Differential effect of atorvastatin and pravastatin on thoracic spine attenuation: A sub-analysis of a randomized clinical trial

BACKGROUND

Statins reduce cardiovascular events and may improve bone mineral density.

METHODS

We conducted a sub-analysis of a randomized clinical trial that investigated the differential effect of moderate vs intensive low-density lipoprotein cholesterol (LDL-C) lowering therapies on coronary artery calcium (CAC) scores, and used the acquired images to assess the change in radiological attenuation of selected thoracic vertebrae. Baseline and 12-month unenhanced chest CT scans were performed in 420 hyperlipidemic, postmenopausal women randomized to atorvastatin (ATV) 80 mg/day or pravastatin (PRV) 40 mg/day in the Beyond Endorsed Lipid Lowering with Electron Beam Tomography Scanning (BELLES) trial. Bone attenuation was measured in three contiguous thoracic vertebrae at baseline and 12 months.

RESULTS

There were no differences in baseline demographic and clinical characteristics between treatment arms. The median percent lowering (interquartile range) in LDL-C was significantly greater with ATV than PRV [-53 (-69 to 20)% vs -28 (-55 to 74)%, p < 0.001], although the CAC score change was similar [12 (-63 to 208)% vs 13 (-75 to 358)%; p = 0.44]. At follow-up, the median bone attenuation loss was significantly greater with PRV than with ATV [-2.6 (-27 to 11)% vs 0 (-11 to 25)%; p < 0.001]. The attenuation loss in the PRV group was comparable to that of a historical untreated general population sample. In the entire cohort, the changes in LDL-C and total cholesterol were inversely correlated with bone attenuation change (p < 0.01). In adjusted multivariable linear regression analyses, race and percent change in LDL-C were independent predictors of bone attenuation change. Age, body mass index, history of smoking, diabetes mellitus, hypertension, peripheral vascular disease, or hormone replacement therapy did not affect percent change in BMD.

CONCLUSIONS

These findings support the hypothesis that there is an interaction between bone and cardiometabolic health and that intensive lipid lowering has a beneficial effect on bone health.

Evaluation of pericoronary adipose tissue attenuation on CT

Pericoronary adipose tissue (PCAT) is the fat deposit surrounding coronary arteries. Although PCAT is part of the larger epicardial adipose tissue (EAT) depot, it has different pathophysiological features and roles in the atherosclerosis process. While EAT evaluation has been studied for years, PCAT evaluation is a relatively new concept. PCAT, especially the mean attenuation derived from CT images may be used to evaluate the inflammatory status of coronary arteries non-invasively. The most commonly used measure, PCAT_MA, is the mean attenuation of adipose tissue of 3 mm thickness around the proximal right coronary artery with a length of 40 mm. PCAT_MA can be analyzed on a per-lesion, per-vessel or per-patient basis. Apart from PCAT_MA, other measures for PCAT have been studied, such as thickness, and volume. Studies have shown associations between PCAT_MA and anatomical and functional severity of coronary artery disease. PCAT_MA is associated with plaque components and high-risk plaque features, and can discriminate patients with flow obstructing stenosis and myocardial infarction. Whether PCAT_MA has value on an individual patient basis remains to be determined. Furthermore, CT imaging settings, such as kV levels and clinical factors such as age and sex affect PCAT_MA measurements, which complicate implementation in clinical practice. For PCAT_MA to be widely implemented, a standardized methodology is needed. This review gives an overview of reported PCAT methodologies used in current literature and the potential use cases in clinical practice.

Registry of Aortic Diseases to Model Adverse Events and Progression (ROADMAP) in Uncomplicated Type B Aortic Dissection: Study Design and Rationale

Purpose

To describe the design and methodological approach of a multicenter, retrospective study to externally validate a clinical and imaging-based model for predicting the risk of late adverse events in patients with initially uncomplicated type B aortic dissection (uTBAD).

Materials and Methods

The Registry of Aortic Diseases to Model Adverse Events and Progression (ROADMAP) is a collaboration between 10 academic aortic centers in North America and Europe. Two centers have previously developed and internally validated a recently developed risk prediction model. Clinical and imaging data from eight ROADMAP centers will be used for external validation. Patients with uTBAD who survived the initial hospitalization between January 1, 2001, and December 31, 2013, with follow-up until 2020, will be retrospectively identified. Clinical and imaging data from the index hospitalization and all follow-up encounters will be collected at each center and transferred to the coordinating center for analysis. Baseline and follow-up CT scans will be evaluated by cardiovascular imaging experts using a standardized technique.

