Comparison of oral anticoagulation by vitamin-K antagonists and non-vitamin-K antagonists for treatment of leaflet thickening after transcatheter aortic valve implantation (TAVI)

INTRODUCTION

Hypoattenuated leaflet thickening (HALT), as identified by CT imaging, is not infrequent after transcatheter aortic valve implantation (TAVI). The best choice of oral anticoagulation is unknown. We compared the effectiveness of Direct Oral AntiCoagulants (DOAC) and Vitamin-K Antagonists (VKA) to resolve HALT in patients with serial CT aquisitions.

METHODS

A total of 46 consecutive TAVI patients in whom anticoagulation had been initiated because of HALT and who underwent follow-up CT were identified. Indication and type of anticoagulation was according to physician discretion. Patients on DOAC were compared to VKA therapy regarding resolution of HALT.

RESULTS

Mean age of the 46 patients was 80 ± 6 years (59% men), and the mean duration of anticoagulation was 156 days. Overall, 41 patients (89%) showed resolution of HALT with anticoagulation therapy, whereas HALT persisted in 5 patients (11%). Resolution of HALT was seen in 26 out of 30 (87%) patients receiving VKA and in 15 out of 16 (94%) patients receiving DOAC, respectively. Groups did not differ regarding age, cardiovascular risk factors, TAVI prosthesis type and size or duration of anticoagulation (all p > 0.05).

CONCLUSION

Anticoagulation therapy resolves leaflet thickening after TAVI in most patients. Non-Vitamin-K antagonists seem to be an effective alternative to Vitamin-K antagonists. This finding needs to be confirmed in larger prospective trials.

Influence of sex on results and consequences of coronary fractional flow reserve in clinical practice: results of a prospective large-scale multicenter registry

Background

Measurement of fractional flow reserve (FFR) is clinically indicated in order to assess the hemodynamic relevance of coronary artery lesions and determine the need for revascularization. Preliminary data sugest that there may be significant differences regarding use and outcome of FFR measurements in men versus women.

Purpose

We therefore analyzed the influence of sex on FFR values and treatment consequences in a large-scale, prospective multicenter registry of consecutive patients undergoing clinically indicated FFR measurements in the setting of chronic or acute coronary syndromes.

Methods

In a large, multicenter prospective registry of patients undergoing FFR, the relationship of stenosis degree to FFR, the influence of FFR on revascularization decisions were compared between male and female patients. (clinicaltrials.gov NCT03055910)

Results

A cohort of 2000 patients from 8 centers was evaluated (73% male, 27% female, median age 69±10 years, 15% acute coronary syndromes). The median number of interrogated lesions was 2 in male and 2 in female patients. A total of 2958 lesions were interrogated by FFR (2156 male, 802 female; 67 LM, 1722 LAD, 646 LCX, 523 RCA). Median stenosis degree was 60% (IQR 50%-70%) in male and, identically, 60% (IQR 50%-70%) in female patients. All the same, median measured FFR values were 0.86 (IQR 0.81–0.92) in male and 0.89 (IQR 0.84–0.93) in female patients (p<0.001). Of all lesions interrrogated, 488/2156 (23%) in men and only 100/802 (12%) in women displayed an FFR value ≤0.80 (p<0.001). The median stenosis degree of lesions with an FFR value ≤0.80 was 70% (IQR 60–80%) in men and 70% (IQR 65–84%) in women (n.s.). In multivariable analysis, stenosis degree, lesion location in LAD, ACS culprit lesion, and male sex were independent predictors of an FFR value ≤0.80. The overall rate of revascularization was 24% in men and 14% in women (p<0.001), driven by lower FFR values in men. In lesions with FFR values ≤0.80, revascularization rate was 94% both in men and in women (n.s.).

Conclusion

Female sex is independently associated with higher FFR values when used to determine the hemodynamic relevance of coronary lesions in the setting of chronic or acute coronary syndromes. Independent of stenosis degree, FFR measurements are significantly less frequently followed by revascularization in women.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): St. Jude Medical

CT analysis of left ventricular function predicts short term survival in patients following transcatheter aortic valve implantation: 1-year outcome data

Introduction

Contrast-enhanced cardiac CT routinely performed prior to transcatheter aortic valve implantation (TAVI), allows assessment of cardiac morphology and function. We assessed left ventricular function in CT as a predictor of survival following TAVI.

Methods

500 consecutive patients referred for CT assessment of aortic root anatomy prior to TAVI were screened for inclusion in this analysis. All CT data sets were acquired using a third-generation dual source system. For assessment of aortic root anatomy, acquisitions were acquired using ECG-gated retrospective spiral acquisition and multiphase reconstructions in 10% increments of the cardiac cycle were rendered (slice thickness 0.75, increment 0.4 mm). left ventricular endocardial contours were automatically traced by a dedicated software (syngo. via, Siemens Healthineers, Forchheim, Germany) throughout the cardiac cycle and manually adjusted if required. Global left ventricular function parameters (end-diastolic and end-systolic volumes, stroke volume, cardiac output and ejection fraction) were derived by volumetric assessment.

Results

Out of 500 patients, 439 patients (mean age 80±6 years, 56% males, and Log EuroScore 23±14%) were included in this analysis (61 patients were excluded due to poor CT image quality or missing outcome data). Previous cardiac surgery had been performed in 15% of the patients, 50% had obstructive CAD with previous interventional or surgical revascularisation and 18% had a previous acute coronary syndrome. One-year survival was 83% (366/439 patients). Parameters of left ventricular function were as follows: mean LVEDV 172±56 ml, mean LVESV 78±62 ml, mean LV ejection fraction 59±18%, mean LV stroke volume index 51±22 ml/m2, mean LV cardiac output 6.6±3.3 L/min and LV cardiac index 3.5±1.7 l/min/m2. Cluster analysis of multiple LV-function surrogate parameters identified a group of patients with higher 1-year mortality, with LVEF identified as a predictor of 1-year survival with a cut-0ff of ≥37% associated with an OR 0f 0.52 (95% CI 0.27 to 0.98).

Conclusion

Assessment of left ventricular function using functional CT data sets is feasible and allows risk stratification of patients following TAVI. Among LV functional parameters, CT derived LV-ejection fraction with a cut-off ≥37% identifies patients with better short-term outcome.

Funding Acknowledgement

Type of funding sources: None.

Influence of gender on coronary atherosclerosis and inflammatory biomarker profile: a CT angiographic study

Background and aims

The burden of coronary atherosclerosis differs between men and women. Beyond traditional cardiovascular risk factors, inflammatory biomarkers can influence plaque formation and progression. We analyzed the influence of gender difference on coronary atherosclerosis and inflammatory cytokines.

Methods

Coronary CT-Angiography was performed in 301 patients and plaque morphology was quantitatively and qualitatively assessed using semi-automated software (Autoplaque version 2.5, Cedars-Sinai Medical Center, Los Angeles, CA). We analyzed total (TPV), non-calcified (NCPV), calcified (CPV) and low-density plaque volume in mm3 (LDPV, defined as plaque attenuation <30HU). Serum was analyzed for various cytokines including Interleukin (IL)-1a, IL-1b, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10, IL-13, Il-15, IL-17, TNF-a, IFNg, CRP, MCP-1, MIP-1a, Eotaxin, G_CSF and GM-CSF using Luminex assay.

Results

Out of 301 patients, 94 (31%) were female and 207 (69%) were male. As compared to women, men were significantly younger (62 vs. 57 years, p<0.001) and showed a higher BMI (28 vs. 26 kg/m2, p=0.005). No differences were seen for hypertension, hyperlipidemia, diabetes, smoking habits and family history of CAD. All plaque characteristics showed significant higher values in men as compared to women (all p<0.05). In men, cytokine profile showed significantly lower serum levels for IL-2 (3.20 [3.20; 7.01] vs. 4.31 [3.20; 9.68]; p=0.01) and Interferon-gamma (3.20 [3.20; 14.72] vs. 8.76 [3.20; 26.26]; p<0.001) and significantly higher levels for MCP-1 (224 [117; 327] vs. 155 [49; 260]; p<0.001). In multivariable logistic regression analysis, Interferon-gamma showed significant inverse association to male gender (OR 0.35; 95% CI: 0.17–0.72; p=0.004), but IL-2 and MCP-1 did not. The association of Interferon-gamma to gender was independent of age (OR 0.57; 95% CI: 0.43–0.76; p<0.001) and BMI (OR 2.12; 95% CI 1.25–3.62; p=0.006)

Conclusion

Coronary plaque volume and morphology significantly differs between men and women and so does the inflammatory cytokine profile. Albeit significantly lower coronary plaque burden in women, serum levels of interferon-gamma - a known pro-inflammatory cytokine - was significantly higher in women with independent association to gender. Whether interferon-gamma plays contradicting roles in the process of coronary atherosclerosis in men and women needs to be explored in future studies to identify potential gender-specific targets for therapeutic interventions.

Funding Acknowledgement

Type of funding sources: None.

Radiation exposure during transcatheter aortic valve implantation (TAVI): comparison of balloon-expandable versus self-expandable prostheses

 

Transcatheter aortoc valve implantation (TAVI) is performed under fluoroscopic control and can be associated with the need for long fluoroscopy times and repeated cine acquisitions in angulated projections. The procedural steps for TAVI with balloon-expandable and self-expanding prostheses differ and may be associated with significant differences in radiation exposure. Published data regarding patient or operator radiation exposure in TAVI are limited to small series. We therefore analyzed the influence of prosthesis type on radiation exposure in a consecutive series of 1185 patients who underwent TAVI between 2016 and 2021.

A cohort of 1185 consecutive patients undergoing TAVI between 2016 and 2021 was analyzed. Radiation exposure was determined by evaluating overall fluoroscopy time, the number of acquired cine sequences, and total dose-area product (DAP). After eliminating patients treated via a non-transfemoral approach, data between patients underging TAVI with self-expanding prostheses and patients undergoing TAVI with balloon-expandable prostheses were compared.

