating an atherosclerotic plaque that impacts the blood flow functional behavior. Anatomical plaque characteristics are essential but not sufficient for a complete functional assessment of CAD. In fact, plaque analysis and visual inspection alone have proven insufficient to determine the lesion severity and hemodynamic repercussion. Furthermore, the fractional flow reserve (FFR) exam, which is considered the gold standard for stenosis functional impair determination, is invasive and contains several limitations. Such a panorama evidences the need for new techniques applied to image exams to improve CAD functional assessment. In this article, we perform a systematic literature review on emerging methods determining CAD significance, thus delivering a unique base for comparing these methods, qualitatively and quantitatively. Our goal is to guide further studies with evidence from the most promising methods, highlighting the benefits from both areas. We summarize benchmarks, metrics for evaluation, and challenges already faced, thus shedding light on the requirements for a valid, meaningful, and accepted technique for functional assessment evaluation. We create a base of comparison based on quantitative and qualitative indicators and highlight the most relevant geometrical metrics that correlate with lesion significance. Finally, we point out future benchmarks based on recent literature.
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Affiliation(s)
- Samuel A Freitas
- Software Innovation Laboratory, Graduate Program in Applied Computing, Universidade do Vale do Rio dos Sinos, São Leopoldo, Brazil
| | - Débora Nienow
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Cristiano A da Costa
- Software Innovation Laboratory, Graduate Program in Applied Computing, Universidade do Vale do Rio dos Sinos, São Leopoldo, Brazil
| | - Gabriel de O Ramos
- Software Innovation Laboratory, Graduate Program in Applied Computing, Universidade do Vale do Rio dos Sinos, São Leopoldo, Brazil.
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van Assen M, Duguay TM, Litwin SE, Bayer RR, Nance JW, Suranyi P, De Cecco CN, Varga-Szemes A, Jacobs BE, Johnson AA, Tesche C, Schoepf UJ. The Feasibility, Tolerability, Safety, and Accuracy of Low-radiation Dynamic Computed Tomography Myocardial Perfusion Imaging With Regadenoson Compared With Single-photon Emission Computed Tomography. J Thorac Imaging 2021; 36:345-352. [PMID: 32205821 DOI: 10.1097/rti.0000000000000502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Computed tomography (CT) myocardial perfusion imaging (CT-MPI) with hyperemia induced by regadenoson was evaluated for the detection of myocardial ischemia, safety, relative radiation exposure, and patient experience compared with single-photon emission computed tomography (SPECT) imaging. MATERIALS AND METHODS Twenty-four patients (66.5 y, 29% male) who had undergone clinically indicated SPECT imaging and provided written informed consent were included in this phase II, IRB-approved, and FDA-approved clinical trial. All patients underwent coronary CT angiography and CT-MPI with hyperemia induced by the intravenous administration of regadenoson (0.4 mg/5 mL). Patient experience and findings on CT-MPI images were compared to SPECT imaging. RESULTS Patient experience and safety were similar between CT-MPI and SPECT procedures and no serious adverse events due to the administration of regadenoson occurred. SPECT resulted in a higher number of mild adverse events than CT-MPI. Patient radiation exposure was similar during the combined coronary computed tomography angiography and CT-MPI (4.4 [2.7] mSv) and SPECT imaging (5.6 [1.7] mSv) (P-value 0.401) procedures. Using SPECT as the reference standard, CT-MPI analysis showed a sensitivity of 58.3% (95% confidence interval [CI]: 27.7-84.8), a specificity of 100% (95% CI: 73.5-100), and an accuracy of 79.1% (95% CI: 57.9-92.87). Low apparent sensitivity occurred when the SPECT defects were small and highly suspicious for artifacts. CONCLUSIONS This study demonstrated that CT-MPI is safe, well tolerated, and can be performed with comparable radiation exposure to SPECT. CT-MPI has the benefit of providing both complete anatomic coronary evaluation and assessment of myocardial perfusion.
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Affiliation(s)
- Marly van Assen
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Radiology, Center for Medical Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | - Taylor M Duguay
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Sheldon E Litwin
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Medicine, Medical University of South Carolina, Division of Cardiology, Charleston, SC
| | - Richard R Bayer
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Medicine, Medical University of South Carolina, Division of Cardiology, Charleston, SC
| | - John W Nance
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Pal Suranyi
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Medicine, Medical University of South Carolina, Division of Cardiology, Charleston, SC
| | - Carlo N De Cecco
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Akos Varga-Szemes
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Brian E Jacobs
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Addison A Johnson
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging
| | - Christian Tesche
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany
| | - U Joseph Schoepf
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging.,Department of Medicine, Medical University of South Carolina, Division of Cardiology, Charleston, SC
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Franke B, Brüning J, Yevtushenko P, Dreger H, Brand A, Juri B, Unbehaun A, Kempfert J, Sündermann S, Lembcke A, Solowjowa N, Kelle S, Falk V, Kuehne T, Goubergrits L, Schafstedde M. Computed Tomography-Based Assessment of Transvalvular Pressure Gradient in Aortic Stenosis. Front Cardiovasc Med 2021; 8:706628. [PMID: 34568450 PMCID: PMC8457381 DOI: 10.3389/fcvm.2021.706628] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/09/2021] [Indexed: 01/07/2023] Open
Abstract
Background: In patients with aortic stenosis, computed tomography (CT) provides important information about cardiovascular anatomy for treatment planning but is limited in determining relevant hemodynamic parameters such as the transvalvular pressure gradient (TPG). Purpose: In the present study, we aimed to validate a reduced-order model method for assessing TPG in aortic stenosis using CT data. Methods: TPGCT was calculated using a reduced-order model requiring the patient-specific peak-systolic aortic flow rate (Q) and the aortic valve area (AVA). AVA was determined by segmentation of the aortic valve leaflets, whereas Q was quantified based on volumetric assessment of the left ventricle. For validation, invasively measured TPGcatheter was calculated from pressure measurements in the left ventricle and the ascending aorta. Altogether, 84 data sets of patients with aortic stenosis were used to compare TPGCT against TPGcatheter. Results: TPGcatheter and TPGCT were 50.6 ± 28.0 and 48.0 ± 26 mmHg, respectively (p = 0.56). A Bland–Altman analysis revealed good agreement between both methods with a mean difference in TPG of 2.6 mmHg and a standard deviation of 19.3 mmHg. Both methods showed good correlation with r = 0.72 (p < 0.001). Conclusions: The presented CT-based method allows assessment of TPG in patients with aortic stenosis, extending the current capabilities of cardiac CT for diagnosis and treatment planning.
