Predictors of adverse cardiac events of coronary myocardial bridging diagnosed with computed tomography angiography

AIMS

Myocardial bridging (MB) is a frequent congenital anomaly of the epicardial coronary arteries commonly considered a benign condition. However, in some cases a complex interplay between anatomical, clinical and physiology factors may lead to adverse events, including sudden cardiac death. Coronary CT angiography (CCTA) emerged as the gold standard noninvasive imaging technique for the evaluation of MB. Aim of the study was to evaluate MB prevalence and anatomical features in a large population of patients who underwent CCTA for suspected CAD and to identify potential anatomical and clinical predictors of adverse cardiac events at long-term follow-up.

METHODS AND RESULTS

Two-hundred and six patients (mean age 60.3 ± 11.8 years, 128 male) with MB diagnosed at CCTA were considered. A long MB was defined as ≥25 mm of overlying myocardium, whereas a deep MB as ≥2 mm of overlying myocardium. The study endpoint was the sum of the following adverse events: cardiac death, bridge-related acute coronary syndrome, hospitalization for angina or bridge-related ventricular arrhythmias and MB surgical treatment. Of the 206 patients enrolled in the study, 9 were lost to follow-up, whereas 197 (95.6%) had complete follow-up (mean 7.01 ± 3.0 years) and formed the analytic population. Nineteen bridge-related events occurred in 18 patients (acute coronary syndrome in 7, MB surgical treatment in 2 and hospitalization for bridge-related events in 10). Typical angina at the time of diagnosis and long MB resulted as significant independent predictors of adverse outcome.

CONCLUSIONS

Typical angina and MB length ≥ 25 mm were independent predictors of cardiac events.

Prevalence and prognosis of structural heart disease among athletes with negative T waves and normal transthoracic echocardiography

INTRODUCTION

The aim of the present study was to evaluate the prevalence and prognosis of structural heart disease (SHD) among competitive athletes with negative T waves without pathological findings at transthoracic echocardiogram.

METHODS

From a prospective register of 450 athletes consecutively evaluated during a second-level cardiological examination, we retrospectively identified all subjects with the following inclusion criteria: (1) not previously known cardiovascular disease; (2) negative T waves in leads other than V1-V2; (3) normal transthoracic echocardiogram. Patients underwent cardiac MRI and CT. The primary endpoint was the diagnosis of definite SHD after multimodality imaging evaluation. A follow-up was collected for a combined end-point of sudden death, resuscitated sudden cardiac death and hospitalization for any cardiovascular causes.

RESULTS

A total of 55 competitive athletes were finally enrolled (50 males, 90%) with a mean age of 27.5 ± 14.1 years. Among the population enrolled 16 (29.1%) athletes had a final diagnosis of SHD. At multivariate analysis, only deep negative T waves remained statistically significant [OR (95% CI) 7.81 (1.24-49.08), p = 0.0285]. Contemporary identification of deep negative T waves and complex arrhythmias in the same patients appeared to have an incremental diagnostic value. No events were collected at 49.3 ± 12.3 months of follow-up.

CONCLUSIONS

In a cohort of athletes with negative T waves at ECG, cardiac MRI (and selected use of cardiac CT) enabled the identification of 16 (29.1%) subjects with SHD despite normal transthoracic echocardiography. Deep negative T waves and complex ventricular arrhythmias were the only clinical characteristic associated with SHD diagnosis.

Preoperative angiography-derived fractional flow reserve may predict coronary artery bypass grafting occlusion and disease progression

BACKGROUND

Graft occlusion after coronary artery bypass grafting (CABG) has been associated with competitive flow of native coronary arteries.

OBJECTIVES

To assess with coronary computed tomography angiography (CCTA) graft occlusion and coronary artery disease (CAD) progression of native vessels after CABG and their relationship with angiography-derived vessel fractional flow reserve (vFFR) performed before surgery.

METHODS

Between 2006 and 2018, serial vFFR analyses were obtained before CABG in each major native coronary vessel from two institutions. All patients underwent follow-up CCTA.

RESULTS

In 171 consecutive patients, serial preoperative angiograms were suitable for vFFR analysis of 298 grafted and 59 nongrafted vessels. Median time between CABG and CCTA was 2.1 years. Preoperative vFFR was assessed in 131 left anterior descending artery (LAD), 132 left circumflex artery (LCX) and 94 right coronary aretry (RCA) and was less than 0.80 in 255 of 298 bypassed vessels. Graft occlusion was observed at CCTA in 28 of 298 grafts. The median preoperative vFFR value of native coronaries was higher in occluded compared with patent grafts (0.75 vs. 0.60, P < 0.001) and was associated with graft. The best vFFR cut-off to predict graft occlusion was 0.67. Progression of CAD was higher in grafted than in nongrafted vessels (89.6 vs. 47.5%, P < 0.001). Pre-CABG vFFR predicted disease progression of grafted native vessels (AUC = 0.83).

CONCLUSION

Preoperative vFFR derived from invasive coronary angiography was able to predict graft occlusion and CAD progression of grafted coronary arteries.

