- Email: [email protected]
Cardiovascular Computed Tomography: Highlights of latest research presented at the 2014 Congress of the European Society of Cardiology
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 4 6 8 e4 7 2
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofCardiovascularCT.com
Congress Report
Cardiovascular Computed Tomography: Highlights of latest research presented at the 2014 Congress of the European Society of Cardiology Annika Schuhba¨ck MD*, Stephan Achenbach MD Department of Cardiology, University of Erlangen, Ulmenweg 18, 91054 Erlangen, Germany
article info Article history: Received 2 October 2014 Accepted 2 October 2014
Keywords: Cardiovascular Computed Tomography European Society of Cardiology Congress 2014
This year’s Congress of the European Society of Cardiology was held in Barcelona from August 30, 2014 to September 3, 2014, and brought together more than 30,000 delegates from around the world. Numerous abstracts pertinent to the field of cardiovascular CT were presented during the meeting. The abstracts highlighted the wide spectrum of clinical situations in which cardiovascular CT may help clinicians in noninvasive, invasive, and interventional cardiology. The following paragraphs list some of the most interesting contributions, although, by necessity, it remains incomplete.
1.
Coronary calcium scoring
Coronary calcium scoring (CCS) is mainly performed for cardiovascular risk assessment. Heo et al demonstrated in a single center study with 9715 asymptomatic patients
undergoing CCS and follow-up for 15 years that in 4864 patients with a baseline CCS of zero the “warranty period” regarding all-cause mortality was 12 years (event rate of less than 4 per 1000 patient years) both for men and women.1 Erbel et al investigated predictors of coronary artery calcification (CAC) progression in 3481 patients with a CCS at baseline and after 5 years.2 Systolic blood pressure, lipid lowering medication, diabetes, and present smoking were predictors for CAC progression beyond predictable levels both in men and women as well as younger age in men. The effect of standard or intensive lipid lowering therapy with pitavastatin with and/ or without eicosapentaenoic acid was addressed in a multicenter prospective randomized study by Urkawa et al in 228 patients from 27 Japanese centers who were examined at baseline and 1-year follow-up.3 They demonstrated that the CCS increased by more than 30% irrespective of a significant reduction of low-density lipoprotein cholesterol by
Conflict of interest: The authors report no conflicts of interest. * Corresponding author. E-mail address: [email protected] (A. Schuhba¨ck). 1934-5925/$ e see front matter ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved. http://dx.doi.org/10.1016/j.jcct.2014.10.001
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 4 6 8 e4 7 2
pitavastatin. There was no significant difference among patients with intensive or standard therapy with and/or without eicosapentaenoic acid. No cardiovascular event occurred during the follow-up period. Auscher et al reported an interesting observation in the immediate postinfarction period. They found that early aggressive lipid lowering therapy significantly increased dense calcium volume in patients.4 Marwan et al compared CAC measured by the Agatston method with the total coronary plaque burden in 1405 consecutive patients with suspected coronary artery disease (CAD) and demonstrated a very close and significant correlation (r ¼ 0.885, P < .0001). However, in 14% of patients without coronary calcium, noncalcified plaque was present.5
2.
Coronary atherosclerotic plaque detection
Besides CCS as a prognostic marker of future cardiovascular events, coronary plaque composition is a field of research regarding the prognostic value of coronary CT angiography (CTA). Low-attenuation plaque volume (density <30 HU), total plaque volume (density <150 HU), positive remodeling, and presence of a napkin ring sign were predictive for future events (all-cause death, myocardial infarction, and coronary revascularization >90 days after CTA) in a study of 1278 consecutive patients with suspected CAD over a median follow-up period of 5.6 years.6 Low-attenuation plaque (hazard ratio 3.36, 95% confidence interval (CI) 1.98e5.70, P < .0001) and total plaque volume (hazard ratio 2.69, 95% CI 1.88e3.84, P < .0001) showed additional prognostic impact regarding future events beyond stenosis assessment and calcium scoring. In another study by Otsuka et al, positive remodeling, low-attenuation plaque, and the “napkin ring sign” were also identified as predictors for future cardiovascular events in diabetic patients with a normal exercise-stress myocardial perfusion single-photon emission CT at baseline and a followup period of 3 years.7 The “napkin ring sign” was also identified to be more frequent in noneST-elevation acute coronary syndrome patients with a thrombolysis in myocardial infarction flow grade less than 2 in a study by Araki et al, who compared 53 patients with 56 patients without presence of the “napkin ring sign” in CTA before invasive coronary angiography (14 of 53 patients compared with 4 of 53 patients, P ¼ .0091).8 The “napkin ring sign” was associated with thin-cap fibroatheroma by optical coherence tomography. Ito et al studied 256 patients who underwent coronary CTA within 1 month after acute coronary syndrome and observed that patients with obstructive high-risk plaques (positive remodeling and/or low-attenuation plaque) had higher risk of cardiac events compared with patients with obstructive nonehighrisk plaques.9 Obstructive lesions in nonculprit vessels were found in 59% of patients, 63 of those (24%) had high-risk plaque features. Cardiac events were observed in 26 patients with 7 acute coronary syndromes and 22 late revascularizations. In patients with obstructive high-risk plaque, incidence was 17.5%, compared with 8.6% in patients with obstructive nonehigh-risk plaques and 6.42% in patients without obstructive plaque (P ¼ .038). Corresponding hazard ratios were 3.62 (95% CI 1.36e10.60, P ¼ .010) when patients with obstructive highrisk plaques were compared with patients without
469
obstructive plaque and 1.48 (95% CI 0.51e4.53, P ¼ .46) in patients with obstructive nonehigh-risk plaques compared with those without obstructive plaques. The possibility to noninvasively follow plaque burden is an interesting aspect of coronary CTA. Shin et al assessed the serial changes of vessel volume, lumen volume, plaque volume, and plaque burden in a multicenter, retrospective registry of 100 patients with suspected CAD and a median rescan interval of 3.4 years.10 They observed a mean annual plaque progression rate of 3.7 4.5% per year and found that the major predictors for plaque progression were age, hypertension, diabetes, and active smoking.