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Affiliation(s)
- Benedikt Franke
- Institute of Computer-assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Brüning
- Institute of Computer-assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Pavlo Yevtushenko
- Institute of Computer-assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Henryk Dreger
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiology and Angiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Anna Brand
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiology and Angiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Benjamin Juri
- Department of Cardiology and Angiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Axel Unbehaun
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Simon Sündermann
- Department of Cardiology and Angiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Alexander Lembcke
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Natalia Solowjowa
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Sebastian Kelle
- Department of Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Titus Kuehne
- Institute of Computer-assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
| | - Leonid Goubergrits
- Institute of Computer-assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Einstein Center Digital Future, Berlin, Germany
| | - Marie Schafstedde
- Institute of Computer-assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Berlin, Germany
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35
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Nous FMA, Geisler T, Kruk MBP, Alkadhi H, Kitagawa K, Vliegenthart R, Hell MM, Hausleiter J, Nguyen PK, Budde RPJ, Nikolaou K, Kepka C, Manka R, Sakuma H, Malik SB, Coenen A, Zijlstra F, Klotz E, van der Harst P, Artzner C, Dedic A, Pugliese F, Bamberg F, Nieman K. Dynamic Myocardial Perfusion CT for the Detection of Hemodynamically Significant Coronary Artery Disease. JACC Cardiovasc Imaging 2021; 15:75-87. [PMID: 34538630 PMCID: PMC8741746 DOI: 10.1016/j.jcmg.2021.07.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/14/2021] [Accepted: 07/21/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVES In this international, multicenter study, using third-generation dual-source computed tomography (CT), we investigated the diagnostic performance of dynamic stress CT myocardial perfusion imaging (CT-MPI) in addition to coronary CT angiography (CTA) compared to invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR). BACKGROUND CT-MPI combined with coronary CTA integrates coronary artery anatomy with inducible myocardial ischemia, showing promising results for the diagnosis of hemodynamically significant coronary artery disease in single-center studies. METHODS At 9 centers in Europe, Japan, and the United States, 132 patients scheduled for ICA were enrolled; 114 patients successfully completed coronary CTA, adenosine-stress dynamic CT-MPI, and ICA. Invasive FFR was performed in vessels with 25% to 90% stenosis. Data were analyzed by independent core laboratories. For the primary analysis, for each coronary artery the presence of hemodynamically significant obstruction was interpreted by coronary CTA with CT-MPI compared to coronary CTA alone, using an FFR of ≤0.80 and angiographic severity as reference. Territorial absolute myocardial blood flow (MBF) and relative MBF were compared using C-statistics. RESULTS ICA and FFR identified hemodynamically significant stenoses in 74 of 289 coronary vessels (26%). Coronary CTA with ≥50% stenosis demonstrated a per-vessel sensitivity, specificity, and accuracy for the detection of hemodynamically significant stenosis of 96% (95% CI: 91–100), 72% (95% CI: 66–78), and 78% (95% CI: 73–83), respectively. Coronary CTA with CT-MPI showed a lower sensitivity (84%; 95% CI: 75–92) but higher specificity (89%; 95% CI: 85–93) and accuracy (88%; 95% CI: 84–92). The areas under the receiver-operating characteristic curve of absolute MBF and relative MBF were 0.79 (95% CI: 0.71–0.86) and 0.82 (95% CI: 0.74–0.88), respectively. The median dose-length product of CT-MPI and coronary CTA were 313 mGy·cm and 138 mGy·cm, respectively. CONCLUSIONS Dynamic CT-MPI offers incremental diagnostic value over coronary CTA alone for the identification of hemodynamically significant coronary artery disease. Generalized results from this multicenter study encourage broader consideration of dynamic CT-MPI in clinical practice. (Dynamic Stress Perfusion CT for Detection of Inducible Myocardial Ischemia [SPECIFIC]; NCT02810795)
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Affiliation(s)
- Fay M A Nous
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Cardiology, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Tobias Geisler
- Department of Cardiology, University of Tuebingen, Tuebingen, Germany
| | - Mariusz B P Kruk
- Coronary Disease and Structural Heart Diseases Department, Institute of Cardiology, Warsaw, Poland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School of Medicine, Tsu, Japan
| | - Rozemarijn Vliegenthart
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Michaela M Hell
- Department of Cardiology, Faculty of Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jörg Hausleiter
- Department of Cardiology, Ludwig-Maximilians University, Munich, Germany
| | - Patricia K Nguyen
- Veterans Affairs Palo Alto Healthcare System, Cardiology Section, Palo Alto, California, USA; Stanford University, Division of Cardiovascular Medicine, Stanford, California, USA; Stanford Cardiovascular Institute, Stanford, California, USA
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Cardiology, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Cezary Kepka
- Coronary Disease and Structural Heart Diseases Department, Institute of Cardiology, Warsaw, Poland
| | - Robert Manka
- Department of Cardiology, University Heart Center and Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Sachin B Malik
- Veterans Affairs Palo Alto Healthcare System, Thoracic and Cardiovascular Imaging Section, Palo Alto, California, USA; Stanford University, Division of Cardiovascular Imaging (Affiliated), Stanford, California, USA
