11th International Conference of Non-Invasive Cardiovascular Imaging
Advanced Accelerator Applications
Inserm U698-Hospital Bichat-Claude Bernard
AP-HP-Hospital Bichat-Claude Bernard, Department of Nuclear Medicine
MediCity Research Laboratory, University of Turku, and National Institute of Health and Welfare
J.M.U. Johanna Silvola
A.I. Virtanen Institute for Molecular Sciences at the University of Eastern Finland
Turku PET Centre, University of Turku & Turku University Hospital
Turku University Hospital, Department of Medicine
North Cardiology Hospital
Mount Sinai School of Medicine
United States of America
University of Ottawa
Gabriele Monasterio Foundation, Department of Cardiovascular Medicine
University Hospital Zurich
United States of America
St. Luke's Mid America Heart Institute
United States of America
University of Missouri-Kansas City
United States of America
Cardiology Center Monzino (IRCCS), Department of Cardiovascular Sciences, University of Milan
Cardiology Center Monzino (IRCCS)
Isala Hospital-Department of Nuclear Medicine
Isala Hospital-Department of Clinical Physics
University of Twente, MIRA-Institute for Biomedical Technology & Technical Medicine
Cardiology Unit-University Hospital
Cardiology Unit-Delta's Hospital
Nuclear Medicine Unit-University Hospital
C.J. Cornelis Jacobus Roos
Leiden University Medical Center, Department of Cardiology
Institute Euromedica-Encephalos, 251 Hellenic Airforce Hospital
Euroclinic Hospital, Institute Euromedica-Encephalos
251 Hellenic Airforce Hospital
Leiden University Medical Center, Department of Radiology, Division of Image Processing
M.A. Michiel De Graaf
Medicine Faculty, Department of Biostatistics
University Hospital ''Nene Teresa''
American Hospital, Balkan Alliance Group
Upper Silesian Cardiology Center
Medical University of Silesia
Upper-Silesian Cardiology Center
University of Michigan
United States of America
National Guard Hospital, King Abdulaziz Cardiac Center (KACC)
University Hospital ''Nene Teresa''
University of Tirana, Faculty of Medicine, Department of Public Health, Division of Biostatistics
Heart Centre & Department of Public Health & Clinical Medicine, Umea University
T.M. Tarek Mohamed Bengrid
Abstracts of original contributions
11th International Conference of
Non-Invasive Cardiovascular Imaging
May 58, 2013
Organised in conjunction with
American Society of Nuclear Cardiology
Cardiovascular Committee of the European Association of Nuclear Medicine
and the Working Group on Nuclear Cardiology and Cardiac CT of the
European Society of Cardiology
Welcome address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgements Graders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Abstracts Presented on Monday 6 May 2013
Oral Abstract Session 1: Young Investigator Award Competition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oral Abstract Session 2: SPECT MPI: New approaches and applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Moderated Posters 1 Morning: Advances in instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Poster Session 1 Morning: Advances in instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Moderated Posters 2 Afternoon: New pharmaceuticals: regandenosin and MIBG . . . . . . . . . . . . . . . . . . . . . . . . . . .
Poster Session 2 Afternoon: New pharmaceuticals: PET, regandenosin and MIBG . . . . . . . . . . . . . . . . . . . . . . . .
Abstracts Presented on Tuesday 7 May 2013
Oral Abstract Session 3: Advances in PET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oral Abstract Session 4: Refining cardiac risk assessment with imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Moderated Posters 3 Morning: Imaging cardiovascular disease mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Poster Session 3 Morning: Imaging cardiovascular disease mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Moderated Posters 4 Afternoon: Left ventricular function and new insights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Poster Session 4 Afternoon: Left ventricular function and new insights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Abstracts Presented on Wednesday 8 May 2013
Oral Abstract Session 5: Novel cardiovascular molecular imaging probes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oral Abstract Session 6: Cardiac CT: New approaches and applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Poster Session 5 Morning: Clinical General and Outcome: Cardiac CT Posters . . . . . . . . . . . . . . . . . . . . . . . . . . .
Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Index of Topics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
This supplement was not sponsored by outside commercial interests. It was funded entirely by the International
Conference on Nuclear Cardiology.
Dear Colleagues and Friends,
It is our great pleasure to welcome you to ICNC11, the International Conference on Nuclear Cardiology and Cardiac
CT. The ICNC meeting has been a key international scientific event for nuclear cardiology and cardiac CT imaging for
more than 20 years. It provides the opportunity for practitioners from all over the world to gather to learn about new
advances and to exchange scientific ideas and experiences in a distinctive environment.
Over the next few days the meeting will provide an exciting and diversified scientific programme which offers a full
spectrum of educational opportunities ranging from continuing education to cutting-edge presentations of new and
original scientific research. A core curriculum, as well as advanced and research tracks will be available. As in the past,
submitted abstracts will come from a wide geographical area which reinforces the message that ICNC is an important
international scientific event. Many Read with the Experts case review sessions will allow participants to improve
their interpretative skills for cardiac CT and SPECT and PET examinations.
Unique to this meeting will be an even greater emphasis on presentations by young investigators. In addition to the
awards and grants we already offer such as the ESC Working Group Travel Grants and the free registration for
presenters in the Young Investigator Awards session, this year we will be offering two new categories of grants, the
ICNC Grants and the ICNC Young Scientist Award. These 25 grants attributed to abstract presenters and young
cardiologists will be generously provided by the ICNC Organising Committee and will carry a stipend of 1 500 per
person. The Young Scientist Award will carry a stipend of 5 000. The winner will be announced at the gala dinner on
Tuesday, 6 May.
The beautiful city of Berlin is the venue for ICNC11. Germanys capital city combines all the things necessary for a
successful congress, including a robust medical science community, a rich history, lively entertainment and
affordability. Indeed, the ICNC organisers have selected this city for its popularity not only within Europe but because it is a
favoured destination from the Americas, Asia and throughout the world.
Thank you for choosing to attend ICNC11. We are pleased that you are here and hope you enjoy the meeting and the
wonderful city of Berlin.
Frank Bengel, DE Organising Co-Chair
Robert Gropler, US Organising Co-Chair
Robert Beanlands, CA Industry Liaison
Programme Committee Chairpersons
Sharmila Dorbala, US Programme Chair
Michael Zellweger, CH Programme Chair
Randall Thompson, US Programme Chair
Robert Hendel, US Meeting Services
Juhani Knuuti, FI Scientific Advisor
The Programme Committee for the International Conference of Non-Invasive Cardiovascular Imaging gratefully
acknowledges the assistance of the following individuals who served as Abstract Graders for the original contributions
sessions. Our experts graded the abstracts anonymously. The authors names and details were not known at any point in
time during the grading process.
Ichiro Matsunari, Japan
Jennifer H Mieres, United States of America
James Min, United States of America
Fernando Mut, Uruguay
Tomoaki Nakata, Japan
Danilo Neglia, Italy
Stephan Nekolla, Germany
Pasquale Perrone-Filardi, Italy
Steven C Port, United States of America
John O Prior, Switzerland
Paolo Raggi, Canada
Ornella Rimoldi, Italy
Dieter Ropers, Germany
Terrence D Ruddy, Canada
Michael Schaefers, Germany
Heinrich R Schelbert, United States of America
Thomas Hellmut Schindler, Switzerland
Arthur Scholte, Netherlands
Stephen Schroeder, Germany
Joanne D Schuijf, Netherlands
Karl Heinz Schuleri, United States of America
Markus Schwaiger, Germany
Udo Sechtem, Germany
Albert Sinusas, United States of America
Riemer Hja Slart, Netherlands
Piotr Slomka, United States of America
Paola Smanio, Brazil
Stephen Stowers, United States of America
Raymond Taillefer, Canada
Nagara Tamaki, Japan
Randall Thompson, United States of America
Mark Travin, United States of America
Mustafa Unlu, Turkey
Berthe Van Eck-Smit, Netherlands
Joao V Vitola, Brazil
Juergen Vom Dahl, Germany
Frans Wackers, United States of America
Lee Samuel Wann, United States of America
Kim Allan Williams, United States of America
Michael JohannesZellweger, Switzerland
Frank Bengel, DE Organising Co-Chair
Robert Gropler, US Organising Co-Chair
Robert Beanlands, CA Industry Liaison
Robert Hendel, US Meeting Services
Juhani Knuuti, FI Scientific Advisor
Sharmila Dorbala, US Programme Chair
Michael Zellweger, CH Programme Chair
Randall Thompson, US Programme Chair
Advisors to the Programme Committee
G DePuey, US
M Freeman, CA
E Garcia, US
G Germano, US
D Glover, US
G Heller, US
L Hofstra, NL
P Kaufmann, CH
A Kitsiou, GR
I Saeed, US Y Sasaki, JP M Schaefers, DE H Schelbert, US
B Zaret, US J Ziffer, US
Oral Abstract Session
Young Investigator Award Competition
Monday 6 May, 2013, 14:0015:30
S. Fuerst1; M. Souvatzoglou1; C. Rischpler1; S.I. Ziegler1;
M. Schwaiger1; S.G. Nekolla1
1Hospital rechts der Isar of the TU Munich, Department of Nuclear
Medicine, Munich, Germany
Purpose: Gadolinium-based MR contrast agents (CA) do not
significantly affect PET annihilation photons. However, by enhancing the
MR signal they possibly influence the MR-derived attenuation
correction in hybrid PET/MR. The aim was to assess this effect on
attenuation map (lmap) generation and PET quantification with the
Biograph mMR PET/MR.
Methods: lmaps were generated by acquiring MR data with a 2-point
DIXON sequence and segmenting them using thresholds. 22 patients
referred for viability imaging were scanned before and after CA
administration. These PET images were reconstructed: post-CA data/
lmap and post-CA data/pre-CA lmap. Volumes of lung, fat and soft
tissue in the lmaps were determined and the response to CA
investigated over time. Myocardial uptake in the left ventricle (LV) was
volumetrically quantified in 17 segment and regional differences
between the data sets were assessed.