Results

The primary end point is the occurrence of late adverse events, defined as aneurysm formation (≥6 cm), rapid expansion of the aorta (≥1 cm/y), fatal or nonfatal aortic rupture, new refractory pain, uncontrollable hypertension, and organ or limb malperfusion. The previously derived multivariable model will be externally validated by using Cox proportional hazards regression modeling.

Conclusion

This study will show whether a recent clinical and imaging-based risk prediction model for patients with uTBAD can be generalized to a larger population, which is an important step toward individualized risk stratification and therapy.Keywords: CT Angiography, Vascular, Aorta, Dissection, Outcomes Analysis, Aortic Dissection, MRI, TEVAR© RSNA, 2022See also the commentary by Rajiah in this issue.

COVID-19 pneumonia chest radiographic severity score: variability assessment among experienced and in-training radiologists and creation of a multireader composite score database for artificial intelligence algorithm development

OBJECTIVE

The purpose was to evaluate reader variability between experienced and in-training radiologists of COVID-19 pneumonia severity on chest radiograph (CXR), and to create a multireader database suitable for AI development.

METHODS

In this study, CXRs from polymerase chain reaction positive COVID-19 patients were reviewed. Six experienced cardiothoracic radiologists and two residents classified each CXR according to severity. One radiologist performed the classification twice to assess intraobserver variability. Severity classification was assessed using a 4-class system: normal (0), mild (1), moderate (2), and severe (3). A median severity score (Rad Med) for each CXR was determined for the six radiologists for development of a multireader database (XCOMS). Kendal Tau correlation and percentage of disagreement were calculated to assess variability.

RESULTS

A total of 397 patients (1208 CXRs) were included (mean age, 60 years SD ± 1), 189 men). Interobserver variability between the radiologists ranges between 0.67 and 0.78. Compared to the Rad Med score, the radiologists show good correlation between 0.79-0.88. Residents show slightly lower interobserver agreement of 0.66 with each other and between 0.69 and 0.71 with experienced radiologists. Intraobserver agreement was high with a correlation coefficient of 0.77. In 220 (18%), 707 (59%), 259 (21%) and 22 (2%) CXRs there was a 0, 1, 2 or 3 class-difference. In 594 (50%) CXRs the median scores of the residents and the radiologists were similar, in 578 (48%) and 36 (3%) CXRs there was a 1 and 2 class-difference.

CONCLUSION

Experienced and in-training radiologists demonstrate good inter- and intraobserver agreement in COVID-19 pneumonia severity classification. A higher percentage of disagreement was observed in moderate cases, which may affect training of AI algorithms.

ADVANCES IN KNOWLEDGE

Most AI algorithms are trained on data labeled by a single expert. This study shows that for COVID-19 X-ray severity classification there is significant variability and disagreement between radiologist and between residents.

Feasibility of Hepatic T1-Mapping and Extracellular Volume Quantification on Routine Cardiac Magnetic Resonance Imaging in Patients with Infiltrative and Systemic Disorders

RATIONALE AND OBJECTIVES

Cardiac magnetic resonance imaging (CMR) is commonly obtained to evaluate for myocardial infiltrative disorders and fibrosis. Pre- and post-Gadolinium contrast T1-mapping sequences are employed to estimate interstitial expansion using extracellular volume fraction (ECV). Given the proximity of the liver to the heart, T1 and ECV quantification of the liver is feasible on CMR. The purpose of this study was to evaluate for hepatic measures of fibrosis and interstitial expansion in patients with amyloidosis or systemic disease on CMR.

MATERIALS AND METHODS

Myocardial and hepatic native T1 values were measured retrospectively using a cardiac short axis modified Look-Locker inversion recovery sequence. Myocardial and hepatic ECV were calculated using pre- and post-contrast T1 and blood pool values according to the following formula: ECV = (Δ(1/T1) myocardium or liver and/or Δ(1/T1) blood)x(1 - hematocrit). Patients were divided into three cohorts by final diagnosis: amyloidosis, systemic disease (e.g. sarcoid, scleroderma), and controls (EF > 50, no ischemia).

RESULTS

Of the 135 patients who underwent CMR, 22 had cardiac amyloidosis (age 59.9 ± 12.6 yrs, 41% female), 20 had systemic disease (age 50.9 ± 13.4 yrs, 35% female), and 93 were controls (age 49.5 ± 17.3 yrs, 50% female). Myocardial T1 and ECV values were highest for patients with amyloid, second highest for systemic disease, and least for controls (T1: 1169 ± 92 vs 1101 ± 53 vs 1027 ± 73 ms, p < 0.0001; ECV: 0.47 ± 0.11 vs 0.31 ± 0.05 vs 0.27 ± 0.04, p < 0.0001). Hepatic T1 and ECV were similarly higher in patients with amyloid and systemic disease compared to controls (T1: 646 ± 101 vs 660 ± 93 vs 595 ± 58 ms, p < 0.0001; ECV: 0.38 ± 0.08 vs 0.37 ± 0.05 vs 0.31 ± 0.03, p < 0.0001). There was a positive correlation between hepatic T1 and ECV (R² = 0.282, p < 0.0001). No patients had abnormal liver function tests or clinical liver disease.

