1
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Left atrial appendage thrombus in acute stroke: diagnostic accuracy of CT angiography compared to transesophageal echocardiography. J Stroke Cerebrovasc Dis 2023; 32:106936. [PMID: 36516592 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106936] [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: 07/24/2022] [Revised: 11/01/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To evaluate the value of an extended emergency computed tomography angiography (CTA) including cardiac imaging in patients with acute ischemic stroke for the detection of left atrial appendage (LAA) thrombus compared to transesophageal echocardiography (TEE) as a reference standard. MATERIALS AND METHODS We conducted a retrospective case-control study of patients with presumed acute ischemic stroke who had undergone non-ECG-gated CTA for the craniocervical vessels with an extended coverage including the heart in the context of emergency stroke evaluation and for whom TEE was available as part of the routine stroke diagnostic. We selected cases with evidence of LAA thrombus in TEE and controls without LAA thrombus in TEE in a 1:3 ratio. Two independent observers analyzed CTA images for presence of LAA thrombus and were blinded to the presence of thrombus in TEE. RESULTS Twenty-two patients with LAA thrombus in TEE, and 66 patients without LAA thrombus in TEE were included. The detection of LAA thrombus using CTA showed a sensitivity of 63.6%, a specificity of 81.8%, a positive predictive value of 53.9% and a negative predicted value of 87.1%. Interobserver agreement was only moderate (Cohen´s κ = 0.43). CONCLUSIONS An extended emergency CTA including cardiac imaging can be helpful in early risk stratification in patients with stroke of cardioembolic origin. However, our data show that a standard CTA of craniocervical vessels with extended coverage of the heart is of limited value when compared to TEE, the standard method of detecting LAA thrombi.
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Budeanu RG, Broemmer C, Budeanu AR, Pop M. Comparing the Diagnostic Performance of ECG Gated versus Non-Gated CT Angiography in Ascending Aortic Dissection: A GRRAS Study. Tomography 2022; 8:2426-2434. [PMID: 36287800 PMCID: PMC9609484 DOI: 10.3390/tomography8050201] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/17/2022] [Accepted: 09/26/2022] [Indexed: 11/27/2022] Open
Abstract
Rationale and Objective: Thoracic CT angiography (CTA) for ascending aortic dissection, a life-threatening emergency, is performed routinely without Electrocardiographic (ECG) gating, therefore allowing the apparition of a pulsation artefact. We aimed to evaluate and compare the diagnostic performance, the inter and intra-reporter agreement of ECG gated CTA and non-ECG gated CTA for detecting ascending aortic dissection, considering their training level. Our hypothesis is that ECG gated CTA has superior diagnostic accuracy for ascending aortic dissection compared to non-gated CTA. Materials and Methods: We collected data using 24 questions survey using clinically validated CT examinations. Sixty-six respondents (medical students, radiology residents, and consultants) blinded to the actual diagnosis independently evaluated the images pertaining to the presence of ascending aortic dissection. The reference standard was represented by clinical and imaging diagnosis. Inter-rater and inter-group concordance was evaluated; the agreement with reference tests was calculated and assessed as a function of reporters’ training level. Results: Reporters’ ascending aortic dissection assessment showed a better correlation with the reference standard in the ECG gated CTA. The inter-rater correlation was higher in the ECG gated CTA compared to non-ECG gated CTA. Observers’ confidence for diagnosing ascending aortic dissection was higher in the ECG gated CTA. Statistically significant differences (p < 0.05) were found between different training levels when assessing non-ECG gated examinations. Conclusions: ECG gated CTA shows a higher diagnostic performance for ascending aortic dissection than non-ECG gated CTA, regardless of the reporters’ training level.
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Affiliation(s)
| | - Christian Broemmer
- ME1 Department, “George Emil Palade” University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540142 Targu Mures, Romania
| | - Anamaria R. Budeanu
- Emergency County Hospital Târgu Mureș, 540136 Targu Mures, Romania
- Correspondence:
| | - Marian Pop
- ME1 Department, “George Emil Palade” University of Medicine, Pharmacy, Science and Technology of Targu Mures, 540142 Targu Mures, Romania
- Radiology and Medical Imaging Department, Emergency Institute for Cardiovascular Disease and Heart Transplant of Targu Mures, 540136 Targu Mures, Romania
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Kozuma K, Chikamori T, Hashimoto J, Honye J, Ikeda T, Ishiwata S, Kato M, Kondo H, Matsubara K, Matsumoto K, Matsumoto N, Motoyama S, Obunai K, Sakamoto H, Soejima K, Suzuki S, Abe K, Amano H, Hioki H, Iimori T, Kawai H, Kosuge H, Nakama T, Suzuki Y, Takeda K, Ueda A, Yamashita T, Hirao K, Kimura T, Nagai R, Nakamura M, Shimizu W, Tamaki N. JCS 2021 Guideline on Radiation Safety in Cardiology. Circ J 2022; 86:1148-1203. [DOI: 10.1253/circj.cj-21-0379] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ken Kozuma
- Division of Cardiology, Teikyo University Hospital
| | | | - Jun Hashimoto
- Department of Radiology, Tokai University School of Medicine
| | - Junko Honye
- Department of Cardiology, Kikuna Memorial Hospital