3. Coronary artery disease and stenosis detection The major clinical indication for coronary CTA is to detect or rule out significant CAD. Braber et al investigated its use in 276 asymptomatic male athletes aged 45 years or older with a low risk for CAD and normal exercise tolerance.11 In 15% of patients, relevant CAD (CCS 100 or luminal stenosis 50%) was observed. Diabetic patients are at risk for development of CAD. Nishio et al investigated 168 asymptomatic type 2 diabetic patients without known or suspected CAD and found that more than the half of the patients (54%) had moderate to severe CAD. During a follow-up period of mean 1062 372 days, 3 major cardiovascular events occurred. However, there was 1 stroke, 1 percutaneous intervention, and 1 unknown death.12 Prado Diaz et al evaluated coronary CTA in 104 patients scheduled for valve surgery and showed that invasive coronary angiography could be avoided in most patients (61.5%) and allowed cost reduction of 49.2% and complications associated with invasive coronary angiography.13 Myocardial bridging is a common phenomenon in cardiac CT. Uusitalo et al showed that only in one-third of patients with myocardial bridging, systolic constriction can be observed in invasive coronary angiography and that none of these patients had abnormal myocardial perfusion during pharmacological stress by positron emission tomography.14 Over the past several years, functional assessment of coronary artery stenoses by coronary CTA has been a major field of research and development. Fractional flow reserve based on coronary CTA data and computational fluid dynamics (FFRCT) seems to be a very promising approach. Gaur et al demonstrated accurate detection of individuals with or without ischemia in a cohort of 254 patients by using this method.15 The authors state that even in the presence of coronary calcification, accurate results were achieved independent of the analyzed vessel territory. For example, for the left anterior descending coronary artery, specificity of CTA to detect hemodynamically significant coronary artery stenoses increased from 43% to 86% in patients with a CCS 300 when FFRCT data were used as compared with CTA data alone and from 37% to 71% in patients with a CCS >300. Sensitivity decreased nonsignificantly from 84% to 76% in patients with a CCS 300 and remained unchanged (86%) in patients with a CCS >300. However, diagnostic accuracy was significantly improved both for patients with a CCS 300 (from 56% to 83%) and a CCS >300 (49% to 75%). Although the method used by
470
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 4 6 8 e4 7 2
Gaur et al is currently only available offsite, Coenen et al reported about a novel FFRCT program allowing completely onsite FFRCT computation.16 In 106 patients with a total of 189 vessels, sensitivity, specificity, and accuracy of FFRCT were 86%, 65%, and 74%, respectively. The “transluminal attenuation gradient” is a potential alternative to identify the hemodynamic relevance of coronary stenoses. Wong et al analyzed the ability of the transluminal attenuation gradient (defined as the linear regression coefficient between luminal attenuation and axial distance) determined by 320-detector row CT for detection of functionally significant stenosis in comparison to invasive FFR assessment. In 119 patients, the transluminal attenuation gradient in combination with CTA results had a sensitivity, specificity, and positive and negative predictive value of 80%, 95%, 92%, and 87% as compared with CTA alone with 95%, 65%, 65%, and 95%, respectively.17 The transluminal attenuation gradient is assessed manually, which may be time-consuming. Mitschke et al evaluated a semiautomatic software that allows coronary plaque assessment in combination with quantification of the luminal contrast density drop over coronary lesions. A total of 23 of 96 (24%) coronary lesions were hemodynamically significant according to invasive FFR. In multiple regression analysis, the contrast density drop was the only independent predictor for hemodynamic significant lesions (P ¼ .0002), whereas plaque characteristics such as noncalcified, low-attenuation plaque, calcified plaque, total coronary plaque burden, and remodeling index were not.18
4.
