Adjusting Atrial Size Parameters for Body Surface Area: Does it Affect the Association with Pulmonary Embolism-related Adverse Events?

PURPOSE

Small left atrial (LA) volume was recently reported to be one of the best predictors of acute pulmonary embolism (PE)-related adverse events (AE). There is currently no data available regarding the impact that body surface area (BSA)-indexing of atrial measurements has on the association with PE-related adverse events. Our aim is to assess the impact of indexing atrial measurements to BSA on the association between computed tomography (CT) atrial measurements and AE.

MATERIALS AND METHODS

Retrospective study (IRB: 2015P000425). A database of hospitalized patients with acute PE diagnosed on CT pulmonary angiography (CTPA) between May 2007 and December 2014 was reviewed. Right and left atrial volume, largest axial area, and axial diameters were measured. Patients undergo both echocardiographies (from which the BSA was extracted) and CTPAs within 48 hours of the procedure. The patient's body weight was measured during each admission. LA measurements were correlated to AE (defined as the need for advanced therapy or PE-related mortality at 30 days) before and after indexing for BSA. The area under the ROC curve was calculated to determine the predictive value of the atrial measurements in predicting AE.

RESULTS

The study included 490 acute PE patients; 62 (12.7%) had AE. There was a significant association of reduced BSA-indexed and non-indexed LA volume (both <0.001), area (<0.001 and 0.001, respectively), and short-axis diameters (both <0.001), and their respective RA/LA ratios (all <0.001) with AE. The AUC values were similar for BSA-indexed and non-indexed LA volume, diameters, and area with LA volume measurements being the best predictor of adverse outcomes (BSA-indexed AUC=0.68 and non-indexed AUC=0.66), followed by non-indexed LA short-axis diameter (indexed AUC=0.65, non-indexed AUC=0.64), and LA area (indexed AUC=0.64, non-indexed AUC=0.63).

CONCLUSION

Adjusting for BSA does not substantially affect the predictive ability of atrial measurements on 30-day PE-related adverse events, and therefore, this adjustment is not necessary in clinical practice. While LA volume is the better predictor of AE, LA short-axis diameter has a similar predictive value and is more practical to perform clinically.

Evaluation of coronary disease among patients undergoing transcatheter aortic valve implantation: propensity score matching analysis

BACKGROUND

Chronic coronary syndrome (CCS) is common among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Current guidelines recommend performance of percutaneous coronary intervention (PCI) of any > 70% proximal coronary lesions prior to TAVI.

AIMS

To evaluate the outcomes of two diagnostic approaches for CCS clearance pre-TAVI and to determine the reduction in the need of invasive angiography (IA).

METHODS

We investigated 2219 patients undergoing TAVI for severe aortic stenosis at two large centers with different pre-procedural strategies for CCS assessment: pre-TAVI computed tomography angiography (CTA) with selective invasive angiography according to CTA results or mandatory IA. We preformed propensity score matching analysis using a 1:1 ratio. The final study cohort included 870 matched patients. Peri-procedural complications were documented according to the VARC-2 criteria. Mortality rates were prospectively documented.

RESULTS

Mean age of the study population was 82 ± 7, of whom 55% were female. Patients in the IA group had significantly higher rates of pre-TAVI PCI compared to the CTA group (39% vs. 22%, p < 0.001). Following TAVI, peri-procedural myocardial infarction (MI) rates were similar between the two groups (0.3% vs. 0.7%, p value = 0.41), but spontaneous MI were significantly lower among the IA group (0% vs. 1.3%, p value = 0.03). Kaplan-Meier's survival analysis found that the cumulative probability of 1-year morality was similar between the two groups (p value log rank = 0.65). Cox regression analysis did not find association between CCS clearance strategy and outcome.

CONCLUSIONS

In elderly patients, CTA-driven approach for CCS evaluation pre-TAVI is a valid strategy with similar outcome as compared to invasive approach. CTA strategy significantly reduces invasive procedures rates without compromising patient's outcome.

Corin and Left Atrial Cardiomyopathy, Hypertension, Arrhythmia, and Fibrosis

Two siblings presented with cardiomyopathy, hypertension, arrhythmia, and fibrosis of the left atrium. Each had a homozygous null variant in CORIN, the gene encoding atrial natriuretic peptide (ANP)-converting enzyme. A plasma sample obtained from one of the siblings had no detectable levels of corin or N-terminal pro-ANP but had elevated levels of B-type natriuretic peptide (BNP) and one of the two protein markers of fibrosis that we tested. These and other findings support the hypothesis that BNP cannot fully compensate for a lack of activation of the ANP pathway and that corin is critical to normal ANP activity, left atrial function, and cardiovascular homeostasis.

Primary Cardiac Lymphoma Patients Presenting With Heart Failure

•DLBCL is the most common type of lymphoma with cardiac involvement. •Obtaining tissue for diagnosis may be challenging in PCLs. •A safe diagnostic procedure may diagnose DLBCL patients with cardiac masses. •R-CHOP chemotherapy protocol is the standard treatment for PCL.

Left atrium volume and ventricular volume ratio algorithm as indication of pulmonary hypertension etiology

BACKGROUND

Pressure overload of the right heart (pulmonary hypertension [PH]) can be an acute or a chronic process with various pathophysiologic changes affecting the dimensions of the heart chambers. The automatic four-chamber volumetric analysis tool is now available to measure the volume of the cardiac chambers in patients undergoing a computed tomography pulmonary angiogram (CTPA).

PURPOSE

To characterize the volumetric changes that occurred in response to increased systolic pulmonary arterial pressures (sPAP) in acute events, such as acute pulmonary embolism (APE), compared with other etiologies.

MATERIAL AND METHODS

Consecutive patients who underwent CTPA and echocardiography within 24 h between 2011 and 2015 were included. Differences in cardiac chamber volumes were investigated in correlation to the patients' sPAP.

RESULTS

The final cohort of 961 patients included 221 (23%) patients diagnosed with APE. The right (RV) to left (LV) ventricular volume ratio (VVR) was higher, while the left atrial (LA) volume index was smaller (P < 0.001) in the patients with APE. A decision tree for the prediction of APE showed that an RV to left VVR >2.8 was characteristic of APE, whereas an LA volume index >37.5 mL/m² was more compatible with PH due to other etiologies (P < 0.001).

CONCLUSION

The combination of VVR and LA volume index may help in differentiating between APE and chronic PH. CTPA-based volumetric information may be used to help clarify the underlying etiology of the dyspnea.

