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Evaluation of Carotid Artery Stenosis: Comparison of Duplex Sonography, Computed Tomographic Angiography and Magnetic Resonance Angiography with Digital Subtraction Angiography
Abstracts
S39
95 Left Atrial Volumes in Hypertension and Hypertrophic Cardiomyopathy
96 Localisation of Regurgitant Defects by Cardiac Magnetic Resonance Imaging in Patients with Mitral Valve Prolapse
S. Eshoo 1 , M. Mikhail 1 , D.L. Ross 1 , C. Semsarian 2 , L. Thomas 1
R. Gabriel 1,2,∗ , A. Kerr 1 , R. Stewart 2 , C. Occleshaw 2
1 Westmead
Hospital, University of Sydney, Australia; 2 Centenary Institute, University of Sydney, Australia
2 Green
Background: Left atrial (LA) enlargement occurs in hypertension (HT) and hypertrophic cardiomyopathy (HCM). We evaluated the changes in total LA volume and in the various phases of atrial filling in patients with left ventricular hypertrophy (LVH) from HT and HCM. Methods: Thirty-one patients with HCM (six excluded due to pacing, two due to septal ablations and one with severe LV dysfunction) (mean age = 51 years) were prospectively recruited and compared to age and sex matched 22 HT patients with LVH. All recruits had a transthoracic echo performed with attention paid to maximising LA size. Maximum (LAESV) and minimum (LAEDV) LA volumes were calculated using Simpson’s biplane method of discs. The pre ‘P’ LA volume (prior to active atrial contraction) was measured as also the passive filling, active filling and conduit volumes. Results: Despite no significant difference in LVH in HT and HCM, LAESV, LAEDV and pre P volumes were increased in the HCM group. In addition, a decrease in active and conduit filling was noted in the HCM group.
Purpose: In mitral regurgitation (MR), the decision regarding mitral valve repair depends on the location and mechanism of regurgitation. We assessed the feasibility of cardiac magnetic resonance imaging (CMR) for mapping mitral regurgitant lesions. Methods: Twenty-seven patients with chronic moderate to severe MR due to mitral valve prolapse underwent CMR on a Siemens Avanto 1.5 T machine followed by transthoracic echocardiography (TTE). On CMR, contiguous (6 mm) long-axis high temporal resolution cine images perpendicular to the valve commissures were obtained across the mitral valve from the medial to the lateral annulus. This technique allows systematic valve inspection and mapping using a six-segment model. CMR mapping was compared with trans-oesophageal echocardiography (TOE) or surgical mapping in 10 patients. Results: Thirty-four of 54 leaflets had prolapse or flail. CMR and TTE agreed on the presence/absence of leaflet abnormality in 53 of 54 leaflets. Of 12 flail leaflets on TTE, 10 were confirmed on CMR, one was reclassified as prolapse – confirmed at surgery. CMR detected one eccentric flail segment not detected by TTE. CMR and TTE agreed on the predominant regurgitant jet direction in 26 of the 27 patients. In 10 patients, CMR correctly classified 56 of 60 segments compared with TOE or surgical operative findings. Conclusion: In patients with MR due to mitral valve prolapse, mapping using CMR is feasible as part of the CMR exam and may be an alternative when preoperative TOE mapping is required.
HT (n = 22)
HCM (n = 22)
104.3 ± 4.3
115.5 ± 6.5
LAESV (mL)
48.1 ± 3.7
82.0 ± 5†
Pre P LAV (mL)
33.1 ± 2.8
61.9 ± 4.9†
Passive emptying fraction (%)
34.2 ± 2.1
25.7 ± 1.7
Conduit volume (mL)
30.8 ± 3.6
15.8 ± 2.1†
Active emptying fraction (%)
42.9 ± 1.9
27.3 ± 2.1†
LV mass (g/m2 )
Mean ± S.E. †
p < 0.05 compared to HT.