Results: For all patients, the volume of lung tissue and fat in the lmaps
after injection of CA was reduced, whereas the amount of soft tissue
was increased. The changes were on average (-12.9 24.9)%,
(-35.8 18.4)% and (16.2 8.3)% for lung, fat and soft tissue. In
none of the patients, the lmap composition recovered to the state
before CA injection until the exam finished. An effect on the SUV of
more than 10% was found in 42.9% of the segments, whereas the
respective global SUV variations ranged between -3.0% and +26.8%.
Conclusions: MR CA has both significant local and global effects in
cardiothoracic imaging. Tissue misclassifications are independent of
the investigated range of delays after CA injection, leading to
hampered quantification of otherwise adequate PET raw data. Thus, lmaps
should be acquired pre-CA and CA-optimized segmentation
parameters are needed.
Room 4 A05
M. Mohamed Mouden1; J.P. Ottervanger1; J.R. Timmer1;
S. Reiffers1; A.H.J. Oostdijk1; S. Knollema1; P.L. Jager1
1Isala Hospital, Zwolle, Netherlands
Purpose: We investigated the influence of coronary artery calcium
(CAC) scores on the visual interpretation of myocardial perfusion
imaging in stable patients referred for the diagnostic work-up of
suspected coronary artery disease (CAD).
Methods: Patients without a previous history of CAD in whom CAC
scoring was concomitantly performed with a hybrid 64-slice SPECT/
CT device were retrospectively identified. For the current analysis we
selected all 151 patients who underwent invasive angiography within
3 months after myocardial perfusion imaging. Experienced readers
interpreted myocardial perfusion images in two separate sessions with
and without knowledge of a patients CAC score. We compared both
readings with regard to the frequency of equivocal readings, and
calculated changes in diagnostic accuracy using angiography with C70%
luminal narrowing as a reference standard for obstructive CAD.
Results: The addition of the CAC score changed the interpretation of
myocardial perfusion images in 56 patients (37%) with a major effect
on diagnostic accuracy in 39 patients (26%). The frequency of
equivocal perfusion interpretations decreased from 21% to 9%
(P = .002). Sensitivity of myocardial perfusion imaging increased
from 48% to 64% (P = .019) with comparable specificity (72% to
68%, P = .628).
Conclusions: In this highly selected group knowledge of the CAC
score improved the interpretation of myocardial perfusion imaging and
reduced the number of equivocal readings.
Objectives: 99mTc-HYNIC-AnnexinA5 (99mTc-HYNIC-Anx) has
been shown to allow in vivo scintigraphic detection of cardiomyocytes
death in experimental myocarditis, via high-affinity binding to
phosphatidylserines. Anx-128 is a new mutant of AnnexinA5 which possesses
an endogenous peptidic chelation site at its N terminus. 99mTc-Anx-128
has been produced according to GMP procedure. The aim of this study
was to compare 99mTc-Anx-128 to 99mTc-HYNIC-Anx in a rat model
of acute myocarditis, to determine its potential interest for further clinical
applications in patients with myocarditis.
Methods: Acute myocarditis was induced in 13 Wistar rats by
immunization with purified rat cardiomyosin (600 lg 9 2, in Freund
adjuvant). Rats were imaged 3 weeks after immunization with both
99mTc-Anx-128 then 99mTc-HYNIC-Anx or vice versa at 2 days
intervals. SPECT/CT images were acquired on a NanoSPECT/CTplus
(Bioscan Inc.) device, 1 hour after tracers injection (60 MBq).
Autoradiography (Beta ImagerTM, Biospace Lab) and histological studies of
heart sections were performed after the second scan. All experiments
were also performed in eight control rats injected with Freund
Results: All immunized rats had positive dual imaging, with similar
myocardial uptake of the two tracers in terms of topography and
intensity. Myocardial-to-background activity ratio was 2.3 1.46* in
immunized rats vs 0.9 0.32 in controls P = .01 using 99mTc-
HYNIC-Anx, and 2.7 1.3* vs 1.16 0.18; P = .004 using
99mTc-Anx128 (*NS). Autoradiographic and histological data confirmed
co-localization of both tracers in myocardial areas of cardiomyocytes
death, and no uptake in normal myocardium of control rats.
Conclusions: 99mTc-Anx-128 is accurate and comparable to
99mTcHYNIC-Anx for in vivo detection of cardiomyocytes death in
experimental acute myocarditis. These results confirm potential interest of
this new tracer for clinical application in patients with myocarditis.
Combining preoperative information from speckle tracking
echocardiography, cardiac CT scan and MRI scan adds
important information in patients receiving cardiac
resynchronization therapy implants
Purpose: To evaluate the incremental value of using preoperative
cardiac CT and MRI in combination with echocardiography evaluation
of segmental mechanical delay, for guiding optimal left ventricular
lead placement in cardiac resynchronization therapy (CRT).
Methods: 23 patients (70 9 years, 78% male, 86% with LBBB, 57%
with ischemic CMP, 91% C NYHA 3) eligible for CRT were included
consecutively. The left ventricular segment with latest mechanical
activation was determined using echocardiography with speckle
tracking radial strain. Cardiac CT scan was used for evaluation of
coronary sinus anatomy. Cardiac MRI was used for evaluation of
viability in each segment. A composite bulls-eye plot was constructed
for each patient, indicating the optimal site for LV lead placement
Results: The latest mechanical delay was in the mid inferolateral
segment (n = 4), base inferolateral (5), mid anterolateral (3), base
anterolateral (2), mid anterior (3), base anterior (1), mid inferior (3) or
base inferior (2). There were 2.5 0.8 veins of suitable size (C1.5 mm
in diameter), and in 13 patients there was a matching vein in the
segment with the latest mechanical delay, i.e. an optimal placement
was possible. In 9/10 of those patients who had no eligible vein
anatomy at the optimal segment, an adjacent segment was available. In
the total group, MRI showed nontransmural (\50%) infarction in 24%
of all segments and transmural infarction (50-100%) in 7%. In one
patient there was transmural infarction in the optimal segment, thereby
altering the optimal LV lead placement.
Conclusions: Using cardiac CT in combination with echocardiography
and MRI makes it possible to determine if an optimal lead placement is
possible already preoperatively, and can be helpful in planning the
targeted implant procedure.
Purpose: Vascular adhesion protein-1 (VAP-1) plays a key role in
recruiting leukocytes into sites of inflammation. VAP-1 is stored in
intracellular granules of endothelial cells, but upon inflammation it is
rapidly translocated to the endothelial cell surface. Using a phage
display approach, we have recently discovered that sialic acid-binding
Ig-like lectin 9 (Siglec-9) is a granulocyte ligand for vascular
adhesion protein 1 (VAP-1) and a 68Ga-Siglec-9 peptide specifically
detects VAP-1 in vasculature at sites of inflammation. Since the
inflammation has a prominent role also in atherosclerosis, the novel
68Ga-Siglec-9 peptide may be a potential tracer for imaging of
inflammation associated with atherosclerotic plaques. This study
investigated the uptake of 68Ga-Siglec-9 in atherosclerotic plaques in
Methods: Six-month-old atherosclerotic low-density lipoprotein
receptor deficient mice expressing only apolipoprotein B100
(LDLR-/-ApoB100/100, n = 15) fed with high-fat diet for four
months and normally fed two-month-old C57BL/6 control mice
(n = 11) were intravenously injected with 19 5 MBq of
68Ga-Siglec-9. The aorta and other tissues were excised at 25 minutes after
tracer injection and measured by gamma counter to clarify
biodistribution of radioactivity. The uptake of 68Ga-Siglec-9 in aorta was
studied in more detailed by autoradiography and histology analyses.
Results: The six-month-old LDLR-/-ApoB100/100 mice
demonstrated highly inflamed and extensive atherosclerotic plaques after
4 months of a high-fat diet, presenting a suitable model for studying
the imaging of atherosclerotic plaque inflammation. The
68Ga-Siglec9 peptide was rapidly excreted through the kidneys to the urine. At
25minutes post-injection the blood radioactivity was still relatively
high. However, the uptake of 68Ga-Siglec-9 in the aorta was
significantly higher in the LDLR-/-ApoB100/100 mice
(0.88 0.32%IA/g) than in the control mice (0.45 0.11%IA/g,
P = .0003), and an autoradiography demonstrated focal uptake of
68Ga-Siglec-9 in atherosclerotic plaques.
Conclusion: Our preliminary results provide evidence that
68Ga-Siglec-9 peptide is accumulated into the plaques of atherosclerotic mice
and that it might be a promising and novel PET tracer to detect plaque
inflammation. Further studies are warranted to determine the
expression level of VAP-1 at different stages of atherosclerotic plaque
Dynamic computed tomography perfusion imaging for the
detection of functionally significant coronary lesions
A. Rossi1; A. Wragg2; A. Dharampal1; S.E. Petersen2;
E. Klotz3; P.J. De Feyter1; F. Pugliese2
1Erasmus MC, Rotterdam, Netherlands; 2Barts and The London NIHR
Cardiovascular Biomedical Research Unit, London, United Kingdom;
3Siemens Healthcare Sector, Forchheim, Germany
Purpose: To evaluate the performance of hyperaemic myocardial
blood flow (MBF) derived from stress computed tomography perfusion
(CTP) imaging in the detection of functionally significant coronary
lesions in a prospective cohort of patients with stable chest pain.
Lesions were defined functionally significant by fractional flow reserve
Methods and Materials: Coronary computed tomography
angiography (CTCA) and CTP were performed in 80 patients (63 males/17
females; mean age 60 10 years) referred for invasive angiography. A
second-generation dual-source CT scanner (Somatom Definition Flash,
Siemens) with a dynamic ECG-triggered axial shuttle mode was used.