Real-Life Diagnostic Performance of the Hypersensitivity Pneumonitis Guidelines: A Multicenter Cohort Study

Hypersensitivity pneumonitis (HP) is a heterogeneous interstitial lung disease (ILD) that may be difficult to confidently diagnose. Recently, the 2020 ATS/JRS/ALAT HP diagnostic guidelines were published, yet data validating their performance in real-life settings are scarce. We aimed to assess the diagnostic performance of the HP guidelines compared to the gold-standard multidisciplinary discussion (MDD). For this purpose, we included consecutive ILD patients that underwent diagnostic bronchoscopy between 2017 and 2020 in three large medical centers. Four diagnostic factors (antigen exposure history, chest computed tomography pattern, bronchoalveolar lavage lymphocyte count, and histology results) were used to assign guidelines-based HP diagnostic confidence levels for each patient. A sensitivity analysis was performed, with MDD diagnosis as the reference standard. Overall, 213 ILD patients were included, 45 (21%) with an MDD diagnosis of HP. The guidelines' moderate (≥70%) confidence threshold produced optimal performance with 73% sensitivity for HP, 89% specificity, and a J-index of 0.62. The area under the receiver operating characteristic curve (AUC) for a correct guidelines-based diagnosis was 0.86. The guidelines had better performance for non-fibrotic than fibrotic HP (AUC 0.92 vs. 0.82). All diagnostic factors, except bronchoalveolar lavage lymphocyte count, were independent predictors for MDD diagnosis of HP in a multivariate analysis. In conclusion, the HP guidelines exhibited a good diagnostic performance compared to MDD diagnosis in real-life setting.

The role of serum and urinary markers in predicting obstructing ureteral stones and reducing unjustified non-contrast computerized tomographic scans in emergency departments

INTRODUCTION

The reported yield of non-contrast computed tomography (NCCT) in assessing flank pain and obstructive urolithiasis (OU) in emergency departments (EDs) is only ~ 50%. We investigated the potential capability of serum and urinary markers to predict OU and improve the yield of NCCT in EDs.

METHODS

All consecutive ED patients with acute flank pain suggestive of OU and assessed by NCCT between December 2019 and February 2020 were enrolled. Serum white blood cells (WBC), C-reactive protein (CRP) and creatinine (Cr) levels, and urine dipstick results were analyzed for association with OU, and unjustified NCCT scan rates were calculated.

RESULTS

NCCTs diagnosed OU in 108 of the 200 study patients (54%). The median WBC, CRP, and Cr values were 9,100/µL, 4.3 mg/L, and 1 mg/dL, respectively. Using ROC curves, WBC = 10,000/µL and Cr = 0.95 mg/dl were the most accurate thresholds to predict OU. Only WBC ≥ 10,000/µL (OR = 3.7, 95% CI 1.6-8.3, p = 0.002) and Cr ≥ 0.95 mg/dl (OR = 5, 95% CI 2.3-11, p < 0.001) were associated with OU. Positive predictive value and specificity for detecting OU among patients with combined WBC ≥ 10,000 and Cr ≥ 0.95 were 83% and 89%, respectively. Patients negative to the serum markers criteria underwent significantly more unjustified NCCTs (p = 0.03). The negative predictive value of the serum criteria for justified NCCT scanning was 81%.

CONCLUSIONS

WBC and Cr may be valuable serum markers in predicting OU among patients presenting to EDs with acute flank pain. They may potentially reduce the number of unjustified NCCT scans in the ED setting.

Data From a One-Stop-Shop Comprehensive Cancer Screening Center

PURPOSE

Cancer is the second leading cause of death globally. However, by implementing evidence-based prevention strategies, 30%-50% of cancers can be detected early with improved outcomes. At the integrated cancer prevention center (ICPC), we aimed to increase early detection by screening for multiple cancers during one visit.

METHODS

Self-referred asymptomatic individuals, age 20-80 years, were included prospectively. Clinical, laboratory, and epidemiological data were obtained by multiple specialists, and further testing was obtained based on symptoms, family history, individual risk factors, and abnormalities identified during the visit. Follow-up recommendations and diagnoses were given as appropriate.

RESULTS

Between January 1, 2006, and December 31, 2019, 8,618 men and 8,486 women, average age 47.11 ± 11.71 years, were screened. Of 259 cancers detected through the ICPC, 49 (19.8%) were stage 0, 113 (45.6%) stage I, 30 (12.1%) stage II, 25 (10.1%) stage III, and 31(12.5%) stage IV. Seventeen cancers were missed, six of which were within the scope of the ICPC. Compared with the Israeli registry, at the ICPC, less cancers were diagnosed at a metastatic stage for breast (none v 3.7%), lung (6.7% v 11.4%), colon (20.0% v 46.2%), prostate (5.6% v 10.5%), and cervical/uterine (none v 8.5%) cancers. When compared with the average stage of detection in the United States, detection was earlier for breast, lung, prostate, and female reproductive cancers. Patient satisfaction rate was 8.35 ± 1.85 (scale 1-10).

CONCLUSION

We present a proof of concept study for a one-stop-shop approach to cancer screening in a multidisciplinary outpatient clinic. We successfully detected cancers at an early stage, which has the potential to reduce morbidity and mortality as well as offer substantial cost savings.

Optimized definition of right ventricular dysfunction on computed tomography for risk stratification of pulmonary embolism

OBJECTIVES

There is an ongoing discussion on the optimal right to left (RV/LV) diameter ratio threshold and the best definition of RV dysfunction on computed tomography pulmonary angiography (CTPA) for risk assessment of pulmonary embolism (PE).

METHODS

On routine diagnostic CTPA, volumetric and diameter measurements (axial and reconstructed views) of the ventricles and reflux of contrast medium into the inferior vena cava (IVC) and hepatic veins were assessed in consecutive PE patients enrolled in a prospective single-center registry. In-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration.

RESULTS

Of 609 patients (median age, 69 [IQR, 56-77] years; 47 % male) included in the analysis, 68 patients (11.2 %) had an adverse outcome and 35 (5.7 %) died. While neither a RV/LV volume ratio ≥1.0 nor RV/LV diameter ratios ≥1.0 were able to predict an adverse outcome, higher thresholds increased specificity. Further, neither volumetric measurements nor reconstruction of images provided superior prognostic information compared to RV/LV ratios measured in axial planes. The combination of an axial RV/LV diameter ratio ≥1.5 with substantial reflux of contrast medium was present in 134 patients (22 %) and associated with the best prognostic performance to predict an adverse outcome in unselected (OR 3.7 [95 % CI, 2.0-6.6]) and normotensive (OR 2.8 [95 % CI, 1.1-6.7]) patients.

CONCLUSION

A new definition of RV dysfunction (axial RV/LV diameter ratio ≥1.5 and substantial reflux of contrast medium to the IVC and hepatic veins) allows an optimized CTPA-based prediction of PE-related adverse outcome.

Evaluation of hemodynamically significant pericardial effusion by analysis of cardiac chambers volume by computed tomography

Objective:

Pericardial effusion may present clinically as pleuritic chest pain, dyspnea or hemodynamic compromise and is a frequent finding in computerized tomographic pulmonary angiography (CTPA) exams. We hypothesized that CTPA-based analysis of the cardiac chamber volumes can be used to predict the hemodynamic significance of pericardial effusion (HsPE) as compared with echocardiography.

Methods:

Retrospective analysis of consecutive patients who underwent CTPA and echocardiography between January 2009 and November 2017 that ruled-out acute pulmonary embolism were included. Differences in cardiac chamber volumes were investigated in correlation to echocardiographic evidence of HsPE.

Results:

The final cohort included 208 patients, of whom 22 (11%) were diagnosed with HsPE. The HsPE patients had much smaller cardiac chamber volumes (Median 78.8 ml (IQR 72.4–89.1)) than patients without HsPE (Median 115.1 ml (IQR 87.4–150). A decision tree for the prediction of HsPE showed multiple cutoff values. Right atrium volume (RA) had the best accuracy (area under the curve 0.851, 95% confidence interval 0.776–0.925, p < .001) for predicting the presence of HsPE. An RA volume ≤86 ml yielded a sensitivity of 95.5%, a specificity of 64%, and a NPV of 99.2% for the presence of HsPE.