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | | | - Mamoru Kato
- Department of Radiology, Akita Cerebrospinal and Cardiovascular Center
| | | | - Kosuke Matsubara
- Department of Quantum Medical Technology, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University
| | - Kazuma Matsumoto
- Department of Radiological Technology, Hyogo College of Medicine College Hospital
| | | | | | | | - Hajime Sakamoto
- Department of Radiological Technology, Faculty of Health Science, Juntendo University
| | - Kyoko Soejima
- Department of Cardiology, Kyorin University Hospital
| | - Shigeru Suzuki
- Department of Radiology, Totsuka Kyouritsu Daini Hospital
| | - Koichiro Abe
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University
| | - Hideo Amano
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | | | | | - Hideki Kawai
- Department of Cardiology, Fujita Health University
| | | | | | | | | | - Akiko Ueda
- Division of Advanced Arrhythmia Management, Kyorin University Hospital
| | | | - Kenzo Hirao
- Division of Cardiovascular Medicine, AOI Universal Hospital
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Ryozo Nagai
- Department of Cardiovascular Medicine, Jichi Medical University
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine
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Reduced Radiation Exposure Protocol during Computer Tomography of the Left Atrium Prior to Catheter Ablation in Patients with Atrial Fibrillation. Diagnostics (Basel) 2022; 12:diagnostics12030612. [PMID: 35328165 PMCID: PMC8947727 DOI: 10.3390/diagnostics12030612] [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: 01/18/2022] [Revised: 02/16/2022] [Accepted: 02/23/2022] [Indexed: 01/27/2023] Open
Abstract
(1) Background: Computer tomography (CT) is an imaging modality used in the pre-planning of radiofrequency catheter ablation (RFA) procedure in patients with cardiac arrhythmias. However, it is associated with a considerable ionizing radiation dose for patients. This study aims to develop and validate low-dose CT scanning protocols of the left atrium (LA) for RFA guidance. (2) Methods: 68 patients scheduled for RFA of atrial fibrillation were sequentially assigned to four groups of ECG-gated scanning protocols, based on the set tube current (TC): Group A (n = 20, TC = 33 mAs), Group B (n = 18, TC = 67 mAs), Group C (n = 10, TC = 135 mAs), and control Group D (n = 20, TC = 600 mAs). We used a 256-row multidetector CT with body weight-dependent tube voltage of 80 kVp (<70 kg), 100 kVp (70−90 kg), and 120 kVp (>90 kg). We evaluated scanning parameters including radiation dose, total scanning procedure time and signal-to-noise ratio (SNR). (3) Results: The average effective radiation dose (ED) was lower in Group A in comparison to Group B, C and D (0.83 (0.76−1.10), 1.55 (1.36−1.67), 2.91 (2.32−2.96) and 9.35 (8.00−10.04) mSv, p < 0.05). The total amount of contrast media was not significantly different between groups. The mean SNR was 6.5 (5.8−7.3), 7.1 (5.7−8.2), 10.8 (10.1−11.3), and 12.2 (9.9−15.7) for Group A, B, C and D, respectively. The comparisons of SNR in group A vs. B and C vs. D were without significant differences. (4) Conclusions: Optimized pre-ablation CT scanning protocols of the LA can reduce an average ED by 88.7%. Three dimensional (3D) models created with the lowest radiation protocol are useful for the integration of electro-anatomic-guided RFA procedures.
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5
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Bernhard B, Erdoes G, Radojewski P, Jung S, Schroth G, Gräni C. Extended Imaging Protocols to Elucidate Sources of Cardiovascular Embolism in the Work-up of Ischemic Stroke. Clin Neuroradiol 2021; 31:897-900. [PMID: 34870718 DOI: 10.1007/s00062-021-01103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Gabor Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Piotr Radojewski
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
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Desai M, Kahaly O, Aslam A, Saifa-Bonsu J, Usmani M, Okabe T, Afzal MR, Houmsse M. Comprehensive strategies to minimize radiation exposure during Interventional electrophysiology procedures: state-of-the-art review. Expert Rev Med Devices 2020; 17:1183-1192. [PMID: 32885677 DOI: 10.1080/17434440.2020.1819789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Cardiac electrophysiology (EP) procedures are frequently performed in patients with cardiac arrhythmias, chronic heart failure, and sudden cardiac death. Most EP procedures involve fluoroscopy, which results in radiation exposure to physicians, patients, and EP lab staff. Accumulated radiation exposure is a known health detriment to patients and physicians. AREA COVERED This review will summarize radiation exposure, dose metrics, complications of radiation exposure, factors affecting radiation exposure, minimizing radiation exposure, zero or near-zero fluoroscopy strategies, and up-to-date research in the area of reducing radiation exposure and best practices. EXPERT COMMENTARY Comprehensive strategies should be implemented in EP laboratories to minimize radiation exposure with standard fluoroscopy. There are routine techniques that can mitigate significant amounts of radiation exposure using standard equipment within the EP lab. The operators need to emphasize that EP practices routinely incorporate non-ionizing radiation sources for cardiac imaging (e.g. magnetic resonance imaging, advanced electroanatomical mapping systems, intracardiac ultrasonography) in addition to other novel technologies to mitigate radiation exposure to patients and physicians.