This technique provides an arterial input function and myocardial
timeattenuation curves fitted to a two-compartment model to give MBF.
Hyperaemia was induced by infusion of adenosine (140 lg/kg body
weight). Three to four minutes into the infusion, 60 mL of contrast
were injected. Gantry rotation time was 285 ms, collimation
64 9 0.6 mm, tube voltage 100 kV and the tube current-time product
was 300 mAs/rotation.
Results: Data from 210 coronary vessels and 210 corresponding
myocardial territories were available for comparison and were included
in the analysis. Functionally significant coronary lesions were found in
56/210 vessels (27%). MBF was 62 (51-74) mL/100 mL/minute in
myocardial territories supplied by vessels with functionally significant
coronary lesions and 109 (92-136) mL/100 mL/minute in the remote
myocardium (P \ .001). The optimal cut-off value of MBF to
discriminate functionally significant coronary lesions was 78 mL/
100 mL/minute. MBF had 88% sensitivity and 90% specificity and an
area under the receiver operating characteristics curve (AUC) of 0.95
(95% CI, 0.92-0.98, P \ .001). By comparison, visual CTCA analysis
yielded 80% sensitivity, 76% specificity and an AUC of 0.78 (95% CI,
0.71-0.85, P \ .001).
Conclusions: MBF performs better than visual CTCA analysis to
predict functionally significant coronary lesions (FFR B 0.75).
Oral Abstract Session
SPECT MPI: New approaches and applications
Monday 6 May, 2013, 16:3018:00
Purpose: The introduction of high-efficiency SPECT cameras for MPI
represents one of the most important hardware developments in
decades. Approximately, 30 laboratories have the multi-pinhole CZT
camera installed as of the summer of 2012. There are no current
guidelines for dosing and imaging times for these cameras.
Methods: A questionnaire was distributed to eight early adopters who
published peer reviewed papers utilizing the multi-pinhole CZT
camera in Europe (N = 4), Australia (N = 1) and North America (N = 3)
requesting yearly patient volume, low and high Tc-99m doses, low and
high dose imaging times, time from low and high dose injection to
imaging, and information about the use of attenuation correction.
Results: Surveyed labs perform close to 20,000 studies a year with 6 of
8 using a stress-rest protocol (rest imaging optional). The stress:rest
dose ratio varies from 1:2 to 1:3, with stress doses ranging from 3 to
10 mCi and stress imaging time from 5 to 11 minutes. The largest
variation was noted in time to rest imaging (3-60 minutes). North
American labs are more likely to perform rest-stress imaging with a 1:3
to 1:4 rest:stress dose ratio and rest doses usually of 5 mCi. Calculated
radiation dose to the patients for low-dose stress only studies was
B3 mSV per study and 3.6-9.1 mSv for a full study. All sites use either
CT or prone imaging attenuation correction.
Room 4 A05
Conclusions: Using CZT SPECT technology results in significant
decreases in radiation doses and imaging time. Sufficient data is now
available to propose unified guidelines for CZT SPECT imaging.
J.G. Romero Farina1; S. Aguade-Bruix1; G. Cuberas-Borros1;
M.N. Pizzi1; G. De Leon1; J. Castell-Conesa1;
D. Garcia-Dorado1; J. Candell-Riera1
1Hospital Universitari Vall dHebron, Barcelona, Spain
Purpose: To evaluate the warranty period (WP) of a normal stress-rest
myocardial perfusion SPECT for exercise stress (ES), ES plus
pharmacologic stress (PhS), and PhS and in different clinical conditions.
WP of normal SPECT is important in order to establish appropriate use
of this technique in different subgroups of patients.
Methods: A cohort of 2,922 patients (62.9 13 years; 53.4% women)
with normal stress-rest myocardial perfusion SPECT was studied. WP
was defined as the time in which a patient remained at low risk (\1%
complications/year) for total mortality (TM) and for hard events (HE)
(cardiovascular death or nonfatal acute myocardial infarction.
Multivariate Cox proportional hazards models and Kaplan-Meier curves
analysis were used to estimate the WP.
Results: 2051 patients underwent ES, 461 underwent ES plus PhS, and
410 underwent PhS. During a follow-up of 5 3.3 years, a significant
(P \ .05) increased of annual TM (1.47%, 2.3% and 4%) and annual
HE (0.4%, 0.9% and 2%) were observed for ES, ES plus PhS, and PhS
respectively. A significant (P \ .05) WP reductions of TM [13.5, 9.6
and 8 months], and HE [34.8, 20.5 and 8.2 months] was observed for
ES, ES plus PhS, and PhS respectively. Clinical variables (age, gender,
diabetes and known coronary artery disease) were other determinants
of the WP. An abnormal gated SPECT (ejection fraction \ 50%)
significantly decreased WP for HE in patients underwent ES plus PhS
(P = 0.001) or PhS (P = .007).
Table of the abstract 56
Conclusions: WP of a normal stress-rest myocardial perfusion SPECT
is very variable since it is mainly determined by the type of stress,
clinical characteristics and left ventricular ejection fraction.
M. Milena Henzlova1; E.J. Levine1; S. Moonthungal1;
M. Fardanesh1; L.B. Croft1; W.L. Duvall1;
1Mount Sinai School of Medicine, New York, United States of America
Purpose: Previous literature suggests that the results of myocardial
perfusion imaging (MPI) add little to the prognosis of patients who
exercise C10 METS during stress testing. With this in mind, we
attempted to determine if a provisional injection protocol could be
developed in which a patient would not receive an injection of
radioisotope if adequate exercise was achieved without symptoms and
a negative ECG response. This protocol would save a substantial
amount of time, radiation exposure, and cost.
Methods: All patients who underwent a stress SPECT MPI over a
6.5 year period from 2004 to 2010 were included. Patients who would
have been considered for a standby injection protocol were: exercise
stress, age \ 65, no known CAD, and an interpretable ECG. Patients
were retrospectively divided into two groups based on whether they
would have received radioisotope or not. Criteria for not injecting
included a maximal predicted heart rate C 85%, C 10 METS of
exercise, no symptoms of chest pain or shortness of breath, and no
ECG changes (ST depression or arrhythmia). The two groups were
then compared based on MPI results and all-cause mortality derived
from the Social Security Death Index.
Results: A total of 24,689 patients underwent SPECT MPI during this
period, and 5,352 would have been eligible for a provisional injection
protocol. There were 3,791 (70.8%) who would have been injected and
1,561 (29.2%) who would not have been. Perfusion results were
abnormal in 5.9% of non-injected group compared to 14.4% in those
who would have been injected. After a mean follow-up of
60.6 21.4 months, 1.1% had died in the non-injected cohort
compared to 2.2% in the injected group.
Conclusion: A provisional injection protocol defined as age \65,
normal rest ECG, no history of CAD, and high level exercise with a
negative ECG response and no symptoms, has a very low 5 year
allcause mortality and low yield of MPI. If adopted it would decrease
radiation exposure, save time and health care costs without
Is necessary to perform an exercise myocardial perfusion
gated SPECT in patients with D-Transposition of the
great arteries after arterial switch operation?
A single centre long-term follow-up
M.N. Pizzi1; S. Aguade-Bruix2; E. Franquet2;
G. Cuberas-Borros1; B. Manso3; J. Casaldaliga4;
G. Romero-Farina5; J. Castell-Conesa2; D. Garcia-Dorado6;
1Universitary Hospital Vall dHebron, Cardiology Department,
Nuclear Cardiology and Cardiac CT Unit, Barcelona, Spain;
2Universitary Hospital Vall dHebron, Nuclear Medicine Department,
Barcelona, Spain; 3Universitary Hospital Vall dHebron, Paediatric
Department, Barcelona, Spain; 4Universitary Hospital Vall dHebron,
Cardiology Department, Adult Congenital Heart Disease Unit,
Barcelona, Spain; 5Hospital Vall dHebron, Cardiology Department,
Epidemiology Unit, Barcelona, Spain; 6Universitary Hospital Vall
dHebron, Cardiology Department, Barcelona, Spain
Objectives: Arterial switch operation (ASO) is the preferred technique
for the correction of transposition of the great arteries (TGA), but
translocation and re-implantation of the coronary arteries can produce
myocardial ischemia. There is no consensus on the need to monitor
these patients to detect abnormalities in myocardial perfusion. The
purpose of this study is to report our experience with exercise
myocardial perfusion gated SPECT with 99mTc-tetrofosmine to evaluate
myocardial perfusion and exercise tolerance after ASO.
Methods: We performed exercise-rest myocardial perfusion gated
SPECT in 67 patients (48 boys, 9.9 3.2 years old), including five
who had referred symptoms and 62 who were asymptomatic.
Myocardial perfusion and left ventricular (LV) wall motion, thickening,
volumes and ejection fraction (EF) were evaluated. We compared
patients with (n: 4) and without (n: 63) peri-operative complications,
and patients with A (normal) (n: 45) and non-A (n: 22) coronary
Results: During exercise testing 67 patients reached 9.8 3.05 METs
and 73.58 14.24% of the predicted peak heart rate. Fifty-nine
patients (88%) had normal myocardial perfusion while only 2 patients
(3%) had reversible defects, and 6 patients (9%) had fixed defects. All
patients with peri-operative ischemic complications had myocardial
perfusion defects (100%) while only 4 patients (6.35%) without
ischemic complications had an abnormal perfusion (P = .0005). We
did not find a significant difference between patients who had an A and
non-A coronary pattern.
Conclusions: The high rate of normality of myocardial perfusion gated
SPECT in our study suggests that myocardial perfusion gated SPECT
should be reserved for patients who have suffered peri-operative
ischemic complications, or those with symptoms, at least during the
first 10 years after the surgery.