Out of the total patient cohort, 46 patients were excluded due to treatment via a non-transfemoral approach. Of the remaining 1139 patients, 437 (38%) were treated with self-expandable prostheses and 702 (62%) were treated with balloon-expandable prostheses. Median age was 81 years, 45% of patients were female. Body weight was slightly but significantly higher in patients treated by balloon-expandable prostheses (median 73 kg vs. 79 kg, p<0.001). Median fluoroscopy time was 453 s (IQR 365–603 s) for self-expandable prostheses vs. 414 s (IQR 341–540 s) for balloon-expandable prostheses (p=0.002). Also, the number of cine acqusitions was significantly higher (median 12 vs. 7; p<0.001), and total DAP was 6442 mGy cm2 (IQR 4452–9669 mGy cm2) for self-expandable vs. 4798 (IQR 3353–6981 mGy cm2) for balloon-expandable prostheses (p<0.001, see Fig. 1). In multivariable analysis, male sex, higher body weight and use of a self-expandable prosthesis were independently associated with higher total DAP.

Transcatheter aortic valve implantation using balloon-expandable prostheses is associated with significantly lower total dose-area product than treatment with self-expandable prostheses. This may be particularly relevant for operators who perform the procedure frequently.

Funding Acknowledgement

Type of funding sources: None.

Membranous septum length as predictor for permanent pacemaker implantation after TAVI

Background

High-degree atrioventricular (AV) block and permanent pacemaker (PPM) implantation represent major complications after transcatheter aortic valve implantation (TAVI). Extension of indication for TAVI towards subjects with lower surgical risk requires to reduce the likelihood for the requirement of permanent pacemaker (PPM) implantation. Data on the role of membranous septum length as potential predictor for AV block after TAVI are scarce.

Purpose

We examined the role of membranous septum length as potential predictor for AV block and the need for PPM implantation in a large cohort of consecutive subjects after TAVI.

Methods

In a cohort of 1365 patients without prior permanent pacemaker who underwent transfemoral TAVI, clinical and procedural characteristics were assessed systematically. Based on cardiac computed tomography performed prior to TAVI, membranous septum length was measured orthogonal to the anulus plane (see figure).

Results

Median age of subjects was 81 (IQR 7) years, 50% were male. Logistic euroSCORE was 12.8 (IQR 15.7), STS score 3 (2.7). 9,8% of subjects had a pre-interventional complete right bundle branch block (RBBB). 71% of patients received a balloon-expandable, 29% a self-expandable valve. In n=153 patients (11.2%), PPM implantation was necessary due to high-degree AV block. Median membranous septum length was 2.9 mm (IQR 2.5mm) in subjects who received a PPM versus 4.3 mm (IQR 3.2 mm) in subjects who did not need a PPM (p=0.061). In univariate regression analysis, pre-interventional complete RBBB (p<0.001, OR 7.8), implantation of a self-expandable prosthesis (p=0002, OR 1.7) and membranous septum length (p=0.027, OR 0.9 per 1 mm) were identified as significant predictors for PPM implantation. In multivariate regression analysis, all parameters remained significant, including membranous septum length (p=0.009, OR 0.9 per 1 mm).

Conclusion

In a large cohort of consecutive patients, we were able to confirm the significant independent predictive value of membranous septum length, in addition to pre-interventional complete RBBB or implantation of a self-expandable prosthesis, regarding the occurrence of post-procedural AV block with the need for PPM implantation. The results may contribute to improved risk stratification for potential PPM implantation after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Side effects and major adverse cardiac events caused by fractional flow reserve measurement: a systematic review and meta-analysis of 12,215 patients

Background

Current guidelines recommend revascularization based on fractional flow reserve (FFR) in angiographically intermediate coronary stenoses. Side effects of FFR caused by adenosine administration are usually transient with little relevance. However, major adverse cardiac events (MACE), such as coronary artery occlusion, may infrequently occur as a consequence of intracoronary wire manipulation and little is known about their incidence. This systematic review aims to analyze the rate of side effects including MACE caused by FFR measurement as reported in large multicenter studies.

Methods

A PubMed database query for “fractional flow reserve” of the type “multicenter study” identified 348 records. Subsequently, one retracted record was excluded, another record was excluded as it contained no digital object identifier, 52 records were excluded since access could not be obtained, and one was a duplicate. Of the 293 records screened, only 15 contained relevant information on adverse effects or events due to FFR measurement and had included at least 100 patients. To systematically report the frequency of adverse events, the micro average for each event type was calculated across all studies where it was described.

Results

This systematic review includes data from 15 studies with a total of 12,215 patients. Measurement of FFR was successful in 99.1% (5,163 of 5,210). Hyperemia for FFR measurement was usually induced by adenosine, in most cases administered intravenously. Adverse effects are summarized in Figure 1. With 34.5% (778 of 2,257) of patients reporting chest pain or discomfort, this was the most common side effect of adenosine administration. Dyspnea was noted by 20.0% (250 of 1,250) of patients. Heart-rhythm disturbances occurred in 3.3% (185 of 5,646) of patients. More specifically, a transient atrioventricular block was reported in 2.6% (115 of 4,396) of patients, whereas ventricular arrhythmia was considerably less frequent with 0.2% (11 of 5,864). Hypotension was described by 0.9% (14 of 1,574) of patients, vomiting or nausea by 0.9% (11 of 1,250), and bronchospasm by 0.2% (11 of 4,836). MACE were infrequent, but not negligible: the pressure wire used for FFR measurement was reported to cause coronary artery dissection in 0.2% (8 of 4,158) of patients, coronary artery occlusion in 0.2% (4 of 2,381) of patients, and coronary artery perforation in 0.1% (2 of 3,228) of patients.

Conclusions

Chest pain, dyspnea, and transient arrhythmias are commonly experienced by patients in the context of adenosine but bear limited clinical relevance. The analysis of a large patient cohort revealed that MACE caused by vessel injury, while infrequent, occur at a rate of approximately 0.5% and should hence be considered relevant.

Funding Acknowledgement

Type of funding sources: None.

CT-FFR in predicting future cardiovascular events

Background

Computational fluid dynamics offer a non-invasive way for functional assessment of coronary stenosis in CT-FFR. Currently, minimal FFR thresholds used for determining ischemia were established in invasive coronary angiography. It remains unknown whether minimal absolute CT-FFR values are the most adequate tool for predicting future cardiovascular events.

Methods

This analysis enrolled 605 of 767 consecutive patients with suspected CAD undergoing CCTA from 2005 to 2007. Of the 161 (21%) patients excluded, image artifacts were the most common cause (97), followed by software error (43) and chronic total occlusion in (15). CT-FFR was measured using an on-site prototype (cFFR Version 3.0, Siemens Healthineers, Forchheim, Germany) by an experienced observer. CT-FFR values were measured at the proximal and distal end of each coronary segment and the maximum drop in CT-FFR (ΔFFR) over one segment recorded, respectively. Follow up data included major cardiovascular events (non-fatal stroke, non-fatal myocardial infarction, cardiovascular death) and revascularization (PCI or CABG).

Results

This study included 605 patients (60±11 years, 61.2% men) with minimal CT-FFR 0.81±0.14. Mean ΔFFR was 0.13±0.11. MACE occurred in 24 (4.0%) cases, revascularization in 66 (10.9%) during a median follow up of 2823 days (7–8 years). The area under the Receiver operator characteristic (ROC) curve was 0.887 for revascularization during follow up and 0.608 for MACE during follow up. AUC for the combined end point of MACE and revascularization was 0.806.

Conclusion

Maximum drop in CT-FFR (ΔFFR) is a good predictor for future revascularization but less useful in predicting MACE. This underlines the current use of CT-FFR in guiding treatment decisions.

Funding Acknowledgement

Type of funding sources: None.

Characterization of Bioactive Compounds from Patchouli Extracted via Supercritical Carbon Dioxide (SC-CO2) Extraction

Patchouli extracts and oils extracted from Pogostemon cablin are essential raw material for the perfume and cosmetics industries, in addition to being used as a natural additive for food flavoring. Steam distillation is a standard method used for plant extraction. However, this method causes thermal degradation of some essential components of the oil. In this study, patchouli was extracted with supercritical carbon dioxide (SC-CO₂) under different conditions of pressure (10–30 MPa) and temperature (40–80 °C). The chemical components of the crude extracted oil and the functional group were characterized using gas chromatography-mass spectrometry (GC-MS) and Fourier Transform Infrared Spectroscopy (FT-IR). The extraction with supercritical carbon dioxide was shown to provide a higher yield (12.41%) at a pressure of 20 MPa and a temperature of 80 °C. Patchouli alcohol, Azulene, δ-Guaiene, and Seychellene are the main bioactive compounds that GC-MS results have identified. FTIR spectra showed alcohol, aldehyde, and aromatic ring bond stretching peaks. Extraction of patchouli with supercritical carbon dioxide provided a higher yield and a better quality of the crude patchouli oil.

Independent predictors of major cardiovascular events as quantitatively assessed by coronary CT-angiography: a long-term follow-up analysis

Introduction

Quantitative CT coronary angiography using semi-automated software provides detailed information about plaque volume and high-risk plaque characteristics, beyond traditional measures like diameter stenosis. We assessed the potential value of plaque quantity and morphology to independently predict MACE in a cohort with long-term follow up.

Methods

In this secondary analysis of 301 symptomatic patients undergoing coronary CTA at baseline, total plaque volume (TPV), non-calcified- (NCPV), calcified- (CPV) and vulnerable coronary plaque volume (in mm3), diameter stenosis (in %) and remodeling index were quantified using semi-automated software (Autoplaque version 2.5, Cedars-Sinai Medical Center, Los Angeles, CA). Patients were followed for major cardiovascular events (MACE), defined as a composite of cardiovascular death, myocardial infarction and coronary revascularization. Optimal thresholds for each quantitative CTA measure were computed using CART-algorithm (Classification and Regression Trees).