Conclusion: HCM results in greater changes to the LA despite the similar degree of LVH suggesting that additional factors such as myocardial disarray in HCM may contribute additionally. doi:10.1016/j.hlc.2007.06.100
1 Cardiology Department, Middlemore Hospital, New Zealand;
Lane Cardiovascular Service, Auckland City Hospital, New Zealand
doi:10.1016/j.hlc.2007.06.101 97 Evaluation of Carotid Artery Stenosis: Comparison of Duplex Sonography, Computed Tomographic Angiography and Magnetic Resonance Angiography with Digital Subtraction Angiography T. Gattorna ∗ , C. Chawantanpipat, M. Stephen, C. Anderson, S. McCormack, G.H. White, M.K.C. Ng Departments of Cardiology, Radiology, Vascular Surgery and Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Background: The accuracy of non-invasive imaging techniques in assessing carotid artery stenosis remains uncertain and there are currently few studies directly comparing all clinically available modalities in the same patient. By determining which imaging modalities can most accurately predict the degree of carotid artery steno-
ABSTRACTS
Heart, Lung and Circulation 2007;16:S1–S201
S40
Abstracts
ABSTRACTS
sis, it may be possible to obviate the need for intra-arterial angiography and its associated risks. Methods: Consecutive patients (n = 9) undergoing assessment for carotid revascularisation underwent noninvasive lesion assessment by duplex ultrasound (DUS), computed tomographic angiography (CTA) and magnetic resonance angiography (MRA). All lesions were assessed by independent observers, blinded to clinical information and other diagnostic tests, according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method. Results for each patient were then compared to the reference standard digital subtraction angiography (DSA), with severe internal carotid artery stenosis defined as 70–99%. Results: DUS tended to overestimate the degree of carotid stenosis for the detection of a 70–99% lesion, with a sensitivity of 100%. CTA had the highest specificity of 100% and a positive predictive value of 100%. By comparison, MRA had a relatively low sensitivity (33%) and low specificity (75%). Conclusion: In this small series, the highest accuracy for non-invasive detection of carotid artery stenosis is DUS in combination with CTA. The combination of CT angiography and duplex sonography may be preferable over DSA as part of a work-up for revascularisation, thus reducing the risk of peri-procedural morbidity and improving overall outcomes. doi:10.1016/j.hlc.2007.06.102 98 Diagnosis and Evaluation of Coronary Aneurysms after Drug Eluting Stent Implantation with Multi-Slice CT Coronary Angiography R. Gurvitch 1,∗ , B.P. Yan 1 , J. Tatoulis 2 , S. Heinz 3 , R.J. Warren 1 1 Department
of Cardiology, Melbourne, Victoria, Australia; of Cardiothoracic Surgery, Melbourne, Victoria, Australia; 3 Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
2 Department
Background: Coronary aneurysms (CA) after drug-eluting stent (DES) implantation although rare, may be associated with significant morbidity. Early detection of CA may allow therapeutic intervention. The use of multi-slice CT coronary angiography (MSCTCA) in the diagnosis of CA after DES implantation has not been previously reported. Methods: We report the use of MSCTCA in two cases of CA >4 years after DES implantation. Results: One patient presented with late stent thrombosis and the other patient with acute coronary syndrome. MSCTCA (Siemens, Sensation, 64 slice × 0.6 mm) accurately delineated aneurysmal segments in both patients corresponding exactly to invasive coronary angiographic findings. Both patients underwent coronary bypass graft surgery and patch repair of the aneurysmal segments.
Heart, Lung and Circulation 2007;16:S1–S201
Conclusion: MSCTCA may be a non-invasive alternative to coronary angiography in the diagnosis of CA after DES. Further evaluation of its utility is warranted. doi:10.1016/j.hlc.2007.06.103 99 A Comparison of Methods for Assessing Total Arterial Compliance Brian A. Haluska 1,2,∗ , Joseph Brown 1,2 , Stephane G. Carlier 1,2 , Thomas H. Marwick 1,2 1 University
Australia; NY, USA
of Queensland Department of Medicine, Brisbane, Research Foundation, New York,
2 Cardiovascular
Background: Reduced total arterial compliance (TAC) is associated with HTN, ischaemia and reduced exercise capacity. We compared three methods of estimating TAC in a large group of patients with and without cardiovascular risk. Methods: We studied 320 patients (170 men; age 55 ± 10); TAC was determined by (1) the pulse-pressure method (PPM) based on the two element Windkessel, (2) the area method (AM), an integral variation of the Windkessel, and (3) the stroke volume/pulse pressure method (SVPP) a ratio of stroke volume and PP. Clinical data, risks factors and TAC by all three methods were then compared. Results: Correlation was good between all methods: PPM/AM r = 0.83, PPM/SVPP r = 0.94 and AM/SVPP r = .80 (all p < 0.0001). Analysis of the subgroups showed significant differences between the groups for all three methods, and PPM showed the largest group differences with the smallest standard deviations (Figure). The independent correlates of patient group in linear regression models were all the same—age, HTN and TAC (all p < .0001) and the variance and model strength were all similar (F = 0.74; R2 = 0.46; p < 0.0001).