CONCLUSION

Hepatic ECV quantification on CMR in patients with amyloidosis and systemic disorders is feasible. Further longitudinal investigation regarding detection of early or subclinical liver disease is warranted.

Evaluating the Performance of a Convolutional Neural Network Algorithm for Measuring Thoracic Aortic Diameters in a Heterogeneous Population

The purpose of this work was to assess the performance of a convolutional neural network (CNN) for automatic thoracic aortic measurements in a heterogeneous population. From June 2018 to May 2019, this study retrospectively analyzed 250 chest CT scans with or without contrast enhancement and electrocardiographic gating from a heterogeneous population with or without aortic pathologic findings. Aortic diameters at nine locations and maximum aortic diameter were measured manually and with an algorithm (Artificial Intelligence Rad Companion Chest CT prototype, Siemens Healthineers) by using a CNN. A total of 233 examinations performed with 15 scanners from three vendors in 233 patients (median age, 65 years [IQR, 54-72 years]; 144 men) were analyzed: 68 (29%) without pathologic findings, 72 (31%) with aneurysm, 51 (22%) with dissection, and 42 (18%) with repair. No evidence of a difference was observed in maximum aortic diameter between manual and automatic measurements (P = .48). Overall measurements displayed a bias of -1.5 mm and a coefficient of repeatability of 8.0 mm at Bland-Altman analyses. Contrast enhancement, location, pathologic finding, and positioning inaccuracy negatively influenced reproducibility (P < .003). Sites with dissection or repair showed lower agreement than did sites without. The CNN performed well in measuring thoracic aortic diameters in a heterogeneous multivendor CT dataset. Keywords: CT, Vascular, Aorta © RSNA, 2022.

Coronary Computed Tomography Angiography Compared With Single Photon Emission Computed Tomography Myocardial Perfusion Imaging as a Guide to Optimal Medical Therapy in Patients Presenting With Stable Angina: The RESCUE Trial

Background

The RESCUE (Randomized Evaluation of Patients with Stable Angina Comparing Utilization of Noninvasive Examinations) trial was a randomized, controlled, multicenter, comparative efficacy outcomes trial designed to assess whether initial testing with coronary computed tomographic angiography (CCTA) is noninferior to single photon emission computed tomography (SPECT) myocardial perfusion imaging in directing patients with stable angina to optimal medical therapy alone or optimal medical therapy with revascularization.

Methods and Results

The end point was first major adverse cardiovascular event (MACE) (cardiac death or myocardial infarction), or revascularization. Noninferiority margin for CCTA was set a priori as a hazard ratio (HR) of 1.3 (95% CI=0, 1.605). One thousand fifty participants from 44 sites were randomized to CCTA (n=518) or SPECT (n=532). Mean follow‐up time was 16.2 (SD 7.9) months. There were no cardiac‐related deaths. In patients with a negative CCTA there was 1 acute myocardial infarction; in patients with a negative SPECT examination there were 2 acute myocardial infarctions; and for positive CCTA and SPECT, 1 acute myocardial infarction each. Participants in the CCTA arm had a similar rate of MACE or revascularization compared with those in the SPECT myocardial perfusion imaging arm, (HR, 1.03; 95% CI=0.61‐1.75) (P=0.19). CCTA segment involvement by a stenosis of ≥50% diameter was a better predictor of MACE and revascularization at 1 year (P=0.02) than the percent reversible defect size by SPECT myocardial perfusion imaging. Four (1.2%) patients with negative CCTA compared with 14 (3.2%) with negative SPECT had MACE or revascularization (P=0.03).

Conclusions

There was no difference in outcomes of patients who had stable angina and who underwent CCTA in comparison to SPECT as the first imaging test directing them to optimal medical therapy alone or with revascularization. CCTA was a better predictor of MACE and revascularization.

Registration Information

URL: https://www.clinicaltrials.gov/. Identifier: NCT01262625.

Can the degree of coronary collateralization be used in clinical routine as a valid angiographic parameter of viability?