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Affiliation(s)
| | - Omar Kahaly
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Adil Aslam
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Jonnie Saifa-Bonsu
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Maham Usmani
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Toshimasa Okabe
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Muhammad R Afzal
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
| | - Mahmoud Houmsse
- Division of Cardiovascular Medicine, The Wexner Medical Center at the Ohio State University Medical Center , Columbus, OH, USA
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Gitsioudis G, Marwan M, Schneider S, Schmermund A, Korosoglou G, Hausleiter J, Schroeder S, Rixe J, Leber A, Bruder O, Katus HA, Senges J, Achenbach S. A systematic report on non-coronary cardiac CTA in 1097 patients from the German cardiac CT registry. Eur J Radiol 2020; 130:109136. [DOI: 10.1016/j.ejrad.2020.109136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/09/2020] [Accepted: 06/15/2020] [Indexed: 12/31/2022]
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Role of pre-procedural CT imaging on catheter ablation in patients with atrial fibrillation: procedural outcomes and radiological exposure. J Interv Card Electrophysiol 2020; 60:477-484. [PMID: 32405889 DOI: 10.1007/s10840-020-00764-4] [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: 03/22/2020] [Accepted: 04/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Cardiac computed tomography (CT) is commonly used to study left atrial (LA) and pulmonary veins (PVs) anatomy before atrial fibrillation (AF) ablation. The aim of the study was to determine the impact of pre-procedural cardiac CT with 3D reconstruction on procedural outcomes and radiological exposure in patients who underwent radiofrequency catheter ablation (RFA) of AF. METHODS In this registry, 493 consecutive patients (age 62 ± 8 years, 70% male) with paroxysmal (316) or persistent (177) AF who underwent first procedure of RFA were included. A pre-procedural CT scan was obtained in 324 patients (CT group). Antral pulmonary vein isolation was performed in all patients using an open-irrigation-tip catheter with a 3D electroanatomical navigation system. Procedural outcome, including radiological exposure, and clinical outcomes were compared among patients who underwent RFA with (CT group) and without (no CT group) pre-procedural cardiac CT. RESULTS Acute PV isolation was obtained in all patients, with a comparable overall complication rate between CT and no CT group (4.3% vs 3%, p = 0.7). No differences were observed about mean duration of the procedure (231 ± 60 vs 233 ± 58 min, p = 0.7) and fluoroscopy time (13 ± 10 vs 13 ± 8 min, p = 0.6) among groups. Cumulative radiation dose resulted significantly higher in the CT group compared with no CT group (8.9 ± 24 vs 4.8 ± 15 mSv, P = 0.02). At 1 year, freedom from AF/atrial tachycardia were comparable among groups (CT group, 227/324 (70%), vs no CT group,119/169 (70%), p = ns). CONCLUSIONS Pre-procedural CT does not improve safety and efficacy of AF ablation, increasing significantly the cumulative radiological exposure.
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Lee HG, Shim J, Choi JI, Kim YH, Oh YW, Hwang SH. Use of Cardiac Computed Tomography and Magnetic Resonance Imaging in Case Management of Atrial Fibrillation with Catheter Ablation. Korean J Radiol 2020; 20:695-708. [PMID: 30993921 PMCID: PMC6470091 DOI: 10.3348/kjr.2018.0774] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 01/21/2019] [Indexed: 12/11/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia associated with the risk of morbidity and mortality in clinical patients. AF is considered as an arrhythmia type that develops and progresses through close connection with cardiac structural arrhythmogenic substrates. Since the introduction of catheter ablation-mediated electrical isolation of arrhythmogenic substrates, cardiac imaging indicates improved treatment outcome and prognosis with appropriate candidate selection, ablation catheter guidance, and post-ablation follow-up. Currently, cardiac computed tomography (CCT) and cardiovascular magnetic resonance (CMR) imaging are essential in the case management of AF at both pre-and post-procedural stages of catheter ablation. In this review, we discuss the roles and technical considerations of CCT and CMR imaging in the management of patients with AF undergoing catheter ablation.
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Affiliation(s)
- Hee Gone Lee
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Jong Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Young Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Yu Whan Oh
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea
| | - Sung Ho Hwang
- Department of Radiology, Korea University Anam Hospital, Seoul, Korea.
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Aortic sac enlargement after endovascular aneurysm repair: volume-related changes and the impact of intraluminal thrombus. Pol J Radiol 2019; 84:e530-e536. [PMID: 32082451 PMCID: PMC7016495 DOI: 10.5114/pjr.2019.91260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 11/06/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose Abdominal aortic aneurysm (AAA) growth after endovascular aneurysm repair (EVAR) is still unpredictable. The issue of optimal frequency of computed tomography angiography for surveillance and its measurement method accuracy remain unclear. We aimed to assess the value of abdominal aneurysm sac volume measurement for detecting expansions and the association of preprocedural intraluminal thrombus (ILT) volume with aneurysm sac growth following EVAR. Material and methods A total of 107 patients underwent elective EVAR. Inclusion criteria provided a cohort of 39 patients. Changes of postoperative maximum aneurysm sac diameter and AAA volume were calculated. Volumetric AAA changes and demographic data of the cases with clinically irrelevant AAA diameter enlargement were evaluated. Preoperative ILT volumes were collected. ILT and AAA sac volume ratio was calculated. Statistical data analysis was performed using standard methods. Results The mean changes of maximum AAA diameter and volume in percentage after EVAR were –5.08 ± 8.20 mm and –13.39 ± 23.32%, respectively. A moderate positive linear correlation between those changes was found (R2 = 0.731; p < 0.0001). The mean relative AAA volume increase in cases without clinically relevant diameter enlargement was 11.50 ± 8.27%. The means of ILT and AAA sac ratios were 0.59 ± 0.17 and 0.52 ± 1.8 in growing AAA sac and in stable or shrinking AAA sac groups, respectively (p = 0.308). Conclusions Volumetric AAA measurement may be useful as an additional method to diameter measurement after EVAR to identify clinically relevant sac growth. Preoperative volume of ILT may not significantly affect the growth rate of AAA after EVAR.