Conclusion:

CTPA-based volumetric information with focus on the RA volume may help predict the presence of HsPE.

Advances in knowledge:

Pericardial effusion is a frequent finding in CTPA exams. Our study shows that CTPA-based volumetric information can predict the presence of HsPE with RA volume as the best indicator.

Evidence for Left Atrial Volume Being an Indicator of Adverse Events in Patients With Acute Pulmonary Embolism: Retrospective Case-control Pilot Study

PURPOSE

To assess the association between computed tomography pulmonary angiography (CTPA) atrial measurements and both 30-day pulmonary embolism (PE)-related adverse events and mortality, and non-PE-related mortality, and to identify the best predictors of these outcomes by comparing atrial measurements and widely used clinical and imaging variables.

PATIENTS AND METHODS

Retrospective single-center pilot study. Acute PE patients diagnosed on CTPA who also had a transthoracic echocardiogram, electrocardiogram, and troponin T were included. CTPA left atrial (LA) and right atrial (RA) volume and short-axis diameter were measured and compared between outcome groups, along with right ventricular/left ventricular diameter ratio, interventricular septal bowing, tricuspid annular plane systolic excursion, electrocardiogram, and troponin T.

RESULTS

A total of 350 patients. LA volume and diameter were associated with PE-related adverse events (P≤0.01). LA volume was the only atrial measurement associated with PE-related mortality (P=0.03), with no atrial measurements associated with non-PE-related mortality. Troponin was most associated with PE-related adverse events and mortality (both area under the curve [AUC]=0.77). On multivariate analysis, combination models did not greatly improve PE-related adverse events prediction compared with troponin alone. For PE-related mortality, the best models were the combination of troponin, age, and either LA volume (AUC=0.86) or diameter (AUC=0.87).

CONCLUSION

Among patients with acute PE, CTPA LA volume is the only imaging parameter associated with PE-related mortality and is the best imaging predictor of this outcome. Reduced CTPA LA volume and diameter, along with increased RA/LA volume and diameter ratios, are significantly associated with 30-day PE-related adverse events, but not with non-PE-related mortality.

Emergency department non-contrast computed tomography for suspicion of obstructive urolithiasis: Yield and consequences

INTRODUCTION

We aimed to analyze patterns of referral, yield, and clinical implications of non-contrast computed tomography (NCCT) in the acute evaluation of flank pain suspected as obstructive urolithiasis (OU) in a high-volume emergency department (ED).

METHODS

The study comprised 506 consecutive NCCTs performed in the ED over four months. Detection rates of OU, incidental, and alternative findings were calculated. Imaging signs suspicious for recent passage of stones were considered positive for OU, while renal stones without signs of obstruction were considered unrelated to the acute presentation. OU, other findings requiring hospitalization, and incidental findings warranting further workup were considered situations in which NCCTs were warranted.

RESULTS

NCCTs confirmed an OU diagnosis in 162 (32%) patients and non-clinically significant nephrolithiasis in 125 (25%). They revealed other findings in 108 (21%) patients, including 42 (8%) with clinically significant incidental findings and 26 (5%) with alternative diagnoses requiring hospitalization. NCCTs were entirely negative in 111 (22%) patients. Corroboration of these outcomes, together with overlapping of OU, incidental, and alternative significant findings in some patients resulted in an overall justified NCCT request rate of 44%.

CONCLUSIONS

The yield of NCCT performed in acute presentations of flank pain suspected as OU is relatively low, and over one-half of the scans are unwarranted. The pattern of requesting NCCT in the ED needs refinement to avoid abuse that may lead to radiation overexposure, psychological burden, physical harm, and financial overload.

Long-term implications of left atrial appendage thrombus identified incidentally by pre-procedural cardiac computed tomography angiography in patients undergoing transcatheter aortic valve replacement

AIMS

The prevalence and prognostic implications of left atrial appendage (LAA) thrombus (LAAT) in patients considered for transcatheter aortic valve replacement (TAVR) are incompletely defined. We, therefore, studied pre-procedural cardiac computed tomography angiography (CCTA) scans of TAVR candidates to determine the prevalence of LAAT and its association with late outcomes.

METHODS AND RESULTS

Baseline clinical variables and CCTA findings from a prospective TAVR registry were analysed for the prevalence of pre-procedural LAAT and its impact on in-hospital outcomes and late mortality. LAAT was differentiated from LAA filling defects (LAAFD) reflecting stasis without clot. Patients (n = 561) with complete in-hospital and late mortality data were included in the study (median follow-up 31.6 months). LAAT and LAAFD were evidenced on pre-procedural CCTA in 24 (4.3%) and 26 (4.6%) patients, respectively. One hundred fourteen (20.3%) patients died during the study period. Though in-hospital adverse event rates (including stroke) did not differ among groups, mortality at long-term follow-up was higher among LAAT patients compared with those with or without LAAFD (58.3% vs. 11.5% vs. 19.0%, respectively; P < 0.003). By multivariable analysis, LAAT (but not LAAFD) was independently associated with all-cause mortality [hazard ratio (HR) = 3.33 (1.83-6.00), P < 0.001]. In patients with LAAT, oral anticoagulation at discharge was associated with lower mortality risk, independently of atrial fibrillation status.

CONCLUSIONS

LAAT visualized by pre-procedural CCTA is an independent predictor of late mortality following TAVR, but not peri-procedural stroke. When reporting TAVR-CCTA, particular note should be made of LAA features and presence of LAAT which may have prognostic and management implications.

Correlation between CT-derived cardiac chamber volume, myocardial injury and mortality in acute pulmonary embolism

INTRODUCTION

The release of troponin in patients with acute pulmonary embolism (PE) is assumed to be secondary to elevated intracardiac chamber pressure. Since right ventricular (RV) hypertrophy does not develop in the acute setting, pressure overload correlates with chamber dilatation, causing myocardial injury. The aim of the present study was to investigate correlations between cardiac chamber volume, troponin and subsequent early mortality in patients with acute PE and refine risk stratification.

MATERIALS AND METHODS

Patients who underwent a computerized tomographic pulmonary angiogram (CTPA) and a troponin test within 24 h of the CTPA were included. Automated software calculated the volumes of the four cardiac chambers indexed to body surface area (BSA) and correlated them to troponin and early all-cause mortality.

RESULTS

The final cohort consisted of 370 patients (56% females) with acute PE. RV volume and right to left ventricular volume ratio (VVR) were the most significant indicators for elevated troponin (receiving operating characteristic [ROC] 0.796, confidence interval [CI]: 0.749-0.843, p < 0.001, and ROC 0.802, CI: 0.753-0.851, p < 0.001, respectively). VVR cutoff values, which are predictive of elevated troponins, correlated with higher 30-day mortality (odds ratio = 3.1, CI 1.5-6.7, p = 0.003) for a VVR >3 compared to a VVR <2.