The success rate of percutaneous coronary artery intervention (PCI) of chronic total occlusion (CTO) lesions have increased in the recent years. However, improvement of function is only possible when significant myocardial viability is present. One of the most important factors of maintaining myocardial viability is the opening and development of collaterals. Our hypothesis was that with a higher degree of collaterals more viable myocardium is present. In 38 patients we compared the degree of collaterals, evaluated with a conventional coronary angiogram (CCA) and graded by the Rentrop classification to transmural extent of the scar obtained in a viability study with magnetic resonance (MRI). We found a statistically significant association of the degree of collaterals determined with Rentrop method and transmural extent of the scar as measured by CMR (p = 0.001; Tau = -0.144). Additionally, associations showed an increase in the ratio between viable vs. non-viable myocardium with the degree of collaterals. Our study suggests that it may be beneficial to routinely grade the collaterals at angiography in patients with CTO as an assessment of myocardial viability.

SCOT-HEART trial: reshuffling our approach to stable ischemic heart disease

The role of diagnostic testing in triaging patients with stable ischemic heart disease continues to evolve towards recognizing the benefits of coronary CT angiography (CCTA) over functional testing. The SCOT-HEART (Scottish Computed Tomography of the HEART) trial highlights this paradigm shift finding a significant reduction of death from coronary heart disease or non-fatal myocardial infarction without a significant increased rate of invasive coronary angiography over a 5 year follow-up period when implementing CCTA with standard care vs standard care alone. The better negative predictive value and ability to identify nonobstructive coronary artery disease to optimize medical therapy highlight the benefits of a CCTA first strategy. With the advent of noninvasive fractional flow reserve (FFR) and widespread availability and ease of CT, CCTA continues to establish itself as a pivotal diagnostic exam for patients with stable ischemic heart disease. In this commentary, we review the SCOT-HEART trial and its impact on CCTA for patients with stable ischemic heart disease.

Novel imaging biomarkers: epicardial adipose tissue evaluation

Epicardial adipose tissue (EAT) is a metabolically activated beige adipose tissue, non-homogeneously surrounding the myocardium. Physiologically, EAT regulates toxic fatty acids, protects the coronary arteries against mechanical strain, regulates proinflammatory cytokines, stimulates the production of nitric oxide, reduces oxidative stress, and works as a thermogenic source against hypothermia. Conversely, EAT has pathologic paracrine interactions with the surrounded vessels, and might favour the onset of atrial fibrillation. In addition, initial atherosclerotic lesions can promote inflammation and trigger the EAT production of cytokines increasing vascular inflammation, which, in turn, may help the development of collateral vessels but also of self-stimulating, dysregulated inflammatory process, increasing coronary artery disease severity. Variations in EAT were also linked to metabolic syndrome. Echocardiography first estimated EAT measuring its thickness on the free wall of the right ventricle but does not allow accurate volumetric EAT estimates. Cardiac CT (CCT) and cardiac MR (CMR) allow for three-dimensional EAT estimates, the former showing higher spatial resolution and reproducibility but being limited by radiation exposure and long segmentation times, the latter being radiation-free but limited by lower spatial resolution and reproducibility, higher cost, and difficulties for obese patients. EAT radiodensity at CCT could to be related to underlying metabolic processes. The correlation between EAT and response to certain pharmacological therapies has also been investigated, showing promising results. In the future, semi-automatic or fully automatic techniques, machine/deep-learning methods, if validated, will facilitate research for various EAT measures and may find a place in CCT/CMR reporting.

Statins Reduce Epicardial Adipose Tissue Attenuation Independent of Lipid Lowering: A Potential Pleiotropic Effect

Background

High epicardial adipose tissue (EAT) attenuation (Hounsfield units [HUs]) on computed tomography is considered a marker of inflammation and is associated with an increased risk of cardiovascular events. Statins reduce the volume of EAT, but it is unknown whether they affect EAT HUs.

Methods and Results

We reviewed the chest computed tomographic scans of 420 postmenopausal women randomized to either 80 mg of atorvastatin or 40 mg of pravastatin daily and rescanned after 1 year to measure change in coronary artery calcium score. EAT HUs were measured near the proximal right coronary artery and remote from any area of coronary artery calcium. Computed tomographic images were also queried for subcutaneous adipose tissue (SubQ) attenuation (HUs) change over time. The mean patients’ age was 65±6 years. The baseline EAT HU value was higher than the SubQ HU value (−89.4±24.0 HU versus −123.3±30.4 HU; P<0.001). The EAT HU value decreased significantly in the entire cohort (−5.4±29.7 HU [−6% change]; P<0.001), but equally in the patients given atorvastatin and pravastatin (−6.35+31 HU and −4.55+28 HU; P=0.55). EAT HU change was not associated with change in total cholesterol, low‐density lipoprotein cholesterol, coronary artery calcium, and EAT volume (all P=not significant). Change in high‐density lipoprotein cholesterol was marginally associated with EAT HU change (P=0.07). Statin treatment did not induce a change in SubQ HUs.