Diagnostic accuracy of subendocardial vs. transmural myocardial perfusion defect for the detection of in-stent restenosis or progression of coronary artery disease after percutaneous coronary intervention

BACKGROUND

The ADVANTAGE study demonstrated in a cohort of stented patients a diagnostic accuracy of stress myocardial CT perfusion (CTP) significantly higher than that of coronary CT angiography (CCTA) for the detection of in-stent restenosis (ISR) or CAD progression vs. quantitative coronary angiography (QCA). This is a pre-defined subanalysis of the ADVANTAGE aimed at assessing the difference in terms of diagnostic accuracy vs. QCA of a subendocardial vs. a transmural perfusion defect using static stress CTP.

METHODS

We enrolled consecutive patients who previously underwent coronary stenting and were referred for QCA. All patients underwent stress CTP and rest CTP ​+ ​CCTA. The diagnostic accuracy of CCTA and CTP were evaluated in territory-based and patient-based analyses. We compared the diagnostic accuracy of "subendocardial" perfusion defect, defined as hypo-enhancement encompassing >25% but <50% of the transmural myocardial thickness within a specific coronary territory vs. "transmural" perfusion defect, defined as hypo-enhancement encompassing >50% of the transmural thickness.

RESULTS

In 150 patients (132 men, mean age 65.1 ​± ​9.1 years), the diagnostic accuracy of subendocardial vs. transmural perfusion defect in a vessel-based analysis was 93.5% vs. 87.7%, respectively (p ​< ​0.0001). The sensitivity and specificity of subendocardial vs. transmural defect were 87.9% vs. 46.9% (p ​< ​0.001) and 94.9% vs. 97.9% (p ​= ​0.004), respectively. In a patient-based analysis, the diagnostic accuracy of the subendocardial vs. transmural approach was 86.6% vs. 68% (p ​< ​0.0001).

CONCLUSIONS

This study shows that detection of a subendocardial perfusion defect as compared to a transmural defect is significantly more accurate to identify coronary territories with ISR or CAD progression.

Comprehensive Evaluation of Left Ventricle Dysfunction by a New Computed Tomography Scanner: The E-PLURIBUS Study

BACKGROUND

Although cardiac magnetic resonance (CMR) is considered the gold standard for myocardial fibrosis detection, cardiac computed tomography (CCT) is emerging as a promising alternative.

OBJECTIVES

The purpose of this study was to assess feasibility and diagnostic accuracy of a comprehensive functional and anatomical evaluation with CCT as compared with CMR in patients with newly diagnosed left ventricular dysfunction (LVD).

METHODS

A total of 128 consecutive patients with newly diagnosed LVD were screened. Based on the exclusion criteria, 28 cases were excluded. CCT was performed within 10 days from CMR. Biventricular volumes and ejection fraction, and presence and pattern of delayed enhancement (DE), were determined, along with evaluation of coronary arteries among patients undergoing invasive angiography in the 6 months after CCT.

RESULTS

Six cases were excluded because of claustrophobia at CMR. Among the 94 patients who formed the study population, the concordance between CCT and CMR in suggesting the cause of the LVD was high (94.7%, 89/94 patients) in the overall population and was 100% for identifying ischemic cardiomyopathy. The CCT diagnostic rate for DE assessment was also high (96.7%, 1,544/1,598 territories) and similar to that of CMR (97.4%; P = 0.345, CCT vs CMR). Moreover, CCT showed high diagnostic accuracy in the detection of DE (94.8%, 95% CI: 93.6%-95.8%) in a territory-based analysis. Biventricular volumes and function parameters as measured by CCT and CMR were similar, without significant differences with the exception of a modest difference in RV volume. CCT was confirmed to be accurate for assessing arterial coronary circulation. The mean radiation exposure of the whole CCT was 7.78 ± 2.53 mSv (0.84 ± 0.24 mSv for DE).

CONCLUSIONS

CCT performed with low-dose whole-heart coverage scanner and high-concentration contrast agent appears an effective noninvasive tool for a comprehensive assessment of patients with newly diagnosed LVD.

459 PREOPERATIVE ANGIOGRAPHY-DERIVED FRACTIONAL FLOW RESERVE MAY PREDICT BYPASS GRAFT OCCLUSION AND DISEASE PROGRESSION AT MID-TERM FOLLOW-UP

Background

Coronary artery bypass grafting (CABG) is the most common revascularization mode for patients with multivessel coronary artery disease (CAD). Despite substantial improvements in the outcome of patients undergoing CABG surgery, graft occlusion remains a weakness of this procedure and has been associated with competitive flow of native coronary arteries. Our study aims to assess graft occlusion and the progression of CAD in native vessels after CABG surgery at follow-up with coronary CT angiography (CCTA), and their relationship with angiography-derived vessel-fractional flow reserve (vFFR) performed before surgery.

Methods

We retrospectively selected patients from two European institutions, treated with CABG between January 2006 and December 2018, who underwent follow-up with CCTA. All patients had a preoperative angiogram performed before CABG.