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Skrebūnas A, Lengvenis G, Builytė IU, Žulpaitė R, Bliūdžius R, Purlys P, Baltrūnas T, Misonis N, Matačiūnas M, Marinskis G, Vajauskas D. Is Abdominal Aortic Aneurysm Behavior after Endovascular Repair Associated with Aneurysm Wall Density on Computed Tomography Angiography? ACTA ACUST UNITED AC 2019; 55:medicina55080406. [PMID: 31349723 PMCID: PMC6723564 DOI: 10.3390/medicina55080406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/07/2019] [Accepted: 07/19/2019] [Indexed: 11/26/2022]
Abstract
Background and objectives: Abdominal aortic aneurysm (AAA) growth is unpredictable after the endovascular aneurysm repair (EVAR). Continuing aortic wall degradation and weakening due to hypoxia may have a role in post-EVAR aneurysm sac growth. We aimed to assess the association of aortic wall density on computed tomography angiography (CTA) with aneurysm growth following EVAR. Materials and Methods: A total of 78 patients were included in the study. The control group consisted of 39 randomly assigned patients without aortic pathology. Post-EVAR aneurysm sac volumes on CTA were measured twice during the follow-up period to estimate aneurysm sac behavior. A maximum AAA sac diameter, aortic wall and lumen densities in Hounsfield units (HU) on CTA were measured. A relative aortic wall density (the ratio of aortic wall to lumen densities) was calculated. A statistical data analysis was performed using standard methods. Results: An increase in the AAA sac volume was observed in 12 (30.8%) cases. Median relative aortic wall density on CTA scores in both the patient and the control group at the level of the diaphragm were similar: 0.15 (interquartile range (IQR), 0.11–0.18) and 0.16 (IQR 0.11–0.18), p = 0.5378, respectively. The median (IQR) relative aortic wall density score at the level of the maximum AAA diameter in the patient group was lower than at the level below renal arteries in the control group: 0.10 (0.07–0.12) and 0.17 (0.12–0.23), p < 0.0001, respectively. The median (IQR) relative growing AAA sac wall density score was lower than a relative stable/shrinking AAA sac wall density score: 0.09 (0.06–0.10) and 0.11 (0.09–0.13), p = 0.0096, respectively. Conclusions: A lower aortic aneurysm wall density on CTA may be associated with AAA growth after EVAR.
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Affiliation(s)
- Arminas Skrebūnas
- Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania.
- Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania.
| | - Givi Lengvenis
- Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania
| | - Inga Urtė Builytė
- Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania
| | - Rūta Žulpaitė
- Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania
| | - Rytis Bliūdžius
- Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania
| | - Petras Purlys
- Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania
| | - Tomas Baltrūnas
- Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania
- Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
| | - Nerijus Misonis
- Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania
- Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
| | - Mindaugas Matačiūnas
- Centre of Radiology and Nuclear Medicine, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
| | - Germanas Marinskis
- Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, 01513 Vilnius, Lithuania
- Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, 08410 Vilnius, Lithuania
| | - Donatas Vajauskas
- Department of Radiology, Medical Academy, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
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12
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Popkirov S, Schlegel U, Weber W, Kleffner I, Altenbernd J. Cardiac Imaging Within Emergency CT Angiography for Acute Stroke Can Detect Atrial Clots. Front Neurol 2019; 10:349. [PMID: 31024438 PMCID: PMC6467937 DOI: 10.3389/fneur.2019.00349] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/21/2019] [Indexed: 11/15/2022] Open
Abstract
Cardiac embolism is presumed to cause a significant portion of cryptogenic strokes. Transesophageal echocardiography may detect intracardiac thrombi, but this remains a rare finding, possibly because remnant clots dissolve spontaneously or following thrombolysis. Cardiac imaging within cerebral CT angiography might offer an alternative method for thrombus detection within hyperacute stroke assessment. In a proof-of-concept study we analyzed records of patients aged ≥ 60 years that presented with suspected stroke and underwent extended cerebral CT angiography as part of their emergency assessment. CT imaging of patients with ischemic stroke or transient ischemic attack (TIA) and atrial fibrillation and of those with embolic strokes of undetermined source (ESUS) was reviewed for intracardiac clots and other cardiac or aortic pathology. Over a period of 3 months 59 patients underwent extended CT angiography for suspected stroke, 44 of whom received a final diagnosis of ischemic stroke or TIA. Of those, 17 had atrial fibrillation, and four fulfilled ESUS criteria. Thrombi were detected within atrial structures on CT angiography in three cases. In two ESUS patients complex atheromatosis of the proximal ascending aorta with irregular and ulcerating plaques was detected. Cardiac imaging within emergency cerebral CT angiography is feasible and can provide valuable diagnostic information in a patient group that might not routinely undergo transesophageal echocardiography. A small change to emergency assessment could potentially uncover cardioembolic pathology in cases that would have remained cryptogenic otherwise.