Conclusions: Normal and abnormal values of TAC vary according to method, which should be expressed. Each of the techniques shows good correlation with each other and similar values. The PPM appears to be slightly more robust in determining differences between groups with and without cardiovascular risk. doi:10.1016/j.hlc.2007.06.104
S39
95 Left Atrial Volumes in Hypertension and Hypertrophic Cardiomyopathy
96 Localisation of Regurgitant Defects by Cardiac Magnetic Resonance Imaging in Patients with Mitral Valve Prolapse
S. Eshoo 1 , M. Mikhail 1 , D.L. Ross 1 , C. Semsarian 2 , L. Thomas 1
R. Gabriel 1,2,∗ , A. Kerr 1 , R. Stewart 2 , C. Occleshaw 2
1 Westmead
Hospital, University of Sydney, Australia; 2 Centenary Institute, University of Sydney, Australia
2 Green
Background: Left atrial (LA) enlargement occurs in hypertension (HT) and hypertrophic cardiomyopathy (HCM). We evaluated the changes in total LA volume and in the various phases of atrial filling in patients with left ventricular hypertrophy (LVH) from HT and HCM. Methods: Thirty-one patients with HCM (six excluded due to pacing, two due to septal ablations and one with severe LV dysfunction) (mean age = 51 years) were prospectively recruited and compared to age and sex matched 22 HT patients with LVH. All recruits had a transthoracic echo performed with attention paid to maximising LA size. Maximum (LAESV) and minimum (LAEDV) LA volumes were calculated using Simpson’s biplane method of discs. The pre ‘P’ LA volume (prior to active atrial contraction) was measured as also the passive filling, active filling and conduit volumes. Results: Despite no significant difference in LVH in HT and HCM, LAESV, LAEDV and pre P volumes were increased in the HCM group. In addition, a decrease in active and conduit filling was noted in the HCM group.
Purpose: In mitral regurgitation (MR), the decision regarding mitral valve repair depends on the location and mechanism of regurgitation. We assessed the feasibility of cardiac magnetic resonance imaging (CMR) for mapping mitral regurgitant lesions. Methods: Twenty-seven patients with chronic moderate to severe MR due to mitral valve prolapse underwent CMR on a Siemens Avanto 1.5 T machine followed by transthoracic echocardiography (TTE). On CMR, contiguous (6 mm) long-axis high temporal resolution cine images perpendicular to the valve commissures were obtained across the mitral valve from the medial to the lateral annulus. This technique allows systematic valve inspection and mapping using a six-segment model. CMR mapping was compared with trans-oesophageal echocardiography (TOE) or surgical mapping in 10 patients. Results: Thirty-four of 54 leaflets had prolapse or flail. CMR and TTE agreed on the presence/absence of leaflet abnormality in 53 of 54 leaflets. Of 12 flail leaflets on TTE, 10 were confirmed on CMR, one was reclassified as prolapse – confirmed at surgery. CMR detected one eccentric flail segment not detected by TTE. CMR and TTE agreed on the predominant regurgitant jet direction in 26 of the 27 patients. In 10 patients, CMR correctly classified 56 of 60 segments compared with TOE or surgical operative findings. Conclusion: In patients with MR due to mitral valve prolapse, mapping using CMR is feasible as part of the CMR exam and may be an alternative when preoperative TOE mapping is required.
HT (n = 22)
HCM (n = 22)
104.3 ± 4.3
115.5 ± 6.5
LAESV (mL)
48.1 ± 3.7
82.0 ± 5†
Pre P LAV (mL)
33.1 ± 2.8
61.9 ± 4.9†
Passive emptying fraction (%)
34.2 ± 2.1
25.7 ± 1.7
Conduit volume (mL)
30.8 ± 3.6
15.8 ± 2.1†
Active emptying fraction (%)
42.9 ± 1.9
27.3 ± 2.1†
LV mass (g/m2 )
Mean ± S.E. †
p < 0.05 compared to HT.