Results

In 171 consecutive patients, serial preoperative angiograms were suitable for vFFR analysis of 298 grafted and 59 non-grafted vessels. Table 1 shows clinical and main procedural characteristics. Preoperative vFFR was assessed in 131 left anterior descending arteries (LAD), 132 left circumflex arteries (LCX) and 94 right coronary arteries (RCA) and was &lt;0.80 in 255 of 298 bypassed vessels. Graft occlusion was observed at CCTA in 28 of 298 grafts. The median preoperative vFFR value of native coronaries was higher in occluded compared to patent grafts (0.75 vs. 0.60, p&lt;0.001) (Figure 1) and was associated with graft type. The best vFFR cut-off to predict graft occlusion was 0.67. The functional CAD progression was higher in grafted compared to non-grafted vessels (89.6% vs 47.5% p &lt; 0.001) and pre-CABG vFFR predicted disease progression of grafted native vessels (AUC=0.83) (Figure 2).

Conclusions

Preoperative vFFR derived from invasive coronary angiography was able to predict graft occlusion and CAD progression of grafted coronary arteries.

584 AN UNUSUAL CASE OF A STRESSED HEART

A 53-year-old woman was admitted to our emergency department complaining severe stabbing and oppressive retrosternal pain radiating posteriorly to left scapulae and left arm The onset was followed by general malaise, nausea, vomiting which she attributed to a period of intense emotional stress. She denied common cardiovascular risk factors, but in 2019 had a suspected acute coronary syndrome with subsequent finding of normal coronary artery at angiography in another institute. Her past medical history included severe asthma on multiple drug therapy with regular follow-up. Physical exam was normal. Electrocardiogram (ECG) showed subtle diphasic-negative T wave in anterior leads with mild ST depression in V4-V5, with patient still symptomatic. Lab examinations showed significantly increased troponins levels (hsTnI 664 ng/L, reference &lt; 34 ng/L) with other lab values within normal range. A transthoracic echocardiogram at the bedside revealed mildly reduced systolic function with hypo-akinesis of the mid-apical anteroseptal and anterior left ventricular myocardial wall. Therefore, acute coronary syndrome was suspected and heparin and aspirin at a loading dose were administered. Still symptomatic, the patient was admitted in the ICU. In the same day a left heart catheterization revealed normal aspect of epicardial coronary arteries and ventriculography showed preserved basal and apical myocardial wall motion but hypo-akinesis of mid-cavitary walls, suggesting a possible mid-ventricular variant of Takotsubo syndrome (Figure 1). The patient was still symptomatic for stabbing chest pain after coronarography. To rule out the suspicion of acute aortic syndrome and pulmonary embolism, she also underwent a contrast-enhanced chest CT scan, that was fortunately normal. During her hospital stay, the patient had no arrhythmic and hemodynamic complications. Peak troponin level was 5027 ng/L. At serial ECGs, she developed diffuse deep T-wave inversion and a mild prolonged QT interval. Echocardiogram was repeated after 4 days showing complete normalization of left ventricular wall motion and restored ejection fraction also.

From the traditional “apical ballooning” Takotsubo Syndrome with apical akinesia and basal hypercontractility, different variants have been described. The mid-ventricular variant, seen in our patient was found in only 14.6% of the cases in the International Takotsubo Registry, followed by basal “reverse” and focal variants (2.2% and 1.5%, respectively).

The Role of Multimodality Imaging for Percutaneous Coronary Intervention in Patients With Chronic Total Occlusions

Background

Percutaneous coronary intervention (PCI) of Chronic total occlusions (CTOs) has been traditionally considered a challenging procedure, with a lower success rate and a higher incidence of complications compared to non-CTO-PCI. An accurate and comprehensive evaluation of potential candidates for CTO-PCI is of great importance. Indeed, assessment of myocardial viability, left ventricular function, individual risk profile and coronary lesion complexity as well as detection of inducible ischemia are key information that should be integrated for a shared treatment decision and interventional strategy planning. In this regard, multimodality imaging can provide combined data that can be very useful for the decision-making algorithm and for planning percutaneous CTO recanalization.

Aims

The purpose of this article is to appraise the value and limitations of several non-invasive imaging tools to provide relevant information about the anatomical characteristics and functional impact of CTOs that may be useful for the pre-procedural assessment and follow-up of candidates for CTO-PCI. They include echocardiography, coronary computed tomography angiography (CCTA), nuclear imaging, and cardiac magnetic resonance (CMR). As an example, CCTA can accurately delineate CTO location and length, distal coronary bed, vessel tortuosity and calcifications that can predict PCI success, whereas stress CMR, nuclear imaging and stress-CT can provide functional evaluation in terms of myocardial ischemia and viability and perfusion defect extension.

Plaque assessment by coronary CT angiography may predict cardiac events in high risk and very high risk diabetic patients: A long-term follow-up study

BACKGROUND AND AIMS

The aim of the present study is to evaluate whether advanced coronary atherosclerosis analysis by CCTA may improve prognostic stratification among diabetic patients at high cardiovascular risk (CV risk).