Epicardial fat
Epicardial fat can be quantified from cardiac CT data sets and is under evaluation regarding its potential for risk stratification. Epicardial fat was associated with coronary calcium progression in 3367 patients studied by Mahabadi et al, especially in young patients and patients with low calcium scores.19 This suggests that epicardial fat may be involved particularly in early coronary atherosclerosis development. Tokioka et al correlated histological findings to multidetector CT parameters or CAD risk factors in a cohort of 79 patients who underwent cardiac surgery.20 Epicardial fat, subcutaneous fat, and pericardial fat samples were obtained from 30 patients referred for coronary bypass surgery (“CAD patients”) and from 49 patients for non-CAD surgery. Multidetector CT was performed before surgery. They found that the number of M1 macrophages was increased in epicardial fat of CAD patients as compared with non-CAD patients (P < .001). The mean CT attenuation of epicardial fat was lower in CAD patients (72 16 HU vs 65 18 HU, P ¼ .0004) and was negatively correlated with the Agatston score (r ¼ 0.235, P ¼ .049).20 No significant differences were observed for subcutaneous or pericardial fat. They postulated that lower CT attenuation epicardial fat may have the potential to become a CAD risk factor and may be caused by hypertrophy of adipose cells. Nakanishi et al investigated the impact of ventricular-specific epicardial fat volume on coronary microcirculatory vasodilator function and found that periventricular (but not periatrial) epicardial fat volume was associated with impaired microcirculation in the left anterior descending coronary artery as measured by
transthoracic Doppler echocardiography.21 The effect of epicardial fat volume on bare-metal stent restenosis was studied by Canpolat et al in a cohort of 529 patients who underwent CTA because of suspected CAD and received a baremetal stent as well as follow-up angiography during the further clinical course.22 The total epicardial fat volume was increased in 230 patients with instent restenosis compared with 299 patients without instent restenosis (95.06 14.6 mm vs 83.45 12.8 mm, P < .001). Patients with an epicardial fat volume >92 mm3 had a 4.5 fold increased risk of developing instent restenosis.
5.
Interventional cardiology
Several abstracts evaluated the utility of cardiovascular CT to support interventional procedures. Araki et al investigated 256 patients with 286 chronic total coronary artery occlusions (CTO) to determine whether the distribution of intramural calcification (calcified lesions including the center of the lumen, 73 lesions) or the presence of extramural calcification (lesions with calcium spots without the center of the lumen, 213 lesions) are related to successful revascularization of CTOs. According to their results, calcification at the entry or exit, the length, or the calcium score of the occluded segment were all not predictive for revascularization success or failure. In patients with severe intramural calcification, revascularization was less often successful compared with extramural calcification (49.3% vs 94.8%, P < .0001).23 This is in line with results of Schuhbaeck et al who evaluated 135 patients with 137 CTOs and found that the degree of cross-sectional vessel calcification was the only relevant parameter to predict recanalization failure in multivariate regression analysis.24 According to their data, calcification 50% of the vessel cross section predicts revascularization success of a CTO lesion with a sensitivity of 78% and a specificity of 46% (area under the curve 0.63). Interestingly, Vaquerizo et al showed in a prospective randomized trial (98 patients, 88% antegrade revascularization strategy) that the information provided by CTA was useful, but did not provide significant impact on revascularization success.25 Another major application of cardiovascular CT in interventional cardiology is its use in evaluation of patients with high-grade aortic stenosis before transcatheter aortic valve replacement (TAVR). Opolski et al showed that dual source CTA detected significant CAD in 270 of 475 patients (57%) undergoing CTA before TAVR.26 In per patient analysis, sensitivity was 98%, but specificity was only 37%. Specificity was somewhat higher in patients with fully evaluable segments (57%). It has already been shown that cardiac CT before TAVR can also provide the potential fluoroscopic projection angle for the implantation procedure. However, Katsianos et al report in a study of 100 consecutive patients undergoing CT and rotational angiography (“DynaCT”) that the angle between the planes calculated by multislice CT and DynaCT was 9.0 3.1 (range 0e14.9 ) and therefore postulate that this may cause a substantial error in relation to the valve height.27 Ciobotaru et al confirmed former results that aortic annulus calcium is strongly correlated with postimplantation paravalvular regurgitation, especially the location of aortic annulus calcium and site of paravalvular regurgitation are closely related (r ¼ 0.84).28 Radial forces play a
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 4 6 8 e4 7 2
role when transcatheter aortic valves are deployed during TAVR. Born et al addressed this issue when comparing patients with no or mild paravalvular leaks to patients with moderate paravalvular leaks in a cohort of 30 patients.29 The shape of the implanted stent was extracted from CT images and a mechanical model was employed to estimate radial forces. They found that the force distribution was less homogenous in the group with moderate paravalvular leakage compared with no or mild paravalvular leakage. Furthermore, they demonstrated that the mean force distribution showed a force concentration at the right coronary sinus, close to the membranous septum. Interestingly, Hamdan et al observed that the length of the membranous septum as assessed by CT was a very powerful preprocedural predictor for pacemaker implantation after TAVR due to high degree atrioventricular blocks, new onset bundle branch blocks, or slow atrial fibrillation in 52 patients undergoing TAVR with a balloon-expandable valve. A mean length of the membranous septum of approximately 6 mm was found in patients who developed an atrioventricular block post-TAVR compared with approximately 9 mm in patients who did not.30 Patients with mitral regurgitation before TAVR showed a significant reduction in the degree of mitral regurgitation after TAVR.31 This was not influenced by mitral annulus calcification but it was inversely related to the diameter of mitral annulus and the degree of calcification of the mitral valve leaflets as assessed by CT. Marwan et al demonstrated that cardiac CT may be a useful tool for sizing of the left atrial appendage before percutaneous closure.32 Major et al were able to exclude left atrial thrombi in 178 of 444 patients with atrial fibrillation undergoing CT and transoesophageal echocardiography before atrial fibrillation ablation.33 A total of 19 patients were false positive for thrombi in CT, and in 4 patients, CT was true positive for thrombus compared with transoesophageal echocardiography. Therefore, cardiac CT had a sensitivity of 100%, a specificity of 90%, a positive predictive value of 17%, and a negative predictive value of 100% to detect left atrial thrombi. Mlynarski et al showed that only in a minority of patients (3% of 315 patients), no appropriate coronary veins for cardiac resynchronization therapy can be found and postulated that unfavorable coronary vein anatomy may be 1 cause of nonresponse to cardiac resynchronization therapy.34 Even in the setting of preoperative planning of mitral valve repair,35 management of patients with atrial septal defects36 or patients with tricuspid regurgitation,37 cardiac CT may provide additional information. In the setting of tricuspid regurgitation, van Rosendael et al identified the anteroposterior tricuspid annulus diameter to be superior for identification of severe regurgitation in comparison with the perimeter and area of the annulus, the degree of tethering of the anterior, septal and posterior tricuspid valve leaflets, right ventricular volumes, and ejection fraction.37
references
1. Heo R, O’Hartaigh B, Gransar H, et al. Gender-based warranty period of a coronary artery calcium score of zero: a 15-year follow-up study. Eur Heart J. 2014;35(Abstract Supplement):683.