Results

Complete follow-up was available for 234 (78%) patients. The mean age was 59±10 years. Over a median follow-up of 10.7 years, the composite outcome occurred in 34 (15%) patients (5 patients with cardiovascular death, 6 with myocardial infarction, 26 with revascularization). Patients experiencing MACE had more frequently hypertension (p=0.03) and a higher Framingham risk score (p=0.002). Survival anaylsis using cox proportional hazard ratios showed significant univariate associations between MACE and TPV (HR 5.16; 95% CI 1.58–16.89; p=0.007), NCPV (HR 4.83; 95% CI 1.45–15.81; p=0.009), CPV (HR 2.86; 95% CI 1.39–5.86; p=0.004), vulnerable plaque volume (HR 3.35; 95% CI 1.52–7.41; p=0.003), diameter stenosis (HR 5.19; 95% CI 2.64–10.22; p<0.001) and remodeling index (HR 4.24; 95% CI 2.03–8.86; p<0.001). In multivariable cox regression analysis diameter stenosis (HR 3.70; 95% CI 1.72–7.93; p=0.001) and remodeling index (HR 2.69; 95% CI 1.19–6.09; p=0.018) remained significant independent predictors of MACE, adjusted for Framingham risk score (HR 2.56; 95% CI 1.26–5.22; p=0.010), however plaque volume and plaque subcomponents did not.

Conclusion

On long term follow-up, remodeling index and coronary diameter stenosis obtained by quantitative coronary CT angiography independently predicted MACE on multivariable assessment. More comprehensive plaque assessment algorithms including plaque volume as well as plaque subcomponents were significantly associated with MACE in univariate, but not multivariate analysis after adjustment for diameter stenosis and remodeling index.

Funding Acknowledgement

Type of funding sources: None.

Double kissing – crush technique to treat coronary bifurcation lesions: analysis of success rate, procedural times and device usage

Background

The Double Kissing Crush (“DK Crush”) technique is one of the recommended planned 2-stent techniques to treat true coronary bifurcation lesions (Medina 1–1-1, Medina 0–1-1). While some trials demonstrated superiority to other techniques, DK Crush requires a sequence of specific and potentially technically challenging steps. No data exists on the procedural difficulty of the various steps required for DK Crush. We therefore analyzed procedural times and device usage in a systematic fashion.

Methods and results

54 patients (42 male, mean age 67±12 years) intended for treatment with DK Crush were enrolled. Detailed procedural characteristics including exact times and device usage for each step of DK Crush were prospectively measured and analyzed.

DK Crush was successful in 48/54 patients (89%). In two patients stenting technique was changed to T- or TAP-stenting due to anatomical reasons at the moment of positioning of the SB stent. In one patient no balloon could cross the lesion and in another the procedure had to be modified due to coronary perforation directly after pre-dilatation. True failure of DK Crush was observed in two cases: In one case, the first rewiring of the SB, in the other, placement of a balloon for first kissing balloon (KB) maneuver in the SB was not possible. These 6 patients were excluded from further analysis.

Median times for each step were: 1:21min (IQR 0:52min-1:50min) for wiring SB, 1:18min (IQR 0:47min-1:42min) for wiring MV, 1:30min (IQR 0:54min-2:15min) for stent placement in the SB, 0:40min (IQR 0:29min-1:21min) for balloon placement in the MV. First rewiring of the SB after SB stent crush required 1:30min (IQR 0:37min-2:05min), 1st KB placement in the SB took 1:42min (IQR 1:00min-3:13min) and 1st KB placement in the MV required 0:45min (IQR 0:27min-1:19min). Stent placement in the MV required 1:34min (IQR 1:09min-2:40min) and 2nd rewiring of the SB 1:21min (IQR 0:55min-2:04min), 2nd KB placement of the SB 2:08min (IQR 1:01min-3:36min) and 2nd KB placement of the MV 0:50min (IQR 0:34min-1:01min). Final POT was performed in all cases. Median total procedure time was 52:35 min (IQR 00:42:54h-1:01:37h). Additional devices were needed in 10% (3x1, 2x2 balloons) for stent placement in the SB; in 46% (20x1, 1x4 wires) for the first rewiring of the SB and in 49% (20x1, 3x2 balloons) for 1st KB placement in the SB. The 2nd rewiring of the SB required additional wires in 32% (13x1, 2x2 wires) and 54% of the patients required additional balloons for the 2nd KB placement in the SB (20x1, 2x2, 1x3, 2x5 balloons).

Final TIMI flow was III in 97.9%. Complications occurred in 6% (n=3), each showing coronary dissection with TIMI III flow in 2 patients and TIMI I flow in 1 patient after placement of additional stents.

Conclusion

DKMC has a high success rate but is a time-consuming and material-intensive technique. The placement of the 2nd KB in the SB requires most of the procedural time and resources.

Funding Acknowledgement

Type of funding sources: None.

Predictors of CT-derived FFR in patients with suspected CAD beyond severity of coronary stenosis

Background

Functional assessment of coronary stenosis using computational fluid dynamics is increasingly used, however other factors besides coronary stenosis may affect the results. We assessed several predictors for CT-derived fractional flow reserve (CT-FFR) in patients with suspected coronary artery disease (CAD) undergoing coronary computed tomographic angiography (CCTA).

Methods

2505 consecutive patients with suspected CAD undergoing CCTA from 2008 to 2016 were screened, 1549 were excluded due to incomplete data (934), image quality (345), software error (147) or other reasons (123). Minimal CT-FFR was measured using an on-site prototype (cFFR Version 3.0, Siemens Healthineers, Forchheim, Germany) in coronaries ≥2mm. Several clinical as well as technical criteria were assessed for predicting the minimal CT-FFR per patient.

Results

956 patients (51±12 years, 51.2% men) were included in this analysis. Mean EF was 59.4±7.4%, heart rate 63±9 bpm, systolic (126.5±20mmHg) and diastolic (70±11 mmHg) blood pressure (BP). Regression analysis and ANOVA showed low but significant impact on minimal CT-FFR (mean 0.85±0.10) by EF, aortic valvular dysfunction, heart rate and systolic blood pressure as well as image quality (esp. blooming and image noise). See Tables 1 and 2.

Conclusion

Coronary stenosis may not be the only relevant predictor for CT-FFR. Several clinical criteria (EF, heart rate, BP, aortic valve dysfunction) as well as image criteria (image quality, artifacts) can affect CT-FFR results.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cleveland Clinic Foundation Table 1. ANOVA analysisTable 2. Regression analysis

Computed tomography-derived characterisation of pericoronary,epicardial and paracardial adipose tissue and its association with myocardial ischemia as assessed by computed and invasive fractional flow

Introduction

Increased pericoronary adipose tissue (PCAT) computed tomography (CT) attenuation derived from coronary CT angiography (CTA) around the right coronary artery (RCA) reflects coronary inflammation and relates to cardiac mortality.

Purpose

We aimed to investigate the yet unclear association between CT-derived characterisation of different cardiac adipose tissue compartments and the presence of myocardial ischemia as assessed by fractional flow reserve (FFR).

Methods

133 stable individuals (64 years, 74% male) with coronary artery disease (CAD) underwent CTA including computed FFR (FFR-CT) measurement followed by invasive angiography with FFR (invasive FFR) assessment. The CT attenuation (HU) and volume (mm3) of PCAT were quantified around the RCA (10 to 50 mm from RCA ostium), the proximal 40 mm of the left anterior descending artery (LAD) and the circumflex artery (LCX) with the help of semi-automated software. The per patient PCAT CT attenuation was calculated as followed: (PCAT CT attenuation of RCA+LAD+LCX)/3. Quantification of epicardial adipose tissue (EAT) and paracardial adipose tissue (PAT; all intrathoracic adipose tissue outside the pericardium) were performed in non-contrast cardiac CT data sets using a fully automated deep-learning based algorithm.

Results

Median FFR-CT was 0.86 [0.79, 0.91] and median invasive FFR was 0.87 [0.81, 0.93]. Patients with presence of myocardial ischemia (n=26) defined by a FFR-CT threshold of ≤0.75 showed a significant higher PCAT CT attenuation of RCA (−75.1 HU vs. −81.1 HU, p=0.011) and per patient (−74.5 HU vs. −77.7 HU, p=0.045) than individuals without myocardial ischemia (n=107). In multivariable analysis adjusted for age, BMI, gender and traditional risk factors, both RCA and per patient PCAT CT attenuation were significant predictors of myocardial ischemia as assessed by FFRCT ≤0.75. Between individuals with myocardial ischemia compared to individuals without myocardial ischemia there was no significant difference neither in the volume and CT attenuation of EAT and PAT nor in the PCAT volume of RCA, LAD, LCX and per patient PCAT volume.

Conclusions

Our observations suggest that PCAT CT attenuation instead of PCAT volume, EAT and PAT measures might be associated with the presence of myocardial ischemia as assessed by FFR.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): German Heart Foundation e.V.

High-degree atrioventricular block after valve-in-valve transcatheter aortic valve implantation: incidence and predictors

Background

High-degree atrioventricular (AV) block and permanent pacemaker (PPM) implantation represent major complications after transcatheter aortic valve implantation (TAVI). Data on the incidence of AV block for patients undergoing valve-in-valve (ViV) TAVI are scarce. We examined the incidence and predictors of periinterventional AV conduction disturbances in a cohort of subjects undergoing ViV TAVI compared to subjects undergoing TAVI of native aortic valves.

Methods

In 50 consecutive patients who underwent ViV TAVI, clinical characteristics, incidence and predictors for AV conduction disturbances as well as intrahospital outcome were assessed. Applying a matched pair approach for age, gender, type and size of transcatheter valve, these subjects were compared to 50 patients undergoing TAVI of native tricuspid aortic valves.

Results

Mean age in both groups was 80±6 years and 50% of subjects were male. In the ViV group, 22 patients (44%) had a stented bioprosthesis, 10 patients (20%) a stentless bioprosthesis and 18 patients (36%) a previous TAVI prosthesis (balloon-expandable: n=15, self-expandable n=3). The majority of subjects (92% in each group) were treated using balloon-expandable valves (ViV group: Sapien XT, n=20 or Sapien 3, n=26, control group: Sapien XT, n=19 or Sapien 3, n=27).

Periinterventional, non-reversible 3rd degree AV-block occurred in 6 patients within each group (12%), and all of the affected patients underwent PPM implantation. Among the 32 patients who underwent ViV-TAVI of a surgically placed bioprosthesis, only 2 (6%) developed a high-degree AV block (1/22 with a stented bioprosthesis and 1/10 with a stentless bioprosthesis). In contrast, high-degree AV block occurred in 4/18 patients (22%) who underwent ViV TAVI of a prior TAVI prosthesis. There was a significant difference in the occurrence of total high-degree AV blocks requiring postinterventional PPM implantation (p=0.033) between subjects who received TAVI of stented bioprostheses and those who received re-TAVI.