METHODS AND RESULTS

The study population consisted of 265 consecutive diabetic patients at high CV risk who underwent CCTA for suspected CAD between January 2011 and December 2016. For every patients both traditional and advanced, qualitative and quantitative coronary plaque analysis were performed. The occurrence of cardiac death, ACS, and non-urgent revascularization were recorded at follow-up. Among the 265 patients enrolled, 21 were lost to follow-up, whereas 244 (92%) had a complete follow-up (mean 45 ± 22 months) and were classified at high (n = 67) or very high cardiovascular risk (n = 177), according to ESC Guidelines. A total of 63 events were recorded (3 Cardiac Death, 3 NSTEMI, 8 unstable angina, 36 late non-urgent revascularization and 13 non-cardiac death) in 57 different patients. Elevated fibro-fatty plaque volume was the only predictor of events over age, gender and traditional risk factor when ACS and MACE were considered as end-points [HR (95% CI) 6.01 (1.65-21.87), p = 0.006 and 3.46 (2.00-5.97); p < 0.001].

CONCLUSION

The present study confirms the prognostic role of advance coronary atherosclerosis evaluation beyond risk factors and stenosis severity, even in diabetics. Despite the very high cardiovascular risk of study population, a not negligible portion (23%) of patients exhibited totally normal coronaries.

Cardiac Care of Non-COVID-19 Patients During the SARS-CoV-2 Pandemic: The Pivotal Role of CCTA

Aim: The aim of this study is to evaluate the potential use of coronary CT angiography (CCTA) as the sole available non-invasive diagnostic technique for suspected coronary artery disease (CAD) during the coronavirus disease 2019 (COVID-19) pandemic causing limited access to the hospital facilities.

Methods and Results: A consecutive cohort of patients with suspected stable CAD and clinical indication to non-invasive test was enrolled in a hub hospital in Milan, Italy, from March 9 to April 30, 2020. Outcome measures were obtained as follows: cardiac death, ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina. All the changes in medical therapy following the result of CCTA were annotated. A total of 58 patients with a mean age of 64 ± 11 years (36 men and 22 women) were enrolled. CCTA showed no CAD in 14 patients (24.1%), non-obstructive CAD in 30 (51.7%) patients, and obstructive CAD in 14 (24.1%) patients. Invasive coronary angiography (ICA) was considered deferrable in 48 (82.8%) patients. No clinical events were recorded after a mean follow-up of 376.4 ± 32.1 days. Changes in the medical therapy were significantly more prevalent in patients with vs. those without CAD at CCTA.

Conclusion: The results of the study confirm the capability of CCTA to safely defer ICA in the majority of symptomatic patients and to correctly identify those with critical coronary stenoses necessitating coronary revascularization. This characteristic could be really helpful especially when the hospital resources are limited

The Potential Role of Cardiac CT in the Evaluation of Patients With Known or Suspected Cardiomyopathy: From Traditional Indications to Novel Clinical Applications

After 15 years from its advent in the clinical field, coronary computed tomography (CCTA) is now widely considered as the best first-step test in patients with low-to-moderate pre-test probability of coronary artery disease. Technological innovation was of pivotal importance for the extensive clinical and scientific interest in CCTA. Recently, the advent of last generation wide-coverage CT scans paved the way for new clinical applications of this technique beyond coronary arteries anatomy evaluation. More precisely, both biventricular volume and systolic function quantification and myocardial fibrosis identification appeared to be feasible with last generation CT. In the present review we would focus on potential applications of cardiac computed tomography (CCT), beyond CCTA, for a comprehensive assessment patients with newly diagnosed cardiomyopathy, from technical requirements to novel clinical applications.

Quantitative Evaluation of COVID-19 Pneumonia Lung Extension by Specific Software and Correlation with Patient Clinical Outcome

Lung infection named as COVID-19 is an infectious disease caused by the most recently discovered coronavirus 2 (SARS-CoV-2). CT (computed tomography) has been shown to have good sensitivity in comparison with RT-PCR, particularly in early stages. However, CT findings appear to not always be related to a certain clinical severity. The aim of this study is to evaluate a correlation between the percentage of lung parenchyma volume involved with COVID-19 infection (compared to the total lung volume) at baseline diagnosis and correlated to the patient's clinical course (need for ventilator assistance and or death). All patients with suspected COVID-19 lung disease referred to our imaging department for Chest CT from 24 February to 6 April 2020were included in the study. Specific CT features were assessed including the amount of high attenuation areas (HAA) related to lung infection. HAA, defined as the percentage of lung parenchyma above a predefined threshold of -650 (HAA%, HAA/total lung volume), was automatically calculated using a dedicated segmentation software. Lung volumes and CT findings were correlated with patient's clinical course. Logistic regressions were performed to assess the predictive value of clinical, inflammatory and CT parameters for the defined outcome. In the overall population we found an average infected lung volume of 31.4 ± 26.3% while in the subgroup of patients who needed ventilator assistance and who died as well as the patients who died without receiving ventilator assistance the volume of infected lung was significantly higher 41.4 ± 28.5 and 72.7 ± 36.2 (p < 0.001). In logistic regression analysis best predictors for ventilation and death were the presence of air bronchogram (p = 0.006), crazy paving (p = 0.007), peripheral distribution (p < 0.001), age (p = 0.002), fever at admission (p = 0.007), dyspnea (p = 0.002) and cardiovascular comorbidities (p < 0.001). In multivariable analysis, quantitative CT parameters and features added incremental predictive value beyond a model with only clinical parameters (area under the curve, 0.78 vs. 0.74, p = 0.02). Our study demonstrates that quantitative evaluation of lung volume involved by COVID-19 pneumonia helps to predict patient's clinical course.