| | - Adriaan Coenen
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Cardiology, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Pim van der Harst
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Christoph Artzner
- Department of Cardiology, University of Tuebingen, Tuebingen, Germany
| | - Admir Dedic
- Department of Cardiology, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Francesca Pugliese
- Centre for Advanced Cardiovascular Imaging, William Harvey Research Institute, Barts National Institute for Health Research Biomedical Research Centre, Queen Mary University of London, London, United Kingdom; Barts Heart Centre, St Bartholomew's Hospital, Barts Health National Health Service Trust, West Smithfield, London, United Kingdom
| | - Fabian Bamberg
- Department of Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Koen Nieman
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Cardiology, Erasmus University Medical Center, University Medical Center Rotterdam, Rotterdam, the Netherlands; Stanford University School of Medicine and Cardiovascular Institute, Stanford, California, USA.
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Esposito A, Francone M, Andreini D, Buffa V, Cademartiri F, Carbone I, Clemente A, Guaricci AI, Guglielmo M, Indolfi C, La Grutta L, Ligabue G, Liguori C, Mercuro G, Mushtaq S, Neglia D, Palmisano A, Sciagrà R, Seitun S, Vignale D, Pontone G, Carrabba N. SIRM-SIC appropriateness criteria for the use of Cardiac Computed Tomography. Part 1: Congenital heart diseases, primary prevention, risk assessment before surgery, suspected CAD in symptomatic patients, plaque and epicardial adipose tissue characterization, and functional assessment of stenosis. LA RADIOLOGIA MEDICA 2021; 126:1236-1248. [PMID: 34160775 PMCID: PMC8370938 DOI: 10.1007/s11547-021-01378-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/20/2021] [Indexed: 12/23/2022]
Abstract
In the past 20 years, Cardiac Computed Tomography (CCT) has become a pivotal technique for the noninvasive diagnostic work-up of coronary and cardiac diseases. Continuous technical and methodological improvements, combined with fast growing scientific evidence, have progressively expanded the clinical role of CCT. Recent large multicenter randomized clinical trials documented the high prognostic value of CCT and its capability to increase the cost-effectiveness of the management of patients with suspected CAD. In the meantime, CCT, initially perceived as a simple non-invasive technique for studying coronary anatomy, has transformed into a multiparametric "one-stop-shop" approach able to investigate the heart in a comprehensive way, including functional, structural and pathophysiological biomarkers. In this complex and revolutionary scenario, it is urgently needed to provide an updated guide for the appropriate use of CCT in different clinical settings. This manuscript, endorsed by the Italian Society of Medical and Interventional Radiology (SIRM) and by the Italian Society of Cardiology (SIC), represents the first of two consensus documents collecting the expert opinion of Radiologists and Cardiologists about current appropriate use of CCT.
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Affiliation(s)
- Antonio Esposito
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | - Marco Francone
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Daniele Andreini
- Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Vitaliano Buffa
- Department of Radiology, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | | | - Iacopo Carbone
- Department of Radiological, Oncological and Pathological Sciences, "Sapienza" University of Rome, Rome, Italy
| | | | - Andrea Igoren Guaricci
- Cardiothoracic Department, University Cardiology Unit, Policlinic University Hospital, Bari, Italy
| | | | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy
| | - Ludovico La Grutta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties-ProMISE, University of Palermo, AOUP P. Giaccone, Palermo, Italy
| | - Guido Ligabue
- Department of Medical and Surgical Sciences, Modena and Reggio Emilia University, Modena, Italy
- Radiology Department, AOU of Modena, Modena, Italy
| | - Carlo Liguori
- Radiology Unit, Ospedale del Mare- A.S.LNa1-Centro, Naples, Italy
| | - Giuseppe Mercuro
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Danilo Neglia
- Cardiovascular Department, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Pisa, Italy
| | - Anna Palmisano
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Sciagrà
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Sara Seitun
- Radiology Department, Ospedale Policlinico San Martino, IRCCS Per L'Oncologia E Le Neuroscienze, Genoa, Italy
| | - Davide Vignale
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | | | - Nazario Carrabba
- Cardiothoracovascular Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Yun CH, Hung CL, Wen MS, Wan YL, So A. CT Assessment of Myocardial Perfusion and Fractional Flow Reserve in Coronary Artery Disease: A Review of Current Clinical Evidence and Recent Developments. Korean J Radiol 2021; 22:1749-1763. [PMID: 34431244 PMCID: PMC8546143 DOI: 10.3348/kjr.2020.1277] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 05/11/2021] [Accepted: 05/15/2021] [Indexed: 11/25/2022] Open
Abstract
Coronary computed tomography angiography (CCTA) is routinely used for anatomical assessment of coronary artery disease (CAD). However, invasive measurement of fractional flow reserve (FFR) is the current gold standard for the diagnosis of hemodynamically significant CAD. CT-derived FFRCT and CT perfusion are two emerging techniques that can provide a functional assessment of CAD for risk stratification and clinical decision making. Several clinical studies have shown that the diagnostic performance of concomitant CCTA and functional CT assessment for detecting hemodynamically significant CAD is at least non-inferior to that of other routinely used imaging modalities. This article aims to review the current clinical evidence and recent developments in functional CT techniques.
