Journal of cardiovascular computed tomography最新文献

Background: Percutaneous coronary intervention (PCI) is often complicated by periprocedural myocardial injury (PMI), resulting in poor clinical outcomes. Therefore, it is important to detect plaque that causes myocardial injury before PCI and clarify the cause of the poor outcomes. We aimed to investigate the relationship between PMI and coronary plaque morphology and plaque volume determined using coronary computed tomography angiography (CCTA) in patients with chronic coronary syndrome (CCS).

Methods: Eighty-nine patients with CCS underwent elective PCI and CCTA before PCI. Plaque morphology and volume of the target and total lesions were assessed and stratified into calcified, fibrous, fibrous fatty, and low-attenuation plaque (LAP). High-risk plaque (HRP) on CCTA was defined as positive remodeling, spotty calcification, and the napkin-ring sign.

Results: Thirty-two and fifty-seven patients were classified into the PMI and non-PMI groups, respectively. The total plaque (TP) and LAP volumes of the target lesions were significantly higher in the PMI group than in the non-PMI group. The TP and LAP volumes of the target lesion on CCTA were significant independent predictors of PMI. Net reclassification and integrated discrimination improvement indices significantly improved when TP and LAP volumes were added to the reference model including clinical characteristics and HRP features. Moreover, the TP and LAP volumes of the total lesions per patient were significantly higher in the PMI group than in the non-PMI group.

Conclusion: In patients with CCS, quantitative plaque assessment using CCTA was associated with occurrence of PMI after PCI.

Background: Fractional flow reserve (FFR)-negative coronary lesions are usually managed medically. Lesion-specific plaque characterization and FFR changes over time remain elusive.

Aims: To assess disease progression in FFR-negative lesions over a two-year period using FFR derived from coronary CT angiography (CCTA) (FFRct) and to investigate whether FFR decline over a two-year period is associated with plaque characteristics.

Methods: This single-center prospective study included patients undergoing coronary angiography with one or more invasive intermediate lesions (FFR 0.81-0.90) in non-stented, non-culprit coronary arteries. Two years after the index procedure, patients underwent CCTA with FFRct and quantitative plaque analysis.

Results: We enrolled 131 patients (152 vessels). Two-year follow-up with FFRct and plaque analysis was available in 68 (52 ​%) patients (73 vessels). Compared to invasive FFR at baseline, FFRct at 2y follow-up was significantly lower (median difference -0.06) at vessel level analysis (p ​< ​0.001). FFR declined in 55 (75 ​%) lesions. The 35 study vessels with an FFRct≤0.80 ​at 2-year follow-up had higher total percent atheroma volume (PAV) (41 ​% vs. 23 ​%; p ​= ​0.002) and more high-risk plaque composition, including noncalcified PAV (30 ​% vs. 18 ​%; p ​= ​0.002), and low-attenuation PAV (1.1 ​% vs. 0.7 ​%; p ​= ​0.046) compared to vessels with an FFRct>0.80 (n ​= ​38). Rates of study vessel revascularization in the 131 patients were 6.9 ​% at 2 years and 15.1 ​% after 4.9 years of follow-up after index procedure.

Conclusions: Rates of coronary revascularization are substantial in patients with medically managed intermediate lesions. In this selected cohort, an FFRct ≤0.80 ​at two-year follow-up was associated with higher plaque burden and presence of high-risk plaque composition.

Background: Standard modifiable cardiovascular risk factors (SMuRF) have been identified for coronary artery disease (CAD) and targeted in primary prevention efforts, resulting in significantly improved outcomes. However, an increasing proportion of individuals present with ST elevation myocardial infarction (STEMI) in the absence of conventionally elevated levels of modifiable risk factors ("SMuRFless"), with significantly worse short-term outcomes. Culprit lesions of the left anterior descending artery (LAD) are more frequently implicated in SMuRFless STEMI patients than those with at least one risk factor. Differences in segmental-level coronary disease burden outside the acute setting in SMuRFless individuals are largely unknown.

Objectives: To characterise vessel-level coronary calcification, comparing SMuRFless to SMuRF≥1 participants.

Methods: Secondary analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) was completed. Coronary artery calcium score (CACS) was measured at baseline and follow-up (median 6.3 years).

Results: 6792 participants were included, with 20.6 ​% classified as SMuRFless. Among participants with detectable coronary calcification at baseline, SMuRFless participants had a significantly higher proportion of their total coronary calcium localised to the LAD, compared to SMuRF≥1 participants (74.2 ​% vs. 58.9 ​%, p ​< ​0.0001). This difference was most pronounced in individuals with higher baseline total CACS (CACS 100-400 Agatston units [AU] and CACS 401+), but attenuated after multivariable adjustment and was not statistically significant in best-subsets modelling. LAD CACS progressed in both groups during follow-up; however, annualised progression rates were similar between SMuRFless and SMuRF≥1 participants after adjustment for total coronary calcium progression and follow-up duration.

Conclusion: SMuRFless MESA participants had a higher unadjusted proportion of coronary calcification in the LAD compared SMuRF≥1 participants; however, this associated attenuated after multivariable adjustment. Further research is warranted to better understand the development of atherosclerotic CAD in SMuRFless individuals, and biological relevance and potentially different susceptibility at the epicardial segment level.

Background: Coronary computed tomography angiography (CCTA) offers excellent negative predictive value for coronary artery disease (CAD). In suspected single-vessel disease, invasive coronary angiography (ICA) could be simplified by deferring visualization of the normal coronary artery as identified on CCTA. This ultraselective ICA strategy might reduce procedure time, contrast use, and radiation exposure. This prospective study evaluated the potential benefits of this strategy.