Cardiac care of Non-COVID-19 patients during the SARS-CoV-2 pandemic: The pivotal role of CCTA

Funding Acknowledgements

Type of funding sources: None.

Aims

To describe the role of coronary CT angiography (CCTA) as the sole available non-invasive diagnostic test for symptomatic patients with suspected CAD in a hub center for cardiovascular emergencies in the presence of limited access to hospital facilities during the COVID-19 pandemic.

Methods and Results

From March 9th to April 30th, during the peak of the COVID-19 pandemic, a consecutive cohort of symptomatic patients with high clinical suspicion of CAD and clinical indication to CCTA were enrolled in a hub hospital in Milan, Italy. When obstructive coronary artery disease was detected (>70% diameter stenosis in a proximal coronary segment or >90% stenosis in any coronary segment) patients were referred to invasive coronary angiography (ICA). Clinical follow-up was assessed in patients in whom ICA was considered deferrable.

Overall, 58 consecutive patients were included. Ten (17.2%) symptomatic patients underwent ICA according to CCTA findings, while in 48 (82.8%) patients ICA was deferred. No clinical events were recorded after a mean follow-up of 49.7 ± 16.8 days. In nine out of ten patients referred to ICA, severe coronary artery disease was confirmed and treated accordingly. Changes in medical therapy were significantly more prevalent in patients with vs. those without CAD at CCTA.

Conclusion

We report a potential pivotal role for CCTA in the triage of non-COVID-19 patients with suspected  CAD during the SARS-CoV-2 pandemic. CCTA may be helpful for identifying patients who necessitate ICA, ensuring adequate resource utilization during the pandemic.

Extent of lung involvement over severity of cardiac disease for the prediction of adverse outcome in COVID-19 patients with cardiovascular disease

Background

Aim of the present study was to assess if the presence of high cardiovascular risk, left ventricle systolic dysfunction or elevated BNP or Troponin are able to independently predict the outcome of patients with known cardiac disease and COVID-19 pneumonia.

Methods and results

From March 7th to April 28th, forty consecutive patients with known cardiac disease (chronic coronary artery disease, n=38; atrial fibrillation, n = 7; valvular disease, n = 13) referred to our emergency department for symptoms of suspected COVID-19, laboratory diagnosis of COVID-19 and typical signs of viral pneumonia at chest CT were enrolled in the study. The only predictor of the composite end-point (all cause of death + invasive ventilation + thromboembolic event) was the lung involvement % at chest CT (OR: 1.06; 95%CI: 1.01–1.11, P = 0.02). In the multivariate analysis, the lung involvement % at chest CT was the only independent predictor of the composite end-point (OR: 1.06; 95%CI: 1.01–1.11, P = 0.034).

Conclusions

The extent of lung involvement by COVID-19 is the only independent predictor of adverse outcome of patients and is predominant over the severity of cardiac disease.

•

Severity of cardiac disease is not an independent predictor of adverse outcome in COVID-19 pneumonia

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The extent of lung involvement is an independent predictor of adverse outcome

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CT scan could be useful in patients with COVID-19 and cardiovascular co-morbidities

Coronary Artery Bypass Grafting or Fractional Flow Reserve–Guided Percutaneous Coronary Intervention in Diabetic Patients With Multivessel Disease

Background:

In diabetic patients with multivessel coronary artery disease, coronary artery bypass grafting (CABG) has shown long-term benefits over percutaneous coronary intervention (PCI). Physiology-guided PCI has shown to improve clinical outcomes in multivessel coronary artery disease, though its impact in diabetic patients has never been investigated. We evaluated long-term clinical outcomes of diabetic patients with multivessel coronary artery disease treated with fractional flow reserve (FFR)–guided PCI compared with CABG.

Methods:

From 2010 to 2018, 4622 diabetic patients undergoing coronary angiography were screened for inclusion. The inclusion criterion was the presence of at least 2-vessel disease defined as with diameter stenosis ≥50%, in which at least 1 intermediate stenosis (diameter stenosis, 30%–70%) was treated or deferred according to FFR. Inverse probability of treatment weighting analysis was used to account for baseline differences with a contemporary cohort of patients treated with CABG. The primary end point was major adverse cardiovascular and cerebrovascular events, defined as all-cause death, myocardial infarction, revascularization, or stroke.

Results:

A total of 418 patients were included in the analysis. Among them, 209 patients underwent CABG and 209 FFR-guided PCI. At 5 years, the incidence of major adverse cardiovascular and cerebrovascular events was higher in the FFR-guided PCI versus the CABG group (44.5% versus 31.9%; hazard ratio, 1.60 [95% CI, 1.15–2.22]; P =0.005). No difference was found in the composite of all-cause death, myocardial infarction, or stroke (28.8% versus 27.5%; hazard ratio, 1.05 [95% CI, 0.72–1.53]; P =0.81). Repeat revascularization was more frequent with FFR-guided PCI (24.9% versus 8.2%; hazard ratio, 3.51 [95% CI, 1.93–6.40]; P <0.001).