CONCLUSION

Cardiac chamber volume correlates to elevated troponin in patients with acute PE. A higher VVR reflects an increased likelihood for myocardial ischemia, as well as an increased short-term mortality risk. These data are available seconds after CTPA performance and may contribute to refining patients' risk stratification.

Prognostic value of right atrial dilation in patients with pulmonary embolism

Aims

Right atrial (RA) dilation and stretch provide prognostic information in patients with cardiovascular diseases. We investigated the prevalence, confounding factors and prognostic relevance of RA dilation in patients with pulmonary embolism (PE).

Methods

Overall, 609 PE patients were consecutively included in a prospective single-centre registry between September 2008 and August 2017. Volumetric measurements of heart chambers were performed on routine non-electrocardiographic-gated computed tomography and plasma concentrations of mid-regional pro-atrial natriuretic peptide (MR-proANP) measured on admission. An in-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration.

Results

Patients with an adverse outcome (11.2%) had larger RA volumes (median 120 (interquartile range 84-152) versus 102 (78-134) mL; p=0.013), RA/left atrial (LA) volume ratios (1.7 (1.2-2.4) versus 1.3 (1.1-1.7); p<0.001) and MR-proANP levels (282 (157-481) versus 129 (64-238) pmol·L^-1; p<0.001) compared to patients with a favourable outcome. Overall, 499 patients (81.9%) had a RA/LA volume ratio ≥1.0 and a calculated cut-off value of 1.8 (area under the curve 0.64, 95% CI 0.56-0.71) predicted an adverse outcome, both in unselected (OR 3.1, 95% CI 1.9-5.2) and normotensive patients (OR 2.7, 95% CI 1.3-5.6). MR-proANP ≥120 pmol·L^-1 was identified as an independent predictor of an adverse outcome, both in unselected (OR 4.6, 95% CI 2.3-9.3) and normotensive patients (OR 5.1, 95% CI 1.5-17.6).

Conclusions

RA dilation is a frequent finding in patients with PE. However, the prognostic performance of RA dilation appears inferior compared to established risk stratification markers. MR-proANP predicted an in-hospital adverse outcome, both in unselected and normotensive PE patients, integrating different prognostic relevant information from comorbidities.

Detection of severe pulmonary hypertension based on computed tomography pulmonary angiography

Pulmonary hypertension (PH) is often diagnosed late in the disease course. As many patients may undergo computed tomography pulmonary angiography (CTPA) for exclusion of pulmonary embolism (PE), we aimed to create a model that can detect the existence of PH and grade its severity. Consecutive patients who underwent CTPA which was negative for PE, and echocardiography study within 24 h, were included. The CT parameters evaluated to assess PH were: the diameters of the main pulmonary artery (MPA), ascending aorta (AA), calculation of each heart chamber volume, and the severity of reflux of contrast material. Randomly, 70% of patients were included in the model creation group, and 30% were used to validate the model. The final study group included 740 patients, 268 male patients, median age 72 years. 374 patients (51%) had PH, of them 94 (13%) had severe PH on the echocardiography. Right atrium (RA) and Left atrium (LA) volume indices were the strongest parameter to indicate PH (area under the curve, AUC = 0.738 and 0.736, respectively), while Right ventricle (RV) and RA volume indices were the strongest parameter to identify severe PH (AUC = 0.735 and 0.715, respectively) with MPA diameter being the least influential indicator (AUC = 0.623). Using the patients age, gender, and multiple CTPA parameters, we created a model for predicting the existence of severe PH. After validation, the model demonstrated 91% sensitivity and a negative predictive value of 97%. Applying our models, CTPA can be used to identify severe PH immediately after the completion of CTPA exam.

Re-Appraisal of Echocardiographic Assessment in Patients with Pulmonary Embolism: Prospective Blinded Long-Term Follow-Up

BACKGROUND

Acute pulmonary embolism (PE) is considered to be one of the most common cardiovascular diseases with considerable mortality. Conflicting data imply possible role for echocardiography in assessing this disease.

OBJECTIVES

To determine which of the echo parameters best predicts short-term and long-term mortality in patients with PE.

METHODS

We prospectively enrolled 235 patients who underwent computed tomography of pulmonary arteries (CTPA) and transthoracic Echocardiography (TTE) within < 24 hours. TTE included a prospectively designed detailed evaluation of the right heart including right ventricular (RV) myocardial performance index (RIMP), RV end diastolic and end systolic area, RV fractional area change, acceleration time (AT) of pulmonary flow and visual estimation. Interpretation and performance of TTE were blinded to the CTPA results.

RESULTS

Although multiple TTE parameters were associated with PE, all had low discriminative capacity (AUC < 0.7). Parameters associated with 30-day mortality in univariate analysis were acceleration time (AT) < 81 msec (P = 0.04), stroke volume < 44 cc (P = 0.005), and RIMP > 0.42 (P = 0.05). The only RV independent echo parameter associated with poor long-term prognosis (adjusted for significant clinical, and routine echo associates of mortality) was RIMP (hazard ratio 3.0, P = 0.04). The only independent RV echo parameters associated with mortality in PE patients were RIMP (P = 0.05) and AT (P = 0.05). Addition of RIMP to nested models eliminated the significance of all other parameters assessing RV function.

CONCLUSIONS

Doppler-based parameters like pulmonary flow AT, RIMP, and stroke volume, have additive value in addition to visual RV estimation to assess prognosis in patients with PE.

Invasive- versus computed tomography-angiography for the evaluation of coronary artery disease among elderly patients undergoing transcatheter aortic valve implantation

Background

Coronary artery disease (CAD) is common among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Current guidelines recommend that percutaneous coronary intervention (PCI) of &gt;70% proximal coronary lesions prior to TAVI. The aim of the current study was to evaluate two approaches to CAD diagnosis pre-TAVI.

Methods

We investigated 2,027 patients undergoing TAVI for severe aortic stenosis at two large centers with different pre-procedural CAD assessment: pre-TAVI computed tomography angiography (CTA) with selective invasive angiography according to CTA results (N=831) or mandatory invasive angiography (IA) (N=1,196). Peri-procedural complications were documented according to the VARC-2 criteria. Mortality rates were prospectively documented.

Results

Mean age of the study population was 86±4, of whom 55% were female. Patients in the IA group had significantly higher rates of pre-TAVI PCI compared to the CTA group (32% vs. 17%, p&lt;0.001). Following TAVI, peri-procedural myocardial infarction (MI) rates were significantly lower among the IA group (0.1% vs. 1.5%, p=0.001). However, multivariate binary logistic regression analysis adjusted for age, gender and cardiovascular risk factors failed to show association between centers strategy and peri-procedural MI. Periprocedural bleeding rates were similar between the groups (3.5% vs. 2.9%, p=0.477). Thirty day, and 1-year mortality crude rates were similar between the groups (2.5% vs. 3.4%, p=0.25, and 10.2% vs. 12.0%, p=0.19). Multivariate cox regression adjusted for age, gender and cardiovascular risk factors did not find association between CAD clearance strategy and outcome.

Conclusions

In elderly patients, CTA driven approach for CAD evaluation pre-TAVI is a valid strategy with similar outcome as compared to invasive approach. CTA strategy significantly reduces invasive procedures rates without compromising patient's outcome.