In logistic regression analysis, pre-existing RBBB represented a significant predictor for periinterventional 3rd degree AV block across the whole cohort (p=0.001, Exp(B)=10.667), both in ViV subjects (p=0.016, Exp(B)=12.0) and in the control group (p=0.018, Exp(B)=10.0).

Conclusion

Periinterventional AV block occurs infrequently in subjects undergoing ViV TAVI for treatment of degenerated surgical bioprostheses. However, patients undergoing ViV TAVI for degenerated transcatheter prostheses as well as subjects with pre-existing RBBB are at substantial risk for the occurence of AV block and require close peri-interventional monitoring.

Funding Acknowledgement

Type of funding sources: None.

Radial versus femoral approach for rotational atherectomy – technical aspects and procedural outcomes

Background

Rotational atherectomy (RA) is a well-established therapy for the treatment of heavily calcified coronary lesions. While the radial approach has evolved into the gold-standard for standard percutaneous coronary intervention (PCI), RA is still often performed via a femoral approach. Concerns over guiding size, sheath size, the delivery of the burr as well as the need for a temporary pacemaker play a role in that decision.

Methods

This retrospective analysis includes all patients undergoing RA from 03/2013 to 06/2019 at one institution. We sought to investigate the procedural outcome and the influence of the percutaneous approach.

Results

A total of 228 patients were planned to undergo RA. Based on operator preference, RA was attempted via the radial approach (RAD) in 78 (34.2%) patients and via the femoral approach (FEM) in 150 (65.8%) patients. The procedure failed in 2.6% (RAD 1.3% vs. FEM 3.3%, p=0.359) due to crossing failure of either the RotaWire (n=5) or the burr (n=1).

The left anterior descending was the most frequently treated vessel in the radial group and significantly more often targeted in comparison to the femoral group (LAD: RAD 44.6% vs. FEM 26.5%, p=0.004). All other vessels were similarly often treated in both groups (LM: RAD 13.3% vs. FEM 17.3%, p=0.414; LCX: RAD 15.7% vs. FEM 23.5%, p=0.155; RCA: RAD 25.3% vs. FEM 31.5%, p=0.315; Bypass: RAD 1.2% vs. FEM 1.2%, p=0.984). RAD-RA was significantly more often performed with a 6F sheath in comparison to FEM-RA (RAD 47.4% vs. FEM 16.7%, p<0.001). A 7F sheath was used in 52.6% of the cases for RAD-RA (men: 85.4%, women: 14.6%, p=0.176) and is therefore the most frequently chosen sheath size within that group. A 7F or 8F sheath was used in 75.3%, respectively 8.0% of the cases in the FEM group (7F: p<0.001; 8F: p=0.010 compared to RAD). There were no significant differences regarding the burr sizes (RAD 1.43±0.17mm vs FEM 1.41±0.18mm, p=0.442).

Whereas the placement of a temporary pacemaker was equal in both groups (RAD 20.8% vs. FEM 30.8%, p=0.110), the femoral group showed a higher number of patients with any back-up pacing, permanent or temporary (RAD 24.7% vs. FEM 39.0%, p=0.031). There were no significant differences in terms of fluoroscopy time (RAD 00:24:65±00:12:48 vs. FEM 00:28:33±00:17:05, p=0.180) and the volume of contrast medium (RAD 217.2±96.3ml vs. FEM 192.9±86.0ml, p=0.118). Moreover, procedural complications (RAD 17.9% vs. FEM 18.0%, p=0.992) and access site related complications (RAD 6.4% vs. FEM 10.0%, p=0.363) occurred equivalently in both groups.

Conclusion

This analysis shows that RA via radial access is as safe and successful as via femoral access. Despite the more frequent use of 6F sheaths, burr sizes did not differ. Additionally, neither fluoroscopy time nor contrast volume indicated a higher complexity of the RAD approach.

Funding Acknowledgement

Type of funding sources: None.

Localization of the femoral artery bifurcation: hips don't lie – in at least 97% of cases

Background

The most common vascular access for structural cardiac interventions such as transcatheter aortic valve implantation (TAVI) is the common femoral artery (CFA). Depending on the procedure CFA puncture has to be performed not only unilaterally, but also bilaterally. Since incorrect localization of femoral access can lead to severe vascular complications, specific knowledge about the exact position of the CFA bifuraction is helpful. Such information might be systematically obtained from pre-TAVI CT scans.

Methods

We performed a retroperspective analysis of consecutive contrast-enhanced pre-TAVI CT angiography data sets (n=1000) to determine the CFA bifurcation localization relative to the femoral head and the correlation to contralateral CFA bifurcation location.

Results

The site of the CFA bifurcation was in 67.2% below the femoral head (−−), in 24.3% within the lower third of the femoral head (−), in 7.4% in the mid (0) and in 1.2% within the upper third (+) of the femoral head. Bifurcations above (++) the femoral head were not detected. CFA bifurcations below the femoral head showed the highest prevalence within men and women in all age groups (50–59, 60–69, 70–79, 80–89, 90–99 years). Bilateral agreement of CFA bifurcations was observed in only 69.3% and was independent of one-sided hip replacement (agreement 72.7%) or two-sided hip replacement (agreement 78.7%). A congruent contralateral left CFA bifurcation below the femoral head could be predicted in 80.6%, whereas CFA bifurcations within the lower and upper margins of the femoral head were congruent in only 65.7% (of these, 49.2% for the lower third, 29.7% for the mid and 36.4% for the upper third).

Conclusion

In conclusion, punctures within the upper third of the femoral head will provide an ideal puncture site in at least 97% of cases, independent of age, sex, or previous hip replacement.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 lockdown on the procedural and intra-hospital outcome of STEMI patients

Background

While during the COVID-19 pandemic the number of patients presenting with ST-segment elevation myocardial infarction (STEMI) decreased, no change in patient or system delay could be shown due to local lockdown (LD) policy. Not much is known about the influence of LD on procedural details and intrahospital outcome of these patients.

Methods

Data was obtained from 511 patients treated for acute STEMI (24hours from symptom onset) from January 2019 to March 8th 2021 at two primary PCI (pPCI) centers in Germany. Patients presenting as intra-hospital STEMI, patients showing no culprit lesion and patients undergoing direct CABG were excluded. Overall, 456 patients (74% male, mean age 64±12) were included. These patients were divided into two groups: complete lockdown (LD; n=58; March 21st–April 20th 2020 and December 16th 2020–March 7th 2021) and no complete lockdown (No-LD; n=398)).

Results

There were no differences in pre-hospital care between the groups: Telemedicine (LD 23.5% vs. No-LD 34.9%; p=0.11), pre-alarm of the cath-lab staff (LD 59.6% vs. 66.6%, p=0.32) and direct admission to the cath-lab (LD 44.8% vs. No-LD 49.8%, p=0.58) were performed as often as in No-LD times. Neither the pain to first medical contact (LD 188±272 Min vs. No-LD 236±317 Min, p=0.29) nor the door to balloon time (55±54 Min vs. No-LD 49±58 Min, p=0.470) as well as other periods showed any difference.

All over cardio-pulmonary resuscitation (CPR; LD 19.0% vs. No-LD 14.3%, p=0.35) or presentation with cardiogenic shock (25.9% vs 23.9%, p=0.74) was equally presented in both groups. However, left ventricular assist devices were implanted more often during LD (6.9% vs. No-LD 1.8%; p=0.017).

Primary radial access was performed in the majority of the cases (LD 60.3% vs. No-LD 58.8%, p=0.82). During LD the culprit lesion was RCA in most cases (46.6% vs. No-LD LAD 46.7%, p=0.341). Stent thrombosis was not more common in out-of-hospital STEMI patients during LD (6.9% vs. 8.0%, p=0.76). Thrombus aspiration was performed in 10.3% during lockdown (vs. No-LD 4.5%, p=0.06), GP-IIb-IIIa inhibitors were not administered more often (LD 19.0% vs. No-LD 19.4%, p=0.92) and no reflow phenomenon was not seen more frequent (LD 20.7% vs. No-LD 21.3% p=0.91). TIMI III flow could be established in the majority of the cases (LD 86.0% vs. No-LD 91.5%, p=0.20).

During further hospital stay, neither the frequency of ventilator (LD 17.2% vs. No-LD 17.0%, p=0.98) nor vasopressor use (LD 20.7% vs. No-LD 20.1% p=0.925) differed. Left ventricular function (47±13% vs. No-LD 45±12%; p=0.34) and maximum creatinkinase (LD 1827±1687 U/l vs. No-LD: 2292±4100 U/l, p=0.40) showed no difference between the groups as did intrahospital death (LD 10.3% vs. No-LD 11.6%, p=0.79).

Conclusion

Despite the known decline in STEMI patients during LD periods, patient care, procedural details and inta-hospital outcome of the ones presenting to a pPCI hospital do not change during LD periods.

Funding Acknowledgement

Type of funding sources: None.

CT-derived characterization of pericoronary, paracardial and epicardial adipose tissue and its association with myocardial ischemia as assessed by adenosine stress CMR perfusion imaging

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): German Heart Foundation e.V.

Introduction

 Increased attenuation of pericoronary adipose tissue (PCAT) around the right coronary artery (RCA) is a new imaging biomarker to detect coronary inflammation derived from routine coronary CT angiography (CTA) and has been shown to be associated with cardiac mortality. Increased volume of epicardial adipose tissue (EAT) has been reported be associated with myocardial ischemia.

Purpose

 We aimed to investigate a potential association between CTA-derived PCAT measures and myocardial ischemia as assessed by adenosine stress CMR perfusion imaging. 