Conclusions:

In diabetic patients with multivessel coronary artery disease, CABG was associated with a lower rate of major adverse cardiovascular and cerebrovascular events compared with FFR-guided PCI, driven by a higher rate of repeat revascularization. At 5-year follow-up, no difference was observed in the composite of all-cause death, myocardial infarction, or stroke between CABG and FFR-guided PCI.

Graphic Abstract:

A graphic abstract is available for this article.

Impact of non-invasive anatomical testing on optimal medical prescription in patients with suspected coronary artery disease

Background

Compared to functional testing, coronary computed tomography angiography (CTA) improves clinical outcomes in patients with suspected coronary artery disease (CAD). This is thought to be the result of an increased prescription of preventive medical therapy (statins and aspirin) when relying on a CTA imaging strategy. We compared the rate of statins prescription in a patient cohort assessed either with coronary CTA or exercise testing, and evaluated the agreement on medication prescriptions.

Methods

Consecutive patients who underwent coronary CTA and exercise test for suspected CAD were included. Four clinical cardiologists independently analysed each case based on clinical information and the result of either coronary CTA or exercise test. For each case, treatment strategy and prescription were recorded while blinded to the results of the other cardiac test. Treatment strategy was reassessed using the alternative imaging modality three weeks after the first evaluation.

Results

A total of 113 patients were included. Mean age was 56.7±11.5 years, 52% were males and diabetes were present in 6%. Coronary CTA showed an obstructive epicardial stenosis in 21.4% and any type of atherosclerotic plaque in 54.2%. Functional testing identified ischemia in 9.1%. The use of coronary CTA resulted in higher number of statin (64.9% vs. 44.5%, P<0.001) and aspirin (21.4% vs. 4.3%, P<0.001) prescriptions. There was a substantial agreement on the prescription of statins (mean Cohen's κ coefficient of 0.79±0.07).

Conclusions

Epicardial atherosclerotic disease was found in half of patients with suspected CAD as assessed by coronary CTA. Compared to functional testing, coronary CTA evaluation by coronary was associated with an increase in the rate preventive therapy prescription.

Correction of lower limb deformities in children with renal osteodystrophy by guided growth technique

PURPOSE

Renal osteodystrophy (ROD) may cause severe lower limb deformities in children. The purpose of this study is to evaluate the efficacy of the temporary hemiepiphysiodesis for the correction of lower limb deformities in children with ROD.

METHODS

Guided growth correction by hemiepiphysiodesis has been performed in skeletally immature patients with deformities of the lower limbs caused by ROD. The correction of the mechanical axes of the lower limbs and its correction speed have been evaluated.

RESULTS

A total of seven patients with ROD, five males and two females, were treated with the above technique. The average age of the patients at their first surgery was 7.8 years (2.9 to 13.6). The average follow-up time 5.2 years (2.3 to 8). There were 13 valgus deformities and one varus deformity of the knee. The measure of the lower limb angular deformity was in the range of 10° to 47°. Restoration of normal mechanical axis was achieved in all patients at the final follow-up. Three patients relapsed and required further hemiepiphysiodesis. The average time for correction was 20 months (7 to 30). The average speed of correction was 0.49° per month for a tibia and 1.73° per month for a femur. There were two minor complications: a screw mobilisation and a screw breakage occurred during removal.

CONCLUSION

Guided growth technique by hemiepiphysiodesis is a mini-invasive surgical procedure that has been found to be effective for the correction of misalignment due to ROD in skeletally immature patients. The method has allowed progressive correction of the deformities at any age in childhood. These patients are predisposed to relapse to their deformities, thus a strict follow-up is required.

Comparison of intra-articular triamcinolone hexacetonide and triamcinolone acetonide in oligoarticular juvenile idiopathic arthritis

OBJECTIVE

To compare the efficacy and safety of intra-articular triamcinolone hexacetonide (TH) and triamcinolone acetonide (TA) in children with oligoarticular juvenile idiopathic arthritis (JIA).

METHODS

One hundred and thirty joints of 85 patients undergoing intra-articular injections were randomly treated with either TH or TA depending on the availability of the drug. The efficacy of both treatments was evaluated prospectively in a blinded fashion. A good response was defined as a decrease in the articular score of > or =60% from baseline. Clinical, laboratory and immunological variables were noted in order to examine possible factors, other than treatment, predictive of the result.

RESULTS

Seventy injections were performed using TH and 60 with TA. The two groups were comparable for clinical, immunological and laboratory characteristics. The rate of response was significantly higher with TH than with TA: 81.4% vs 53.3% (P = 0.001) at 6 months, 67.1 vs 43.3% (P = 0.006) at 12 months, and 60 vs 33.3% (P = 0.002) at 24 months.

CONCLUSION

At comparable doses TH appeared to be much more effective than TA for intra-articular use, in both short- and long-term follow-up. This result was not affected by disease duration or degree of local and systemic inflammation.

[Role of mutilating surgery in the treatment of non-chemosensitive pediatric soft tissue sarcomas. Experience of the Italian Cooperative Group Studies RMS-79 and RMS-88]

Aim of the study was to evaluate the role of mutilating surgery in the patients with non chemosensitive soft tissue sarcomas (STS) registered in the Italian Studies. Between 1979 and 1995, 114 patients (pts) with "non chemosensitive" localized STS were enrolled in the cooperative studies RMS-79 (33) and RMS-88 (81). Median age: 89 months (range 1-194).

