Journal of Cardiovascular Computed Tomography - Articles in Press

Society News - Uncorrected Proof

2010-09-07

‘Porcelain Heart’ Cardiomyopathy Secondary to Hyperparathyroidism: Radiographic, Echocardiographic and Cardiac CT Appearances - Accepted Manuscript

2010-09-02

What is the Optimal Number of Readers Needed to Achieve High Diagnostic Accuracy in Coronary Computed Tomographic Angiography? A Comparison of Alternate Reader Combinations - Accepted Manuscript

2010-09-02

Abstract: Background: Coronary computed tomographic angiography (CCTA) possesses high accuracy to detect coronary artery disease (CAD), although studies have reported differences in diagnostic performance. Prior trials utilized different numbers of interpreters, for which the optimal number to detect CAD is unknown.Objective: We compared the diagnostic performance of 1, 2, 3 and 5 randomly selected interpreters for CCTA.Methods: We evaluated 50 patients randomly selected from 2 multicenter studies with both 64-detector CCTA and invasive quantitative coronary angiography (QCA). Five blinded, experienced readers independently interpreted CCTA, and assessed for obstructive CAD (≥50% stenosis) and high-risk CAD (left main, proximal left anterior descending, or 3-vessel stenoses). A core lab performed QCA. For each patient, different random combinations of readers were selected; the accuracy of 1, 2, and 5 readers was compared to 3 readers.Results: Obstructive and high-risk CAD was observed in 20/50 (40%) and 6/50 (12%) of patients, respectively. Using combinations of 1, 2, 3, or 5 readers, there was a range of per-patient diagnostic performance (sensitivity 100% each; specificity 67-90%; accuracy 80-94%, p=NS), per-segment diagnostic performance (sensitivity 67-83%; specificity 87-93%; accuracy 87-92%, p<0.001 for 1 vs. 3 and 2 vs. 3 readers), and detection of high-risk CAD (sensitivity 83-100%; specificity 73-80%; accuracy 76-82%, p=NS). The highest diagnostic accuracy was observed using 3 readers for each comparison.Conclusion: The diagnostic performance of CCTA to detect obstructive or high-risk CAD is generally high irrespective of the number of readers. Consensus interpretation by 3 or more readers provides the highest diagnostic accuracy.

Coronary calcium test phantom containing true CaHA microspheres for evaluation of advanced CT calcium scoring methods - Uncorrected Proof

Ben A. Arnold, Matthew J. Budoff, Janis Child, Ping Xiang, Song S. Mao — 2010-08-27

Background: Test phantoms with simulated micro-calcifications of true calcium hydroxyapatite (CaHA) density were not available to validate advanced calcium scoring methods or plaque density measurements.Objectives: We evaluated a coronary calcium scoring (CCS) test phantom containing very small CaHA microspheres and validated a new scoring method for measurements of plaque densities.Methods: The semianthropomorphic CCS phantom was constructed with CaHA microspheres (volumes, 0.05–3.1 mm3) with the approximate density of biologic calcifications. QRM and CCS phantoms were scored with a new calibrated and automated calcium scoring method (N-vivo; Image Analysis). The densities of the microspheres and 609 individual patient plaques were measured.Results: The range of measured densities of the CaHA microspheres was approximately equivalent to that measured in the patient coronary calcifications. The smallest microspheres scored with the calibrated/automated and the Agatston methods had volumes of 0.075 mm3 and 0.27 mm3, respectively. The standard deviations of the mass scores of the microspheres ranged from 0.02 to 0.17 mg with regression slope of 0.962 and R2 = 0.997. The relationship of measured density to measured mass of the patient plaques was similar to that of the microspheres, suggesting that vascular calcifications are CaHA density.Conclusions: The CaHA microspheres of the CCS test phantom were found to be representative in density and size of coronary calcifications. The measurements show that CT calcium scoring underestimates plaque density and greatly overestimates volume. The heterogeneity of calcium concentration densities measured in the patient plaques was due largely to CT scanner measurement errors.