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2. Erbel R, Lehmann N, Chursidze S, et al. Risk factors influencing coronary artery calcification (CAC) progression. Eur Heart J. 2014;35(Abstract Supplement):52e53. 3. Urakawa S, Kohno K, Miyoshi T, et al. Effect of pitavastatin and eicosapentaenoic acid on coronary artery calcification detected by multi detector-row computed tomography. Eur Heart J. 2014;35(Abstract Supplement):452. 4. Auscher S, Heinsen L, Vinther K, Lambrechtsen J, Egstrup K. Effects of intensive lipid lowering therapy on coronary plaques composition in patients with acute myocardial infarction. Assessment with serial coronary CT-angiography. Eur Heart J. 2014;35(Abstract Supplement):452. 5. Marwan M, Schmidkonz C, Mitschke M, et al. Comparison of Agatston score and global plaque volume using multidetector computed tomography in a large patient cohort. Eur Heart J. 2014;35(Abstract Supplement):716. 6. Nadjiri J, Jaehnichen C, Will A, et al. Incremental prognostic value of quantitative plaque assessment in coronary CT angiography during 5 years of follow up. Eur Heart J. 2014;35(Abstract Supplement):808. 7. Otsuka K, Fukuda S, Tanaka A, et al. Prognostic impact of vulnerable plaque on computed tomographic coronary angiography with normal myocardial perfusion image in patients with diabetes. Eur Heart J. 2014;35(Abstract Supplement):688. 8. Araki M, Kakuta T, Lee T, Murai N, Kanaji Y, Matsuda J. Impact of napkin-ring sign by 320-slice coronary computed tomography and thin-cap fibroatheroma by optical coherence tomography on slow flow phenomenon during PCI in non-ST elevation ACS. Eur Heart J. 2014;35(Abstract Supplement):684. 9. Ito H, Motoyama S, Sarai M, et al. Prediction of cardiac events at non-culprit lesions in patients with acute coronary syndromes by plaque characteristics on coronary computed tomography angiography. Eur Heart J. 2014;35(Abstract Supplement):459. 10. Shin S, Park HB, Choi JH, Lee BK, Kim YJ, Chang HJ. The Determinant of coronary artery plaque progression by serial coronary computed tomography angiography (ACCORSS study). Eur Heart J. 2014;35(Abstract Supplement):623. 11. Braber TL, Mostered A, Prakken NHJ, et al. Coronary artery disease in asymptomatic male athletes aged 45 years or older with a low ESC SCORE risk: the emerging role of coronary CT angiography. Eur Heart J. 2014;35(Abstract Supplement):865. 12. Nishio M, Ueda Y. Prevalence and severity of coronary artery disease among asymptomatic diabetic patients evaluated by coronary computed tomography angiography. Eur Heart J. 2014;35(Abstract Supplement):453. 13. Prado Diaz S, Iglesias Del Valle D, Refoyo Salicio E, et al. Profitability of coronary computed tomography as evaluation before valve surgery. Eur Heart J. 2014;35(Abstract Supplement):964. 14. Uusitalo V, Saraste A, Pietila M, et al. The functional effects of intramyocardial course of coronary arteries and its relation to coronary atherosclerosis. Eur Heart J. 2014;35(Abstract Supplement):519. 15. Gaur S, Leipsic J, Achenbach S, et al. Diagnostic performance of non-invasive fractional flow reserve derived from coronary computed tomography angiography: influence of vessel territory and calcification. Eur Heart J. 2014;35(Abstract Supplement):714e715. 16. Coenen A, Lubbers MM, Kurata A, et al. Coronary CT angiography-derived fractional flow reserve, performed onsite using a novel reduced-order model, validated by invasive fractional flow reserve. Eur Heart J. 2014;35(Abstract Supplement):715. 17. Wong DTL, Ko BS, Nerlekar N, et al. Diagnostic accuracy of transluminal attenuation gradient on 320-detector row CT for detection of functionally significant stenosis assessed by
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Fractional Flow Reserve (FFR). Eur Heart J. 2014;35(Abstract Supplement):715. Mitschke MM, Marwan M, Achenbach S, Dey D, Schuhba¨ck A. Non-invasive prediction of hemodynamic significant coronary artery stenoses by contrast density drop in coronary CT angiography. Eur Heart J. 2014;35(Abstract Supplement):624e625. Mahabadi AA, Lehmann N, Kaelsch H, et al. Epicardial adipose tissue promotes progression of coronary artery calcification in the early phase of atherosclerosis: results from the Heinz Nixdorf Recall study. Eur Heart J. 2014;35(Abstract Supplement):683e684. Tokioka K, Nakamura K, Miyoshi T, et al. Association between histological findings in epicardial adipose tissue and MDCT parameters in patients with coronary artery disease. Eur Heart J. 2014;35(Abstract Supplement):703. Nakanishi K, Fukuda S, Shimada K, et al. Peri-ventricular epicardial adipose tissue accumulation is associated with impaired coronary microcirculation. Eur Heart J. 2014;35(Abstract Supplement):684. Canpolat