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Affiliation(s)
- Chun-Ho Yun
- Department of Radiology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chung-Lieh Hung
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan.,Institute of Biomedical Sciences, Mackay Medical College, New Taipei, Taiwan
| | - Ming-Shien Wen
- Department of Cardiology, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Liang Wan
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Aaron So
- Department of Medical Biophysics, University of Western Ontario, Imaging Program, Lawson Health Research Institute, London, Canada
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Serruys PW, Hara H, Garg S, Kawashima H, Nørgaard BL, Dweck MR, Bax JJ, Knuuti J, Nieman K, Leipsic JA, Mushtaq S, Andreini D, Onuma Y. Coronary Computed Tomographic Angiography for Complete Assessment of Coronary Artery Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:713-736. [PMID: 34384554 DOI: 10.1016/j.jacc.2021.06.019] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 01/09/2023]
Abstract
Coronary computed tomography angiography (CTA) has shown great technological improvements over the last 2 decades. High accuracy of CTA in detecting significant coronary stenosis has promoted CTA as a substitute for conventional invasive coronary angiography in patients with suspected coronary artery disease. In patients with coronary stenosis, CTA-derived physiological assessment is surrogate for intracoronary pressure and velocity wires, and renders possible decision-making about revascularization solely based on computed tomography. Computed tomography coronary anatomy with functionality assessment could potentially become a first line in diagnosis. Noninvasive imaging assessment of plaque burden and morphology is becoming a valuable substitute for intravascular imaging. Recently, wall shear stress and perivascular inflammation have been introduced. These assessments could support risk management for both primary and secondary cardiovascular prevention. Anatomy, functionality, and plaque composition by CTA tend to replace invasive assessment. Complete CTA assessment could provide a 1-stop-shop for diagnosis, risk management, and decision-making on treatment.
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Affiliation(s)
- Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; NHLI, Imperial College London, London, United Kingdom.
| | - Hironori Hara
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands. https://twitter.com/hara_hironori
| | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Juhani Knuuti
- Heart Center, Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Koen Nieman
- Department of Radiology and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jonathon A Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
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Lin L, Zhou X, Dekkers IA, Lamb HJ. Cardiorenal Syndrome: Emerging Role of Medical Imaging for Clinical Diagnosis and Management. J Pers Med 2021; 11:734. [PMID: 34442378 PMCID: PMC8400880 DOI: 10.3390/jpm11080734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/24/2021] [Accepted: 07/24/2021] [Indexed: 12/16/2022] Open
Abstract
Cardiorenal syndrome (CRS) concerns the interconnection between heart and kidneys in which the dysfunction of one organ leads to abnormalities of the other. The main clinical challenges associated with cardiorenal syndrome are the lack of tools for early diagnosis, prognosis, and evaluation of therapeutic effects. Ultrasound, computed tomography, nuclear medicine, and magnetic resonance imaging are increasingly used for clinical management of cardiovascular and renal diseases. In the last decade, rapid development of imaging techniques provides a number of promising biomarkers for functional evaluation and tissue characterization. This review summarizes the applicability as well as the future technological potential of each imaging modality in the assessment of CRS. Furthermore, opportunities for a comprehensive imaging approach for the evaluation of CRS are defined.
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Affiliation(s)
- Ling Lin
- Cardiovascular Imaging Group (CVIG), Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.L.); (I.A.D.); (H.J.L.)
| | - Xuhui Zhou
- Department of Radiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen 510833, China
| | - Ilona A. Dekkers
- Cardiovascular Imaging Group (CVIG), Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.L.); (I.A.D.); (H.J.L.)
| | - Hildo J. Lamb
- Cardiovascular Imaging Group (CVIG), Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (L.L.); (I.A.D.); (H.J.L.)