Conclusion: HCM results in greater changes to the LA despite the similar degree of LVH suggesting that additional factors such as myocardial disarray in HCM may contribute additionally. doi:10.1016/j.hlc.2007.06.100
1 Cardiology Department, Middlemore Hospital, New Zealand;
Lane Cardiovascular Service, Auckland City Hospital, New Zealand
doi:10.1016/j.hlc.2007.06.101 97 Evaluation of Carotid Artery Stenosis: Comparison of Duplex Sonography, Computed Tomographic Angiography and Magnetic Resonance Angiography with Digital Subtraction Angiography T. Gattorna ∗ , C. Chawantanpipat, M. Stephen, C. Anderson, S. McCormack, G.H. White, M.K.C. Ng Departments of Cardiology, Radiology, Vascular Surgery and Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Background: The accuracy of non-invasive imaging techniques in assessing carotid artery stenosis remains uncertain and there are currently few studies directly comparing all clinically available modalities in the same patient. By determining which imaging modalities can most accurately predict the degree of carotid artery steno-
ABSTRACTS
Heart, Lung and Circulation 2007;16:S1–S201
S40
Abstracts
ABSTRACTS
sis, it may be possible to obviate the need for intra-arterial angiography and its associated risks. Methods: Consecutive patients (n = 9) undergoing assessment for carotid revascularisation underwent noninvasive lesion assessment by duplex ultrasound (DUS), computed tomographic angiography (CTA) and magnetic resonance angiography (MRA). All lesions were assessed by independent observers, blinded to clinical information and other diagnostic tests, according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method. Results for each patient were then compared to the reference standard digital subtraction angiography (DSA), with severe internal carotid artery stenosis defined as 70–99%. Results: DUS tended to overestimate the degree of carotid stenosis for the detection of a 70–99% lesion, with a sensitivity of 100%. CTA had the highest specificity of 100% and a positive predictive value of 100%. By comparison, MRA had a relatively low sensitivity (33%) and low specificity (75%). Conclusion: In this small series, the highest accuracy for non-invasive detection of carotid artery stenosis is DUS in combination with CTA. The combination of CT angiography and duplex sonography may be preferable over DSA as part of a work-up for revascularisation, thus reducing the risk of peri-procedural morbidity and improving overall outcomes. doi:10.1016/j.hlc.2007.06.102 98 Diagnosis and Evaluation of Coronary Aneurysms after Drug Eluting Stent Implantation with Multi-Slice CT Coronary Angiography R. Gurvitch 1,∗ , B.P. Yan 1 , J. Tatoulis 2 , S. Heinz 3 , R.J. Warren 1 1 Department
of Cardiology, Melbourne, Victoria, Australia; of Cardiothoracic Surgery, Melbourne, Victoria, Australia; 3 Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
2 Department
Background: Coronary aneurysms (CA) after drug-eluting stent (DES) implantation although rare, may be associated with significant morbidity. Early detection of CA may allow therapeutic intervention. The use of multi-slice CT coronary angiography (MSCTCA) in the diagnosis of CA after DES implantation has not been previously reported. Methods: We report the use of MSCTCA in two cases of CA >4 years after DES implantation. Results: One patient presented with late stent thrombosis and the other patient with acute coronary syndrome. MSCTCA (Siemens, Sensation, 64 slice × 0.6 mm) accurately delineated aneurysmal segments in both patients corresponding exactly to invasive coronary angiographic findings. Both patients underwent coronary bypass graft surgery and patch repair of the aneurysmal segments.
Heart, Lung and Circulation 2007;16:S1–S201
Conclusion: MSCTCA may be a non-invasive alternative to coronary angiography in the diagnosis of CA after DES. Further evaluation of its utility is warranted. doi:10.1016/j.hlc.2007.06.103 99 A Comparison of Methods for Assessing Total Arterial Compliance Brian A. Haluska 1,2,∗ , Joseph Brown 1,2 , Stephane G. Carlier 1,2 , Thomas H. Marwick 1,2 1 University
Australia; NY, USA
of Queensland Department of Medicine, Brisbane, Research Foundation, New York,
2 Cardiovascular
Background: Reduced total arterial compliance (TAC) is associated with HTN, ischaemia and reduced exercise capacity. We compared three methods of estimating TAC in a large group of patients with and without cardiovascular risk. Methods: We studied 320 patients (170 men; age 55 ± 10); TAC was determined by (1) the pulse-pressure method (PPM) based on the two element Windkessel, (2) the area method (AM), an integral variation of the Windkessel, and (3) the stroke volume/pulse pressure method (SVPP) a ratio of stroke volume and PP. Clinical data, risks factors and TAC by all three methods were then compared. Results: Correlation was good between all methods: PPM/AM r = 0.83, PPM/SVPP r = 0.94 and AM/SVPP r = .80 (all p < 0.0001). Analysis of the subgroups showed significant differences between the groups for all three methods, and PPM showed the largest group differences with the smallest standard deviations (Figure). The independent correlates of patient group in linear regression models were all the same—age, HTN and TAC (all p < .0001) and the variance and model strength were all similar (F = 0.74; R2 = 0.46; p < 0.0001).
Conclusions: Normal and abnormal values of TAC vary according to method, which should be expressed. Each of the techniques shows good correlation with each other and similar values. The PPM appears to be slightly more robust in determining differences between groups with and without cardiovascular risk. doi:10.1016/j.hlc.2007.06.104