Conclusions

Statins induced a decrease in EAT HUs over time, independent of intensity of low‐density lipoprotein cholesterol lowering. The positive effect on EAT and the neutral effect on SubQ suggest that statins induced a decrease in metabolic activity in EAT by reduction in cellularity, vascularity, or inflammation. The clinical significance of the observed change in EAT HUs remains to be demonstrated.

2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 1: Radiation Physics and Radiation Biology: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways Developed in Collaboration With Mended Hearts

The stimulus to create this document was the recognition that ionizing radiation-guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure for clinical personnel. Although the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. The American College of Cardiology leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. Part I: Radiation Physics and Radiation Biology addresses the issue of medical radiation exposure, the basics of radiation physics and dosimetry, and the basics of radiation biology and radiation-induced adverse effects. Part II: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x-ray fluoroscopy, x-ray computed tomography, and nuclear scintigraphy) and will be published in the next issue of the Journal.

Correction to: Imaging the myocardial ischemic cascade

In the original publication of the article, the seventh author name "Matthias Gutberlet" has been misspelt.

On the data acquisition, image reconstruction, cone beam artifacts, and their suppression in axial MDCT and CBCT - A review

PURPOSE

In the clinic, computed tomography (CT) has evolved into an essential modality for diagnostic imaging by multidetector row CT (MDCT) and image guided intervention by cone beam CT (CBCT). Recognizing the increasing importance of axial MDCT/CBCT in clinical and preclinical applications, and the existence of CB artifacts in MDCT/CBCT images, we provide a review of CB artifacts' root causes, rendering mechanisms and morphology, and possible solutions for elimination and/or reduction of the artifacts.

METHODS

By examining the null space in Radon and Fourier domain, the root cause of CB artifacts (i.e., data insufficiency) in axial MDCT/CBCT is analytically investigated, followed by a review of the data sufficiency conditions and the "circle +" source trajectories. The rendering mechanisms and morphology of CB artifacts in axial MDCT/CBCT and their special cases (e.g., half/short scan and full scan with latitudinally displaced detector) are then analyzed, followed by a survey of the potential solutions to suppress the artifacts. The phenomenon of imaged zone indention and its variation over FBP, BPF/DBPF, two-pass and iterative CB reconstruction algorithms and/or schemes are discussed in detail.

RESULTS

An interdomain examination of the null space provides an insightful understanding of the root cause of CB artifacts in axial MDCT/CBCT. The decomposition of CB artifacts rendering mechanisms facilitates understanding of the artifacts' behavior under different conditions and the potential solutions to suppress them. An inspection of the imaged zone intention phenomenon provides guidance on the design and implementation of CB image reconstruction algorithms and schemes for CB artifacts suppression in axial MDCT/CBCT.

CONCLUSIONS

With increasing importance of axial MDCT/CBCT in clinical and preclinical applications, this review article can update the community with in-depth information and clarification on the latest progress in dealing with CB artifacts and thus increase clinical/preclinical confidence.

Imaging the myocardial ischemic cascade

Non-invasive imaging plays a growing role in the diagnosis and management of ischemic heart disease from its earliest manifestations of endothelial dysfunction to myocardial infarction along the myocardial ischemic cascade. Experts representing the North American Society for Cardiovascular Imaging and the European Society of Cardiac Radiology have worked together to organize the role of non-invasive imaging along the framework of the ischemic cascade. The current status of non-invasive imaging for ischemic heart disease is reviewed along with the role of imaging for guiding surgical planning. The issue of cost effectiveness is also considered. Preclinical disease is primarily assessed through the coronary artery calcium score and used for risk assessment. Once the patient becomes symptomatic, other imaging tests including echocardiography, CCTA, SPECT, PET and CMR may be useful. CCTA appears to be a cost-effective gatekeeper. Post infarction CMR and PET are the preferred modalities. Imaging is increasingly used for surgical planning of patients who may require coronary artery bypass.

Coronary Artery Disease - Reporting and Data System (CAD-RADS): An Expert Consensus Document of SCCT, ACR and NASCI: Endorsed by the ACC

The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.

Anatomical risk models for paravalvular leak and landing zone complications for balloon-expandable transcatheter aortic valve replacement

BACKGROUND

Though several anatomical characteristics have been reported separately as risk factors for paravalvular leak (PVL) and landing zone (LZ) complications after transcatheter aortic valve replacement (TAVR), multivariate risk models are needed.