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Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Uwe Schlegel
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Werner Weber
- Institute of Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Ilka Kleffner
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Jens Altenbernd
- Institute of Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany.,Institute of Diagnostic and Interventional Radiology, St. Marien-Hospital Hamm, Hamm, Germany
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Sarkozy A, De Potter T, Heidbuchel H, Ernst S, Kosiuk J, Vano E, Picano E, Arbelo E, Tedrow U. Occupational radiation exposure in the electrophysiology laboratory with a focus on personnel with reproductive potential and during pregnancy: A European Heart Rhythm Association (EHRA) consensus document endorsed by the Heart Rhythm Society (HRS). Europace 2018; 19:1909-1922. [PMID: 29126278 DOI: 10.1093/europace/eux252] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/07/2017] [Indexed: 12/21/2022] Open
Affiliation(s)
- Andrea Sarkozy
- University Antwerp and University Hospital of Antwerp, Cardiology department, Antwerp, Belgium
| | - Tom De Potter
- Cardiology Department, OLV Hospital, Moorselbaan, 164 Aalst B-9300, Belgium
| | - Hein Heidbuchel
- University Antwerp and University Hospital of Antwerp, Cardiology department, Antwerp, Belgium
| | - Sabine Ernst
- Cardiology Department, Royal Brompton And Harefield Hospital Sydney Street Chelsea Wing, Level 4 London, SW3 6NP, UK
| | - Jedrzej Kosiuk
- Cardiology Department, University Hospital of Leipzig, Leipzig, Germany
| | - Eliseo Vano
- Department Radiology, Medical School and San Carlos University Hosp Radiology, Madrid 28040, Spain
| | | | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona. IDIBAPS, Institut d'Investigació August Pi i Sunyer, Hospital Clínic de Barcelona Villarroel, 17008036 Barcelona, Spain
| | - Usha Tedrow
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street Boston, MA 02115, USA
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Kumagai Y, Iwayama T, Arimoto T, Kutsuzawa D, Hashimoto N, Tamura H, Nishiyama S, Takahashi H, Shishido T, Yamauchi S, Yamanaka T, Miyamoto T, Watanabe T, Kubota I, Watanabe M. Biatrial volume, estimated using magnetic resonance imaging, predicts atrial fibrillation recurrence after ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1635-1642. [PMID: 30288753 DOI: 10.1111/pace.13521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 09/25/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The predictive value of left atrial volume (LAV) in atrial fibrillation (AF) is known, but the relationship of right atrial volume (RAV) and biatrial volume (BAV) with AF recurrence after pulmonary vein isolation (PVI) is not clear. Cardiac magnetic resonance (CMR) imaging allows us to more precisely quantify atrial volume. We investigated LAV, RAV, and BAV as predictors of AF recurrence following PVI in AF patients. METHODS AND RESULTS We assessed 100 AF patients (age = 59.8 ± 9.5 years, 74 males, 26 females) who underwent nonenhanced CMR before their first PVI. LAV and RAV were measured using CMR. All patients were in sinus rhythm during CMR. BAV was calculated as the sum of LAV and RAV. During the 8-month follow-up, AF recurrence occurred in 23 patients. LAV, RAV, and BAV were significantly greater in patients with AF recurrence than in those without (LAV, 103.7 ± 25.8 vs 81.8 ± 24.2 mL, P < 0.001; RAV, 109.4 ± 27.0 vs 82.2 ± 19.6 mL, P < 0.001; BAV, 213.1 ± 46.7 vs 164.1 ± 38.7 mL, P < 0.001). Multivariate logistic regression analysis revealed that increased LAV, RAV, and BAV were significantly correlated with AF recurrence. The area under the receiver operation characteristic curve for BAV showed the largest value compared to that of LAV or RAV alone. CONCLUSIONS LAV, RAV, and BAV were independent predictors of AF recurrence after PVI. Quantifying BAV may additionally improve prognostic stratification compared with LAV or RAV.
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Affiliation(s)
- Yu Kumagai
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Tadateru Iwayama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Takanori Arimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Daisuke Kutsuzawa
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Naoaki Hashimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Harutoshi Tamura
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Satoshi Nishiyama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Hiroki Takahashi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Tetsuro Shishido
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Sou Yamauchi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Tamon Yamanaka
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Takuya Miyamoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Isao Kubota
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
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Tudos Z, Skala T, Homola M, Moravec O, Taborsky M, Kocher M, Cerna M, Ctvrtlik F, Odstrcil F, Langova K, Klementova O. ECG non-gated multi-detector computed tomography protocol prior to catheter ablation of atrial fibrillation provides sufficient data quality with lower radiation exposure compared to ECG-gated protocol - results of a prospective, randomized and blinded study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:310-318. [PMID: 30181665 DOI: 10.5507/bp.2018.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The role of ECG-gating in left atrium (LA) computed tomography (MDCT) imaging is not precisely defined. METHODS AND RESULTS 62 patients were randomized according to ECG gating with prospective evaluation of image quality, Volume CT Dose Index, Dose Length Product, Effective Dose and registration error between anatomical map and MDCT. We found significant difference in all radiation variables, but not in visual quality, registration error, CA duration, CA fluoroscopy time and CA fluoroscopy dose. CONCLUSION Helical non-gated MDCT achieved a radiation dose more than four times lower with comparable image quality and course of ablation compared to ECG-gated protocol.
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Affiliation(s)
- Zbynek Tudos
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Tomas Skala
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Martin Homola
- Department of Medical Physics and Radiation Protection, University Hospital Olomouc, Czech Republic
| | - Ondrej Moravec
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Milos Taborsky
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Martin Kocher
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Marie Cerna
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Filip Ctvrtlik
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Frantisek Odstrcil
- Department of Radiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
- Department of Radiological Methods, Faculty of Health Sciences, Palacky University Olomouc, Czech Republic
| | - Katerina Langova
- Department of Medical Biophysics, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Olga Klementova
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
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Liddy S, Buckley U, Kok HK, Loo B, Glover B, Dhillon GR, Buckley O. Applications of cardiac computed tomography in electrophysiology intervention. Eur Heart J Cardiovasc Imaging 2017; 19:253-261. [DOI: 10.1093/ehjci/jex312] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/23/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- S Liddy
- Department of Radiology, Tallaght Hospital, Tallaght, Dublin 24, Ireland
| | - U Buckley
- UCLA Cardiac Arrhythmia Center & Neurocardiology Research Center of Excellence, David Geffen School of Medicine, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - H K Kok
- Department of Radiology, Papworth Hospital NHS Foundation Trust, Cambridge, CB23 3RE, UK
| | - B Loo
- Department of Cardiology, Tallaght Hospital, Tallaght, Dublin 24, Ireland
| | - B Glover
- Cardiac Arrhythmia Department, Queens University, 99 University Ave, Kingston, ON K7L 3N6, Canada
| | - G R Dhillon
- Cardiac Arrhythmia Department, Queens University, 99 University Ave, Kingston, ON K7L 3N6, Canada
| | - O Buckley
- Department of Radiology, Tallaght Hospital, Tallaght, Dublin 24, Ireland
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The Left Atrio-Vertebral Ratio: a new simple means for assessing left atrial enlargement on Computed Tomography. Eur Radiol 2017; 28:1310-1317. [PMID: 28956130 DOI: 10.1007/s00330-017-5041-3] [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: 03/03/2017] [Revised: 08/12/2017] [Accepted: 08/17/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The purpose of this study is to describe a new method to quickly estimate left atrial enlargement (LAE) on Computed Tomography. METHODS Left atrial (LA) volume was assessed with a 3D-threshold Hounsfield unit detection technique, including left atrial appendage and excluding pulmonary venous confluence, in 201 patients with ECG-gated 128-slice dual-source CT and indexed to body surface area. LA and vertebral axial diameter and area were measured at the bottom level of the right inferior pulmonary vein ostium. Ratio of LA diameter and surface on vertebra (LAVD and LAVA) were compared to LA volume. In accordance with the literature, a cutoff value of 78 ml/m2 was chosen for maximal normal LA volume. RESULTS 18% of LA was enlarged. The best cutoff values for LAE assessment were 2.5 for LAVD (AUC: 0.65; 95% CI: 0.58-0.73; sensitivity: 57%; specificity: 71%), and 3 for LAVA (AUC: 0.78; 95% CI: 0.72-0.84; sensitivity: 67%; specificity: 79%), with higher accuracy for LAVA (P=0.015). Inter-observer and intra-observer variability were either good or excellent for LAVD and LAVA (respective intraclass coefficients: 0.792 and 0.910; 0.912 and 0.937). CONCLUSION A left atrium area superior to three times the vertebral area indicates LAE with high specificity. KEY POINTS • Left atrial enlargement is a frequent condition associated with poor cardiac outcome. • Left atrial enlargement is highly time-consuming to diagnose on CT. • The left atrio-vertebral ratio quickly assesses left atrial enlargement. • A left atrial area > three times vertebral area is highly specific.