Purpose: Cardiac allograft vasculopathy (CAV) is common among
orthotopic heart transplant (OHT) patients and is the major factor
affecting mortality. Serial myocardial perfusion imaging (MPI) is
useful diagnostically and prognostically, and with current technology
can be performed at minimal dosimetry. However, neither the time
course to positivity nor the correlates of this are known.
Methods: Using the OHT and MPI electronic databases at a single
center, we identified 192 patients who had undergone OHT and serial
MPIs between January 1, 2000 and December 31, 2011. Collected
data included gender, age, diabetes, hyperlipidemia, hypertension,
smoking, family history of premature CAD and time to an abnormal
MPI (AMPI) defined by a summed stress score [3.
Results: The 192 OHT patients underwent 801 MPIs over a mean
follow up period of 5.6 (+2.7) years. A total of 54 patients (28%)
ultimately developed an AMPI. Of these 54 patients, 11% (6 patients)
had an AMPI by 1 year, 57% (31 pts) by 3 years, 78% (42 pts) by
5 years, 93% (50 pts) by 7 years, and thereafter only 1 patient per year
had an AMPI in the final 4 years. The average time to AMPI was
6 years. Demographic and atherosclerotic risk factor data were not
statistically different between the 54 patients who developed an AMPI
vs those who did not.
Conclusions: Serial MPI is helpful in identifying CAV following
OHT, with significant conversion to abnormality even during the first
several years following OHT. Traditional risk factors do not correlate
with those OHT patients who develop early post-transplant cardiac
Conversion to abnormal MPI over time
Moderated Posters Advances in instrumentation
Monday 6 May, 2013, 08:3012:30
D. Daniel Zalkind1; V.T. Tsatkin1; Y.L. Liu1; A.S. Sinusas1;
1Yale-New Haven Medical Center, New Haven, United States of
Purpose: The utility of CT based attenuation correction (AC) has been
shown in previous multi-center trials for SPECT cameras with sodium
iodide (NaI) detectors, although remains undefined for hybrid
highsensitivity cadmium-zinc-tellurium (CZT) SPECT cameras with
diagnostic 64-slice CT (Discovery NMCT570c). The CZT detectors
allow imaging with decreased radiotracer dose. The aim of this study
was to further reduce the dose by applying one higher dose AC CT
scan to both rest and stress images, and to evaluate the impact on
quantification of SPECT integrated defect size (IDS, %LV volume).
Methods: Forty-four consecutive hybrid SPECT/CT rest and stress
scans were processed using the GE Xeleris software. Patient had a
mean age of 63.1 15.8 years, mean BMI 29.4 5.4 and 66% male
gender. IDS was calculated at rest using a gender-matched low-risk
database, after attenuation correction with either the phase-matched
rest CT (120 kV and 20 mA) or the phase mismatched stress CT
(120 kV and 80 mA) AC maps using the Yale WLCQ software. A
paired two-tail Student t-test and Pearson correlation were used to
compare IDS within each coronary distribution (LAD, LCX, and RCA)
after processing with the low and high dose CT attenuation maps.
Results: The AC CT for the stress phase resulted in a radiation dose of
2.72 mSv (high dose) and the CT for the rest phase resulted in a low
radiation dose of 0.33 mSv (low dose). There was no statistically
significant difference in IDS between the rest perfusion processed with
the low-dose CT at rest, and the rest perfusion images processed with
the high-dose stress CT within each coronary distributions (LAD:
0.39 0.31, P = .9, r = 0.61; LCX: 1.2 4.8, P = .93, r = 0.97,
RCA: 0.62 0.77, P = .52, r = .87).
Conclusions: The application of the stress CT AC map to the rest
SPECT images did not significantly change the rest IDS. Therefore,
one can eliminate the low dose rest CT AC map without compromising
SPECT quantification, further reducing the radiation dose associated
with hybrid CZT SPECT/CT.
Assessment of left ventricular ejection fraction (LVEF) with
hybrid solid-state cadmiun zinc telluride (CZT) SPECT
imaging with and without CT attenuation correction:
comparison to 2D echocardiography
M.J. Maria Jimena Salas P.1; V. Tsatkin1; Y. Liu1; R. Russell1;
1Yale University, New Haven, United States of America
Purpose: Gated SPECT is used to calculate LVEF and provides results
comparable to other methods. However, data is limited on accuracy of
hybrid solid state CZT SPECT for estimation of LVEF using an
integrated 64-slice CT for attenuation corrected (AC). We sought to
compare the LVEF determined by gated SPECT with and without AC
(no AC) and 2D echocardiography (2DE).
Methods: We retrospectively reviewed all rest 99mTc-tetrofosmin
SPECT scans performed on a hybrid CZT SPECT/CT (Discovery
NM570c) in patients having 2DE within 24 hours of SPECT processed
with AC and no AC over a 6 month period. CT was performed using
low dose protocol and free breathing. LVEF was calculated from
SPECT with WLCQ software with and without AC. Two operators
independently processed the LVEFs. 2DE EF was measured by the
biplane disk method. Interobserver variability was defined and
Pearsons correlation coefficients used for comparisons.
Results: 52 patients were identified, 32 males and 20 females,
meeting the inclusion criteria. The interobserver variability for LVEF
was low (SEM = 2.7%) and correlation high (r = 0.99). There was
excellent correlation between no AC and AC LVEF (r = 0.98). 2DE
LVEF correlated with SPECT LVEF with AC (r = 0.73) and no AC
(r = 0.74). There were differences in the correlation between 2DE
and SPECT LVEF when patients were grouped by gender (females:
r = 0.90; males: r = 0.70), presence/absence of LV hypertrophy
(LVH: r = 0.89; no LVH: r = 0.81), and patients with high
([80 mL) or low (\80 ml) LVEDV (low EDV: r = 0.60; high EDV:
r = 0.78).
Conclusions: LVEF assessed using a hybrid CZT SPECT/64-slice CT
was similar with AC and no AC, and correlated highly with 2DE
LVEF. There was an improved correlation in females, high LVEDV,
and no LVH, suggesting an influence of LV wall thickness.
C. Chunlei Han1; H. Merisaari1; V. Oikonen1; S. Nesterov1;
Purpose: In analysis of cardiac PET water perfusion data, several
studies have suggested that the spillover activity from right ventricular
cavity (RV) to the septum should be corrected. Despite this, the
correction is not implemented in routine analysis. This study investigates
the bias in perfusion estimation without RV spill-over correction,
based on simulation data.
Methods: Time-active curves (TAC) from left (LV) and right
ventricular cavities were derived from typical clinical 15O-labelled water
studies. One-tissue compartment model (Iida et al., 1989) was
employed to simulate noise free curves according to our study
protocol. Water model without RV spill-over correction (LVModel) as
implemented in Carimas v2.6 (a data analysis package) was compared
with a new model with RV spill-over correction (LV_RVModel),
which was implemented to Carimas v2.6 as a modeling plugin.
In LV_RVModel, the myocardial ROI TAC was expressed as:
ROI(t) = Va_lv*LV(t) + Va_rv*RV(t) + alpha*C(t), where Va_lv
and Va_rv are spill-over fractions from LV and RV, respectively, and
alpha is perfusable tissue fraction.
Results: RV affects significantly the perfusion estimation and this
effect becomes bigger for higher perfusion values and larger Va_rv.
When ground values of Va_rv = 0.1, 0.15, 0.2, 0.25 mL/mL, for
ground flow value of 0.98 mL/g/minute (as rest condition), estimated
flow values with LVModel were 0.94(-13%), 0.85(-20%), 0.78(-27%)
and 0.72(-33%) mL/g/minute, respectively; for ground flow value of
3.2 mL/g/minute (as stress condition), estimated values with LVModel
were 2.66(-17%), 2.34(-27%), 2.07(-36%) and 1.84(-43%) mL/g/
minute, respectively. Meanwhile, estimated flow values from
LV_RVModel were very close to ground values (error \ 2%).
Conclusions: Simulations confirm that spill-over from RV leads to
severe underestimation of perfusion in septum, unless correction is
applied in the analysis tool.
I. Casans-Tormo1; R. Diaz-Exposito1; A.C. Orozco-Molano1;
1Nuclear Medicine, Hospital Clnico Universitario, Valencia, Spain;
2Cardiology, Hospital Francisco de Borja, Gandia, Spain
Purpose: To assess the influence of 128 3 128 acquisition matrix in
GSPECT image quality analyzed in function of patients
Material and Methods: We have studied a prospective group of 71 p
(31 women-43.7%), mean age 65 10 (42-82 y/o, more than 70 (28/
71-39.4%) with known or suspected CAD, submitted to detect possible
myocardial ischemia. GSPECT was performed 1 hour after injection of
a 99mTc-tracer (2 day-protocol, 20 mCi-70 kg), obtaining two
simultaneous acquisitions with 64 3 64 and 128 3 128 matrix at
stress and at rest in 52 p and stress only in 16 p, with a total of 240
explorations, 120 with each matrix size (68 stress and 52 rest),
Butterworth filter (order 5, cutoff 0.56 (64)-0.30 (128), pixel size mm 6.3
(64)-3.1(128), QGS program. We perform visual semi-quantitative
analysis of global image quality (IQ), delimitation of ventricular cavity
(VC) and of perfusion defect (PD) considering 1-poor, 2-middle,
3-good, 4-excellent, analyzing differences between the two matrix size
studies respect to age, gender, body mass index (BMI), rest
end-systolic volume (ESV) existence of perfusion defects or rest FE \ 50%,
obtained from usual 64 3 64 GSPECT, and also assessing possible
interference of intestinal activity.