METHODS

Patients that underwent balloon-expandable TAVR with multidetector cardiac computed tomography (MDCT) sizing were studied. MDCT images were analyzed and the association between anatomical factors and ≥mild PVL, ≥moderate PVL, and LZ complications (annular rupture, requirement of new permanent pacemaker, and coronary obstruction) was determined, and subsequently competing predictive models were developed and validated.

RESULTS

A total of 316 consecutive TAVR patients were included. Median age was 82.0 years (74.0-87.0) and STS score was 8.3% (5.4-10.9). Factors associated with ≥mild PVL included TAVR with Sapien/Sapien XT vs. Sapien 3 (OR = 2.50, 95% CI = 1.24-5.07), LVOT nontubularity (OR = 1.02, 95% CI = 1.01-1.04), LZ calcification (OR = 1.01, 95% CI = 1.00-1.01), and low cover index (OR = 0.94, 95% CI = 0.91-0.96). Factors associated with LZ complications included LZ calcification (OR = 1.01, 95% CI 1.00-1.01), leaflet asymmetry (OR = 1.01, 95% CI 1.01-1.02), and cover index (OR = 1.09, 95% CI 1.03-1.14). Predictive models for ≥mild PVL (AUC = 0.71, 95% CI = 0.66-0.77), ≥moderate PVL (AUC = 0.75, 95% CI = 0.65-0.84), and LZ complications (AUC = 0.77, 95% CI = 0.67-0.87) were created using procedural details and anatomical data from the MDCT. Clinical variables were not included as they were poorly correlated with the occurrence of PVL and LZ complications. For each outcome, the area under the curve (AUC) of the multivariate model was superior to the model consisting only of individual factors.

CONCLUSIONS

A model using procedural/anatomical characteristics derived from MDCT predicts ≥mild PVL, ≥moderate PVL, and LZ complications post-TAVR. Incorporation of anatomical risks into clinical practice may help stratify patients before TAVR. © 2017 Wiley Periodicals, Inc.

CAD-RADS™: Coronary Artery Disease - Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology

The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.

Sudden cardiac death from structural heart diseases in adults: imaging findings with cardiovascular computed tomography and magnetic resonance

Sudden cardiac death (SCD) is defined as the unexpected natural death from a cardiac cause within an hour of the onset of symptoms in the absence of any other cause. Although such a rapid course of death is mainly attributed to a cardiac arrhythmia, identification of structural heart disease by cardiovascular computed tomography (CCT) and cardiovascular magnetic resonance (CMR) imaging is important to predict the long-term risk of SCD. In adults, SCD most commonly results from coronary artery diseases, coronary artery anomalies, inherited cardiomyopathies, valvular heart diseases, myocarditis, and aortic dissection with coronary artery involvement or acute aortic regurgitation. This review describes the CCT and CMR findings of structural heart diseases related to SCD, which are essential for radiologists to diagnose or predict.

Mapping the future of cardiac MR imaging: case-based review of T1 and T2 mapping techniques

Cardiac magnetic resonance (MR) imaging has grown over the past several decades into a validated, noninvasive diagnostic imaging tool with a pivotal role in cardiac morphologic and functional assessment and tissue characterization. With traditional cardiac MR imaging sequences, assessment of various pathologic conditions ranging from ischemic and nonischemic cardiomyopathy to cardiac involvement in systemic diseases (eg, amyloidosis and sarcoidosis) is possible; however, these sequences are most useful in focal myocardial disease, and image interpretation relies on subjective qualitative analysis of signal intensity. Newer T1 and T2 myocardial mapping techniques offer a quantitative assessment of the myocardium (by using T1 and T2 relaxation times), which can be helpful in focal disease, and demonstrate special utility in the evaluation of diffuse myocardial disease (eg, edema and fibrosis). Altered T1 and T2 relaxation times in disease states can be compared with published ranges of normal relaxation times in healthy patients. In conjunction with traditional cardiac MR imaging sequences, T1 and T2 mapping can limit the interpatient and interstudy variability that are common with qualitative analysis and may provide clinical markers for long-term follow-up.

The role of cardiovascular magnetic resonance in stratifying paravalvular leak severity after transcatheter aortic valve replacement: an observational outcome study

BACKGROUND

Significant paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) confers a worse prognosis. Symptoms related to significant PVL may be difficult to differentiate from those related to other causes of heart failure. Cardiovascular magnetic resonance (CMR) directly quantifies valvular regurgitation, but has not been extensively studied in symptomatic post-TAVR patients.