Funding Acknowledgement

Type of funding source: None

Cardiac Gated Computed Tomography Angiography Discloses a Correlation Between the Volumes of All Four Cardiac Chambers and Heart Rate in Men But Not in Women

Background: Currently, normal values of the cardiac chambers' volumes are adjusted only for gender and body surface area (BSA). We aim to investigate the association between the heart rate and the volume of each of the four cardiac chambers using cardiac-gated computed tomography angiography (CCTA).

Methods: A total of 350 consecutive patients without known cardiac diseases or significant (>50%) stenosis undergoing CCTA between January 2009 and June 2014 for suspected coronary artery disease were included. Cardiac chamber volumes adjusted to BSA were calculated using automated model-based segmentation analysis software of the CCTA data and correlated with patients' mean heart rate during the scan.

Results: There were 240 men and 110 women, median interquartile range age was 55 years (47–61). Women were older 59.0 years (53.7–64) versus 52.0 years (45.0–59.0), had higher prevalence of hyperlipidemia, diabetes mellitus, anemia, and hypothyroidism, and higher median heart rates 64.0 (59.7–66.0) versus 60.0 (55.0–65.0) (p < 0.001). Men had a negative correlation between the volume of each cardiac chamber and the heart rate [r_{age_adj} = (−0.4)–(−0.27), p < 0.001 for all], whereas such a correlation was not found in women. The multivariate analysis showed that a decrease of five beats per minute was associated with an increase of 4%–5% in volume of each chamber in men. There was no such association among females.

Conclusions: Lower heart rate is associated with an increase of each cardiac chamber volume by CCTA in men. This association is not found in women. More extensive studies are required to further elaborate on these gender differences.

High Prevalence of Right Ventricular/Left Ventricular Ratio ≥1 Among Patients Undergoing Computed Tomography Pulmonary Angiography

AIM

Increased ratio between the right and left ventricular (RV/LV) diameters ≥1 is considered an important imaging marker for risk stratification among patients diagnosed with acute pulmonary embolism (PE). Our goal was to assess the prevalence of RV/LV≥1 among consecutive patients undergoing computed tomography pulmonary angiography, and to compare the prevalence of RV/LV≥1 between patients with and without PE.

METHODS

Retrospective analysis of consecutive patients who underwent computed tomography pulmonary angiography due to clinical suspicion of PE between January 1, 2014 and December 31, 2014. The axial RV/LV diameters were measured. The prevalence of RV/LV ≥1 was compared between patients with and without PE and among PE patients, between those with central versus peripheral PE.

RESULTS

The final cohort included 862 patients. A total of 142 (16.5%) had PE. RV/LV ≥1 was found in 553 (64.1%) of all patients, of them in 453 (63%) patients without PE and in 100 (70.4%) patients with PE (P=0.117). On multivariate analysis, PE was not significantly associated with RV/LV ≥1 (odds ratio [OR]: 1.4; 95% confidence interval [CI]: 0.9-2.1; P=0.102). There was no significant difference in the prevalence of RV/LV ≥1 among patients with central versus peripheral PE distribution (79.5% vs. 67%, P=0.101). Older age (OR: 1.03; 95% CI: 1.02-1.04; P<0.001) and male gender (OR: 1.51; 95% CI: 1.11-2.03; P=0.008), among all patients, were significantly associated with RV/LV diameter ≥1.

CONCLUSION

As RV/LV ≥1 is highly prevalent (64.1%), without a significant difference between those with and without PE, an RV/LV ≥1 might not represent the cardiac response to the acute PE event, but rather the patient's baseline condition.

Deep Learning-based Approach for Automated Assessment of Interstitial Lung Disease in Systemic Sclerosis on CT Images

Purpose

To develop a deep learning algorithm for the automatic assessment of the extent of systemic sclerosis (SSc)-related interstitial lung disease (ILD) on chest CT images.

Materials and Methods

This retrospective study included 208 patients with SSc (median age, 57 years; 167 women) evaluated between January 2009 and October 2017. A multicomponent deep neural network (AtlasNet) was trained on 6888 fully annotated CT images (80% for training and 20% for validation) from 17 patients with no, mild, or severe lung disease. The model was tested on a dataset of 400 images from another 20 patients, independently partially annotated by three radiologist readers. The ILD contours from the three readers and the deep learning neural network were compared by using the Dice similarity coefficient (DSC). The correlation between disease extent obtained from the deep learning algorithm and that obtained by using pulmonary function tests (PFTs) was then evaluated in the remaining 171 patients and in an external validation dataset of 31 patients based on the analysis of all slices of the chest CT scan. The Spearman rank correlation coefficient (ρ) was calculated to evaluate the correlation between disease extent and PFT results.

Results

The median DSCs between the readers and the deep learning ILD contours ranged from 0.74 to 0.75, whereas the median DSCs between contours from radiologists ranged from 0.68 to 0.71. The disease extent obtained from the algorithm, by analyzing the whole CT scan, correlated with the diffusion lung capacity for carbon monoxide, total lung capacity, and forced vital capacity (ρ = -0.76, -0.70, and -0.62, respectively; P < .001 for all) in the dataset for the correlation with PFT results. The disease extents correlated with diffusion lung capacity for carbon monoxide, total lung capacity, and forced vital capacity were ρ = -0.65, -0.70, and -0.57, respectively, in the external validation dataset (P < .001 for all).

Conclusion

The developed algorithm performed similarly to radiologists for disease-extent contouring, which correlated with pulmonary function to assess CT images from patients with SSc-related ILD.Supplemental material is available for this article.© RSNA, 2020.

Impact of right ventricular volumes on the outcomes of TAVR: a volumetric analysis of preprocedural computed tomography

AIMS

The aim of this study was to assess the prognostic implications of increased right ventricle volume index (RVVI) using cardiac-gated computed tomography angiography (CCTA) data among patients undergoing transcatheter valve replacement (TAVR).

METHODS AND RESULTS

CCTA of 323 patients who underwent TAVR at Stanford University Medical Center (CA, USA) and Tel Aviv Medical Center (Israel) between 2013 and 2016 was analysed by an automatic four-chamber volumetric software and grouped into quartiles according to RVVI. Higher one-year mortality rates were noted for the upper quartiles - 5%, 4.9%, 8.6%, and 16% (p=0.039), in Q1 <59 ml/m2, Q2 59-69 ml/m2, Q3 69-86 ml/m2, and Q4 >86 ml/m2, respectively. However, the differences were not significant after propensity score adjustments. Sub-analyses of Q1 demonstrated an escalating risk for one-year mortality in concordance to RVVI: HR 2.28, HR 2.76, and HR 4.7, for the upper 25th, 15th, and 5th percentiles, respectively (p<0.05 for all comparisons). After propensity score adjustments for clinical and echocardiographic characteristics, only the upper 5th percentiles (RVVI >120 ml/m2) retained statistical significance (HR 2.82, 95% CI: 1.02-7.78, p=0.045). Notably, 68.7% of patients from this group were considered low-intermediate risk for surgery.

CONCLUSIONS

Cardiac volumetric data by CCTA performed for procedural planning may help to predict outcome in patients undergoing TAVR.