Methods

In this single-centre study 109 stable individuals (mean age of 62 ± 11 years, 77% males) with coronary artery disease underwent CTA followed by adenosine stress CMR perfusion imaging to detect myocardial ischemia. PCAT CT attenuation (HU) and PCAT volume (cm3) was measured around the RCA (10 to 50 mm from RCA ostium), the proximal 40 mm of the left anterior descending artery (LAD) and the circumflex artery (LCX) using semi-automated software. Per patient PCAT CT attenuation was calculated as followed: (PCAT attenuation of RCA + LAD + LCX)/3). Non-contrast CT data sets were used for coronary calcium scoring and the quantification of EAT (located between the myocardial surface and the pericardium) and paracardial adipose tissue (PAT; intrathoracic and outside of the pericardium). 

Results

 Between patients with evidence of significant myocardial ischemia as assessed by adenosine stress CMR perfusion imaging (n = 35) and patients without myocardial ischemia (n = 74) there was no significant difference in the CT attenuation of RCA (-85.3 HU vs. -85.7  HU, p = 0.87), LAD (-84.8 HU vs. -85.7 HU, p = 0.66) and LCX (-82.8 HU vs. -83.2 HU, p = 0.79) as well as in the per patient PCAT CT attenuation (-84.2 HU vs. -84.9 HU, p = 0.76). Neither did patients with myocardial ischemia within the RCA territory show increased RCA PCAT CT attenuation (-87.7 HU vs. -85.3 HU, p = 0.40); nor was such a relationship found for the territory of the LAD (-80.6 HU vs.  85.8 HU, p = 0.11) or LCX (-83.1 HU vs. -83.0 HU, p = 0.99). The CT attenuation of EAT (-77.9 vs. -78.7 HU, p = 0.65) and PAT (-89.9 HU vs. -90.0 HU, p = 0.93) did not differ between patients with myocardial ischemia compared to patients without myocardial ischemia. Between patients with myocardial ischemia and patients without myocardial ischemia there was no significant difference in the volumes of EAT (118.1 cm3 vs. 110.6 cm3, p = 0.55), PAT (279.5 cm3 vs. 240.9 cm3, p = 0.20) and the per patient PCAT volume (1021.9 mm3 vs. 1015.5 mm3, p = 0.90). In logistic regression analysis the volume and CT attenuation of the different intrathoracic fat compartments PCAT, EAT and PAT were not independently associated with the presence of myocardial ischemia (n.s.). 

Conclusions

  In this single-centre study CTA-derived quantified CT attenuation and volume of PCAT, EAT and PAT were not associated with myocardial ischemia as assessed by adenosine stress CMR perfusion imaging.

Resolution of leaflet thrombosis under anticoagulant therapy in patients after transcatheter aortic valve implantation: influence of prosthesis type and size

Introduction

Leaflet thrombosis can frequently be identified by computed tomography angiography (CTA) in patients after transcatheter aortic valve implantation (TAVI). Oral anticoagulation is assumed to lead to resolution of thrombosis. We analyzed the resolution of leaflet thrombosis after TAVI by anticoagulant therapy in serial CTA and assessed the influence of prosthesis type.

Methods

Consecutive TAVI patients who underwent CTA follow-up were screened and individuals with leaflet thrombosis on CTA (defined by the presence of hypo-attenuated leaflet thickening, HALT) in whom oral anticoagulation was initiated and who underwent follow-up CTA were included. The type of anticoagulation was according to physicians' discretion. We assessed the resolution of HALT and compared patients with and without resolution of HALT regarding prosthesis type, prosthesis diameter and type of anticoagulation.

Results

Out of 395 patients screened for participation, 36 patients (mean age 80±7, 67% men) with leaflet thrombosis underwent follow-up CTA at a medial interval of 3 months (IQR: 3; 5.75 months) after anticoagulation was initiated. 36 patients received either vitamin-K antagonists (n=28, 78%) or Factor-Xa Inhibitors (n=8, 22%). A total of 22 (61%) balloon-expandable and 14 (39%) self-expandable transcatheter aortic valves were implanted. Nominal prosthesis diameter was 23, 25, 26, 27 and 29 mm in 7 (19%), 1 (3%), 10 (28%), 7 (19%) and 11 (31%) patients, respectively. 30 patients (83%) with anticoagulation showed resolution of HALT, whereas persistent HALT was detected in 6 patients (17%), of whom 1 patient with balloon-expandable and 5 patients with self-expandable valve. No difference was seen in duration of anticoagulation between patients with and without resolution of HALT (p=0.984). In univariate analysis, prosthesis type (balloon-expandable vs. self-expandable valves) showed a significant association of self-expandable valves with lack of resolution of leaflet thrombosis (p=0.017). In multivariable logistic regression analysis, this association persisted (p=0.043) and was independent of the type of anticoagulation (p=0.660) and prosthesis diameter (p=0.942).

Conclusion

Persisting leaflet thrombosis despite anticoagulation is not infrequent and seems to be associated with prosthesis-type rather than small valve diameter or type of anticoagulation. Further research is necessary to identify structural aortic valve determinants for this finding.

Funding Acknowledgement

Type of funding source: None

Comparison of fractional flow reserve and instantaneous wave-free ratio for the hemodynamic assessment of jailed side branches in bifurcation stenting

Background

Provisional side-branch stenting strategy is one of the preferred strategies for treatment of bifurcation lesions. Whereas using fraction flow reserve (FFR) for the physiologic assessment of jailed side branches is well studied, the reliability of resting indices such as instantaneous wave free ratio (iFR) is unknown.

Methods

Consecutive patients with provisional stenting of a bifurcation and a jailed side branch were enrolled in this study. FFR and iFR were measured and, after assuring absence of baseline shift and drift, both measurements were repeated after 3 minutes. Hyperemia was induced by intra-coronary adenosine with a dose of 48μg for the right coronary artery and 96μg for the left coronary artery. Cut-off for the assumed functional significance of a stenosis was 0.80 for FFR and 0.89 for iFR. The decision to treat the side branch was left to the interventionalist's discretion.

Results

37 jailed side branches in 36 patients (age 68.4±8.2; male 81% (n=29)) were consecutively enrolled in the study. The main vessel was the left main in 3% (n=1), the left anterior descending (LAD) in 65% (n=24), the diagonal branch (D1) in 3% (n=1), the left circumflex artery (LCX) in 24% (n=9) and the right coronary artery (RCA) in 5% (n=2). The Medina classification revealed true bifurcation stenosis defined as Medina 1–1-1 prior to treatment in 35% (n=13).

FFR showed 35% (n=13) of the stenosis to be functionally significant with a high reproducibility of the results (r=0.986). FFR showed a low correlation with angiographic assessment (r=−0.477). iFR indicated hemodynamic relevance in 38% of lesions (n=14) with a high reproducibility (r=0.967) and also correlated poorly with angiographic assessment (r=−0.271). iFR was found to closely correlate with FFR in jailed side branches (r=0.720, Figure 1A). Bland-Altman analysis showed iFR and FFR agreed with a mean difference between FFR and iFR of −0.054±0.146. In 81% (n=30) FFR and iFR showed the same results regarding functional significance. In 8% (n=3) FFR was ≤0.80 and iFR >0.89, in 11% (n=4) FFR was >0.80 and iFR was ≤0.89 (Figure 1B).

Side branch treatment was performed in 32% (n=12). All of these lesions showed functional significance in FFR or iFR. Stent implantation was performed in 8% (n=3), balloon angioplasty in 19% (n=7) and balloon angioplasty with a drug-eluting balloon in 5% (n=2).

Conclusions

The results of this study confirm the poor correlation of angiographic and functional assessment of coronary artery stenoses. Our data show close agreement of iFR and FFR in stent-jailed side branches. Therefore, iFR can be considered as a reliable technique for guidance of provisional side branch stenting.

Figure 1

Funding Acknowledgement

Type of funding source: None

The association of pericoronary adipose tissue attenuation with major adverse cardiac events (MACE) and atherosclerosis-relevant inflammatory mediators

Background

Increased attenuation of pericoronary adipose tissue (PCAT) around the right coronary artery (RCA) is a new imaging biomarker to detect coronary inflammation derived from routine coronary CT angiography (CTA).

Purpose

We aimed to investigate a potential association between RCA PCAT attenuation and i) serum levels of atherosclerosis-relevant cytokines, ii) different grades of coronary calcification iii) future coronary revascularization within the same coronary artery and iV) MACE (defined by revascularization, myocardial infarction (MI) and/or cardiac death).

Methods

In 293 stable individuals (59.0±9.8 years, 69% males) with intermediate likelihood for coronary artery disease (CAD) blood was drawn and subsequently analyzed for different atherosclerosis-relevant cytokines interleukin (IL)-2, IL- 4, IL-6, IL-7, IL-8, IL-10, IL-13, Il-15, IL-17, TNF-a, IP-10, CRP, MCP-1, MIP-1a, Eotaxin and GM-CSF, followed by coronary calcium scoring (CCS) in non-contrast CT followed by CTA. PCAT CT attenuation (HU) was measured around the RCA (10 to 50 mm from RCA ostium) and the proximal 40 mm of the left anterior descending artery (LAD) and the circumflex artery (LCX) using semi-automated software. Increased RCA PCAT attenuation was defined as PCAT attenuation above the highest quartile (>−73.5 HU). A long-term follow-up over 9.6 years was performed.

Results

PCAT attenuation was similar in different grades of coronary calcification (CAC=0,-80.3 HU; CAC 1–99, −79.2 HU; CAC 100–400, −79.5 HU; CAC >400, −81.0 HU; p>0.05). Adipocytokine MCP-1 (r=0.23, p<0.01) and pro-inflammatory mediator IL-7 (r=0.12, p=0.04) correlated positively with RCA PCAT attenuation, whereas anti-inflammatory mediators Il-4, -10 and -13 correlated inversely (each r<−0.12, each p<0.05). In patients with increased RCA PCAT attenuation the serum levels of MCP-1 were increased (2.37 vs. 2.20, p<0.01), whereas anti-inflammatory mediators IL-4 and -13 were reduced (each p<0.05). 40 patients experienced MACE during follow-up. In multivariable Cox regression analysis, when adjusted by age, gender, baseline medications, obstructive coronary stenosis and CCS, the highest quartiles of PCAT attenuation are an independent predictor of MACE (HR 7.9, p=0.035). In patients with percutaneous coronary intervention (PCI) of the RCA during follow-up, RCA PCAT attenuation was increased at baseline CTA (−73.1 vs −80.2 HU, p=0.008). In patients with PCI of the LAD or LCX during follow-up, PCAT attenuation of LAD and LCX were not increased at baseline CTA (p>0.05).