U, Yorgun H, Sahiner L, et al. Association of epicardial fat measured by 64-multidetector computed tomography with bare-metal stent restenosis. Eur Heart J. 2014;35(Abstract Supplement):802e803. Araki M, Muramatsu T, Tsukahara R, et al. Impact of calcium distribution for successful revascularization of coronary artery CTO lesion: assessed from computed tomography coronary angiography. Eur Heart J. 2014;35(Abstract Supplement):476. Schuhbaeck A, Marwan M, Schneider C, et al. A CT-based score to predict the success of interventional revascularization of chronic total coronary occlusions. Eur Heart J. 2014;35(Abstract Supplement):551. Vaquerizo B, Barros A, Pujadas S, et al. Role of multi-detector computed tomography coronary angiography in percutaneous coronary intervention of chronic total occlusions: TACCTO prospective randomized trial. Eur Heart J. 2014;35(Abstract Supplement):38. Opolski MP, Kim WK, Walther C, et al. Diagnostic accuracy of computed tomography angiography for the detection of coronary artery disease in patients referred for transcatheter aortic valve implantation. Eur Heart J. 2014;35(Abstract Supplement):715e716. Katsianos K, Von Bodman G, Fueller M, et al. TAVI: comparison of multislice computed tomography and rotational angiography based 3D reconstruction imaging for
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the measurement of the fitting angulation for the aortic valve prosthesis implantation. Eur Heart J. 2014;35(Abstract Supplement):972. Ciobotaru CV. Impact of 3D aortic annulus shape and calcification on paravalvular regurgitation post TAVI. Eur Heart J. 2014;35(Abstract Supplement):415e 416. Born S, Gessat M, Suendermann SH, Hopf R, Ruiz CE, Falk V. Patterns in deformation and contrast force of implanted aortic valve stents. Eur Heart J. 2014;35(Abstract Supplement):201. Hamdan A, Guetta V, Raanani E, et al. Computedtomographic assessment of membranous septal anatomy for risk prediction of atrioventricular block associated with transcatheter aortic balloon expandable valve implantation. Eur Heart J. 2014;35(Abstract Supplement):200. Amat Santos IJ, Revilla Orodea A, Lopez J, et al. Computed tomography for the assessment of mitral valve in patients undergoing transcatheter aortic valve. Eur Heart J. 2014;35(Abstract Supplement):212. Marwan M, Bittner D, Mitschke M, Schuhbaeck A, Achenbach S, Schlundt C. CT sizing of left atrial appendage prior to percutaneous closure using watchman device: feasibility and initial experience. Eur Heart J. 2014;35(Abstract Supplement):200. Major GP, Szilveszter B, Horvath T, et al. Diagnostic performance of cardiac CT in detecting left atrial thrombus. Eur Heart J. 2014;35(Abstract Supplement):201. Mlynarski R, Mlynarska A, Sosnowski M. Analysis of coronary venous system by means of cardiac computer tomography. Eur Heart J. 2014;35(Abstract Supplement):85. Solowjowa N, Penkalla A, Dandel M, et al. Mitral valve and left ventricular reverse remodeling after surgical repair of submitral left ventricular aneurysms assessed with multislice computed tomography. Eur Heart J. 2014;35(Abstract Supplement):963e964. Morimitsu Y, Osawa K, Miyoshi T, et al. Usefulness of cardiac computed tomography for assessing of atrial septum defect in adult compared with transesophageal and transthoracic echocardiography and invasive catheterization. Eur Heart J. 2014;35(Abstract Supplement):199e200. Van Rosendael PJ, Joyce EM, Katsanos S, et al. Geometrical remodeling of the tricuspid valve in functional tricuspid regurgitation assessed with multi-detector row computed tomography. Eur Heart J. 2014;35(Abstract Supplement):964.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofCardiovascularCT.com
Congress Report
Cardiovascular Computed Tomography: Highlights of latest research presented at the 2014 Congress of the European Society of Cardiology Annika Schuhba¨ck MD*, Stephan Achenbach MD Department of Cardiology, University of Erlangen, Ulmenweg 18, 91054 Erlangen, Germany
article info Article history: Received 2 October 2014 Accepted 2 October 2014
Keywords: Cardiovascular Computed Tomography European Society of Cardiology Congress 2014
This year’s Congress of the European Society of Cardiology was held in Barcelona from August 30, 2014 to September 3, 2014, and brought together more than 30,000 delegates from around the world. Numerous abstracts pertinent to the field of cardiovascular CT were presented during the meeting. The abstracts highlighted the wide spectrum of clinical situations in which cardiovascular CT may help clinicians in noninvasive, invasive, and interventional cardiology. The following paragraphs list some of the most interesting contributions, although, by necessity, it remains incomplete.