Results: Mean BMI was 31.2 6.5 (22.5-58.6), with 21/71 (29.6%)
more than 30. 31/71 p (43.7%) with ESV \ 25 mL, 32/71 (45.1%)
with PD, 18/71 (25.3 %) with FE \ 50% and 15/71 (21.1%) with
intestinal interference. Visual parameters graded 2-4. Global Q was in
general better in 128 than 64, without age differences. Better IQ at S
and R in 128 than 64 in women and p with ESV \ 25 mL
(24/3177.4% of women had ESV \ 25 mL), higher IQ and PD in 128 than 64
at R in p with BMI more than 30 (80.9%) vs lower than 30 (32%)
p:0.03, better VC in 71.8% p without perfusion defects or attenuation
only vs 40.6% with perfusion defects (p:0.04) and in p with FE C 50%
than \50% (p:0.002). Better delimitation with intestinal activity in
11/15 (73%) of p that showed intestinal interference.
Conclusion: In this study with simultaneous acquisition in 128 3 128
and 64 3 64 matrix size, we obtained higher quality images in general
with 128 than 64, specially in patients with BMI [ 30, ESV \ 25 ml
(77% were women), without perfusion defects, with FE [ 50%, and
also better delimitation with intestinal activity, all of that could
improve interpretative certainly and diagnostic accuracy.
Rapid SPECT MPI using 128 3 128 matrix acquisition with
iterative resolution recovery and attenuation correction
A. Amelia Jimenez-Heffernan1; A. Ortega-Carpio2;
C. Salgado-Garcia1; E. Sanchez De Mora1; J. Lopez-Martin1;
C. Ramos-Font1; R. Lopez-Aguilar1; S. Aguade-Bruix3
1Hospital Juan Ramon Jimenez, Department of Diagnostic Imaging,
Huelva, Spain; 2Centro de Salud El Torrejon, Huelva, Spain; 3Hospital
Vall dHebron, Department of Nuclear Medicine, Barcelona, Spain
Purpose: To assess the contribution of 128 3 128 matrix acquisition
to improving the diagnostic quality and reducing LVEF overestimation
of rapid SPECT/CT reconstruction with ordered subset expectation
maximum and resolution recovery (OSEM-RR) with attenuation
Methods: We studied 461 consecutive patients (54% male, age:
64.5 11.7 years, weight: 79.5 15.2 kg) referred for 99mTc
SPECT/CT MPI using a 128 3 128 matrix and OSEM-RR
reconstruction with AC. For comparison we used a group of 572 patient who
underwent rapid SPECT with the usual 64 3 64 matrix, all other
parameters identical. 60 frames of 12 second duration were acquired
over 908 using a standard hybrid system. Our protocol performs 12
iterations with a maximum number of 10 subsets. A 2-day stress/rest
protocol was used. Stress was exercise combined with adenosine in 365
and regadenoson in 96 patients respectively. Image quality (poor,
medium, good or very good), diagnostic performance (normal,
abnormal and normalcy rate) and LVEF quantification were assessed.
Results: Images were of very good quality, clearly showing or
suggesting the papillary muscles in all cases. MPI was reported as normal
in 46.7%, abnormal in 51.3% and equivocal in 2% of patients
respectively. Normalcy rate using a very low pretest likelihood of
disease (Millers score modified) was 57.8%. In the 64 3 64 matrix
group reports were normal in 55%, abnormal in 43.6% and equivocal
in 1.4% of patients respectively and the normalcy rate was 68.6%. The
lower normalcy rate and increment of abnormal studies with the
128 3 128 matrix was mostly due to small basal inferolateral defects,
which we hypothesize could be related to the higher activity of the
adjacent posteromedial papillary muscle. Mean LVEF in normal
perfusion patients was 63.3% for 128 3 128 and 67.2% for 64 3 64
matrix respectively, a significant difference (P \ .05).
Conclusion: The 128 3 128 matrix produces higher quality images
with lower overestimation of LVEF, nevertheless careful attention
must be paid to the area basal to the posteromedial papillary muscle in
order to avoid false positive readings.
R. Conwell1; C. Chuanyong Bai1; L. Abreu1; J. Maddahi2
1Digirad Corporation, Poway, United States of America;
2UCLA-David Geffen School of Medicine, Los Angeles, CA,
United States of America
Purpose: Patient radiation dose in conventional myocardial perfusion
SPECT (MPI) is approximately 11.4 mSv using the standard one-day
rest/stress protocol with 370 MBq rest and 1017.5 MBq stress Tc-99m
sestamibi injection. In this work, we evaluated the potential of
submSv (\1 mSv) patient radiation dose through the use of
highsensitivity SPECT systems, advanced reconstruction algorithms, and
modified imaging protocols.
Methods: Sixty-six consecutive patient studies with list-mode data
acquisition were performed on a triple-head dedicated cardiac SPECT
camera with solid-state detectors. The average injection was 340.4 and
1306.1 MBq and the average acquisition time was 11.4 and 4.2
minutes for rest and stress studies, respectively. For each patient, a full
time dataset and a 1/3 time dataset were generated from the list-mode
data with the latter using every third of the list-mode events. The full
time data was reconstructed using a 3D-OSEM algorithm with
resolution recovery (nSPEED). The 1/3 time data was reconstructed with
an improved 3D-OSEM algorithm (nSPEED2) that incorporated a 3D
maximum a posteriori technique and a weighted-Gaussian filter
for better noise/resolution trade-off. Images were interpreted by a
blinded expert nuclear cardiologist for quality and diagnostic
Results: The 1/3 time nSPEED2 images showed diagnostic agreement
with the full time nSPEED images in 64/66 (97%) of the studies. The
quality of the 1/3 time nSPEED2 images was better than or equivalent
to that of the full time nSPEED images in 65/66 (99%) stress and 62/66
(94%) rest studies. The 1/3 time data corresponded to 3.8-minutes rest
and 1.4-minutes stress acquisitions; hence, if using longer acquisition
time, the patient dose can be reduced to \1 mSv at 15 minutes (see
Conclusion: Patient studies showed potential sub-mSv rest and stress
radiation dose when using a high-sensitivity camera for data
acquisition and an advanced algorithm (nSPEED2) for image reconstruction.
Overall sub-mSv MPI radiation dose can be achieved for patients with
normal stress diagnosis when using stress-only protocols.
Patient dose vs acquisition time
Caution is required when comparing left ventricular
function calculated using newer gated SPECT iterative
reconstruction algorithms to the previously used filtered
backprojection reconstruction method
D. Doumit Daou1; C. Coaguila2; M. Tawileh1
1APHP, Cochin Hospital, Department of Nuclear medicine, Paris,
France; 2Hospital Sud-Francilien, Corbeil-Essonnes, France
Purpose: Gated SPECT myocardial perfusion (GSPECT) has been
extensively validated for the quantification of left ventricular (LV)
function especially with QGS. This was done with filtered
backprojection reconstruction method (FBP). Recent developments in nuclear
medicine technologies allow simple application of iterative
reconstruction with and without resolution recovery. We aimed to compare
the performance of the QGS software for the quantification LV
function when using FBP as compared to iterative reconstruction (OSEM)
and iterative reconstruction combined to resolution recovery
Methods: Our study included 51 consecutive patients addressed for
myocardial perfusion scintigraphy. Studies were acquired on a
twoheaded gamma-camera (Symbia, Siemens). GSPECT studies were
reconstructed using three different methods (FBP, OSEM, and
3DFlash) and then processed with the QGS software. LV end diastolic
volumes (EDV), end systolic volumes (ESV) and LVEF were
Results: LVEF was higher with FBP (72 13%) than OSEM (70 11%,
P \ .0001) and 3D-Flash (69 12%, P \ .0001), respectively.
LV EDV was lower with FBP (70 23 mL) than OSEM (74 25 mL,
P \ .0001) and 3D-Flash (80 26 mL, P \ .0001), respectively.
LV ESV was lower with FBP (22 14 mL) than OSEM (24 16 mL,
P \ .0001) and 3D-Flash (27 17 mL, P \ .0001), respectively.
Bland-Altman analysis for the combined EDV and ESV (n = 102)
between FBP and 3D-Flash showed that the difference in LV volumes
between the two methods increased with their average LV volumes
(r = 0.61, P \ .0001). This also was also verified for FBP and OSEM:
r = 0.44 (P \ .0001).
Conclusions: Newer iterative reconstruction methods (OSEM,
3DFlash) give significantly different LVEF and volumes than those
obtained with FBP. This should be considered when adopting newer
reconstruction algorithms in clinical practice.
Poster Session 1
Advances in Instrumentation
Monday 6 May, 2013, 08:3012:30
Correlation of myocardial ischemia with contraction
asynchrony measured by single photon emission computed
tomography synchronized with electrocardiogram
C. Carlos Guizar1; E. Alexanderson1; S. Hernandez1;
Objective: To establish the correlation between regional changes in
the synchrony of ventricular contraction and the presence of moderate
to severe ischemia on gated-SPECT.
Methods: We included men and women over age 40 who underwent
gatedSPECT in the period from January 1, 2006 to January 1, 2008 and had
moderate to severe myocardial ischemia, expressed as a summed difference
score (SDS) C 9 points, with no evidence of infarction. For the image
analysis we used Emory Cardiac ToolboxTM 3.1 (Emory University Atlanta
Georgia) software. Myocardial perfusion was analyzed in 17-segment polar
maps, obtaining the summed stress score (SSS), the summed rest score
(SRS) and the summed difference score (SDS). End diastolic volume, end
systolic volume and ejection fraction of the left ventricle were also obtained.
The sequential activation of the left ventricle was assessed in visual form
from the polar map, thereby detecting the territories in which the activation
occurred delayed. Synchrony indices were obtained as the standard
deviation of timing phase angles and bandwidth.
Results: We included 34 patients, with a mean age of 67.5 9.2 years,
67% were male patients (n = 23) and 33% female (n = 11). The 47%
had severe ischemia and 53% moderate ischemia. The mean SSS was
14.12 5.77, whereas for the SRS was 0. The mean ejection fraction
was 66.21 12.31%, the end diastolic volume of 84.85 mL, and the
end systolic 32.84 33.03 23.89 mL. Ischemia was observed on the
anteroseptal region in 38% of cases, on the inferior wall in 29%, on the
lateral wall in 21% and on the apex in 12%. The synchrony polar map
showed contraction delay in the ischemic region in 58.8% of cases.