Conclusions

The information captured by PCAT attenuation is independent of coronary calcification and showed a trend towards a weak association with serum levels of atherosclerosis-relevant inflammatory biomarkers. Increased RCA PCAT attenuation is an independent predictor of MACE and could guide future prevention strategies in stable patients.

Funding Acknowledgement

Type of funding source: None

Early single center experience with a novel transcatheter anuloplasty system for the treatment of functional tricuspid regurgitation

Background

Functional tricuspid regurgitation (TR) is increasingly recognized as relevant, but undertreated clinical entity. Since surgical repair or replacement of the tricuspid valve is associated with high mortality, many patients with with severe tricuspid regurgitation are not referred to surgery. Transcatheter anuloplasty is a new interventional treatment option for tricuspid regurgitation. We report the outcome of a consecutive single-center series of 11 patients treated with this technique.

Methods

Clinical and procedural data as well as mid-term outcome of a series comprising 11 consecutive patients (9 female, mean age 80±5 years, mean LV-EF 53±7, mean PAP 27±4 mmHg) who underwent transcatheter tricuspid anuloplasty for secondary tricuspid regurgitation in a 12-month period (Octover 2018–October 2019) were systematically collected, including pre- and post-procedural transthoracic/transesophageal echocardiogryphy (TTE/TEE). Patients were selected for the procedure based on clinical, echocardiographic and CT findings. All patients were treated using the Cardioband® system (Hersteller, Ort) in general anesthesia under 4D-TEE guidance.

Results

Mean procedural duration was 259±46 min across all 11 patients. Device success was 91%. In one patient extensive tricuspid annular excursions prevented anuloplasty band implantation. The mean grade of TR severity was reduced from 3.5 to 2.1, p=0,00016 (vena contracta decreased from 11±4 to 6±3 mm, p=0,0047).73% of all patients achieved pos-procedure TR severity ≤2. Procedural complications were infrequent: one patient required coronary stent implantation to the RCA kinking and in an further patient, transient 3rd degree AV bock occurred during the procedure. No patient died during the index hospital stay or during the follow up period (median follow up of 4 months). The NYHA classification improved from a median of III before the procedure to a median of II at follow-up (p=0,00022).

Conclusion

Transcatheter tricuspid annuloplasty permits effective treatment of functional tricuspid regurgitation with a low complication rate and sustained symptomatic improvement.

Funding Acknowledgement

Type of funding source: None

Influence of lesion location on the accuracy of CT derived FFR: head-to-head comparison with invasive FFR

Background

The accuracy of CT-derived FFR (FFRCT) has been repeatedly reported. However, the influence of lesion location on accuracy is unknown. Therefore, we evaluated the diagnostic accuracy of FFRCT to detect lesion-specific ischemia and determined the influence of lesion location (proximal vs. distal vessel segments) compared to invasively measured FFR in patients with suspected CAD.

Methods

A total of 136 vessels in which “Dual-Source”-CT coronary angiography had been performed due to suspected CAD and who were further referred for invasive coronary angiography with invasive FFR measurement within three months of the index CT examination were retrospectively identified and screened for inclusion in this analysis. Patients with either left main coronary artery stenoses, bifurcation or ostial stenoses were excluded. Invasive FFR was measured using a pressure wire (CERTUS®, St. Jude Medical, Minnesota, USA or Verrata®, Volcano, San Diego, USA). FFRCT was calculated using an on-site prototype (cFFR Version 3.0, Siemens Healthineers, Forchheim, Germany). All vessels were analyzed by an experienced observer blinded to the results of invasive FFR. Stenoses with invasively measured FFR ≤0.80 were classified as hemodynamically significant. We evaluated the diagnostic accuracy of FFRCT in proximal vs. non-proximal vessel segments. Proximal lesions included stenoses located in segment one, six, eleven and twelve. All other stenoses were categorized as distal lesions.

Results

Out of 136 coronary stenoses, 47 (35%) were located in proximal segments and 89 (65%) lesions were located in distal segments. Compared to invasive FFR, the sensitivity of FFRCT to correctly identify/exclude hemodynamically significant stenoses in proximal vessel segments was 93% (95% CI: 68–99.8%) and the specificity was 100% (95% CI: 89–100%), compared to a sensitivity of 72% (95% CI: 46.5–90%) and a specificity of 87% (95% CI: 77–94%) for FFRCT in distal lesions. The positive predictive value was 100% and the negative predictive value was 97% (95% CI: 82.8–99.5%) compared to a positive predictive value of 59% (95% CI: 42–93.9%) and a negative predictive value of 93% (95% CI: 85.4–96.3%) for proximal vs. distal vessel segment, respectively. This corresponds to an accuracy of 98% vs. 84%, respectively (p=0.02). ROC-Curve analysis showed a slightly higher – albeit non-significant – area under the curve for FFRCT to detect hemodynamic relevance in proximal lesions compared to distal lesions (AUC 0.95, p<0.001 vs. AUC: 0.86, p<0.001, respectively, p=0.2).

Conclusion

FFRCT obtained using an on-site prototype shows overall a high diagnostic accuracy for detecting lesions causing ischemia as compared to invasive FFR with a trend towards better diagnostic performance in proximal vessel segments.

Funding Acknowledgement

Type of funding source: None

Changes of tricuspid valve geometry after interventional implantation of an anuloplasty band

Background

Implantation of an anuloplasty band (Cardioband, Edwards Lifesciences) is a new treatment option for patients with functional tricuspid regurgitation (TR). The initial clinical results are promising. Nevertheless very few details about the mechanism of reducing TR beyond the basic principle of reducing the annular perimeter are known. Therefore we sought to study the changes of the tricuspid valve geometry after Cardioband implantation.

Methods

In all patients, that were treated by Cardioband implantation for tricuspid valve implantation at our institution, fluoroscopic images of the implant were optained at an angle, which would correspond to an echocardiographic “enface” view of the tricuspid valve. In these images the area enclosed by the implant, the perimeter of this area, the septal to lateral diameter, the anterior to posterior diameter and the length of the implant before and after contracting the band was measured. In all patients an echocardiographic evaluation of the tricuspid regurgitation before and after cardioband implantation was performed. These clinical finding were correlated to changes of the above mentioned dimension in the fluoroscopic images.

Results

Between October 2018 und January 2019 17 patients with severe tricuspid regurgitation were treated by Cardioband implantation. In one patient the procedure had to be aborted due to extensive movement of the tricuspid annulus. In the remaining 16 patients (mean age 78±8 years, 7 males) the procedure could be completed successfully and the required measurements were done. The mean severity grade (5 grade scale) of the TR was 3.5±0.6 before and 2±0.7 (p<0.0001) after the implantation, the corresponding mean vena contracta changed from 12±4 mm to 6±3 mm (p<0.000, 51% reduction). The area decreased after band contraction from 10.6±1.4 cm2 to 4.7±1.4 cm2 (p<0.0001; 56% reduction), the perimeter from 13.4±1.8 cm to 9.6±1.6 cm (p<0.0001; 28% reduction) the septal to lateral diameter from 2.8±0.5 cm to 1.6±0.2 cm (p<0.0001; 40% reduction), the anterior to posterior diameter from 4.8±0.9 cm to 3.8±1.0 cm (p<0.005; 19% reduction) and the measured device length from 8.6 cm±1.0 to 5.8±0.8 cm (p<0.0001; 32% reduction). The strongest correlation was seen between area reduction and reduction of the vena contracta (r=0.5), reduction of the septal to lateral dimension as well as the reduction of the device length had a weaker correlation (r=0.3 and r=0.2). The reduction of the anterior posterior diameter and perimeter reduction showed no relevant correlation with regard to TR reduction.

Conclusion

In our patient population Cardioband implantation lead to effective TR reduction. Area reduction and reduction of the septal to lateral diameter of the tricuspid valve seem to have the strongest impact. These findings may be considered when implantations techniques are being optimized or when new devices for TR treatment are developed.

Funding Acknowledgement

Type of funding source: None

P3376Software-based automated CT analysis for planning TAVI-Procedures: Systematic validation against expert and novice human interpretation

Introduction

Cardiac computed tomography (CT) is an established modality for planning TAVI procedures.

We validated CT parameters measured by automated software analysis and by newly trained readers against expert readers.

Methods

Consecutive patients with symptomatic severe aortic valve stenosis referred for CT assessment of the aortic root prior to TAVI were included in this analysis. Measurements were performed manually by an expert reader, a newly trained reader as well as semi-automatically using a commercially available workstation. Manual measurements were performed as per clinical standard. For semi-automatic analysis, CT data sets were exported to a dedicated workstation with fully automated detection of the aortic annulus plane.

Results

Out of 159 consecutive patients, 146 patients were included in this analysis (83+10 years). The median annulus area for expert reader, newly trained reader and software measurement was 468 mm2, 511 mm2 and 513 mm2, respectively (p=0.28) whereas the mean annulus diameter showed a mean±SD of 25.6±2 mm, 25.5±2 mm and 25.6±2 mm, respectively, p=0.47. Agreement between expert and newly trained reader for annulus area was good with Bland-Altman analysis showing a systematic overestimation of the annulus area for the newly trained reader of 16 mm2 (95% limits of agreement 42 to −74 mm2) and for automatic software of 20 mm2 (95% limits of agreement 60 to −99 mm2). Assuming an annulus area-based recommendation for a balloon-expandable Sapien 3 prosthesis (23, 26 or 29 mm prosthesis), kappa statistics revealed moderate agreement between expert measurement, newly trained reader and software measurement (κ 0.60 for newly trained reader, κ 0.58 for software measurement, p<0.0001 for all). The time needed for annulus adjustment measurement for the newly trained reader compared to software measurement was 2±0.6 minutes vs. 1±0.5 minutes, respectively, p<0.0001). The software correctly identified the annulus plane without reader correction in 49% of cases and in 51% of cases manual correction of the cusp insertion point or annular tracing had to be performed. Agreement between expert predicted angulation and software predicted angulation was excellent in 55%, good in 29% vs. 31%, moderate in 11% vs. 6% and fair in 5% vs. 8% for LAO/RAO orientation, CAU/CRA orientation, respectively (assuming excellent agreement when difference: <5°, good agreement: 5–10°, moderate agreement: 10–15° and fair agreement: >15°).