Pre-procedural planning for percutaneous atrial septal defect closure: Transesophageal echocardiography compared with cardiac computed tomographic angiography - Uncorrected Proof

2010-08-19

Background: The safety and efficacy of percutaneous closure of atrial septal defects (ASDs) is determined by several variables, including defect size, presence of adequate rim tissue, relationship to other cardiac structures, and associated congenital anomalies.Objective: We sought to determine the accuracy of computed tomographic angiography (CTA) in predicting a defect’s size compared with pre-procedural transesophageal echocardiography (TEE) and to the current “gold standard” balloon sizing by intracardiac echocardiography (ICE).Methods: Thirty-five consecutive patients referred for possible percutaneous closure of suspected secundum ASD were evaluated with gated multislice CTA after initial TEE screening. Axial and sagittal image planes of the ASD from the CTA multiplanar reformation (MPR) images were used to measure the defect size and surface area.Results: Of the 35 patients with secundum-type ASDs, 5 subjects had disqualifying anatomy by CTA and 2 had an unsuccessful closure, resulting in a procedural success rate of 93%. Measurement of defect area by gated MPR images provided the strongest correlate to ICE balloon size. In large ASDs, TEE was less well correlated to the maximum defect size and identification of the inferior/inferoposterior rims than CTA.Conclusions: Cardiac CTA is an accurate and useful technique for pre-procedural assessment of ASDs and may be superior to conventional TEE in large defects that could have deficient inferior rims.

Periprocedural safety of 64-detector row coronary computed tomographic angiography: Results from the prospective multicenter ACCURACY trial - Uncorrected Proof

2010-08-19

Background: Coronary computed tomographic angiography (CCTA) requires iodinated contrast and often atrioventricular nodal blocking agents and nitroglycerin for heart rate lowering and coronary vasodilation, respectively. To date, the periprocedural safety of CCTA is unknown.Objectives: The purpose of this study was to evaluate the periprocedural safety of CCTA.Methods: We prospectively evaluated 232 patients with symptomatic chest pain without preexisting renal insufficiency at 16 sites who underwent CCTA as part of the Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography (ACCURACY) trial. Patients received iodinated contrast, β-blockers, and nitroglycerin as part of a predefined CCTA protocol. We assessed the rates of adverse events (AEs) related to these agents.Results: As measured by serum creatinine and creatinine clearance, no significant change was observed in renal function from baseline (1.00 ± 0.19 mg/dL; modification of diet in renal disease [lsqb]MDRD[rsqb]: 76.91 ± 17.96 mL/min/1.73 m2) to 48 hours (1.0 ± 0.2 mg/dL; P = 1.00; MDRD change: 0.2 ± 12.4 mL/min/1.73 m2; P = 0.83) or at 30 days (1.0 ± 0.2 mg/dL; P = 0.52; MDRD change: −0.9 ± 16.9 mL/min/1.73 m2; P = 0.77). Mean systolic blood pressure decreased from baseline (133 ± 19 mm Hg) at 1 hour (125 ± 17 mm Hg; P < 0.001) and rebounded at 48 hours (133 ± 17 mm Hg). Mean heart rate decreased from baseline (65 ± 10 beats/min) at 1 hour (60 ± 7 beats/min) but rose at 48 hours (69 ± 11 beats/min; P < 0.001. All patients were asymptomatic from baseline to follow-up.Conclusions: The performance of CCTA is safe with low rates of AEs.

From histology to computed tomography: Every picture tells a story - Corrected Proof

Andrew Farb — 2010-08-09

Deriving a sequence of pathophysiologic events that are responsible for a disease entity is a well-established pathway to advancing medical diagnosis and treatment. Our current understanding of the underlying mechanisms of atherosclerotic plaque progression, plaque disruption, and coronary thrombosis rests on seminal observations by cardiovascular pathologists, beginning in the 19th century, with work accelerating in the past 2 decades of the 20th century. Through detailed histologic studies, pathologists outlined a sequence of likely morphologic changes that result in plaque progression and are associated with clinical events such as acute myocardial infarction (MI) and sudden coronary death. Stary et al proposed an important and useful classification scheme focused on lipid accumulation within an expanding extracellular matrix plaque forming lipids pools (plaque types I–III) with more advanced plaques characterized by lipids cores and variable amounts of fibrous or calcified tissue (types IV, V, VII, and VIII); plaques with surface defects, hematoma, or thrombosis were denoted as type VI.