Patients with asynchrony in the polar map had a significantly larger
bandwidth than those without delay in the polar map, with 60 22
and 44 16 , respectively (P = .02). There was no significant
difference in the standard deviation (21.5 10 vs 21.44 9 , P = .94).
There was also no association between the degree of ischemia and the
presence of asynchrony in the polar map (P = .315).
Conclusions: Moderate to severe ischemia was associated with the
presence of delay in the contraction of the same region with
considerable frequency (58.8%), but the delay was slight. Only the bandwidth
measurement was significantly increased in these cases, so this index is
probably more sensitive than the standard deviation to detect slight
delays in contraction associated with myocardial ischemia.
Coronary stent evaluation with MDCT: comparison between
low-osmolar, high-iodine concentration iomeprol-400 and
iso-osmolar, lower-iodine concentration iodixanol-320
Purpose: To compare Iomeprol-400 with Iodixanol-320 for
multidetector computed tomography coronary angiography (MDCT-CA)
evaluation of coronary stents. Appropriateness of MDCT-CA stents
evaluation is still a matter for debate and is unknown if contrast
medium characteristics may affect MDCT-CA diagnostic performance.
Methods: We randomized 254 patients undergoing MDCT-CA
coronary stent follow-up to Iomeprol-400 at 5.0 mL/second flow rate
(group 1, n = 83), Iodixanol-320 at 6.2 mL/second flow rate (group 2,
n = 87) and Iodixanol-320 at 5.0 mL/second flow rate (group 3,
n = 84). Heart rate (HR) before and after scanning, HR variation,
premature heart beats (PHB) and heat sensation by visual analog scale
(VAS) during scanning were recorded. Mean attenuation was measured
in the aortic root and coronary arteries. Image quality score and type of
artifacts were assessed.
Results: In group 3, VAS was significantly lower than in groups 2 (4.3
vs 5.3 mm) and 1 (4.3 vs 8 mm) and HR after imaging was
significantly lower than in groups 2 (53.7 vs 56.7 bpm) and 1 (53.7 vs
56.2 bpm). Number of patients with PHB during the scan was
significantly lower in group 3 than in other groups. Mean attenuation was
significantly lower in group 3 than in other groups. In group 3, stent
evaluability was significantly higher and artifact rate was significantly
lower than in group 2 (99% vs 91% and 4% vs 15%) and 1 (99% vs
92% and 4% vs 17%), respectively.
Conclusions: Iodixanol-320 provides better image quality of coronary
stents, allowing higher MDCT-CA evaluability in comparison with
V. Vitaliy Androshchuk1; L. Hossen1; E. Reyes1;
K. Wechalekar1; J. Bailey1; S. Gregg1; S.R. Underwood1
1Royal Brompton Hospital, London, United Kingdom
Background: Myocardial perfusion scintigraphy (MPS) is degraded by
scattering of photons, which can reduce diagnostic accuracy. Scatter
correction (SC) using the triple-energy-window (TEW) technique can
correct for the degradation but Monte Carlo (MC) simulation is thought
to be more accurate. We have compared a MC-based SC reconstruction
(Hybrid recon, Hermes Medical Solutions) with a TEW technique
(Xeleris, GE Healthcare).
Methods: Twenty consecutive patients with known or suspected
coronary disease and a clinical referral for MPS were selected
retrospectively. MPS was performed using 99mTc-tetrofosmin
(250 + 750 MBq 1-day stress-rest protocol) with a dual detector
camera and CT attenuation correction (Infinia Hawkeye, GE
Healthcare). Tomograms were reconstructed using iterative reconstruction
alone (NC) and were compared with reconstructions using MC
correction with attenuation and resolution recovery (AR-MC), and TEW
correction with attenuation correction (A-TEW). The studies were
reviewed by an experienced observer blinded to the reconstruction
technique and to the previous clinical report. Parameters recorded were
diagnostic interpretation (normal, reversible, fixed or mixed defects),
interpretative confidence (3-high to 0-absent), image quality score
(3-0), artefact scores (3-0), summed segmental scores, left ventricular
ejection fraction (LVEF) and end-diastolic volume (EDV). The
reconstructions were then viewed in pairs for observer preference.
Advances in Instrumentation / Journal of Nuclear Cardiology Supplement (2013) 20 (Supplement 1)
Results: There was no difference in diagnosis between NC, AR-MC,
A-TEW (P = .98). Also, there was no difference in diagnostic
confidence scores between NC, AR-MC and A-TEW (1.90 0.72,
2.00 0.73, 1.95 0.89, respectively; P = .68). Stress image quality
was higher with AR-MC (2.30 0.66) and NC (2.25 0.64) than
A-TEW (1.65 0.59) (P = .0029 and P = .0018, respectively).
ARMC had less stress low count artefact than A-TEW (0.25 0.55 vs
0.75 0.55, P = .0066). AR-MC and NC were both preferred over
A-TEW but were equally preferred to each other. Left ventricular
functional data and summed perfusion scores were not significantly
different between techniques.
Conclusion: Imaging performance of MPS with iterative
reconstruction (NC) can be improved more by AR-MC than by A-TEW.
Although the advantage of AR-MC over NC is small at conventional
doses of tracer, it may allow reduction of dose without loss of
diagnostic performance, but this application remains to be studied.
Introduction: The new multipinhole cardiac SPECT/CT cameras with
cadmium zinc-telluride (CZT) detectors are highly sensitive, produce
high image quality but rely on dedicated reconstruction algorithms.
The influence of image processing steps may be different as compared
to standard SPECT protocols. We determined the intra- and
interoperator variability of these processing steps on the final result of
myocardial perfusion imaging studies.
Methods: The population consisted of 20 consecutive patients (7
women and 13 men, BMI 22-40, age 34-79) who underwent a
oneday protocol stress- and rest CZT-SPECT/CT (GE Discovery NM/
CT 570c) using Tc99m-tetrofosmin. Data were processed twice by
three experienced operators. Processing steps include determining of
myocardial axes and boundaries, masking of the myocardium and
manual SPECT/CT co-registration for attenuation correction. We
used a 17-segment cardiac model and calculated the difference
between stress and rest of % segmental uptake values (after
normalisation of peak activity to 100%) for non-corrected (NC) and
attenuation-corrected (AC) image sets. AC includes one extra
processing step, i.e. SPECT/CT co-registration. Operator variation was
considered significant for the diagnosis of ischemia when greater
Results: As a measure of inter-operator variation, the mean operator
variation across all 340 segments was 2.5% (Q1-Q3: 1.8-2.8%) for the
NCand 4.2% (Q1-Q3: 3.2-5.1%) for AC images (P \ .01). In more
than 3% (NC) and 28% (AC) of the cases, inter-operator variation was
greater than 5%. The mean intra-operator variation across all 680
segments was 2.2% (Q1-Q3: 1.6-2.2%) for the NCand 3.4% (Q1-Q3:
2.6-3.9%) for AC images. In more than 5% (NC) and 13% (AC) of the
cases, intra-operator variation was greater than 5%.
Conclusion: Intra- and inter-operator variation in image processing of
SPECT-CT CZT gamma camera data is significant and may influence
the final diagnosis of ischemia. Especially the use of attenuation
correction significantly increases this variation. Clearer guidelines for
image processing are necessary in order to improve the reproducibility
of the results and to obtain a more reliable diagnosis of ischemia.
A. Alp Notghi1; G. James1; A. Jennings1; J. Obrien1
1Sandwell and West Birmingham Hospitals NHS Trust, Birmingham,
We have looked at repeatability of LV function parameters in the same
patient using gated myocardial perfusion scan (MPS).
16 patients (6 male, 10 female) were entered into this study, median
age of 69 (range 34-69 years), mean weight of 76 kg (range 44-90 kg).
Each patient had three consecutive MPS. Rest MPS (400 MBq
tetrofosmin) was followed on the same day with stress MPS (800 MBq),
pattient then returned for a second rest MPS (400 MBq) the next day.
On each occasion two consecutive MPI acquisitions were performed
(180 degrees, 60 projections 18 seconds/projection, 8 bin gating). The
two consecutive studies were added to obtain the equivalent of a
standard full time acquisition for each occasion. Cedar Sinai QGS
(Autoquant7 Philips Medical Systems) was used to obtain EDV, ESV
and LVEF. Paired t-test (P) and Pearson correlation (r) was calculated
to compare data.
There was a wide range of EDV (76-333 mL), ESV (7-226 mL) and
EF (21-73%). The full-time stress data were analysed twice (n = 16),
to establish the repeatability of the QGS calculations. There was no
significant difference in the EDV, ESV and EF when same data were
analysed twice (Pearson correlation 0.993, 0.998 and 0.971
respectively, mean difference 0.38 mL, 0.68 mL, 0% respectively, P NS).
Then day one and day two rest studies were compared (n = 16). This
compared results obtained at separate occasions from the same patient.
There was no significant difference in calculated EDV, ESV or EF
between the two separate rest studies (Pearson correlation 0.989, 0.992
and 0.938 respectively, mean difference 0.44 mL, 0.81 mL, 0.37%
respectively, P NS).
Finally the half-time consecutive studies where compared (n = 32) to
see if the QGS calculations are reliably reproducible in low count
acquisitions when conceivable the ventricular wall delineation may be
difficult. There was again no difference in the results of paired EDV,
ESV, and EF (Pearson correlation 0.996, 0.996 and 0.961 respectively,
mean difference 0.61 mL, 1.00 mL, 0.82% respectively, P NS).
Conclusion: QGS gives reproducible parameters for consecutive
measurements of left ventricular function. The results suggest very
high accuracy of reproducibility for individual patients even with very
low count studies.