HISTOLOGY

fibrosarcoma 29, Malignant Perpheral Nerve Sheath Tumors (MPNST) 40, malignant fibrous histiocytoma 5, hemangiopericytoma 6, leiomyosarcoma 4, others 20, STS nos 10. The cases were classified according to the IRS staging system as Gr. I 46, Gr. II 24, Gr. III 44. Twelve out of 114 pts (7%), 5/33 (14%) in the first study and 7/81 (8%) in the second, underwent mutilating surgery: 8 pts (of whom 3 were < 2 y of age) had a fibrosarcoma and 4 a MPNST. The mutilating procedure was carried out at diagnosis in 6 cases (4 in RMS-79 and 2 in RMS-and 88) and achieved radicality in 5/6 cases. It was performed after ineffective chemotherapy (CT) in 5 pts (1 in RMS-79 and 4 in RMS-88). One pt (RMS-88) underwent mutilation after multiple local recurrences treated with CT, radiotherapy and conservative excisions (RMS-88) and died. The procedures consisted of 5 amputations, 4 demolitive excisions of extremities with functional impairment, 1 nephrectomy, 1 excision of deferents with spermatic vesicae and 1 mastectomy.

OUTCOME

At present 6/12 pts, 5 with fibrosarcoma and 1 with MPNST, are alive with no evidence of disease (NED), 4 of the first and 2 of the second study. Of the 5 Gr. I patients, 4 are alive (NED) and 1 died of 2nd tumor; 1 Gr. II pt is alive NED; of the 5 Gr. III pts 1 is alive NED and 4 died (3 of metastatic spread and 1 of 2nd tumor); the pt amputated after repeated local relapses (Gr. II) is dead of pulmonary metastases.

CONCLUSIONS

In the RMS-79 study the mutilations were frequent and were performed at diagnosis in several cases; this trend decreased in the 2nd study in which chemotherapy was attempted in most of the patients. Probably the timing of mutilating procedures was not always adequate (too early or too late). The outcome of pts undergone mutilations is similar to that of the whole group of 114 pts, whose overall survival at 10 years is 64% (C.I. 60-77). Only fibrosarcomas and MPNST probably requires a more aggressive surgical behaviour. At present we avoid initial demolitive surgery; it should be planned without delay after the first local relapse or after initial ineffective CT and RT.

Primary re-excision: the Italian experience in patients with localized soft-tissue sarcomas

Primary re-excision (PRE) is a wide, non-mutilating procedure carried out in patients with soft-tissue sarcomas (STS) when microscopic residuals are left after initial excision or when there are insufficient data on its completeness. The aim of this study was to evaluate the role of PRE in patients enrolled in two consecutive Italian studies between January 1988 and September 1999. Of 126 patients with grade IIa tumors. 53 underwent PRE (23 rhabdomyosarcomas [RMS] and 30 non-RMS STS [NRSTS]). The primary sites were the extremities in 20, paratesticular 15, trunk 9, head-neck-non-parameningeal (HNnPM) 6, bladder 1, other sites in 2; the tumor (T) status was T1a in 30, T1b in 10, T2a in 9, and T2b in 4; the median interval between primary surgery and PRE was 36 days. Of the 53 patients, 45 had complete histologic excision of the tumor (residuals were found in 21/45 specimens) and subsequently received chemotherapy (CT) alone: 39/45 are in their first complete remission (CR) with a median follow-up of 53 months; 6/45 (3 RMS, 3 NRSTS) relapsed, 4 locally (2 extremities, 2 trunk), and 1 of these died of progressive disease, and 2 with metastatic spread died of their disease. In 8/53 cases (HNnPM 4. extremities 2, bladder 1, trunk 1) PRE did not achieve complete removal of the residuals (3 T1a, 2 Tlb, 2 T2a, 1 T2b); these patients were treated with CT and/or radiotherapy (RT); 1 also underwent further surgery. PRE was able to achieve or confirm complete excision in 45/53 patients, and 39 maintained the first CR without RT. The histologic types and the presence of residuals at PRE did not predict the failures; PRE was effective especially in extremity, trunk, and paratesticular sites, whereas its role was uncertain in large sarcomas over 5 cm in size.

Spinal involvement in Pyle's disease

BACKGROUND

Pyle's disease is a rare skeletal dysplasia involving the metaphyses of long bones. To date, spinal involvement has been only rarely described in the literature.

OBJECTIVE

To show that spinal changes, which are an expression of the same growth defect of the long bones, are an important and constant sign of the disease in the families studied.

MATERIALS AND METHOD

The radiographic skeletal changes in five patients have been observed.

RESULTS

The pathognomonic metaphyseal widening of tubular bones (known as the 'Erlenmeyer flask sign') was associated with the spinal changes in all cases. Radiographic findings in the spine varied from moderate platyspondyly to the bodies having the appearance of a biconcave lens. This may be attributed to two main causes: (1) a defect in the modelling process of the vertebrae (comparable to that observed in the metaphyses) and (2) chronic pathological fractures secondary to osteoporosis (a typical feature of Pyle's disease).