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Liu CY, Tang CX, Zhang XL, Chen S, Xie Y, Zhang XY, Qiao HY, Zhou CS, Xu PP, Lu MJ, Li JH, Lu GM, Zhang LJ. Deep learning powered coronary CT angiography for detecting obstructive coronary artery disease: The effect of reader experience, calcification and image quality. Eur J Radiol 2021; 142:109835. [PMID: 34237493 DOI: 10.1016/j.ejrad.2021.109835] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/28/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To investigate the effect of reader experience, calcification and image quality on the performance of deep learning (DL) powered coronary CT angiography (CCTA) in automatically detecting obstructive coronary artery disease (CAD) with invasive coronary angiography (ICA) as reference standard. METHODS A total of 165 patients (680 vessels and 1505 segments) were included in this study. Three sessions were performed in order: (1) The artificial intelligence (AI) software automatically processed CCTA images, stenosis degree and processing time were recorded for each case; (2) Six cardiovascular radiologists with different experiences (low/ intermediate/ high experience) independently performed image post-processing and interpretation of CCTA, (3) AI + human reading was performed. Luminal stenosis ≥50% was defined as obstructive CAD in ICA and CCTA. Diagnostic performances of AI, human reading and AI + human reading were evaluated and compared on a per-patient, per-vessel and per-segment basis with ICA as reference standard. The effects of calcification and image quality on the diagnostic performance were also studied. RESULTS The average post-processing and interpretation times of AI was 2.3 ± 0.6 min per case, reduced by 76%, 72%, 69% compared with low/ intermediate/ high experience readers (all P < 0.001), respectively. On a per-patient, per-vessel and per-segment basis, with ICA as reference method, the AI overall diagnostic sensitivity for detecting obstructive CAD were 90.5%, 81.4%, 72.9%, the specificity was 82.3%, 93.9%, 95.0%, with the corresponding areas under the curve (AUCs) of 0.90, 0.90, 0.87, respectively. Compared to human readers, the diagnostic performance of AI was higher than that of low experience readers (all P < 0.001). The diagnostic performance of AI + human reading was higher than human reading alone, and AI + human readers' ability to correctly reclassify obstructive CAD was also improved, especially for low experience readers (Per-patient, the net reclassification improvement (NRI) = 0.085; per-vessel, NRI = 0.070; and per-segment, NRI = 0.068, all P < 0.001). The diagnostic performance of AI was not significantly affected by calcification and image quality (all P > 0.05). CONCLUSIONS AI can substantially shorten the post-processing time, while AI + human reading model can significantly improve the diagnostic performance compared with human readers, especially for inexperienced readers, regardless of calcification severity and image quality.
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Affiliation(s)
- Chun Yu Liu
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Chun Xiang Tang
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Xiao Lei Zhang
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Sui Chen
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Yuan Xie
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Xin Yuan Zhang
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Hong Yan Qiao
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Chang Sheng Zhou
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Peng Peng Xu
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Meng Jie Lu
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Jian Hua Li
- Department of Cardiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Guang Ming Lu
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China
| | - Long Jiang Zhang
- Department of Diagnostic Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu 210002, PR China.
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Vattay B, Boussoussou M, Borzsák S, Vecsey-Nagy M, Simon J, Kolossváry M, Merkely B, Szilveszter B. Myocardial perfusion imaging using computed tomography: Current status, clinical value and prognostic implications. IMAGING 2021. [DOI: 10.1556/1647.2020.00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
AbstractCombined anatomical and functional evaluation of coronary artery disease (CAD) using computed tomography (CT) has recently emerged as an accurate, robust, and non-invasive tool for the evaluation of ischemic heart disease. Cardiac CT has become a one-stop-shop imaging modality that allows the simultaneous depiction, characterization, and quantification of coronary atherosclerosis and the assessment of myocardial ischemia. Advancements in scanner technology (improvements in spatial and temporal resolution, dual-energy imaging, wide detector panels) and the implementation of iterative reconstruction algorithms enables the detection of myocardial ischemia in both qualitative and quantitative fashion using low-dose scanning protocols. The addition of CT perfusion (CTP) to standard coronary CT angiography is a reliable tool to improve diagnostic accuracy. CTP using static first-pass imaging enables qualitative assessment of the myocardial tissue, whereas dynamic perfusion imaging can also provide quantitative information on myocardial blood flow. Myocardial tissue assessment by CTP holds the potential to refine risk in stable chest pain or microvascular dysfunction. CTP can aid the detection of residual ischemia after coronary intervention. Comprehensive evaluation of CAD using CTP might therefore improve the selection of patients for aggressive secondary prevention therapy or coronary revascularization with high diagnostic certainty. In addition, prognostic information provided by perfusion CT imaging could improve patient outcomes by quantifying the ischemic burden of the left ventricle. The current review focuses on the clinical value of myocardial perfusion imaging by CT, current status of CTP imaging and the use of myocardial CTP in various patient populations for the diagnosis of ischemic heart disease.