Gated blood pool SPECT: QBS software performs better
with iterative reconstruction combined to resolution
recovery than with filtered backprojection
D. Doumit Daou1; C. Coaguila2; C. Meyer1; F. Amegassi1
1APHP, Cochin Hospital, Department of Nuclear Medicine, Paris,
France; 2Hospital Sud-Francilien, Corbeil-Essonnes, France
Purpose: Gated blood pool SPECT (GSPECT RNA) radionuclide
angiography (RNA) is interesting for the evaluation of cardiac
function. We previously validated the use of QBS software (Cedars Sinai)
for the quantification of both left ventricular (LV) and right ventricular
(RV) function. This was done with filtered backprojection
reconstruction method (FBP). We aimed to study the performance of the
QBS software for the quantification LV and RV function when using
FBP as compared to iterative reconstruction with resolution recovery
Poster Session 5
Clinical General and Outcome: Cardiac CT Posters
Wednesday 8 May, 2013, 08:3012:30
Quantitative cardiac SPECT and coronary calcium score in
the detection of coronary artery disease: Validation of
findings by coronary angiography
M. Kaminek1; I. Metelkova1; M. Budikova1; E. Buriankova1;
R. Formanek1; L. Henzlova1; P. Koranda1; E. Sovova1;
1University Hospital Olomouc, Olomouc, Czech Republic;
2CMI, ICRC-FNUSA, Brno, Czech Republic
Purpose: To analyse sensitivity and specificity of SPECT and to assess
the diagnostic potential of quantitative parameters of perfusion, left
ventricular function and coronary artery calcium (CAC) score to
identify high risk patients with multivessel coronary artery disease.
Methods: 702 patients underwent stress gated SPECT study and then
coronary angiography. We quantified summed difference score (converted
to % of ischemic myocardium), left ventricular ejection fraction (LVEF),
end-diastolic/end-systolic volumes, transient ischemic dilatation (TID)
ratio. In patients with a dilated left ventricle, we measured CAC score.
Results: Sensitivity and specificity of SPECT were 91% (456/502) and
76% (151/200), respectively. There was not significant difference
between sensitivity in men and women (91% vs 90%, P = NS).
Sensitivity was significantly higher in patients with multivessel
disease (87% in 1-vessel disease vs 95% and 94% in 2- and 3-vessel
disease, respectively, P \ 0.05). In quantitative analysis, % of
ischemic myocardium rose with a number of diseased vessels: 11% 11%,
15% 12% and 19% 14% in patients with 1-, 2- and 3-vessel
disease, respectively. The sign of postischemic left ventricular stunning
(poststress worsening of the LVEF [ 5% and/or TID ratio [ 1.17) was
observed in 46%, 49%, and 63% of patients with 1-, 2- and 3-vessel
disease, respectively. In the subgroup of 81 patients with a dilated left
ventricle, combining SPECT with CAC score (at a cutoff of 1000)
improved sensitivity from 80% to 91% and negative predictive value
from 66% to 81% (P \ .05), in association with not significant change
in specificity and positive predictive value.
Conclusions: Quantitative SPECT enables identification of high risk
patients with a large ischemia and postischemic stunning with probable
multivessel disease. In patients with a dilated left ventricle, the
accuracy of SPECT has been improved by combination with CAC score.
Simultaneous evaluation of myocardial perfusion imaging
(MPI) and coronary calcium score (CCS) in patients with
intermediate likelihood of CAD: A 5 year follow-up study
Aim: Hybrid SPECT-CT tomographs offer the opportunity to
simultaneously evaluate both functional (MPI) and morphoanatomical
(CCS) aspects of the atherosclerosis. The aim of this study is to assess
the additional prognostic value of CCS in adjunct to MPI in the
evaluation of patients with intermediate-risk of CAD.
Materials and Methods: Study population consisted of 367
prospective patients who were clinically scheduled for MPI and classified at
intermediate risk on the basis of the Framingham Risk Score. All
subjects underwent contextual rest sestamibi MPI and CCS evaluation
as a part of a standard two-days stress-rest MPI protocol. Studies were
acquired with an hybrid Symbia T2 tomograph (Siemens). Summed
Stress Scores (SSS) and Agatston data were calculated for all patients
and MPI studies were considered positive (+) if SSS [ 3. Subjects
were divided into four groups on the basis of tests results: MPI- and
CCS \ 400 (group A); MPI- and CCS C 400 (group B); MPI+and
CCS \ 400 (group C); and MPI+ and CCS C 400 (group D).
Results: Fifteen patients were excluded because of sub-optimal quality
of imaging and other 22 subjects did not complete the follow-up. The
remaining 330 patients (216 men, mean age 67 12 years) were
prospectively followed for an average of 63 9 months and the
outcome events considered were: cardiac death, non-fatal myocardial
infarction, hospitalization for unstable angina and late ([90 days)
coronary revascularization. Group A consisted of 126 patients, group B
of 58, group C of 32 and group D of 114. The cardiac event rate in the
study population was 2.7%/year. Annual event rates for overall cardiac
events in group A, B, C and D were 0.3, 1.4, 4.4 and 5.6%/year
respectively. Patients with a normal MPI had higher survival free of
cardiac events (P \ .01); additionally an increase in global chi-square
in predicting all cardiac events occurred when CCS data were added to
MPI information. Kaplan-Meier curves showed a significant difference
in event-free survival at 5 years in the four groups.
Conclusions: Although this study suffers from several limitations it
outlines that an hybrid approach, combining an anatomic assessment of
coronary atherosclerotic plaque burden (which probably better estimates
longer-term prognosis) with a functional evaluation of myocardial
ischemia (more closely related to a short-term risk) may contribute to refine
temporal risk stratification among subjects at intermediate likelihood of
CAD. Multicenter trials are mandatory to confirm these preliminary
findings and to assess their potential impact in larger clinical settings.
M.N. Pizzi1; A. Roque2; S. Aguade-Bruix3; G. Cuberas-Borros4;
H. Cuellar-Calabria2; B. Garcia Del Blanco4; G. Romero-Farina4;
J. Castell-Conesa3; D. Garcia-Dorado4; J. Candell-Riera4
1Universitary Hospital Vall dHebron, Cardiology Department,
Nuclear Cardiology and Cardiac CT Unit, Barcelona, Spain;
2Universitary Hospital Vall dHebron, Radiology Department,
Barcelona, Spain; 3Universitary Hospital Vall dHebron, Nuclear
Medicine Department, Barcelona, Spain; 4Universitary Hospital Vall
dHebron, Cardiology Department, Barcelona, Spain
Introduction and Objectives: The anatomic extension and severity of
the coronary disease have routinely used in the prognosis evaluation of
patients and the decision of revascularization. However, this is a
unidimensional viewpoint of a multi-dimensional problem. We have now
the possibility of integrating non-invasively function and anatomic
images to improve our understanding of the coronary artery disease,
especially helpful in the determination of the culprit lesion.
Methods: We analyzed 30 patients (mean age: 65.5 6.77 years, 90%
men, pre-test prevalence of 63.3% 21.88%) with known significant
coronary artery disease ([50% stenoses) in at least one vessel who had
undergone a gated SPECT, a coronary computed tomography angiography
(CTA) and an invasive angiography (IA). We looked for the ability of the
different techniques in the determination of the culprit lesion (the most
stenotic lesion in the anatomic explorations and the most severe perfusion
defect in the functional test) using the hybrid imaging as the gold standard.
In the hybrid images we considered the culprit vessel the one with a
significant stenosis causing the most severe perfusion defect.
Results: In 3 of 30 CTA (10%), in 4 of 30 IA (13%), and in 3 of 30
SPECT (10%) we could not determine only one culprit vessel-region
due to the presence of two similar stenoses or two similar perfusion
defects. In all these cases SPECT-CTA hybrid images could determine
culprit lesion. After the exclusion of these doubtful cases, we observed
an 81% (22/27) concordance (kappa: 0.692) between SPECT and
hybrid images, 85% (23/27) of concordance (kappa: 0.776) between
CTA and hybrid images, and 88% (23/26) concordance (kappa: 0.817)
between IA and hybrid images. Concordance between SPECT and
hybrid images was 100% for left anterior descending artery (LDA) but
only 64% (9/14) for right coronary-left circumflex artery. Concordance
between anatomic explorations was 80% (20/25) for LDA and 93%
(26/28) for right coronary-left circumflex artery.
Conclusions: When analyzed separately, SPECT, CTA and IA could
not determine the culprit vessel-region in 10-13% of patients while
hybrid images could do it in all cases. There is 80-85% of concordance
between SPECT, CTA, IA and hybrid images for the diagnosis of the
culprit lesion. SPECT was more accurate in the LDA territory while
anatomic explorations did it better in the inferior territory.
C. Christos Graidis1; T. Christoforidou1; D. Dimitriadis1;
V. Karasavvidis1; V. Psifos1; K. Gourgiotis1; G. Karakostas1;
M. Giannadaki1; I. Neroladakis1; G. Dimitriadis1
1Euromedica-Blue Cross Hospital, Thessaloniki, Greece
Background: Myocardial bridging (MB) is a congenital structural
variant in which a segment of the epicardial coronary artery tunnels
into and is surrounded by the myocardium. The depiction rate of MB
varies significantly between catheter coronary angiography and
autopsy studies. Conventional coronary angiography is the gold
standard for detection, but it is invasive and may not be sensitive enough to
detect a thin bridge.
Purpose: The aim of this study was to assess the depiction rate of MB
by coronary computed tomographic angiography in Northern Greece
and to determine the anatomical features of the tunneling vessels.
Methods: Between January 2009 and March 2012, a total of 1884
consecutive patients who underwent 64-row MDCT coronary
angiography in our institution, were retrospectively reviewed to identify the
presence and the location of MB and determine morphologic features
and relation to atherosclerosis.