METHODS

CMR was compared to qualitative (QE) and semi-quantitative echocardiography (SQE) for classifying PVL and prognostic value at one year post-imaging in 23 symptomatic post-TAVR patients. The primary outcome was a composite of all-cause death, heart failure hospitalization, and intractable symptoms necessitating repeat invasive therapy; the secondary outcome was a composite of all-cause death and heart failure hospitalization. The difference in event-free survival according to greater than mild PVL versus mild or less PVL by QE, SQE, and CMR were evaluated by Kaplan-Meier survival analysis.

RESULTS

Compared to QE, CMR reclassified PVL severity in 48% of patients, with most patients (31%) reclassified to at least one grade higher. Compared to SQE, CMR reclassified PVL severity in 57% of patients, all being reclassified to at least one grade lower; SQE overestimated PVL severity (mean grade 2.5 versus 1.7, p=0.001). The primary and secondary outcomes occurred in 48% and 35% of patients, respectively. Greater than mild PVL by CMR was associated with reduced event-free survival for the primary outcome (p<0.0001), however greater than mild PVL by QE and SQE were not (p=0.83 and p=0.068). Greater than mild PVL by CMR was associated with reduced event-free survival for the secondary outcome, as well (p=0.012).

CONCLUSION

In symptomatic post-TAVR patients, CMR commonly reclassifies PVL grade compared with QE and SQE. CMR provides superior prognostic value compared to QE and SQE, as patients with greater than mild PVL by CMR (RF>20%) had a higher incidence of adverse events.

Effect of intensive versus moderate lipid-lowering therapy on epicardial adipose tissue in hyperlipidemic post-menopausal women: a substudy of the BELLES trial (Beyond Endorsed Lipid Lowering with EBT Scanning)

OBJECTIVES

This study sought to evaluate the effect of intensive and moderate statin therapy on epicardial adipose tissue (EAT).

BACKGROUND

EAT has been associated with coronary artery disease severity and outcome. It is currently unknown whether EAT volume changes over time when patients are exposed to statin therapy.

METHODS

Subanalysis of a randomized study of atorvastatin 80 mg/day versus pravastatin 40 mg/day for 1 year in a clinical trial designed to assess the progression of coronary artery calcium (CAC) in hyperlipidemic post-menopausal women. Patients underwent cardiac computed tomography scans at the start and end of the trial period.

RESULTS

Of 420 patients, 194 received atorvastatin and 226 pravastatin; the median low-density lipoprotein change was -53.3% and -28.3% with atorvastatin and pravastatin, respectively (p < 0.001). Baseline EAT correlated with age, body mass index, hypertension, diabetes mellitus, high-density lipoprotein, triglyceride levels, and CAC (p < 0.001). At the end of follow-up, EAT regressed more in the atorvastatin than in the pravastatin group (median, -3.38% vs. -0.83%, p = 0.025). The EAT percent change from baseline was significant in the atorvastatin, but not the pravastatin group (p < 0.001 and p = 0.2, respectively). There was no correlation between lipid lowering and EAT regression. CAC progressed significantly in both groups from baseline.

CONCLUSIONS

In hyperlipidemic post-menopausal women, statin therapy induced EAT regression, although intensive therapy was more effective than moderate-intensity therapy. This effect does not seem linked to low-density lipoprotein lowering and may be secondary to other actions of statins such as anti-inflammatory effects.

Epicardial adipose tissue is increased in patients with systemic lupus erythematosus

OBJECTIVE

Morbidity and mortality secondary to premature cardiovascular disease (CVD) in systemic lupus erythematosus (SLE) remain significant issues. The pathogenesis of CVD in SLE patients has not been fully explored. Epicardial adipose tissue (EAT) is believed to contribute to atherosclerosis development, through a paracrine and systemic inflammatory effect. We measured EAT volume in 162 SLE patients and 86 matched controls to assess the association of EAT with markers of atherosclerosis, cardiovascular risk and immunoactivation.

METHODS

Clinical and laboratory characteristics collected included anthropomorphic measures, disease activity and damage indices, blood pressure measurement, lipid profile, inflammatory indices, adipokine levels and measures of adiposity. Coronary artery calcium (CAC) and EAT volume were measured using non-contrast cardiac computed tomography.

RESULTS

EAT volume was greater in patients with SLE [(mean ± SD) 96.8 ± 45.9 cm(3)] than controls (78.2 ± 40.7 cm(3); P = 0.001). The EAT volume was 31% larger (95% CI, 16.5%-47.4%) in SLE patients than controls (P < 0.001 adjusted for age, sex, and race; after additional adjustment for waist circumference P = 0.007). Within SLE patients, after adjusting for age, race, sex, and waist circumference, EAT volume was associated with cumulative corticosteroid dose (P = 0.007), current corticosteroid use (P < 0.001), HDL cholesterol (P = 0.033), and triglycerides (P = 0.005). EAT was significantly correlated with CAC score (P < 0.001), but the association was attenuated after adjustment for Framingham risk score (P = 0.051).