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Affiliation(s)
- Borbála Vattay
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Melinda Boussoussou
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Sarolta Borzsák
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Milán Vecsey-Nagy
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Judit Simon
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Márton Kolossváry
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Dai X, Yu Y, Yu L, Zhang L, Zhang J. Design and rationale of randomized CT-PRECISION study. Cardiovasc Diagn Ther 2021; 11:760-767. [PMID: 34295702 DOI: 10.21037/cdt-21-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/28/2021] [Indexed: 11/06/2022]
Abstract
Background Coronary computed tomography angiography (CCTA) combined with dynamic CT myocardial perfusion imaging (CT-MPI) and CCTA combined with CT fractional flow reserve (CT-FFR) are both expected to be efficient one-stop shop imaging strategies to guide clinical management. The aim of the study is to determine which of these two methods has superiority in terms of guiding treatment in patients with intermediate to high pretest probability of coronary artery disease (CAD). Methods CT-PRECISION (Computed Tomography myocardial PeRfusion imaging vErsus Computed tomography derived fractional flow reServe: impact ON guiding treatment and prognosis in patients with intermediate to high pretest probability of CAD) is a multicenter, prospective, open-label, randomized study to directly compare the clinical value of guiding treatment and prognostic discrimination of CCTA + dynamic CT-MPI strategy and CCTA + CT-FFR strategy in patients with intermediate to high pretest probability of CAD. Four hundred and twelve patients will be enrolled in this study and randomized to CCTA + dynamic CT-MPI arm and CCTA + CT-FFR arm. All patients will be followed up for at least 2 years. The primary endpoint is the rate of unnecessary invasive coronary angiography (ICA) within 90 days, which is defined as ICA without revascularization. The secondary endpoints will include: (I) a composite of major adverse cardiac events (MACE, defined as all-cause mortality, non-fatal myocardial infarction, rehospitalization due to aggravated angina symptoms, and late revascularization); (II) symptom change at 1 year; (III) the rate of late revascularization after CT examination; (IV) reclassification rate of CCTA + dynamic CT-MPI and CCTA + CT-FFR guided strategies compared with CCTA alone; (V) overall radiation dose, contrast media usage and medical cost. Discussion The study will provide valuable information about the optimal CT-based diagnostic strategy with regard to the clinical management of patients with intermediate to high pretest probability of CAD. Trial registration The study is registered at Chinese Clinical Trial Registry (ChiCTR) with the identifier number ChiCTR2000041102. The first enrollment is planned for January 2021.
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Affiliation(s)
- Xu Dai
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yarong Yu
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lihua Yu
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Lei Zhang
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiayin Zhang
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Narula J, Chandrashekhar Y, Ahmadi A, Abbara S, Berman DS, Blankstein R, Leipsic J, Newby D, Nicol ED, Nieman K, Shaw L, Villines TC, Williams M, Hecht HS. SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2021; 15:192-217. [PMID: 33303384 PMCID: PMC8713482 DOI: 10.1016/j.jcct.2020.11.001] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Y Chandrashekhar
- University of Minnesota and VA Medical Center, Minneapolis, MN, USA
| | - Amir Ahmadi
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suhny Abbara
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Ron Blankstein
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | | | - David Newby
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - Edward D Nicol
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Leslee Shaw
- New York-Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, VA, USA
| | - Michelle Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, United Kingdom
| | - Harvey S Hecht
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Prevention of Coronary Artery Disease-Related Heart Failure: The Role of Computed Tomography Scan. Heart Fail Clin 2021; 17:187-194. [PMID: 33673944 DOI: 10.1016/j.hfc.2021.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
During the past decade, coronary computed tomography angiography has emerged as the primary modality to noninvasively detect and rule out coronary artery disease. Therefore, this technique could play an important role in identifying patients at high risk of heart failure, considering the high prevalence of coronary artery disease in these patients. The latest technologies have also increased diagnostic accuracy, helping to close the gap with the other functional imaging modalities.
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Prospective comparison of integrated on-site CT-fractional flow reserve and static CT perfusion with coronary CT angiography for detection of flow-limiting coronary stenosis. Eur Radiol 2021; 31:5096-5105. [PMID: 33409778 DOI: 10.1007/s00330-020-07508-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/23/2020] [Accepted: 11/11/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To compare the diagnostic power of separately integrating on-site computed tomography (CT)-derived fractional flow reserve (CT-FFR) and static CT stress myocardial perfusion (CTP) with coronary computed tomography angiography (CCTA) in detecting patients with flow-limiting CAD. The flow-limiting stenosis was defined as obstructive (≥ 50%) stenosis by invasive coronary angiography (ICA) with a corresponding perfusion deficit on stress single photon emission computed tomography (SPECT/MPI). METHODS Forty-eight patients (74 vessels) were enrolled who underwent research-indicated combined CTA-CTP (320-row CT scanner, temporal resolution 137 ms) and SPECT/MPI prior to conventional coronary angiography. CT-FFR was computed on-site using resting CCTA data with dedicated workstation-based software. All five imaging modalities were analyzed in blinded independent core laboratories. Logistic regression and the integrated discrimination improvement (IDI) index were used to evaluate incremental differences in CT-FFR or CTP compared with CCTA alone. RESULTS The prevalence of obstructive CAD defined by combined ICA-SPECT/MPI was 40%. Per-vessel sensitivity and specificity were 95 and 42% for CCTA, 76 and 89% for CCTA + CTP, and 81 and 96% for CCTA + CT-FFR, respectively. The diagnostic performance of CCTA (AUC = 0.82) was improved by combining it with CT-FFR (AUC = 0.92, p = 0.01; IDI = 0.27, p < 0.001) or CTP (AUC = 0.90, p = 0.02; IDI = 0.18, p = 0.003). CONCLUSION On-site CT-FFR combined with CCTA provides an incremental diagnostic improvement over CCTA alone in identifying patients with flow-limiting CAD defined by ICA + SPECT/MPI, with a comparable diagnostic accuracy for integrated CTP and CCTA. KEY POINTS • Both on-site CT-FFR and CTP perform well with high diagnostic accuracy in the detection of flow-limiting stenosis. • Comparable diagnostic accuracy between CCTA + CT-FFR and CCTA + CTP is demonstrated to detect flow-limiting stenosis. • Integrated CT-FFR and CCTA derived from a single widened CCTA data acquisition can accurately and conveniently evaluate both coronary anatomy and physiology in the future management of patients with suspected CAD, without the need for additional vasodilator administration and contrast and radiation exposure.