1.
Coronary calcium scoring
Coronary calcium scoring (CCS) is mainly performed for cardiovascular risk assessment. Heo et al demonstrated in a single center study with 9715 asymptomatic patients
undergoing CCS and follow-up for 15 years that in 4864 patients with a baseline CCS of zero the “warranty period” regarding all-cause mortality was 12 years (event rate of less than 4 per 1000 patient years) both for men and women.1 Erbel et al investigated predictors of coronary artery calcification (CAC) progression in 3481 patients with a CCS at baseline and after 5 years.2 Systolic blood pressure, lipid lowering medication, diabetes, and present smoking were predictors for CAC progression beyond predictable levels both in men and women as well as younger age in men. The effect of standard or intensive lipid lowering therapy with pitavastatin with and/ or without eicosapentaenoic acid was addressed in a multicenter prospective randomized study by Urkawa et al in 228 patients from 27 Japanese centers who were examined at baseline and 1-year follow-up.3 They demonstrated that the CCS increased by more than 30% irrespective of a significant reduction of low-density lipoprotein cholesterol by
Conflict of interest: The authors report no conflicts of interest. * Corresponding author. E-mail address: [email protected] (A. Schuhba¨ck). 1934-5925/$ e see front matter ª 2014 Society of Cardiovascular Computed Tomography. All rights reserved. http://dx.doi.org/10.1016/j.jcct.2014.10.001
J o u r n a l o f C a r d i o v a s c u l a r C o m p u t e d T o m o g r a p h y 8 ( 2 0 1 4 ) 4 6 8 e4 7 2
pitavastatin. There was no significant difference among patients with intensive or standard therapy with and/or without eicosapentaenoic acid. No cardiovascular event occurred during the follow-up period. Auscher et al reported an interesting observation in the immediate postinfarction period. They found that early aggressive lipid lowering therapy significantly increased dense calcium volume in patients.4 Marwan et al compared CAC measured by the Agatston method with the total coronary plaque burden in 1405 consecutive patients with suspected coronary artery disease (CAD) and demonstrated a very close and significant correlation (r ¼ 0.885, P < .0001). However, in 14% of patients without coronary calcium, noncalcified plaque was present.5
2.
Coronary atherosclerotic plaque detection
Besides CCS as a prognostic marker of future cardiovascular events, coronary plaque composition is a field of research regarding the prognostic value of coronary CT angiography (CTA). Low-attenuation plaque volume (density <30 HU), total plaque volume (density <150 HU), positive remodeling, and presence of a napkin ring sign were predictive for future events (all-cause death, myocardial infarction, and coronary revascularization >90 days after CTA) in a study of 1278 consecutive patients with suspected CAD over a median follow-up period of 5.6 years.6 Low-attenuation plaque (hazard ratio 3.36, 95% confidence interval (CI) 1.98e5.70, P < .0001) and total plaque volume (hazard ratio 2.69, 95% CI 1.88e3.84, P < .0001) showed additional prognostic impact regarding future events beyond stenosis assessment and calcium scoring. In another study by Otsuka et al, positive remodeling, low-attenuation plaque, and the “napkin ring sign” were also identified as predictors for future cardiovascular events in diabetic patients with a normal exercise-stress myocardial perfusion single-photon emission CT at baseline and a followup period of 3 years.7 The “napkin ring sign” was also identified to be more frequent in noneST-elevation acute coronary syndrome patients with a thrombolysis in myocardial infarction flow grade less than 2 in a study by Araki et al, who compared 53 patients with 56 patients without presence of the “napkin ring sign” in CTA before invasive coronary angiography (14 of 53 patients compared with 4 of 53 patients, P ¼ .0091).8 The “napkin ring sign” was associated with thin-cap fibroatheroma by optical coherence tomography. Ito et al studied 256 patients who underwent coronary CTA within 1 month after acute coronary syndrome and observed that patients with obstructive high-risk plaques (positive remodeling and/or low-attenuation plaque) had higher risk of cardiac events compared with patients with obstructive nonehighrisk plaques.9 Obstructive lesions in nonculprit vessels were found in 59% of patients, 63 of those (24%) had high-risk plaque features. Cardiac events were observed in 26 patients with 7 acute coronary syndromes and 22 late revascularizations. In patients with obstructive high-risk plaque, incidence was 17.5%, compared with 8.6% in patients with obstructive nonehigh-risk plaques and 6.42% in patients without obstructive plaque (P ¼ .038). Corresponding hazard ratios were 3.62 (95% CI 1.36e10.60, P ¼ .010) when patients with obstructive highrisk plaques were compared with patients without
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obstructive plaque and 1.48 (95% CI 0.51e4.53, P ¼ .46) in patients with obstructive nonehigh-risk plaques compared with those without obstructive plaques. The possibility to noninvasively follow plaque burden is an interesting aspect of coronary CTA. Shin et al assessed the serial changes of vessel volume, lumen volume, plaque volume, and plaque burden in a multicenter, retrospective registry of 100 patients with suspected CAD and a median rescan interval of 3.4 years.10 They observed a mean annual plaque progression rate of 3.7 4.5% per year and found that the major predictors for plaque progression were age, hypertension, diabetes, and active smoking.