Conclusion

Novice human interpretation manually and with semi-automatic assessment of the aortic root for planning TAVI procedures is feasible with good agreement with expert measurement for annulus dimensions and prediction of implantation angles, however with a trend for systematic overestimation of the annulus area. For semi-automatic assessment, reader correction of cusp insertion point and annular dimensions have to corrected for in 50% of cases

5963Automated quantification of epicardial adipose tissue from non-contrast CT on multi-center and multi-vendor data using deep learning

Background

Epicardial adipose tissue (EAT), a metabolically active visceral fat depot surrounding the coronary arteries, has been shown to promote the development of atherosclerosis in underlying coronary vasculature.

Purpose

We evaluate the performance of deep learning (DL), a sub-group of machine learning algorithms, for robust and fully automated quantification of EAT on multi-center cardiac CT data.

Methods

In this study, 850 non-contrast calcium scoring CT scans, from multiple cohorts, scanners and protocols, with manual measurements of EAT from 3 different readers were considered. The DL method was based on a convolutional neural network trained to reproduce the expert measurement. DL global performance was first assessed using all the scans, and then compared to inter-observer variability on a subset of 141 scans. Finally, automated EAT progression was compared to manual measurement using baseline and follow-up serial scans available for 70 subjects. The proposed model was validated using 10-fold cross validation.

Results

Automated quantification was performed in 1.57±0.49 seconds compared to 15 minutes for manual measurement. DL provided high agreement with expert manual quantification for all scans (R=0.974, p<0.001) with no significant bias (0.53 cm3, p=0.13). EAT volume was higher in patients with hypertension (+18.02 cm3, p<0.001, N=442), with diabetes (+18.33 cm3, p<0.001, N=75) and with hypercholesterolemia (+7.33 cm3, p=0.039, N=508). Manual EAT volumes measured by two experienced readers on 141 scans were highly correlated (R=0.984, p<0.001) but presented a significant difference of 4.35 cm3 (p<0.001). On these 141 scans, DL quantifications were highly correlated to both experts' measurements (R=0.973, p<0.001; R=0.979, p<0.001) with significant and non-significant bias for readers 1 and 2 (5.19 cm3, p<0.001; 0.84 cm3, p=0.26), respectively. In 70 subjects, EAT progression quantified by DL correlated strongly with EAT progression measured by the expert reader (R=0.905, p<0.001) with no significant bias (0.64 cm3, p=0.43), and was related to increased non-calcified plaque burden quantified from coronary CT angiography (5.7% vs 1.8%, p=0.026).

Automated vs. manual EAT volume

Conclusion

Deep learning allows rapid, robust and fully automated quantification of EAT from calcium scoring CT. It performs as an expert reader and can be implemented for routine cardiovascular risk assessment.

Acknowledgement/Funding

1R01HL133616/01EX1012B/Adelson Medical Research Foundation

3258Perivascular fat attenuation index stratifies the cardiac risk associated with high-risk plaque features on coronary computed tomography angiography

Background

Qualitative high-risk plaque (HRP) features detected on coronary computed tomography angiography (CCTA) are associated with increased risk of adverse cardiac events. Coronary inflammation is a key determinant of plaque progression and instability and can now be captured on routine CCTA as inflammation-induced changes in perivascular adipose tissue composition, detectable by the perivascular Fat Attenuation Index (FAI).

Purpose

To explore the ability of perivascular FAI phenotyping to stratify the cardiac risk associated with the presence of adverse plaque morphology on routine CCTA.

Methods

This was a post-hoc analysis of the CRISP-CT (Cardiovascular RISk Prediction using Computed Tomography) study, which involved 3912 patients (mean age 55.7±13.7 years, 41.1% females) undergoing clinically-indicated CCTA in two centres (Erlangen, Germany & Cleveland, USA). Perivascular FAI mapping was performed around the proximal 10–50 mm of the right coronary artery and defined as the weighted mean attenuation of the perivascular adipose tissue, as previously validated. HRP features were defined as the presence of ≥1 of the following: positive remodelling, low-attenuation plaque, spotty calcification or napkin-ring sign (A). Cox regression models (adjusted for age, sex, epicardial fat volume and coronary artery disease [≥50% stenosis]) were used to explore the association between FAI, HRP, and future major adverse cardiac events (MACE: defined as the composite of cardiac mortality and non-fatal myocardial infarction).

Results

At baseline the prevalence of HRP and high FAI (≥-70.1 Hounsfield Units, as previously validated) was 23.6% (n=923) and 24.3% (n=952) respectively. Over a median follow-up period of 5.6 years (25th-75th percentile: 4.0–7.0 years) there were 91 confirmed MACE. Patients with both HRP features (HRP+) and high FAI (FAI+) had a 6.3-fold (P<0.001) higher adjusted risk of MACE compared to individuals with neither of these risk features (HRP-/FAI-) (B). Furthermore, patients without HRP features but with high FAI (HRP-/FAI+) had a 4.9-fold (P<0.001) higher adjusted risk of MACE compared to the reference (HRP-/FAI-) group. However, among patients with low FAI, there was no significant difference in the prospective risk of MACE between HRP+ and HRP- patients (P=0.87).

Conclusion

FAI is associated with an increased risk of adverse events in both patients with and without high-risk plaques, highlighting coronary inflammation as a major determinant of plaque vulnerability, independent of adverse plaque morphology. Non-invasive characterization of coronary inflammation using CCTA-derived FAI can improve risk stratification by supplementing the traditional anatomical assessment of the coronary vasculature with a functional marker of disease activity.

Acknowledgement/Funding

British Heart Foundation, National Institute of Health Research, Oxford Biomedical Research Centre

6114Indications, procedural parameters, complications and consequences of fractional flow reserve measurements in a multicenter cohort

Background

Determination of the Fractional Flow Reserve (FFR) has become part of routine clinical practice. Contemporary clinical use, consequences as well as complications in consecutive, large cohorts have not been thoroughly investigated. We report the results of the prospective Fractional Flow Reserve Fax Registry F (FR2) conducted in Germany.

Purpose

To systematically analyze indications, procedural parameters, complications and consequences of intracoronary pressure measurements in a large contemporary cohort.

Methods

Data of 2000 consecutive patients undergoing clinically indicated FFR, iFR or pd/pa measurements in 8 interventional centres in Germany were prospectively collected in a systematic fashion. Data included basic patient characteristics, procedural aspects of intracoronary pressure measurements, associated complications, visual stenosis degree, measurement results and treatment decisions.

Results

Mean patient age was 68±11 years, 73% of patients were male. Of all patients, 300 patients (15%) had an acute coronary syndrome (STEMI: 9; NSTEMI: 94; unstable angina: 197) and 1002 patients (50%) had undergone previous revascularization. A mean of 1.7±0.9 measurements were performed per patient, for which an average of 1.02 pressure wires were required (more than 1 wire in 64 patients). For all 3373 interrogated lesions, median stenosis degree was 60%. Vasodilator-free measurements were performed in 415/3373 cases (12%, iFR: 346; pd/pa: 69). For vasodilation, i.v. adenosine was used in 396 cases (13%), i.c. adenosine in 2628 cases (87%), and other drugs in 10 cases (0.3%). Measurement was performed before potential revascularization in 3232 cases (96%) and during or following PCI in 141 cases. In 2958 lesions analyzed by FFR, mean FFR was 0.87, with 588 FFR measurements ≤0.80 (19.8%). Median FFR values were higher for i.c than i.v. adenosine administration (0.88 vs. 0.84), but not significantly different after adjustment for stenosis degree. In 735 cases (20.2%), intracoronary pressure measurement was followed by revascularization measures, while in 2637 cases (79.8%), no revascularization or no further revascularization was performed. In 36 out of 117 stenoses visually estimated to be ≥90%, revascularization was deferred following pressure measurement (31%). In 75 out of 2958 lesions analyzed by FFR, revascularization was performed even though FFR was >0.80 (3%). Severe complications (vessel dissection or occlusion) occurred in 5 out of 2000 patients as a consequence of intracoronary pressure measurement, resulting in death of 1 patient.

Conclusion

In clinical practice, the majority of intracoronary pressure measurements are performed in stenoses of intermediate angiographic severity and revascularization is deferred in approximately 80% of lesions. Vasodilator-free measurements are infrequent and route of adenosine administration has no effect on results. Complication rate is low but not negligible.

Acknowledgement/Funding

Abbott Vascular

P6164High level of EPA is associated with lower perivascular coronary attenuation as measured by coronary CTA

Introduction

Pericoronary adipose tissue (PCAT) composition has been recently shown to be a potential novel marker of coronary inflammation with higher PCAT attenuation shown to indicate increased cardiac mortality. Polyunsaturated fatty acids (PUFAs), especially Omega-3 fatty acids (n3), are thought to alter inflammatory response and intake of high dose Eicosapentaenoic acid (EPA, C20_5 n3) was shown to decrease mortality, however exact pathophysiological mechanisms are unclear. Therefore, we sought to determine whether blood levels of PUFAs are associated with differences in pericoronary fat attenuation.

Methods

In 64 symptomatic patients with intermediate pretest-likelihood for coronary artery disease presenting with atypical angina, coronary CTA was performed. PCAT attenuation was measured in Hounsfield Units (HU) around the proximal 40mm of the right coronary artery (RCA) using semi-automated software. Erythrocyte membrane fatty acid composition (in percentage) was analyzed with a standardized analytical methodology, displaying a variety of fatty acids including n-3 fatty acids using gas chromatography.