Methods: This was a multicentre prospective registry in three hospitals in the Netherlands. The study included patients over 18 years undergoing ICA for suspected CAD limited to a single coronary artery on CCTA. The primary endpoint was accuracy of CCTA in predicting a normal coronary artery on ICA. Secondary endpoints included potential reductions in procedure time, radiation exposure, and contrast volume with an ultraselective ICA approach.

Results: In total 102 patients were included. CCTA was correct in predicting a non-obstructive coronary artery in all patients (100 ​%). By deferring visualization of the normal coronary, a CCTA-guided ICA would have led to a reduction in procedure time (49 ​% [IQR 41-59]; 6.64 ​min [5.07-8.68] vs 3.18 ​min [2.42-4.41]), radiation exposure (35 ​% [25-44]; 5.09 ​Gy ​cm² [3.11-7.88] vs 3.17 ​Gy ​cm² [1.96-5.08]), and the amount of contrast agent used (33 ​% [28-41]; 71 ​ml [60-84] vs 46 ​ml [37-55]).

Conclusions: This study demonstrated excellent performance of CCTA in predicting a normal coronary artery in patients with suspected single-vessel CAD. A CCTA-guided ultraselective ICA is feasible and offers substantial reductions in procedure time and materials, contrast agent volume and radiation exposure.

Background: Coronary CT angiography (CCTA) is a key non-invasive tool for evaluating coronary artery disease (CAD). While energy-integrating detector CT (EID-CT) offers high negative predictive value (NPV), its positive predictive value (PPV) is limited in heavily calcified vessels. Photon-counting detector CT (PCD-CT), with higher spatial resolution and reduced blooming, may enhance diagnostic performance. Current PCD-CT systems provide both standard-resolution (SR) and ultra-high-resolution (UHR) modes, but the clinical impact of these modes remains under investigation.

Objectives: To compare the diagnostic accuracy and image quality of SR-PCD-CT versus EID-CT in quantifying coronary stenosis, using quantitative coronary angiography (QCA) as reference.

Materials and methods: In this prospective, single-centre study, 21 patients (5 women, mean age 71.5 years) with suspected CAD underwent CCTA with both EID-CT and SR-PCD-CT prior to QCA. A total of 301 coronary segments were assessed for stenosis severity, with ≥50 ​% stenosis deemed significant. Image quality was graded using a 5-point scale.

Results: No significant differences in percentage diameter stenosis (%DS) were found between imaging techniques (p ​= ​0.20). Both EID-CT and SR-PCD-CT showed good agreement with QCA (AUC: PCD-CT 0.89, EID-CT 0.86). Specificity and NPV were high for both; sensitivity and PPV were moderate. SR-PCD-CT yielded higher image quality compared to EID-CT (p ​< ​0.001).

Conclusions: In standard resolution mode, PCD-CT offers excellent image quality for quantifying coronary stenosis at comparable diagnostic accuracy compared to EID-CT.

Background: Coronary artery disease (CAD) is common in patients with severe aortic stenosis (AS) and may impact transcatheter aortic valve replacement (TAVR) procedural and long-term outcomes. CT coronary angiography (CTA) and CT-derived fractional flow reserve (FFR_CT) are tools used to assess CAD. However, adoption in the TAVR population is hindered by safety concerns with nitroglycerin and beta-blockers. The safety, accuracy, and utility of CTA and FFR_CT optimised with these medications for TAVR have not been established.

Methods: This international, multi-center, prospective registry included severe AS patients referred for TAVR, assessed for CAD with CTA and FFR_CT. Patients all received nitroglycerin and beta-blockers as needed to optimise image quality. Severe ventricular dysfunction, recent syncope/heart failure, critical hemodynamics, or prior revascularization were excluded. Significant CAD was defined as CTA stenosis ≥50 ​% and FFR_CT≤0.75. Primary endpoint was per-patient sensitivity and negative predictive value (NPV) of CTA compared to invasive coronary angiography (ICA). Secondary endpoints included specificity and positive predictive value (PPV) of CTA and FFR_CT, safety, feasibility (non-evaluable rate), and the modelled potential of CTA ​+ ​FFR_CT to reduce pre-TAVR ICA.

Results: 327 patients (75.9 ​± ​9.7 years, 53 ​% male) underwent CTA. CTA was safe and well tolerated in nearly all patients, with transient hypotension in 4 (1.2 ​%). CTA was evaluable in 326 patients (99.7 ​%), with 9 (2.8 ​%) having a non-evaluable vessel. FFR_CT and ICA were performed in 110 (33.6 ​%) and 133 (40.7 ​%) patients, respectively. Per-patient sensitivity, specificity, NPV, and PPV of CTA were 100 ​%, 71.4 ​%, 100 ​%, and 75.9 ​% and per-vessel 82.7 ​%, 78.9 ​%, 92.3 ​%, and 59.9 ​%. FFR_CT improved specificity and PPV to 88.9 ​% and 88.0 ​% for per-patient and 95.1 ​% and 81.8 ​% for per-vessel analysis. Using a simulated triage model deferring ICA in patients with CTA <50 ​% or ≥50 ​% stenosis with FFR_CT >0.75, 267 patients (81.7 ​%) could potentially have avoided ICA.

Conclusion: Coronary CTA performed with nitroglycerin and selective use of beta-blockers is safe and effective for assessing CAD in stable severe AS patients. Combining CTA and FFR_CT enhances diagnostic accuracy, potentially reducing the need for invasive angiography and streamlining TAVR workup.