3. Coronary artery disease and stenosis detection The major clinical indication for coronary CTA is to detect or rule out significant CAD. Braber et al investigated its use in 276 asymptomatic male athletes aged 45 years or older with a low risk for CAD and normal exercise tolerance.11 In 15% of patients, relevant CAD (CCS 100 or luminal stenosis 50%) was observed. Diabetic patients are at risk for development of CAD. Nishio et al investigated 168 asymptomatic type 2 diabetic patients without known or suspected CAD and found that more than the half of the patients (54%) had moderate to severe CAD. During a follow-up period of mean 1062 372 days, 3 major cardiovascular events occurred. However, there was 1 stroke, 1 percutaneous intervention, and 1 unknown death.12 Prado Diaz et al evaluated coronary CTA in 104 patients scheduled for valve surgery and showed that invasive coronary angiography could be avoided in most patients (61.5%) and allowed cost reduction of 49.2% and complications associated with invasive coronary angiography.13 Myocardial bridging is a common phenomenon in cardiac CT. Uusitalo et al showed that only in one-third of patients with myocardial bridging, systolic constriction can be observed in invasive coronary angiography and that none of these patients had abnormal myocardial perfusion during pharmacological stress by positron emission tomography.14 Over the past several years, functional assessment of coronary artery stenoses by coronary CTA has been a major field of research and development. Fractional flow reserve based on coronary CTA data and computational fluid dynamics (FFRCT) seems to be a very promising approach. Gaur et al demonstrated accurate detection of individuals with or without ischemia in a cohort of 254 patients by using this method.15 The authors state that even in the presence of coronary calcification, accurate results were achieved independent of the analyzed vessel territory. For example, for the left anterior descending coronary artery, specificity of CTA to detect hemodynamically significant coronary artery stenoses increased from 43% to 86% in patients with a CCS 300 when FFRCT data were used as compared with CTA data alone and from 37% to 71% in patients with a CCS >300. Sensitivity decreased nonsignificantly from 84% to 76% in patients with a CCS 300 and remained unchanged (86%) in patients with a CCS >300. However, diagnostic accuracy was significantly improved both for patients with a CCS 300 (from 56% to 83%) and a CCS >300 (49% to 75%). Although the method used by
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Gaur et al is currently only available offsite, Coenen et al reported about a novel FFRCT program allowing completely onsite FFRCT computation.16 In 106 patients with a total of 189 vessels, sensitivity, specificity, and accuracy of FFRCT were 86%, 65%, and 74%, respectively. The “transluminal attenuation gradient” is a potential alternative to identify the hemodynamic relevance of coronary stenoses. Wong et al analyzed the ability of the transluminal attenuation gradient (defined as the linear regression coefficient between luminal attenuation and axial distance) determined by 320-detector row CT for detection of functionally significant stenosis in comparison to invasive FFR assessment. In 119 patients, the transluminal attenuation gradient in combination with CTA results had a sensitivity, specificity, and positive and negative predictive value of 80%, 95%, 92%, and 87% as compared with CTA alone with 95%, 65%, 65%, and 95%, respectively.17 The transluminal attenuation gradient is assessed manually, which may be time-consuming. Mitschke et al evaluated a semiautomatic software that allows coronary plaque assessment in combination with quantification of the luminal contrast density drop over coronary lesions. A total of 23 of 96 (24%) coronary lesions were hemodynamically significant according to invasive FFR. In multiple regression analysis, the contrast density drop was the only independent predictor for hemodynamic significant lesions (P ¼ .0002), whereas plaque characteristics such as noncalcified, low-attenuation plaque, calcified plaque, total coronary plaque burden, and remodeling index were not.18
4.
Epicardial fat
Epicardial fat can be quantified from cardiac CT data sets and is under evaluation regarding its potential for risk stratification. Epicardial fat was associated with coronary calcium progression in 3367 patients studied by Mahabadi et al, especially in young patients and patients with low calcium scores.19 This suggests that epicardial fat may be involved particularly in early coronary atherosclerosis development. Tokioka et al correlated histological findings to multidetector CT parameters or CAD risk factors in a cohort of 79 patients who underwent cardiac surgery.20 Epicardial fat, subcutaneous fat, and pericardial fat samples were obtained from 30 patients referred for coronary bypass surgery (“CAD patients”) and from 49 patients for non-CAD surgery. Multidetector CT was performed before surgery. They found that the number of M1 macrophages was increased in epicardial fat of CAD patients as compared with non-CAD patients (P < .001). The mean CT attenuation of epicardial fat was lower in CAD patients (72 16 HU vs 65 18 HU, P ¼ .0004) and was negatively correlated with the Agatston score (r ¼ 0.235, P ¼ .049).20 No significant differences were observed for subcutaneous or pericardial fat. They postulated that lower CT attenuation epicardial fat may have the potential to become a CAD risk factor and may be caused by hypertrophy of adipose cells. Nakanishi et al investigated the impact of ventricular-specific epicardial fat volume on coronary microcirculatory vasodilator function and found that periventricular (but not periatrial) epicardial fat volume was associated with impaired microcirculation in the left anterior descending coronary artery as measured by
transthoracic Doppler echocardiography.21 The effect of epicardial fat volume on bare-metal stent restenosis was studied by Canpolat et al in a cohort of 529 patients who underwent CTA because of suspected CAD and received a baremetal stent as well as follow-up angiography during the further clinical course.22 The total epicardial fat volume was increased in 230 patients with instent restenosis compared with 299 patients without instent restenosis (95.06 14.6 mm vs 83.45 12.8 mm, P < .001). Patients with an epicardial fat volume >92 mm3 had a 4.5 fold increased risk of developing instent restenosis.