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Cernica D, Hodas R, Himcinschi E, Beganu E, Benedek T. Actual Dose-Reduction Strategies in Cardiac Computed Tomography. JOURNAL OF INTERDISCIPLINARY MEDICINE 2017. [DOI: 10.1515/jim-2017-0062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Computed tomography (CT) in cardiac examination is a powerful imaging tool that has developed rapidly during the last decade and continues to increase its potential by bringing novel technologies. Due to its noninvasive character, cardiac CT became a largely used method in detecting coronary diseases or functional issues at the expense of conventional coronary angiography. The accuracy of images has also increased, especially since new generation dual-source multi-slice detectors were developed. Although there are continuous improvements that serve to gain better-quality images, thus increasing their diagnostic accuracy, there is an inconvenient that became a serious topic for debate in the current literature: exposure to higher doses of radiation during cardiac CT examinations. Fortunately, physicians and manufacturers are taking into consideration the need to apply new strategies for radiation dose-reduction. Thus, this objective can be achieved by using patient-tailored dose-reduction strategies and by modulating the technical features of the CT scanners in order to gather high-quality images with minimal radiation exposure. The aim of this manuscript was to review the current literature data on dose-reduction strategies that are used for cardiovascular computed tomography scans.
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Affiliation(s)
- Daniel Cernica
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Roxana Hodas
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Elisabeta Himcinschi
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Elena Beganu
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Theodora Benedek
- Center of Advanced Research in Multimodality Cardiac Imaging, Cardio Med Medical Center , Tîrgu Mureș , Romania
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
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19
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IWAYAMA TADATERU, ARIMOTO TAKANORI, ISHIGAKI DAISUKE, HASHIMOTO NAOAKI, KUMAGAI YU, KOYAMA YO, KIRIBAYASHI NOBUYUKI, NETSU SHUNSUKE, NISHIYAMA SATOSHI, TAKAHASHI HIROKI, SHISHIDO TETSURO, MIYAMOTO TAKUYA, SATO TOSHIMITSU, WATANABE TETSU, KUBOTA ISAO. The Clinical Value of Nongated Dual-Source Computed Tomography in Atrial Fibrillation Catheter Ablation. J Cardiovasc Electrophysiol 2015; 27:34-40. [DOI: 10.1111/jce.12826] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 08/15/2015] [Accepted: 08/25/2015] [Indexed: 11/27/2022]
Affiliation(s)
- TADATERU IWAYAMA
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - TAKANORI ARIMOTO
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - DAISUKE ISHIGAKI
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - NAOAKI HASHIMOTO
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - YU KUMAGAI
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - YO KOYAMA
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - NOBUYUKI KIRIBAYASHI
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - SHUNSUKE NETSU
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - SATOSHI NISHIYAMA
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - HIROKI TAKAHASHI
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - TETSURO SHISHIDO
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - TAKUYA MIYAMOTO
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - TOSHIMITSU SATO
- Division of Radiology; Yamagata University School of Medicine; Yamagata Japan
| | - TETSU WATANABE
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
| | - ISAO KUBOTA
- Department of Cardiology, Pulmonology, and Nephrology; Yamagata University School of Medicine; Yamagata Japan
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20
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Heidbuchel H, Wittkampf FHM, Vano E, Ernst S, Schilling R, Picano E, Mont L, Jais P, de Bono J, Piorkowski C, Saad E, Femenia F. Practical ways to reduce radiation dose for patients and staff during device implantations and electrophysiological procedures. Europace 2014; 16:946-64. [PMID: 24792380 DOI: 10.1093/europace/eut409] [Citation(s) in RCA: 212] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Despite the advent of non-fluoroscopic technology, fluoroscopy remains the cornerstone of imaging in most interventional electrophysiological procedures, from diagnostic studies over ablation interventions to device implantation. Moreover, many patients receive additional X-ray imaging, such as cardiac computed tomography and others. More and more complex procedures have the risk to increase the radiation exposure, both for the patients and the operators. The professional lifetime attributable excess cancer risk may be around 1 in 100 for the operators, the same as for a patient undergoing repetitive complex procedures. Moreover, recent reports have also hinted at an excess risk of brain tumours among interventional cardiologists. Apart from evaluating the need for and justifying the use of radiation to assist their procedures, physicians have to continuously explore ways to reduce the radiation exposure. After an introduction on how to quantify the radiation exposure and defining its current magnitude in electrophysiology compared with the other sources of radiation, this position paper wants to offer some very practical advice on how to reduce exposure to patients and staff. The text describes how customization of the X-ray system, workflow adaptations, and shielding measures can be implemented in the cath lab. The potential and the pitfalls of different non-fluoroscopic guiding technologies are discussed. Finally, we suggest further improvements that can be implemented by both the physicians and the industry in the future. We are confident that these suggestions are able to reduce patient and operator exposure by more than an order of magnitude, and therefore think that these recommendations are worth reading and implementing by any electrophysiological operator in the field.