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From Inception to 2020: a Review of Dynamic Myocardial CT Perfusion Imaging. CURRENT CARDIOVASCULAR IMAGING REPORTS 2021. [DOI: 10.1007/s12410-020-09551-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Levi J, Wu H, Eck BL, Fahmi R, Vembar M, Dhanantwar A, Fares A, Bezerra HG, Wilson DL. Comparison of automated beam hardening correction (ABHC) algorithms for myocardial perfusion imaging using computed tomography. Med Phys 2021; 48:287-299. [PMID: 33206403 PMCID: PMC8022227 DOI: 10.1002/mp.14599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/23/2020] [Accepted: 11/05/2020] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Myocardial perfusion imaging using computed tomography (MPI-CT) and coronary CT angiography (CTA) have the potential to make CT an ideal noninvasive imaging gatekeeper exam for invasive coronary angiography. However, beam hardening can prevent accurate blood flow estimation in dynamic MPI-CT and can create artifacts that resemble flow deficits in single-shot MPI-CT. In this work, we compare four automatic beam hardening correction algorithms (ABHCs) applied to CT images, for their ability to produce accurate single images of contrast and accurate MPI flow maps using images from conventional CT systems, without energy sensitivity. METHODS Previously, we reported a method, herein called ABHC-1, where we iteratively optimized a cost function sensitive to beam hardening artifacts in MPI-CT images and used a low order polynomial correction on projections of segmentation-processed CT images. Here, we report results from two new algorithms with higher order polynomial corrections, ABHC-2 and ABHC-3 (with three and seven free parameters, respectively), having potentially better correction but likely reduced estimability. Additionally, we compared results to an algorithm reported by others in the literature (ABHC-NH). Comparisons were made on a digital static phantom with simulated water, bone, and iodine regions; on a digital dynamic anthropomorphic phantom, with simulated blood flow; and on preclinical porcine experiments. We obtained CT images on a prototype spectral detector CT (Philips Healthcare) scanner that provided both conventional and virtual keV images, allowing us to quantitatively compare corrected CT images to virtual keV images. To test these methods' parameter optimization sensitivity to noise, we evaluated results on images obtained using different mAs. RESULTS In images of the static phantom, ABHC-2 reduced beam hardening artifacts better than our previous ABHC-1 algorithm, giving artifacts smaller than 1.8 HU, even in the presence of high noise which should affect parameter optimization. Taken together, the quality of static phantom results ordered ABHC-2> ABHC-3> ABHC-1>> ABHC-NH. In an anthropomorphic MPI-CT simulator with homogeneous myocardial blood flow of 100 ml⋅min-1 ⋅100 g-1 , blood flow estimation results were 122 ± 24 (FBP), 135 ± 24 (ABHC-NH), 104 ± 14 (ABHC-1), 100 ± 12 (ABHC-2), and 108 ± 18 (ABHC-3) ml⋅min-1 ⋅100 g-1 , showing ABHC-2 as a clear winner. Visual and quantitative evaluations showed much improved homogeneity of myocardial flow with ABHC-2, nearly eliminating substantial artifacts in uncorrected flow maps which could be misconstrued as flow deficits. ABHC-2 performed universally better than ABHC-1, ABHC-3, and ABHC-NH in simulations with different acquisitions (varying noise and kVp values). In the presence of a simulated flow deficit, all ABHC methods retained the flow deficit, and ABHC-2 gave the most accurate flow ratio and homogeneity. ABHC-3 corrected phantom flow values were slightly better than ABHC-2, in noiseless images, suggesting that reduced quality in noisy images was due to reduced estimability. In an experiment with a pig expected to have uniform flow, ABHC-2 applied to conventional images improved flow maps to compare favorably to those from 70keV images. CONCLUSION The automated algorithm can be used with different parametric BH correction models. ABHC-2 improved MPI-CT blood flow estimation as compared to other approaches and was robust to noisy images. In simulation and preclinical experiments, ABHC-2 gave results approaching gold standard 70 keV measurements.
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Affiliation(s)
- Jacob Levi
- Department of Physics, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Hao Wu
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Brendan L Eck
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Rachid Fahmi
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Mani Vembar
- Philips Healthcare, Cleveland, OH, 44143, USA
| | | | - Anas Fares
- Cardiovascular Imaging Core Laboratory, Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH, 44106, USA
| | - Hiram G Bezerra
- Cardiovascular Imaging Core Laboratory, Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, OH, 44106, USA
| | - David L Wilson
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, 44106, USA
- Department of Radiology, Case Western Reserve University, Cleveland, OH, 44106, USA
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Seitun S, Clemente A, De Lorenzi C, Benenati S, Chiappino D, Mantini C, Sakellarios AI, Cademartiri F, Bezante GP, Porto I. Cardiac CT perfusion and FFR CTA: pathophysiological features in ischemic heart disease. Cardiovasc Diagn Ther 2020; 10:1954-1978. [PMID: 33381437 DOI: 10.21037/cdt-20-414] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Cardiac computed tomography (CCT) has rapidly evolved, becoming a powerful integrated tool for the evaluation of coronary artery disease (CAD), and being superior to other noninvasive methods due to its high accuracy and ability to simultaneously assess both lumen stenosis and atherosclerotic plaque burden. Furthermore, CCT is regarded as an effective gatekeeper for coronary angiography, and carries independent important prognostic information. In the last decade, the introduction of new functional CCT applications, namely CCT perfusion (CCTP) imaging and CT-derived fractional flow reserve (FFRCTA), has opened the door for accurate assessment of the haemodynamic significance of stenoses. These new CCT technologies, thus, share the unique advantage of assessing both myocardial ischemia and patient-specific coronary artery anatomy, providing an integrated anatomical/functional analysis. In the present review, starting from the pathophysiology of myocardial ischemia, we evaluate the existing evidence for functional CCT imaging and its value in relation to alternative, well-established, non-invasive imaging modalities and invasive indices of ischemia (currently the gold-standard). The knowledge of clinical applications, benefits, and limitations of these new CCT technologies will allow efficient and optimal use in clinical practice in the near future.