5.
Interventional cardiology
Several abstracts evaluated the utility of cardiovascular CT to support interventional procedures. Araki et al investigated 256 patients with 286 chronic total coronary artery occlusions (CTO) to determine whether the distribution of intramural calcification (calcified lesions including the center of the lumen, 73 lesions) or the presence of extramural calcification (lesions with calcium spots without the center of the lumen, 213 lesions) are related to successful revascularization of CTOs. According to their results, calcification at the entry or exit, the length, or the calcium score of the occluded segment were all not predictive for revascularization success or failure. In patients with severe intramural calcification, revascularization was less often successful compared with extramural calcification (49.3% vs 94.8%, P < .0001).23 This is in line with results of Schuhbaeck et al who evaluated 135 patients with 137 CTOs and found that the degree of cross-sectional vessel calcification was the only relevant parameter to predict recanalization failure in multivariate regression analysis.24 According to their data, calcification 50% of the vessel cross section predicts revascularization success of a CTO lesion with a sensitivity of 78% and a specificity of 46% (area under the curve 0.63). Interestingly, Vaquerizo et al showed in a prospective randomized trial (98 patients, 88% antegrade revascularization strategy) that the information provided by CTA was useful, but did not provide significant impact on revascularization success.25 Another major application of cardiovascular CT in interventional cardiology is its use in evaluation of patients with high-grade aortic stenosis before transcatheter aortic valve replacement (TAVR). Opolski et al showed that dual source CTA detected significant CAD in 270 of 475 patients (57%) undergoing CTA before TAVR.26 In per patient analysis, sensitivity was 98%, but specificity was only 37%. Specificity was somewhat higher in patients with fully evaluable segments (57%). It has already been shown that cardiac CT before TAVR can also provide the potential fluoroscopic projection angle for the implantation procedure. However, Katsianos et al report in a study of 100 consecutive patients undergoing CT and rotational angiography (“DynaCT”) that the angle between the planes calculated by multislice CT and DynaCT was 9.0 3.1 (range 0e14.9 ) and therefore postulate that this may cause a substantial error in relation to the valve height.27 Ciobotaru et al confirmed former results that aortic annulus calcium is strongly correlated with postimplantation paravalvular regurgitation, especially the location of aortic annulus calcium and site of paravalvular regurgitation are closely related (r ¼ 0.84).28 Radial forces play a
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role when transcatheter aortic valves are deployed during TAVR. Born et al addressed this issue when comparing patients with no or mild paravalvular leaks to patients with moderate paravalvular leaks in a cohort of 30 patients.29 The shape of the implanted stent was extracted from CT images and a mechanical model was employed to estimate radial forces. They found that the force distribution was less homogenous in the group with moderate paravalvular leakage compared with no or mild paravalvular leakage. Furthermore, they demonstrated that the mean force distribution showed a force concentration at the right coronary sinus, close to the membranous septum. Interestingly, Hamdan et al observed that the length of the membranous septum as assessed by CT was a very powerful preprocedural predictor for pacemaker implantation after TAVR due to high degree atrioventricular blocks, new onset bundle branch blocks, or slow atrial fibrillation in 52 patients undergoing TAVR with a balloon-expandable valve. A mean length of the membranous septum of approximately 6 mm was found in patients who developed an atrioventricular block post-TAVR compared with approximately 9 mm in patients who did not.30 Patients with mitral regurgitation before TAVR showed a significant reduction in the degree of mitral regurgitation after TAVR.31 This was not influenced by mitral annulus calcification but it was inversely related to the diameter of mitral annulus and the degree of calcification of the mitral valve leaflets as assessed by CT. Marwan et al demonstrated that cardiac CT may be a useful tool for sizing of the left atrial appendage before percutaneous closure.32 Major et al were able to exclude left atrial thrombi in 178 of 444 patients with atrial fibrillation undergoing CT and transoesophageal echocardiography before atrial fibrillation ablation.33 A total of 19 patients were false positive for thrombi in CT, and in 4 patients, CT was true positive for thrombus compared with transoesophageal echocardiography. Therefore, cardiac CT had a sensitivity of 100%, a specificity of 90%, a positive predictive value of 17%, and a negative predictive value of 100% to detect left atrial thrombi. Mlynarski et al showed that only in a minority of patients (3% of 315 patients), no appropriate coronary veins for cardiac resynchronization therapy can be found and postulated that unfavorable coronary vein anatomy may be 1 cause of nonresponse to cardiac resynchronization therapy.34 Even in the setting of preoperative planning of mitral valve repair,35 management of patients with atrial septal defects36 or patients with tricuspid regurgitation,37 cardiac CT may provide additional information. In the setting of tricuspid regurgitation, van Rosendael et al identified the anteroposterior tricuspid annulus diameter to be superior for identification of severe regurgitation in comparison with the perimeter and area of the annulus, the degree of tethering of the anterior, septal and posterior tricuspid valve leaflets, right ventricular volumes, and ejection fraction.37
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