CONCLUSIONS

The finding of platyspondyly of varying severity widens the spectrum of radiographic findings in this disease and can assist in diagnosis.

Pseudomalignant myositis ossificans in children. Description of a case and review of the literature

The authors report a rare case of pseudomalignant myositis ossificans occurring during childhood. A female aged 10 years with no previous history of trauma came to their observation with findings of pain and progressive swelling in the gluteal region. The severity of the clinical findings and the absence of characteristic ossification in the x-rays obtained at the onset of the disease suggested that neoplastic pathology be excluded. Diagnosis (bone scan, CT scan, MRI, angiography, biopsy) and the progression of the disease, until its complete clinical resolution, are discussed in light of a review of the literature (44 cases of pseudomalignant myositis ossificans during pediatric age). All of the elements that may be of help in diagnosis and capable of avoiding surgical procedures that are either untimely or improper are emphasized.

Voluntary hip dislocation in Down's syndrome: report of two cases

Two cases of monolateral voluntary hip dislocation in Down's syndrome are reported. No surgical procedure was permitted by the family in either case, thus showing the natural evolution of the joint morphology. In the case observed a year after the onset of hip dislocation CT Scan already showed an initial smoothing of the posterior acetabular wall. In the other case, after a 9 year follow-up, the voluntary hip dislocation was followed by progressive subluxation and fixed dislocation at the end. This suggests that only early surgical treatment can prevent this outcome.

Spondylocostal dysplasia (Jarcho-Levin syndrome)

The authors report 3 cases of rare spondylocostal dysplasia (Jarcho-Levin syndrome) associated with multiple visceral anomalies (V.A.C.TE.R.L. syndrome). The difficulty encountered in treating the disease because of the complexity and multiplicity of the visceral anomalies, and the extent and type of associated vertebral deformities is emphasized. The cases described revealed a moderate amount of progression, and were able to be treated non-surgically. It is also emphasized that even when there is moderate scoliosis associated costal deformities may cause anti-cosmetic thoracic gibbosity.

Monoarticular juvenile chronic arthritis of the shoulder. Report of a case and review of the literature

In 20% of the cases Juvenile Chronic Arthritis (JCA) has a monoarticular onset. Usually the inflammatory process spreads out to other joints with pauciarticular or polyarticular course. Very rarely the disease persists in one joint only and this is in about 70% of the cases, the knee. We describe a case of Monoarticular JCA with isolate and persistent involvement of the shoulder never reported in the literature. The clinical, pathologic features and different diagnoses are discussed.

A 20-year follow-up study of a case of surgically treated massive osteolysis

Massive osteolysis of the humerus occurred in a 19-year-old male. The lesion was successfully treated with an autogenous fibular shaft transplant. During the 20-year follow-up period, humerus function was restored. Roentgenograms showed incorporation of the graft without any recurrence of the disease. This experience and reports in the literature show that only predominantly cortical autogeneic bone grafting has been successful. This could be due to the intrinsic characteristic of cortical bone. In fact, it seems that cortical bone shows greater resistance to erosion than cancellous bone to the lymphangiomatous osteolytic tissue. Therefore, autogenous bone grafting could be considered as a reasonable alternative to radiotherapy, particularly in young people with monostotic disease localized in bones that are easily operable and have no soft-tissue involvement.

[Septic arthritis in children]

Seventy-five cases of children affected with septic arthritis for a total of 85 joints were followed-up after an average of 6 years and 9 months and evaluated according to Rigault clinical and radiographic criteria. Prognosis of the disease was related to age (less favorable results during neonatal age), to the joint affected (the hip and shoulder obtained the worst results, the knee the best), and to delay in diagnosis. Early and suitable surgical treatment associated with systemic antibiotic therapy is required.

[Torsional defects of the lower limb: an evaluation of the reliability of the results obtained by CT]

The torsional angle was calculated goniometrically of 9 femurs and 2 tibio-peroneal groups, and then compared to the values obtained from CT scans of the corresponding bones. The results show how the methods adopted up to now have been inaccurate and have yielded only gross definitions of the axis of the femoral neck. As far as this feature is concerned, an error of +/- 6.5 degrees can be estimated, with limits of confidence of 95%, after applying a more accurate system of measurement to the images and considering statistical interferences. After pointing out the advantages of this method, we suggest that the test performed in vivo be systematically proposed to all those patients in whom a more accurate diagnosis would lead to a different medical/surgical therapy considering that: 1) the inevitable error such a measurement bears can be contained between acceptable limits; 2) the radiation dose sufficient to distinguish the bone from the other surrounding tissues is much reduced with respect to the dosage necessary to perform a common CT of the inferior limbs. It comprises one topogram and four tomograms, with a total dose to the patient of approximately 10-20 mGy.

Primary clavicular localisation of Ewing's tumour treated by total cleidectomy. Case report and review of the literature

The authors report a case of Ewing's sarcoma localised in the clavicle followed up 5 years after total cleidectomy. There was no recurrence and excellent function of the shoulder, which justifies this method as it may be the treatment of choice for this rare localisation as opposed to the less reliable partial cleidectomy.