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Affiliation(s)
- Sara Seitun
- Department of Radiology, IRCCS Policlinico San Martino Hospital, Genoa, Italy
| | - Alberto Clemente
- Department of Radiology, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Massa, Italy
| | - Cecilia De Lorenzi
- Department of Radiology, IRCCS Policlinico San Martino Hospital, Genoa, Italy
| | - Stefano Benenati
- Clinic of Cardiovascular Diseases, IRCCS Policlinico San Martino Hospital, University of Genoa, Genoa, Italy
| | - Dante Chiappino
- Department of Radiology, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Massa, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Science, Institute of Radiology, "G. d'Annunzio" University, Chieti, Italy
| | - Antonis I Sakellarios
- Unit of Medical Technology and Intelligent Information Systems, Department of Materials Science and Engineering, University of Ioannina, Ioannina, Greece
| | | | - Gian Paolo Bezante
- Clinic of Cardiovascular Diseases, IRCCS Policlinico San Martino Hospital, University of Genoa, Genoa, Italy
| | - Italo Porto
- Clinic of Cardiovascular Diseases, IRCCS Policlinico San Martino Hospital, University of Genoa, Genoa, Italy
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49
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Cost-effectiveness of stress CTP versus CTA in detecting obstructive CAD or in-stent restenosis in stented patients. Eur Radiol 2020; 31:1443-1450. [PMID: 32885295 PMCID: PMC7880924 DOI: 10.1007/s00330-020-07202-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/16/2020] [Accepted: 08/18/2020] [Indexed: 11/30/2022]
Abstract
Objectives The aim of this retrospective study was to determine cost-effectiveness of stress myocardial CT perfusion (CTP), coronary CT angiography (CTA), and the combination of both in suspected obstructive coronary artery disease (CAD) or in-stent restenosis (ISR) in patients with previous coronary stent implantation. Methods A decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALYs) associated with CTA, CTP, and CTA + CTP. Model input parameters were obtained from published literature. Probabilistic sensitivity analysis was performed to evaluate overall model uncertainty. A single-variable deterministic sensitivity analysis evaluated the sensitivity of the results to plausible variations in model inputs. Cost-effectiveness was assessed based on a cost-effectiveness threshold of $100,000 per QALY. Results In the base-case scenario with willingness to pay of $100,000 per QALY, CTA resulted in total costs of $47,013.87 and an expected effectiveness of 6.84 QALYs, whereas CTP resulted in total costs of $46,758.83 with 6.93 QALYs. CTA + CTP reached costs of $47,455.63 with 6.85 QALYs. Therefore, strategies CTA and CTA + CTP were dominated by CTP in the base-case scenario. Deterministic sensitivity analysis demonstrated robustness of the model to variations of diagnostic efficacy parameters and costs in a broad range. CTP was cost-effective in the majority of iterations in the probabilistic sensitivity analysis as compared with CTA. Conclusions CTP is cost-effective for the detection of obstructive CAD or ISR in patients with previous stenting and therefore should be considered a feasible approach in daily clinical practice. Key Points • CTP provides added diagnostic value in patients with previous coronary stents. • CTP is a cost-effective method for the detection of obstructive CAD or ISR in patients with previous stenting. Electronic supplementary material The online version of this article (10.1007/s00330-020-07202-z) contains supplementary material, which is available to authorized users.
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50
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Tian XW, Ma AL, Zhou RB, Jiang LJ, Hao Y, Zou XG. Advances in Cardiac Computed Tomography Functional Imaging Technology. Cardiology 2020; 145:615-622. [PMID: 32829331 DOI: 10.1159/000505317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 12/09/2019] [Indexed: 11/19/2022]
Abstract
Cardiovascular disease (CVD) is the leading cause of death among patients in China, and cardiac computed tomography (CT) is one of the most commonly used examination methods for CVD. Coronary artery CT angiography can be used for the morphologic evaluation of the coronary artery. At present, cardiac CT functional imaging has become an important direction of development of CT. At present, common CT functional imaging technologies include transluminal attenuation gradient, stress dynamic CT myocardial perfusion imaging, and CT-fractional flow reserve. These three imaging modes are introduced and analyzed in this review.
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Affiliation(s)
- Xu-Wei Tian
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China
| | - Ai-Lin Ma
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China
| | - Ren-Bing Zhou
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China
| | - Liu-Jiang Jiang
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China
| | - Yue Hao
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China
| | - Xiao-Guang Zou
- Department of Radiology, Department of Medical Imaging, The First People's Hospital Kashgar Region, Kashgar, China,
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