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Affiliation(s)
- Hein Heidbuchel
- Department of Cardiovascular Medicine, University Hospital Gasthuisberg, University of Leuven, 3000 Leuven, Belgium
| | - Fred H M Wittkampf
- Heart Lung Center, Department of Cardiology, University Medical Center, 3584 CX Utrecht, The Netherlands
| | - Eliseo Vano
- Radiology Department, Medicine School, Complutense University and San Carlos Hospital, IdISSC, Madrid 28040, Spain
| | - Sabine Ernst
- NIHR Biomedical Research Unit and Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, SW3 6NP, London, UK
| | - Richard Schilling
- Biomedical Research Unit, Bart's Health NHS Trust and the William Harvey Research Institute, London EC1A 7BE, UK
| | - Eugenio Picano
- CNR Biomedical Sciences Department, Institute of Clinical Physiology, 56124, Pisa, Italy
| | - Lluis Mont
- Department of Cardiology, Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia 08036, Spain
| | - Pierre Jais
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Joseph de Bono
- Queen Elizabeth Medical Centre, Department of Cardiology, Birmingham, United Kingdom
| | | | - Eduardo Saad
- Hospital Pró-Cardíaco, Setor de Arritmia Invasiva, Rio de Janeiro, Brazil
| | - Francisco Femenia
- Biomedical Research Unit, Bart's Health NHS Trust and the William Harvey Research Institute, London EC1A 7BE, UK
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21
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Fahlenkamp U, Lembcke A, Roesler R, Schwenke C, Huppertz A, Streitparth F, Taupitz M, Hamm B, Wagner M. ECG-gated imaging of the left atrium and pulmonary veins: Intra-individual comparison of CTA and MRA. Clin Radiol 2013; 68:1059-64. [DOI: 10.1016/j.crad.2013.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 04/26/2013] [Accepted: 05/03/2013] [Indexed: 11/30/2022]
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22
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Ning Z, Min ZG, Jiang HX, Hu BL. Diagnostic accuracy of multidetector computed tomography in the detection of left atrial/left atrial appendage thrombus: a meta-analysis. Intern Med J 2013; 43:573-80. [PMID: 22931360 DOI: 10.1111/j.1445-5994.2012.02932.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 08/18/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Z. Ning
- The First Affiliated Hospital of Guangxi Medical University; Nanning China
| | - Z.-G. Min
- Department of Radiology; College of Medicine; Xi'an Jiaotong University; Xi'an China
| | - H.-X. Jiang
- The First Affiliated Hospital of Guangxi Medical University; Nanning China
| | - B.-L. Hu
- Guangxi Medical Information Instituted; Nanning China
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Abstract
Various electrophysiological procedures and device implantation has been shown to improve morbidity and mortality in patients with atrial fibrillation (AF) and patients with heart failure (HF). Noninvasive cardiac imaging is used extensively in the preprocedural patient selection and for procedural guidance. In this review, we will discuss the application of preprocedural cardiac imaging in patients with AF prior to pulmonary vein and left atrial ablation as well as insertion of left atrial occluder device. We also discuss the role of noninvasive cardiac imaging in the selection of appropriate HF patients for device therapy as well as their use in guiding implantation of biventricular pacemaker for cardiac resynchronization therapy by assessing left ventricular ejection fraction, coronary venous anatomy, mechanical dyssynchrony and myocardial scar. We describe new research associated with preprocedural imaging in these patient cohorts.
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24
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Rajiah P, Halliburton SS, Flamm SD. Strategies for dose reduction in cardiovascular computed tomography. APPLIED RADIOLOGY 2012. [DOI: 10.37549/ar1920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Sandra S. Halliburton
- Cardiovascular Imaging Laboratory, Imaging Institute, and Cardiovascular Medicine, Heart and Vascular Institute
| | - Scott D. Flamm
- Cardiovascular Imaging Laboratory, Imaging Institute, and Cardiovascular Medicine, Heart and Vascular Institute, at Cleveland Clinic
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25
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Hsieh BPC, Jha O, Chandra R, Garcia M, Boxt L, Taub C. Novel computed tomography indexes of left atrial appendage stasis. Int J Cardiovasc Imaging 2012; 29:237-44. [PMID: 22588712 DOI: 10.1007/s10554-012-0062-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Accepted: 04/28/2012] [Indexed: 11/28/2022]
Abstract
Contrast enhanced multi-detector computed tomography (MDCT) may detect left atrial appendage (LAA) thrombus; however, its ability to qualify LAA stasis has not been studied. We sought to identify MDCT derived LAA radiographic parameters which could qualify LAA stasis as defined by established transesophageal echocardiography (TEE) parameters. Pre-procedural MDCT followed by TEE (median procedural time difference of 11 days) from 45 patients who underwent ablation for atrial fibrillation were analyzed retrospectively. Contrast enhanced, non-gated, helical MDCT (64 detector row) was performed according to the institutional protocol. Using a combination of parametric and nonparametric tests, the mean attenuation and heterogeneity parameters of LAA attenuation were correlated with the presence of spontaneous echocardiographic contrast and Doppler derived LAA emptying velocity on TEE. If significant correlation is observed, a receiver operating curve analysis will be performed. The baseline characteristics of the studied population were; age, 62 ± 11; CHADS2 score, 2.0 ± 1.2; heart rate, 79 ± 10 bpm; left ventricular ejection fraction, 49 ± 14%. SEC was seen on TEE in 19 patients; ten with mild, eight with moderate, and one had severe SEC. No patients had LAA thrombus. Compared with the group without SEC, those with SEC had significantly increased coefficient of variation (0.19 vs. 0.14, p = 0.014) and range to mean ratio (1.04 vs. 0.73, p = 0.011). There was no significant correlation between mean LAA attenuation and LAA emptying velocity. However, the range, range to mean ratio, standard deviation and coefficient of variation of LAA attenuation had a significantly negative correlation with LAA emptying velocity (r = -0.486, r = -0.497, r = -0.434, r = -0.466, respectively, all p < 0.05). On receiver operating curve analysis, each of the heterogeneity parameters significantly discriminated LAA emptying velocities ≤30 cm/s, with areas under the curve of 0.88, 0.83, 0.81 and 0.76 respectively. In patients with atrial fibrillation, increased contrast heterogeneity within the LAA on MDCT correlated with decreased LAA emptying velocity on TEE. Contrast enhanced MDCT provides an adjunctive, noninvasive technique for Qualification of LAA stasis.