P1423 Significantly higher 1-year mortality rate in patients undergoing TAVR with higher right ventricular volumes, as calculated by pre-procedural CT angiography

Background

Cardiac gated computed tomography angiography (CCTA) is the mandatory pre-interventional imaging planning procedure in patients eligible for trans-catheter valve implantation (TAVR). Automated analysis of the cardiac chambers" volumes including the right ventricle (RV), can be obtained from the CCTA and thus contribute to patient selection.

Objectives

To assess the prognostic implications of increased RV volume using a fast automated volumetric analysis software on preprocedural CCTA data among patients undergoing TAVR.

Methods

CCTA of patients who underwent TAVR at two medical centers – Stanford University Medical Center (California, USA) and Tel Aviv Medical Center (Israel) – between 2013 and 2016 were analyzed by an automatic four chamber volumetric analysis (4CVA) software, and grouped according to their RV volume index, into those with the largest RV (upper 5th percentile of RV volume index (&gt;120 ml/m2; n = 16) versus those within the 95th percentile lower volumes index (≤120 ml/m2; n = 307). Differences in baseline characteristics between the groups were adjusted for with a propensity score. The risk for one year mortality following the TAVR was compared between the two groups.

Results

In total 323 patients were included. There were no major differences in background and demographic characteristics between the study groups. A significantly higher 1-year mortality rate was found for patients with large RV (31.3% vs. 7.5%, p = 0.008). After adjustment for clinical characteristics, patients with RV volume index &gt;120 ml/m2 were at almost a 5 times higher risk for 1-year mortality compared to patients with smaller RV (HR 4.9, 95% CI 1.8-13.1, p = 0.002). The addition of echocardiographic parameters to the propensity score did not eliminate the significance of RV volume index &gt;120 ml/m2 as an independent predictor for mortality at 1-year. An analysis of RV as a continuous variable demonstrated that the risk for 1-year mortality increased by 2% for every 1 ml/m2 RV volume enlargement (p = 0.013).

Conclusions

Cardiac volumetric data by CCTA performed for procedural planning may help predict outcome in patients undergoing TAVR.

Abstract P1423 Figure. Cox survival curves according to RVi

Quantitative assessment of effective regurgitant orifice: impact on risk stratification, and cut-off for severe and torrential tricuspid regurgitation grade

Aims 

Asses the added value of quantitative evaluation of tricuspid regurgitation (TR), the proper cut-off value for severe TR and ‘torrential TR’ based on outcome data. The added value of quantitative evaluation of TR, and the cut-off values associated with increased mortality are unknown.

Methods and results

In patients with all-cause TR assessed both qualitatively and quantitatively by proximal iso-velocity surface area method, long-term and 1-year outcome analysis was conducted. Thresholds for excess mortality were assessed using spline curves, receiver-operating characteristic curves, and minimum P-value analysis. The study involved 676 patients with all-cause TR (age 73.9 ± 14 years, male 45%, ejection fraction 52.9 ± 14%). Effective regurgitant orifice (ERO) was strongly associated with decreased survival in unadjusted [hazard ratio (HR) 2.38 (1.79–3.01), P &lt; 0.0001 per 0.1 cm2 increment] and adjusted [2.6 (1.25–5.0), P = 0.01] analyses. Quantitative grading was superior to qualitative grading in prediction of outcome (P &lt; 0.01). The optimal cut-off value for the best separation in survival between groups of patients with severe vs. lesser degree of TR was 0.35 cm2 [P &lt; 0.0001, HR =2.0 (1.5–2.7)]. ERO negatively impacted survival, even when including only the subgroup of patients with severe TR [HR 1.5 (1.01–2.3); P = 0.04]. The optimal threshold corresponding for the best separation for survival between groups of patients with severe vs. ‘torrential’ TR was 0.7 cm2 [P = 0.005, HR =2.6 (1.2–5.1)].

Conclusion 

TR can be severe and even ‘torrential’ and is associated with excess mortality. Quantitative assessment of TR by ERO measurement is a powerful independent predictor of outcome, superior to standard qualitative assessment. The optimal cut-off above which mortality is increased is 0.35 cm2, similar albeit slightly lower than suggested in recent guidelines. Torrential TR &gt;0.7 cm2 is associated with poorer survival compared to patients with severe TR (ERO &gt; 0.4 cm2 and &lt;0.7 cm2).

Data from an integrated cancer prevention center screening for multiple cancer types

e13069

Background: Cancer is the second leading cause of death globally, and was responsible for ~9.6 million deaths in 2018. Importantly, between 30–50% of cancers can be prevented by avoiding risk factors and implementing existing evidence-based prevention strategies. Methods: We present the results of 15758 adults who came to our clinic between 2006 and 2018. Patients were counseled on reducing risk factors and screened for early detection of 11 of the most common cancer types. Patients were examined by specialists in internal medicine, surgery, plastic surgery, OBGYN, urology, oncology, oral surgery, gastroenterology, and others. Women underwent vaginal US, pap smear, mammography (40yr) and US/MRI of the breast with a clinical indication. Men underwent PSA/free PSA ( > 40yr). LDCT for moderate smokers. Colonoscopy was recommended to all subjects ( > 40yr). Results: A total of 7900 (50.1%) men and 7857 women (49.9%) mean age 46.9±11.3 years were screened. A total of 418 (2.7%) malignant lesions were detected in patients who had been screened, 245 (1.6%) of which were detected through our screening: skin 66 (0.4%), prostate 30 (0.2%), thyroid 28 (0.2%), breast 28 (0.2%), colorectal 19 (0.1%), urinary 13 (0.08%), lung 11 (0.07%), cervical 11 (0.07%), other/unknown 9 (0.06%), hematologic 8 (0.05%), ovarian 5 (0.03%), uterine 5 (0.03%), pancreas 3 (0.02%), testicular 3 (0.02%), oropharyngeal 2 (0.01%), hepatobiliary 2 (0.01%), stomach 1 (0.01%), larynx 1 (0.01%). A total of 17 (0.1%) malignant lesions were missed: breast 3 (0.02%), colorectal 3 (0.02%), skin 2 (0.01%), thyroid 2 (0.01%), hematologic 2 (0.01%), pancreas 2 (0.01%), kidney 1 (0.01%), lung 1 (0.01%), brain 1 (0.01%). A total of 147 (0.9%) malignant lesions developed > 1year after a visit. Only forty-nine of the cancer patients (12.5%) died after 18.9±17.8 months at a mean age of 66.5±12.2 years. Significantly, better than the expected cancer mortality in general. First-degree family member with cancer (HR = 1.46) and advanced age (HR = 21.8) was associated with increased cancer risk (P < 0.05). Conclusions: One stop shop cancer screening, in the setting of a multidisciplinary outpatient clinic is feasible, can detect cancer at an early stage, and can significantly improve survival.

Prognostic implications of small left atria on hospitalized patients

Aims

To demonstrate the association between small left atria (LA) and outcome in a relatively large heterogeneous population of hospitalized patients.