President’s Page: The way ahead - Corrected Proof

Matthew Budoff — 2010-08-09

Dear Colleagues, The Society of Cardiovascular Computed Tomography (SCCT) has a well-established annual scientific meeting with almost 1,000 attendees, has a membership base of nearly 3,500, and has a dedicated journal. This is fairly standard for large societies, but the incredible point to remember is that the Society is only 4 years old. SCCT forefathers (literally four fathers: Achenbach, Poon, Berman, and Ziffer) have paved the way for us to do great things, laying a strong foundation for us to build on.

Right aortic arch and its variants - Uncorrected Proof

Jeffrey P. Kanne, J. David Godwin — 2010-07-22

Abstract: A number of congenital anomalies of the aortic arch complex can occur, ranging from asymptomatic normal variations in arch vessel branch pattern to symptomatic vascular rings, stenoses, and arch interruptions with a frequency ranging from 0.5% to 3.0%. A right aortic arch is present in 0.1% of the population and can occur in isolation or be associated with congenital heart disease. Patients may present at any age with signs and symptoms of airway or esophageal compression, heart failure, or abnormal chest imaging studies. This pictorial essay will show the computed tomography and appearances of congenital variations of the right aortic arch and use Edwards’ hypothetical embryonic double aortic arch model to explain the cause of some of these variants.

Keeping score of coronary artery disease using cardiac CT angiography: Can reasonable experts agree? - Corrected Proof

Todd C. Villines — 2010-07-21

The most frequent indication for performing cardiac computed tomographic angiography (CCTA) is to exclude the presence of potentially flow-limiting coronary artery disease (CAD) in appropriately selected symptomatic patients. This binary diagnostic approach (presence or absence of obstructive CAD) is clinically efficient and grounded on data from more than 50 studies that showed impressive accuracy of modern CCTA compared with invasive coronary angiography. Compared with other widely available noninvasive tests to assess for significant CAD, such as stress nuclear myocardial perfusion imaging (MPI) and stress echocardiography, CCTA is the most sensitive and specific noninvasive test available to clinicians. In contrast to stress nuclear MPI and stress echocardiography, CCTA often depicts nonobstructive, subclinical coronary atherosclerosis. Until recently, little was known about the prognostic information that may be obtained from the detailed anatomic assessment of CAD visualized with the use of CCTA.

Cardiac Imaging: A Multimodality Approach, first edition - Corrected Proof

Thanjavur Bragadeesh — 2010-07-20

The English edition published in 2009 is a revised translation of the German edition first published in 2007. The book encompasses 289 pages, 13 chapters, and 607 illustrations from 27 contributors, and it provides a comprehensive review of cardiac imaging. The contents of the book are divided into 2 sections: the first section is on imaging modalities, and the second section deals with imaging in specific cardiac disease states. The chapters are succinct, yet rich in detail with well laid-out figures and tables that are easy to read.

Ex vivo evaluation of coronary atherosclerotic plaques: Characterization with dual-source CT in comparison with histopathology - Uncorrected Proof

2010-06-07

Background: Identification and differentiation of coronary atherosclerotic plaques may improve risk stratification for incident coronary events.Objective: We investigated the ability of dual-source computed tomography (CT) to depict and characterize atherosclerotic coronary plaques.Methods: Contrast-enhanced CT was performed in 25 human heart specimens with a total of 322 histologically determined plaques. Coronary plaques were classified on CT as (1) noncalcified, mixed, or calcified and (2) by CT attenuation values. Atherosclerotic plaques were histopathologically characterized according to the Stary classification.Results: CT detected 79% (245/322) of all plaques. Lesions missed by CT were generally early lesions, type I (n = 31), type II (n = 38), or type III (n = 8), according to Stary. CT detected 29% of early (Stary I–III) and 100% of advanced (Stary IV–VIII) plaques. Plaque classification as noncalcified was sensitive (100%) and specific (72%) for early, whereas classification as mixed/calcified was sensitive (92%, 89%) and specific (100%) for advanced plaques. Calcified plaques on CT were detected with high sensitivity (80%) and specificity (95%). Other subtypes were not distinguishable with CT according to the presence or absence of calcification. CT density was significantly higher for advanced (306 ± 470 HU) than for early (42 ± 14 HU; P < 0.01) plaques. The mean CT density value of type VII plaques (512 ± 349 HU) was significantly higher than those of other plaques (34–101 HU; P < 0.001).Conclusions: CT reliably depicts advanced coronary plaques and allows for the differentiation between early and advanced plaques.