Results

Patients were divided into two groups (each n=32) using the median PCAT attenuation of −78.1 Hounsfield units (HU), resulting in one group with low (−95.58 to −78.17 HU) and one with high (−78.06 to −62.92 HU) PCAT attenuation. Among both groups, no differences were seen in age, sex, BMI, traditional cardiovascular risk factors or the number of cardiovascular risk factors (all p>0.05). In univariate analysis, significantly higher values of EPA (1.00% [0.78; 1.26] vs. 0.78% [0.63; 0.99]; p=0.02) were seen in patients with lower PCAT attenuation. All other fatty acids showed no significant differences (all p>0.05). Moreover, a significant negative correlation was seen between PCAT attenuation and EPA (Pearson correlation coefficient −0.38; p=0.002), but not for age, sex, BMI or number of cardiovascular risk factors (all p>0.1). Multivariable linear regression analysis confirmed this association and showed a significant inverse association of EPA to PCAT attenuation (β=−0.31, p=0.017), independent of age, gender, BMI and number of CV risk factors (all p>0.1).

Conclusion

High levels of EPA are associated with lower PCAT attenuation on coronary CTA indicating different composition of pericoronary adipose tissue potentially caused by a lesser degree of coronary inflammation.

P815Tako-Tsubo Cardiomyopathy: clinical correlations of typical and atypical left ventricular contraction patterns

Background

Takotsubo cardiomyopathy (TCM) is diagnosed in 1–2% of all patients presenting with acute coronary syndrome (ACS). Clinical differences in individuals presenting with either the typical (apical) or atypical (midventricular, basal and focal) localization of left ventricular contraction abnormalities are not well understood.

Methods

We retrospectively analyzed 102 consecutive patients diagnosed with TCM based on clinical presentation, coronary angiography, and laevocardiography. Patients with different contraction abnormality patterns were compared regarding sex, clinical presentation, trigger for TCM, LV-function and LV enddiastolic pressure (LVEDP) as well as coronary artery disease.

Results

Of all TCM 102 patients, 69 (68%) presented with the typical pattern of apical contraction abnormality. 33 patients (32%) had an atypical pattern: 22 (22%) with the midventricular type, 2 (2%) with the basal type and 9 (9%) with a focal type. There was no difference in sex distribution among the different types of TCM (female: typical 86% vs atypical 85% p=0.83).

Presentation as a ST-elevation ACS was more common in patients with atypical compared to typical TCM (21% vs. 17%; p=0.85), but without statistical significance. Cardiogenic shock (typical 6% vs atypical 3%; p=0.91) as well as intra-hospital death (typical 3% vs atypical 3%; p=0.56) were rare in both types.

A trigger was not more common in patients with typical TCM (58% vs atypical 55%; p=0.91). The trigger was more often physical in typical (73%) and atypical TCM (78%) than psychological, but the distribution did not differ between the two types (p=0.92).

83.6% of the patients showed an impaired LV-EF. Median LV-EF in patients with typical TCM (35% (IQR 25–40)) tended to be lower than in patients with atypical TCM (40% (IQR 25–40); p=0.63; LV-EF ≤30% typical TCM 45% vs. atypical TCM 39%; p=0.75). In 72% (73/102) of the patients the LVEDP was determined. In 75% (55/73) the LVEDP was elevated (>15mmHg). LVEDP tended to be more often elevated in patients with typical TCM (83% vs. atypical 52%; p=0.11).

Extent of coronary artery disease did not differ in the different types of TCM. Coronary stenosis >50% was rare (typical TCM 20% vs atypical TCM 9%; p=0.26), whereas exclusion of coronary artery disease was common in both types (typical TCM 71%; atypical TCM 76%; p=0.79).

Conclusion

While an apical contraction anomaly is the most common type of presentation in TCM, atypical contraction patterns are found in 32% of the patients. Overall, psychological triggers are not found as frequently in TCM as previously described. Patients with typical and atypical TCM do not differ in clinical presentation, LV-EF, LVEDP and extent of coronary artery disease.

CT-derived left ventricular global strain: a head-to-head comparison with speckle tracking echocardiography

We assessed CT-derived left ventricular strain in a cohort of patients referred for transcatheter aortic valve implantation (TAVI) and validated it against 2 dimensional speckle tracking echocardiography as the gold standard. 65 consecutive patients with symptomatic aortic valve stenosis referred for CT imaging prior to TAVI were included in this analysis. For all patients, retrospectively ECG-gated multi-phase functional CT data sets acquired with identical reconstruction parameters were available. All data sets were acquired using a third generation dual source system. In all patients, multiphase reconstructions in increments of 10% of the cardiac cycle were rendered (slice thickness 0.75, increment 0.5 mm, medium smooth reconstruction kernel) and transferred to a dedicated workstation (Ziostation2, Ziosoft Inc., Tokyo, Japan). Additional functional reconstructions for dynamic assessment and quantification of strain were processed. Multiplanar reconstructions (MPR) of the left ventricle similar to standard echocardiographic 4, 2 and apical 3 chamber views were rendered in CT. Similar to echocardiographic longitudinal strain, the perimeter of the left ventricle was manually traced within the myocardium and peak maximal shortening as a parameter representing longitudinal strain was calculated for each view and averaged to obtain a marker for global longitudinal strain (CT perimeter-derived strain). Furthermore, for quantification of 3-dimensional strain, endocardial and epicardial borders of myocardium were marked in six short axis views and peak maximum 3- dimensional strain of the myocardium was calculated in standard six basal, six mid and four apical segments. 3-dimensional strain values of the 16 standard segments as well as perimeter-derived strain values in the three standard windows were averaged to obtain global strain. Echocardiography was performed in all patients before CT data acquisition. Digital loops were acquired from three apical views (four-, two-, and three chamber views). For assessment of 2 dimensional global longitudinal strain (GLS), recordings were processed with acoustic-tracking software allowing offline semiautomated speckle-based strain analyses. The mean age of all 65 patients was 81 ± 5 years. The mean echocardiographic ejection fraction and mean echocardiographic GLS were 50 ± 12% and -13.6 ± 4.5%, respectively. The mean CT-derived peak 3-dimensional global strain and mean peak strain derived by perimeter was 43.2 ± 13.5% and -11.2 ± 3.5%, respectively. Both CTderived global 3D-strain and perimeter derived strain showed a significant correlation to GLS derived by echocardiography (r = -0.8, p < 0.0001 for 3D strain and r = 0.71, p < 0.0001 for perimeter-derived strain). Bland-Altman analysis showed a systematic underestimation (i. e. worse strain values) of CT perimeter-derived strain compared to GLS by echocardiography (mean difference -2.4% with 95% limits of agreement between 4% to -9%). ROC Curve analysis assuming a normal GLS when less than -18% showed that a CT-derived peak 3-dimensional global strain cut-off-value of 45% has a sensitivity of 91% and a specificity of 60% for detecting normal left ventricular strain (AUC 0.81, p = 0.001). For CT perimeter-derived strain, a cut-off value of -12%-assuming a normal echocardiographic GLS when less than -18%-achieved a sensitivity of 82% and a specificity of 61% (AUC of 0.82, p = 0.001) for detecting abnormal left ventricular strain. Using dedicated software, assessment of CT-derived left ventricular strain is feasible and comparable to strain derived by echocardiographic 2 dimensional speckle tracking.

Leaflet thrombosis following transcatheter aortic valve implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is increasingly being offered to high-risk patients with symptomatic aortic valve stenosis. Recent reports have suggested a high incidence of subclinical leaflet thrombosis following bioprosthestic aortic valve replacement. We report the frequency and clinical presentation of leaflet thrombosis identified by cardiac CT in patients referred for follow-up contrast enhanced CT angiography following TAVI.

METHODS

91 consecutive patients referred for follow-up contrast-enhanced CT angiography following TAVI were screened for inclusion in this analysis. Out of these, 13 patients were excluded. All CT examinations were performed using a 2nd or a 3rd generation dual-source system (Somatom Definition Flash/Force, Forchheim, Germany). In all patients, retrospectively ECG-gated spiral acquisition with tube modulation was performed to allow for assessment of leaflet motion. All prostheses were analyzed for presence of leaflet thrombosis defined as hypo-attenuated leaflet thickening with or without leaflet restriction. Post-procedural antithrombotic regimen as well as symptom status was documented in all patients.

RESULTS

78 consecutive patients (35 males, 81 ± 4 years) were analyzed. TAVI had been performed in all patients (76 transfemoral access, 2 transapical access) with either balloon-expandable prostheses (4 Sapien XT, 64 Sapien 3) or self-expandable prostheses (5 SJM Portico, 5 Symetis Acurate). Follow-up CT angiography was performed at a median of 4 months following index procedure (Interquartile range 1 month). Leaflet thrombosis was detected in 18 patients (23%, 14 Sapien 3, 1 Sapien XT, 2 SJM Portico, 1 Symetis Acurate). In patients with leaflet thickening on CT, only 11% were on either oral anticoagulation or new oral anticoagulants versus 50% for patients with no leaflet thickening (p 0.002). In patients with leaflet thrombosis, 3 leaflets were affected in 5 patients, 2 leaflets in 5 patients and in 8 patient only 1 leaflet was affected. Clinical symptoms (angina, dyspnea or both) were reported in 2/18 patients with leaflet thrombosis (11%) and in both patients a significant increase of the mean echocardiographic gradient over the prosthesis was documented. The peak and mean echocardiographic gradients obtained at the day of CT examination was significantly higher in symptomatic patients versus asymptomatic patients (peak 46 ± 7 vs. 23 ± 11 mmHg, mean 29 ± 7 vs. 12 ± 6 mmHg, p = 0.01 and 0.002, respectively). Follow-up CT was available for 4 patients with complete resolution of the hypo-attenuated leaflet thickening following treatment.

CONCLUSION

Leaflet thrombosis following TAVI is a relatively frequent finding in patients referred for contrast enhanced CT angiography following TAVI. In the majority of patients it follows a subclinical course and is substantially more frequent in individuals who are not on oral anticoagulation. However, in patients with relevant increase in prosthetic gradients, symptomatic presentations are possible.

Recurrent shock and pulmonary edema due to acetazolamide medication after cataract surgery

OBJECTIVE

We report a patient with recurrent shock and transient non-cardiogenic pulmonary edema within a period of two months - every time occurring after cataract surgery and a single oral dose of standard post-operative medication with acetazolamide.

DATA SOURCES

Records of the intensive care unit, review of the literature.

CONCLUSIONS

This case demonstrates a rare but severe side effect of acetazolamide. We also present a review of the literature to raise the awareness of health care providers for this special form of non-cardiogenic pulmonary edema.