CONCLUSION

The increased EAT volume seen in SLE patients is associated with corticosteroid use. Corticosteroids could have adverse cardiovascular effects in SLE via an increase in EAT volume, a marker of risk in the general population.

A system for seismocardiography-based identification of quiescent heart phases: implications for cardiac imaging

Seismocardiography (SCG), a representation of mechanical heart motion, may more accurately determine periods of cardiac quiescence within a cardiac cycle than the electrically derived electrocardiogram (EKG) and, thus, may have implications for gating in cardiac computed tomography. We designed and implemented a system to synchronously acquire echocardiography, EKG, and SCG data. The device was used to study the variability between EKG and SCG and characterize the relationship between the mechanical and electrical activity of the heart. For each cardiac cycle, the feature of the SCG indicating Aortic Valve Closure was identified and its time position with respect to the EKG was observed. This position was found to vary for different heart rates and between two human subjects. A color map showing the magnitude of the SCG acceleration and computed velocity was derived, allowing for direct visualization of quiescent phases of the cardiac cycle with respect to heart rate.

Aortic volume as an indicator of disease progression in patients with untreated infrarenal abdominal aneurysm

OBJECTIVE

The maximal diameter of an abdominal aortic aneurysm (AAA) and the change in diameter over time reflect rupture risk and are used for surgical planning. However, evidence has emerged that aneurysm volume may be a better indicator of AAA remodeling. The purpose of this study was to assess the relationship between the volume and maximal diameter of the abdominal aorta in patients with untreated infrarenal AAA.

MATERIALS AND METHODS

This was a retrospective study of 100 patients with infrarenal AAA who were followed for more than 6 months. We examined 2 sets of computed tomography images for each patient, acquired ≥ 6 months apart. The maximal diameter and volume of the infrarenal abdominal aorta were determined by semiautomated segmentation software.

RESULTS

At baseline, mean maximal infrarenal diameter was 5.1 ± 1.0 cm and mean aortic volume was 139 ± 72 mL. There was good correlation between the maximal diameter and aortic volume at baseline (r(2) = 0.55; P<0.001). The mean change in maximal diameter between studies was 0.2 ± 0.3 cm and the mean volume change was 19 ± 19 mL. However, the correlation between diameter change and volume change was modest (r(2) = 0.34; P=0.001). Most patients (n = 64) had no measurable change in maximal diameter between studies (≤ 2 mm), but the change in volume was found to vary widely (-2 to 69 mL).

CONCLUSION

In patients with untreated infrarenal AAA, a change in aortic volume can occur in the absence of a significant change in maximal diameter. Additional work is needed to examine the relationship between change in AAA volume and outcomes in this patient group.

Epicardial adipose tissue volume and coronary artery calcium to predict myocardial ischemia on positron emission tomography-computed tomography studies

BACKGROUND

There appears to be an association of epicardial adipose tissue (EAT) with coronary artery disease (CAD) and its risk factors. EAT is assumed to influence CAD development by altering vasomotor tone and via toxic paracrine effects. The relationship of EAT to myocardial perfusion has not been studied.

METHODS

Quantification of EAT and CAC was performed on positron emission tomography/computed tomography (PET/CT) studies in 45 subjects (77% intermediate pre-test probability of CAD) with mild-moderate myocardial ischemia (5-14% perfusion defect, n = 23), severe ischemia (≥15% defect, n = 22) and a control group with no ischemia matched for CAD risk factors (n = 52).

RESULTS

EAT volume showed a better correlation with myocardial ischemia than total CAC (r = .47 vs r = .28, P < .01). EAT volume increased significantly from the control group to subjects with mild-moderate and severe ischemia (96.9, 124.5, and 143.9 cm(3), P < .01 for both ischemia groups vs controls). Total mean CAC was significantly higher in the severe ischemia group (676.3) than in control group (229.4) (P < .01). Multivariable logistic regression analyses showed that EAT volume was, but CAC was not, a significant predictor of ischemia after adjustment for age, sex, body mass index, and each other. EAT volume was a better predictor of ischemia than total CAC [area under the curve (AUC): .764 vs .6291, P = .04]. The combination of EAT + CAC (AUC = .7694) did not improve over EAT volume alone (P = .57).

CONCLUSIONS

In this study, EAT volume assessed by CT was an independent predictor of ischemia on PET, and outperformed CAC score in a CAD naïve population at intermediate pre-test probability of disease.