Coronary artery to main pulmonary artery fistulae via a Vieussens' arterial ring - Corrected Proof

Mohammad I. Hirzallah, Eric Horlick, Leon Zelovitzky — 2010-06-07

Abstract: Coronary artery fistulae are rare abnormal communications between a coronary artery and a cardiac chamber or a great vessel which may shunt blood flow away from the myocardial capillary network. Vieussens arterial ring is usually described as a collateral pathway between the left anterior descending and right coronary arteries, pathology of Vieussens arterial ring are exceedingly rare. We present a case of a complex coronary artery to pulmonary artery fistula via an aneurysmal Vieussens arterial ring, with emphasis on computerized tomography and invasive angiography findings and management.

Interobserver variations of plaque severity score and segment stenosis score in coronary arteries using 64 slice multidetector computed tomography: A substudy of the ACCURACY trial - Corrected Proof

2010-06-07

Background: Assessing the severity of coronary plaque for the risk stratification and management of coronary artery disease is important. Multidetector computed tomography has been shown to be a useful tool to measure coronary plaque; however, interreader variability is a concern.Objective: We measured interobserver variations of plaque severity score (PSS) and segment stenosis score (SSS) as measured by the total plaque severity score (TPS) and total segment stenosis score (TSS).Methods: Cardiac CT scans (n = 221) of the ACCURACY trial were interpreted by 3 different readers blinded to patient characteristics. PSS (mild, 1; moderate, 2; and severe, 3) and SSS (stenosis 1%–29%, 1; 30%–49%, 2; 50%–69%, 3; and ≥70%, 4) were calculated with the 15-segment American Heart Association model. TPS and TSS were determined by summing the segments for each interpreter. TPS and TSS were compared for correlation and variation among any 2 of the 3 readers.Results: A highly significant correlation was observed among any 2 of the 3 readers for both TPS and TSS. For TPS, the r = 0.91, 0.93, 0.94 (P < 0.001) for A vs B, B vs C, A vs C, respectively, and for TSS, r = 0.91, 0.92, 0.93 (P < 0.001) for A vs B, B vs C, A vs C, respectively. On Bland Altman plot, the mean difference between the scores of any 2 readers was 3.33 ± 3.93, 1.65 ± 2.88, and 1.68 ± 2.92 for TPS and 4.19 ± 4.73, 2.54 ± 4.02, and 1.65 ± 3.18 for TSS.Conclusion: Semiquantitative measures of coronary plaque burden, including the TPS and TSS, can be determined with a high degree of interobserver agreement, suggesting their potential role as tools to aid in the assessment of coronary heart disease.

Ventricular septal rupture and right ventricular intramyocardial dissection secondary to acute inferior myocardial infarction - Corrected Proof

Márcio Sommer Bittencourt, Martin Seltmann, Gerd Muschiol, Stephan Achenbach — 2010-06-07

Abstract: A 61-year-old female patient presented with sub acute myocardial infarction with an occluded right coronary artery on invasive evaluation and a ventricular septal rupture on echocardiogram. Cardiac computed tomography (CT) was performed to better define the septal anatomy. As the anatomy on cardiac CT was considered unfavorable for percutaneous intervention, the patient underwent successful surgical repair.

Tissue characterization of a papillary fibroelastoma on the aortic valve by contrast-enhanced 320-detector row computed tomography - Corrected Proof

2010-06-07

Abstract: A 56-year-old woman with a mass on the aortic valve as seen on echocardiogram underwent pre-operative contrast-enhanced cardiac computed tomography prior to removal. The mass was confirmed to be a papillary fibroelastoma histologically. Spatial co-registration between the contrast-enhanced CT cross-sectional images of the mass and the Movat's pentachrome staining revealed an association of elastic fibers with higher levels of attenuation and collagen fibers with lower levels of attenuation on CT.