Methods and results

In a single-centre retrospective study, all inpatients that underwent an echocardiographic assessment between 2011 and 2016 and had an available left atrial volume index (LAVI) measurement were included. The cohort consisted of 17 343 inpatients who had an available LAVI measurement, 288 with small LA (LAVI <16 mL/m2), 7531 patients had LAVI within normal limits (16–34 mL/m2) divided into low normal (16–24.9 mL/m2; n = 2636) and high normal (25–34 mL/m2; n = 4895), 4720 patients had large LAVI (34.1–45 mL/m2) and 4804 had very large LAVI (>45 mL/m2). Median follow-up time was 2.4 years. After adjustments for age, gender, and baseline characteristics with a P-value <0.2 in univariable analyses (body mass index, haemoglobin, ischaemic heart disease, valvulopathy, atrial fibrillation, diabetes mellitus, hypertension, hyperlipidaemia, smoking, renal dysfunction, lung disease, and malignancy) small LA was associated with a higher risk for in-hospital mortality (odds ratio 2.9, 95% confidence interval (CI) 1.4–5.7; P = 0.002] and all-cause mortality [hazard ratio (HR) 2.1, 95% CI 1.6–2.8; P < 0.001] compared with high normal LA. For every mL/m2 decrease below high normal LA size the risk for in-hospital and long-term all-cause mortality increased by 10% (HR 1.1, 95% CI 1.02–1.18; P = 0.005) and 8% (HR 1.08, 95% CI 1.05–1.12; P < 0.001), respectively.

Conclusion

Small LA are independently associated poorer short- and long-term mortality. LA volume should be referred to as J-shaped in terms of mortality.

Helsinki committee approval number

0170-17-TLV.

Impact of left ventricular filling parameters on outcome of patients undergoing trans-catheter aortic valve replacement

Aim

To assess the impact of left ventricular (LV) filling parameters on outcomes following trans-catheter aortic valve replacement (TAVR).

Methods and results

A total of 526 TAVR patients were compared with 300 patients with severe aortic stenosis (AS) treated conservatively. Clinical variables were collected along with echocardiographic data at baseline, 1 month, and 6 months after study entry. End points included all-cause mortality and the combination of death and heart failure admission. LV filling parameters associated with mortality included reduced A wave velocity (P = 0.005) and shorter deceleration time (DT) (P = 0.0005). DT was superior to all other parameters (P = 0.05) apart from patients with atrial fibrillation in whom E/e' was better. Short DT (<160 ms) was associated with lower survival than long DT (≥220 ms; P = 0.002) or intermediate DT (P = 0.05), even after adjustment for age, gender, stroke volume index (SVI), and co-morbidities. However, patients with short baseline DT exhibited greater improvement in DT, E/A, and systolic pulmonary pressure at follow-up than patients with baseline DT ≥160 ms (P < 0.05 for all time x group interactions). Most importantly, among patients with short DT, TAVR was associated with better survival than conservative treatment (46 ± 7 vs. 28 ± 12% at 3 years, P = 0.05), even after adjustment for age, gender, and SVI (P = 0.05).

Conclusion

Short DT is an independent predictor of adverse outcome following TAVR. Nevertheless, LV filling parameters improve in most patients post TAVR, and TAVR is associated with improved survival compared with conservative therapy, even in patients with evidence of elevated LV filling. Thus, evidence of elevated LV filling should not be viewed as a contraindication for TAVR.

Very Small Left Atrial Volume as a Marker for Mortality in Patients Undergoing Nongated Computed Tomography Pulmonary Angiography

Objectives: To evaluate the association between very small left atria (VSLA) on nongated computed tomography pulmonary angiography (CTPA) and mortality in patients without pulmonary embolism (PE). Methods: Patients who underwent nongated CTPA between 2011 and 2015 in order to rule out PE, and had an echocardiogram within 24 h of the CTPA, were retrospectively identified. The left atrial volume of nongated CTPA was calculated using automatic 4-chamber volumetric analysis software. The association between the lowest 5th percentile of the left atrial volume index, referred to as the VSLA group, and mortality was investigated after adjustment for age, gender, background diseases, and laboratory values. Results: The study cohort included 241 patients. Patients with VSLA had a left atrial volume index <24 mL/m2 (n = 11). Demographics and background diseases did not differ between the study groups. The median follow-up was 22.7 months (IQR 0.03-54.3). VSLA was an independent predictor of mortality (HRadj = 3.6; 95% CI 1.46-8.87; p = 0.005), along with malignancy (HRadj = 2.28; 95% CI 1.32-3.93; p = 0.003) and lower hemoglobin (HRadj = 0.86; 95% CI 0.76-0.99; p = 0.032). Conclusions: Our findings suggest that VSLA on nongated CTPA may serve as a marker for mortality. The use of CTPA volumetric analysis can help risk stratification in patients with dyspnea and no PE.

Automated volumetric analysis of four cardiac chambers in pulmonary embolism

Identification of patients with acute pulmonary embolism (PE) who might be at risk of circulatory collapse by using a fast, automated system is highly desired. It was our objective to investigate whether automated cardiac volumetric analysis following computerised tomographic pulmonary angiography (CTPA) is useful to identify increased clot load and adverse prognosis in patients with acute PE. We retrospectively analysed a consecutive series of non-gated CTPA studies of 124 patients with acute PE and 43 controls. Right and left ventricular diameters (RV/LV) were measured on four-chamber view, while each cardiac chamber underwent automatic volumetric measurements. Findings were correlated to the pulmonary arterial obstruction index (PAOI). Outcome was expressed by admission to an intensive care unit (ICU) or mortality within 30 days. There was a significant positive correlation between the PAOI and the volumes of the right side cavities (r=0.25 for the atrium and r=0.49 for the ventricle), and between the right-to-left atrial and ventricular volume ratios (r=0.49 and r=0.57, respectively). Results for the combined outcome of mortality or ICU admission that fell in the upper tertile of the right atrial and right ventricular volumes yielded hazard ratios of 3.9 and 3.3, respectively, compared to those in the lower tertile. RV/LV diameter ratio did not correlate with outcome. In conclusion, adverse outcome and significant pulmonary clot load in patients with acute PE are associated with a volume shift towards right heart cavities, which correlates to prognosis better than the CT-measured RV/LV diameter ratio, suggesting the advantage of using fast fully automatic volumetric analysis to identify patients at risk.

Shift Work and the Risk of Coronary Artery Disease: A Cardiac Computed Tomography Angiography Study

AIMS

Shift work disrupts the normal circadian rhythm and is associated with risk factors for coronary artery disease (CAD) and a higher incidence of CAD morbidity and mortality. Cardiac computed tomography angiography (CCTA) is a robust noninvasive modality for assessing the presence, extent, and severity of CAD. We sought to investigate whether shift workers are prone to a higher burden of CAD compared to non-shift workers.

METHODS

We conducted a historically prospective study in consecutive patients who underwent CCTA and answered a telephonic questionnaire. Due to significant differences in age and gender, we compared 89 well-matched pairs of shift workers and non-shift workers with the use of propensity scores.

RESULTS

Our cohort consisted of 349 participants, of whom 94 (26.9%) were shift workers. The mean age was 50.7 years, and 62.5% were males. After pairing, we showed that shift workers had a higher prevalence of CAD than non-shift workers (74.2 vs. 53.9%, respectively, p = 0.01), and a lower prevalence of coronary calcium scores of zero (46.8 vs. 63.4%, respectively, p = 0.034). Stenosis >50% was more prevalent in shift workers than in non-shift workers (20.2 vs. 11.2%, respectively, p = 0.006), and the extent of CAD (defined as the presence of ≥1-vessel disease) tended to be higher in shift workers than in non-shift workers (25.8 vs. 13.5%, respectively, p = 0.06).