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Affiliation(s)
- Bill P C Hsieh
- Montefiore Medical Center, Albert Einstein College of Medicine, 1825 Eastchester Road, Suite W1-120, Bronx, NY 10461, USA
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26
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Thai WE, Wai B, Lin K, Cheng T, Heist EK, Hoffmann U, Singh JP, Truong QA. Pulmonary venous anatomy imaging with low-dose, prospectively ECG-triggered, high-pitch 128-slice dual-source computed tomography. Circ Arrhythm Electrophysiol 2012; 5:521-30. [PMID: 22586259 DOI: 10.1161/circep.111.968313] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The efforts to reduce radiation from cardiac computed tomography (CT) are essential. Using a prospectively triggered, high-pitch dual-source CT protocol, we aim to determine the radiation dose and image quality in patients undergoing pulmonary vein (PV) imaging. METHODS AND RESULTS In 94 patients (61±9 years; 71% male) who underwent 128-slice dual-source CT (pitch 3.4), radiation dose and image quality were assessed and compared between 69 patients with sinus rhythm and 25 patients with atrial fibrillation. Radiation dose was compared in a subset of 19 patients with prior retrospective or prospectively triggered CT PV scans without high pitch. In a subset of 18 patients with prior magnetic resonance imaging for PV assessment, PV anatomy and scan duration were compared with high-pitch CT. Using the high-pitch protocol, total effective radiation dose was 1.4 (1.3, 1.9) mSv, with no difference between sinus rhythm and atrial fibrillation (1.4 versus 1.5 mSv; P=0.22). No high-pitch CT scans were nondiagnostic or had poor image quality. Radiation dose was reduced with high-pitch (1.6 mSv) compared with standard protocols (19.3 mSv; P<0.0001). This radiation dose reduction was seen with sinus rhythm (1.5 versus 16.7 mSv; P<0.0001) but was more profound with atrial fibrillation (1.9 versus 27.7 mSv; P=0.039). There was excellent agreement of PV anatomy (κ 0.84; P<0.0001) and a shorter CT scan duration (6 minutes) compared with magnetic resonance imaging (41 minutes; P<0.0001). CONCLUSIONS Using a high-pitch dual-source CT protocol, PV imaging can be performed with minimal radiation dose, short scan acquisition, and excellent image quality in patients with sinus rhythm or atrial fibrillation. This protocol highlights the success of new cardiac CT technology to minimize radiation exposure, giving clinicians a new low-dose imaging alternative to assess PV anatomy.
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Affiliation(s)
- Wai-ee Thai
- Cardiac MR PET CT Program, Division of Cardiology and Department of Radiology and the Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Halliburton SS, Abbara S, Chen MY, Gentry R, Mahesh M, Raff GL, Shaw LJ, Hausleiter J. SCCT guidelines on radiation dose and dose-optimization strategies in cardiovascular CT. J Cardiovasc Comput Tomogr 2011; 5:198-224. [PMID: 21723512 DOI: 10.1016/j.jcct.2011.06.001] [Citation(s) in RCA: 358] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 06/01/2011] [Accepted: 06/01/2011] [Indexed: 02/08/2023]
Abstract
Over the last few years, computed tomography (CT) has developed into a standard clinical test for a variety of cardiovascular conditions. The emergence of cardiovascular CT during a period of dramatic increase in radiation exposure to the population from medical procedures and heightened concern about the subsequent potential cancer risk has led to intense scrutiny of the radiation burden of this new technique. This has hastened the development and implementation of dose reduction tools and prompted closer monitoring of patient dose. In an effort to aid the cardiovascular CT community in incorporating patient-centered radiation dose optimization and monitoring strategies into standard practice, the Society of Cardiovascular Computed Tomography has produced a guideline document to review available data and provide recommendations regarding interpretation of radiation dose indices and predictors of risk, appropriate use of scanner acquisition modes and settings, development of algorithms for dose optimization, and establishment of procedures for dose monitoring.
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Affiliation(s)
- Sandra S Halliburton
- Imaging Institute, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J1-4, Cleveland, OH 44195, USA.
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Ector J, Heidbüchel H. Saving the patient the radiation: no need for ECG-gating during cardiac computed tomography. Europace 2010; 12:1053-4. [PMID: 20587538 DOI: 10.1093/europace/euq186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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