CONCLUSIONS

In this CCTA study, we showed in a well-matched cohort of consecutive patients that shift workers had a higher prevalence and extent of CAD than non-shift workers.

Identification of Pulmonary Hypertension Caused by Left-Sided Heart Disease (World Health Organization Group 2) Based on Cardiac Chamber Volumes Derived From Chest CT Imaging

BACKGROUND

Evaluations of patients with pulmonary hypertension (PH) commonly include chest CT imaging. We hypothesized that cardiac chamber volumes calculated from the same CT scans can yield additional information to distinguish PH related to left-sided heart disease (World Health Organization group 2) from other PH subtypes.

METHODS

Patients who had PH confirmed by right heart catheterization and contrast-enhanced chest CT studies were enrolled in this retrospective multicenter study. Cardiac chamber volumes were calculated using automated segmentation software and compared between group 2 and non-group 2 patients with PH.

RESULTS

This study included 114 patients with PH, 27 (24%) of whom were classified as group 2 based on their pulmonary capillary wedge pressure. Patients with group 2 PH exhibited significantly larger median left atrial (LA) volumes (118 mL vs 63 mL; P < .001), larger median left ventricular (LV) volumes (90 mL vs 76 mL; P = .02), and smaller median right ventricular (RV) volumes (173 mL vs 210 mL; P = .005) than did non-group 2 patients. On multivariate analysis adjusted for age, sex, and mean pulmonary arterial pressure, group 2 PH was significantly associated with larger median LA and LV volumes (P < .001 and P = .008, respectively) and decreased volume ratios of RA/LA, RV/LV, and RV/LA (P = .001, P = .004, and P < .001, respectively). Enlarged LA volumes demonstrated a high discriminatory ability for group 2 PH (area under the curve, 0.92; 95% CI, 0.870-0.968).

CONCLUSIONS

Volumetric analysis of the cardiac chambers from nongated chest CT scans, particularly with findings of an enlarged left atrium, exhibited high discriminatory ability for identifying patients with PH due to left-sided heart disease.

Mechanisms of Effort Intolerance in Patients With Heart Failure and Borderline Ejection Fraction

Combining echocardiography and cardiopulmonary stress testing allows noninvasive assessment of hemodynamics, and oxygen extraction (A-VO₂ difference). We evaluated mechanisms of effort intolerance in patients with heart failure with borderline (40% to 49%) left ventricular ejection fraction (EF) (HF and Borderline Ejection fraction). We included 89 consecutive patients with HF and Borderline Ejection fraction (n = 25; 63.6 ± 14 years, 64% men), control subjects (n = 22), patients with HF with preserved EF (n = 26; EF ≥50%), and patients with HF with reduced EF (n = 16; <40%). Various echo parameters (left ventricular volumes, EF, stroke volume, mitral regurgitation [MR] volume, e', right ventricle end-diastolic area, and right ventricle end-systolic area), and ventilatory or combined parameters (peak oxygen consumption [VO₂] and A-VO₂ difference) were measured at 4 predefined activity stages. Effort-induced functional MR was frequent and more prevalent in HF and Borderline Ejection fraction than in all the other types of HF. In multivariable analysis heart rate response (p <0.0001), A-VO₂ difference (p = 0.02), stroke volume (p = 0.002), and right ventricle end-systolic area were the only independent predictors of exercise capacity in HF and Borderline Ejection fraction but peak EF was not. In HF and Borderline Ejection fraction exercise intolerance is predominantly due to chronotropic incompetence, peripheral factors, and limited stroke volume reserve, which are related to right ventricle dysfunction and functional MR but not to left ventricular ejection fraction. Combined testing can be helpful in determining mechanisms of exercise intolerance in HF and Borderline Ejection fraction.

Comparison of the Edwards SAPIEN S3 Versus Medtronic Evolut-R Devices for Transcatheter Aortic Valve Implantation

New generation of the most widely used devices for transcatheter aortic valve implantation have been recently introduced into practice. We compare the short-term outcomes of transcatheter aortic valve implantation with the Edwards SAPIEN S3 and the Medtronic Evolut-R. We performed a retrospective analysis from a single high-volume tertiary center. Valve Academic Research Consortium-2 criteria were used to define composite end points of device success and safety at 30 days. Study population included 232 patients implanted with the SAPIEN S3 (n = 124) and Evolut-R (n = 108). Device success reached 91.9% and 95.4% in the SAPIEN S3 and Evolut-R groups, respectively (p = 0.289). Postprocedural echocardiography showed greater aortic valve gradients (22.8 ± 7 vs 16 ± 9 mm Hg, p <0.001) among SAPIEN S3 group. Paravalvular leak of ≥ moderate severity was observed in 2.4% and 0% in the SAPIEN S3 and Evolut-R groups, respectively (p = 0.251). Similar rates of in-hospital complications, including major bleedings, vascular complications, and pacemaker implantations were recorded in both groups. At 30-day follow-up, the combined safety end point was reached in 5.6% and in 6.5% of patients in the SAPIEN S3 and Evolut-R groups, respectively (p = 0.790). During follow-up of 237 ± 138 days, all-cause mortality was higher in patients implanted with Evolut-R compared with SAPIEN S3 (7 vs 1 cases, respectively, p = 0.006), however, cardiovascular mortality was not significantly different between groups. In conclusions, in a single-center comparative analysis, comparable rate of device success as well as safety profile and long-term cardiovascular mortality were observed with the SAPIEN S3 and Evolut-R valves.

Use of New Imaging CARTO® Segmentation Module Software to Facilitate Ablation of Ventricular Arrhythmias

INTRODUCTION

A new imaging software (CARTO® Segmentation Module, Biosense Webster) allows preprocedural 3-D reconstruction of all heart chambers based on cardiac CT. We describe our initial experience with the new module during ablation of ventricular arrhythmias.

METHODS AND RESULTS

Eighteen consecutive patients with idiopathic ventricular arrhythmias or ischemic ventricular tachycardia (VT) were studied. In the latter group, a combined endocardial and epicardial ablation was performed. Of the 14 patients with idiopathic arrhythmias, 12 were ablated in the outflow tract (OT), 1 in the midseptal left ventricle, and 1 at the left posterior fascicular area; acute successful ablation was achieved in 11 (78.6%) patients. The procedure was discontinued due to close proximity of the arrhythmia origin to the coronary arteries (CA) in 2 patients. Acute successful uncomplicated ablation was achieved in all 4 patients with ischemic VT. During ablation in the coronary cusps commissures, the CARTO® Segmentation Module accurately defined the cusps anatomy. The precise anatomic location provided by the module assisted in successfully ablating when information from activation mapping was not optimal, by ablating at the opposite side of the cusps. In addition, by demonstrating the precise location of the CA, it allowed safe ablation of arrhythmias that originated in close proximity to the CA both in the OT area and the epicardium, eliminating the need for repeat angiography.

CONCLUSIONS

The CARTO® Segmentation Module is useful for accurate definition of the exact anatomic location of ventricular arrhythmias and for safely ablating them especially in close proximity to the CA.