Results: A total of 338 (226 males, 44 females; mean age,
55.4 12.6 years; age range 24-90 years) out of 1,884 (17.9%)
patients showed 353 cases of MB. One hundred ninety-one tunneling
segments (54.2%) were situated in the middle portion of the left
anterior descending coronary artery (LAD), 103 segments (29.2%)
were in the distal portion of the LAD, 38 segments were in the
proximal part of the LAD (10.8%), 6 (1.7%) in the first diagonal
branch, 6 (1.7%) in the ramus intermediate, 3 (0.8%) in the second
diagonal branch, and 3 (0.8%) in the Right coronary artery. Depth
ranged from 0.1 to 4.1 mm. Intramuscular segment length ranged from
9 to 38 mm. All intramuscular segments were without evidence of
atherosclerosis. We found proximal intima to be without
atherosclerosis in 44.1% of patients (149/338) and with atherosclerosis in 55.9%.
Distally atherosclerosis was absent in 95.9% of cases.
Conclusions: Our study showed that MDCT is a reliable and
noninvasive tool for diagnosing coronary myocardial bridging, since it
accurately determines the location, depth, and length of MB. We found
the incidence of myocardial bridging in this patient group to be 17.9%,
higher than the depiction rate of MB by catheter CAG reported in the
literature and in concordance with other studies using MDCT. The
most common location of MB was in the LAD. We also observed that
most atherosclerotic plaques in the host vessel were located at the
segment proximal to the tunneled segment there was no evidence of
atherosclerosis within any intramuscular segment.
M. Zapparoli1; J. Vitola1; F.R. Farias1; S.S. Zier1; C. Cunha1;
J.J. Cerci1; O.J. Kormann1; A. Stier Jr1; O. Franca Neto1;
1Quanta Diagnostico e Terapia, Curitiba, Brazil
Purpose: To determine the cost effectiveness of performing coronary
CT angiography (CCTA) as a gatekeeper for invasive angiography
(ICA) in patients with suspected coronary artery disease and mild
ischemia on SPECT-MPI.
Methods: Data from patients without known coronary artery disease
(CAD), with mild ischemia (SSS ranging from 4 to 8) detected on
SPECT-MPI and submitted or not to CCTA between 12/2011 and
08/2012, were retrospectively analyzed from Quanta database (Curitiba,
Brazil). We modeled two diagnostic scenarios in which patients would
be: (1) submitted directly to ICA (U$ 800.00 per procedure) after the
abnormal SPECT; (2) submitted to CCTA (U$ 500.00 per procedure),
followed by ICA only when obstructive disease was detected. For cost
analysis purposes, the CCTA frequencies of normal, non-obstructive
(\50% stenosis) and obstructive (C50% stenosis) CAD results of the
subgroup submitted to CCTA were extrapolated to the whole cohort.
Results: During the observation period of 9 months, 5,345 patients
were referred for SPECT-MPI. Of these, 1,450 had mild ischemia on
SPECT-MPI, but 564 had previous history of CAD. From the
remaining 886 patients suitable for analysis, CCTA was performed in
only 75 (8.5%). The clinical and SPECT characteristics of the groups
submitted or not to CCTA are presented in the Table. There were 36
(48%) normal, 26 (34.7%) non-obstructive and only 13 (18.3%)
obstructive results by CCTA. The CCTA first strategy would avoid an
unnecessary ICA in 82.7% of patients. Applying the procedures costs
in each strategy, the total cost would be U$ 708,800.00 on the direct
ICA group and U$ 566,200.00 on the CCTA first strategy, with a net
economy of 20.1%.
Conclusion: A CAD diagnostic strategy in which CCTA is applied as a
gatekeeper to ICA in patients with mild ischemia by SPECT is very
cost-effective, but still remains highly underused in Curitiba, Brazil.
Clinical and SPECT variables by group
Integration of single-photon emission computed tomography
(SPECT) and cardiac computed tomography (CCT) for the
triage of patients with equivocal stenoses in clinical practice
L. Luigi Di Serafino1; G. Toth1; S.A. Pyxaras1; F. De Vroey1;
J. Geraedts2; H. Declercq2; P. Vanhoenacker1; B. De Bruyne1;
W. Wijns1; C. Van Mieghem1
1OLV Hospital Aalst, Cardiovascular Center, Aalst, Belgium;
2St Blasius Hospital, Dendermonde, Belgium
Purposes: The aim of this study was to evaluate the diagnostic
accuracy of sequential CCT and SPECT imaging in the evaluation of
patients with CAD and at least one equivocal stenosis detected at CCT,
in comparison with invasive coronary angiography (ICA) and FFR.
Methods: All consecutive patients with stable angina and at least one
equivocal stenosis (% diameter stenosis between 30% and 70%)
detected at CCT (Dual source CT), underwent SPECT followed by
ICA and FFR measurement. At CCT, an equivocal stenosis was
assessed as being significant (50-70%) by visual estimation.
Intravenous (IV) adenosine infusion was used as stressor for SPECT. At
quantitative coronary angiography, a lesion was considered significant
when the %DS was [50%. FFR was measured for all equivocal
stenoses detected by CCT using a 0.014 pressure guide wire system (St
Jude Medical Systems). Maximum hyperemia was induced by IV
adenosine infusion. An FFR B 0.80 was used as threshold to define a
functionally significant stenosis.
Results: A total of 51 patients were prospectively enrolled and 121
stenoses were evaluated. At CCT, 60 stenoses (49%) in 43 patients
(84%), were considered anatomically significant. Using SPECT,
inducible myocardial ischemia was detected in only 30 patients. At
ICA, 45 stenoses (37%), in 29 patients (57%), were found to be
anatomically significant. Using FFR, only 36 stenoses (30%), in 28 patients
(55%), were determined as being functionally significant: these patients
subsequently underwent revascularization. In comparison with ICA,
CCT showed high sensitivity (90%) and lower specificity (77%), when
assessing anatomical severity of CAD. In comparison with FFR, CCT
was suboptimal for determining the functional significance of a stenosis
(sensitivity: 89%, specificity: 22%). Combining CCT with SPECT
imaging (hybrid imaging), as compared with FFR, did not improve
diagnostic accuracy (sensitivity: 64%, specificity: 48%). In addition,
hybrid imaging was significantly less sensitive (64% vs 89%, P = .05)
as compared with CCT alone. Considering patient management, the
FFR result was used as decisive to proceed with revascularization. The
noninvasive hybrid approach resulted in appropriate patient triage in
65% of the patients: 17 of the 22 patients who underwent
revascularization were correctly identified, 16 of the 29 patients who were treated
medically had a normal CCT-SPECT result.
Conclusions: In patients with equivocal stenoses at CCT, the
combination with SPECT imaging did not improve diagnostic accuracy to
detect ischemia-provoking CAD. This combination of tests did not
result in reliable patient management.
Pre-operative CT coronary angiography in patients with
mitral valve prolapse referred for surgical repair:
Comparison of accuracy, radiation dose and cost versus
invasive coronary angiography
Purpose: To evaluate the accuracy of low dose multidetector computed
tomography coronary angiography (MDCT) vs invasive coronary
angiography (ICA) in ruling out CAD in patients with mitral valve
prolapse and severe mitral regurgitation (MVP) before cardiac surgery
and to compare the overall effective radiation dose (ED) and cost of a
diagnostic approach in which conventional ICA should be performed
only in patients with significant CAD as detected by MDCT.
Materials and Methods: Eighty patients with MVP and without
history of CAD were randomized to MDCT (Group 1) or ICA (Group 2)
to rule out CAD before surgery. However, ICA was also performed as
gold standard reference in Group 1 to test the diagnostic accuracy of
MDCT. A diagnostic work-up A in whom all patients underwent
lowdose MDCT as initial diagnostic test and those with positive findings
were referred for ICA was compared with work-up B in which all
patients were referred for ICA according to the standard of care in
terms of ED and cost.
Results: The two groups were homogeneous in terms of gender, age
and body mass index. The overall feasibility and accuracy in a
patientbased model were 99% and 93%, respectively. The overall ED and
costs were significantly lower in diagnostic work-up A compared to
diagnostic work-up B.
Conclusions: The accuracy of low dose MDCT for ruling out the
presence of significant CAD in patients undergoing elective valve
surgery for mitral valve prolapse is excellent with a reduction of
overall radiation dose exposure and costs.
Association of atherosclerosis of the descending thoracic
aorta with coronary artery disease on multi-detector row
computed tomography in patients with suspected coronary
Purpose: The association between atherosclerosis in the descending
thoracic aorta (DTA) visualized on CTA and CAD has not been
extensively explored. Therefore, we assessed the presence, severity and
extent of DTA atherosclerosis and evaluated the association of DTA
atherosclerosis with CAD in patients with suspected CAD who
Methods: A total of 345 patients (54 12 years, 54% men) with
suspected CAD underwent a non-contrast enhanced scan for calcium
scoring and a CTA to evaluate CAD. CTA scans were classified as
non-significant CAD or significant CAD, based on \50% or C50%
luminal stenosis, respectively. The DTA was divided into segments
according to the posterior intercostal arteries. Per segment maximal
wall thickness was measured and the presence of plaque (C2 mm wall
thickness) was determined. In addition, plaque composition was scored
as non-calcified or mixed and mean wall thickness was calculated.
Results: Significant CAD was present in 152 (44%) patients. DTA
atherosclerotic plaque was identified in 279 (81%) patients.
Differences in DTA atherosclerosis between patients with and without CAD
are presented in the table. Multivariate linear regression analysis
corrected for age and other risk factors demonstrated independent
associations of DTA wall thickness (OR 2.3, 95% CI 1.4-3.8,
P = .001) and presence of DTA plaque (OR 6.8, 95% CI 1.4-32.6,
P = .017) with significant CAD.
Conclusions: The presence, severity and extent of DTA atherosclerosis
were independently related with significant CAD on CTA in patients
with suspected CAD.
Table of the abstract 357
Cardiac CT and non-invasive electrocardiographic imaging
of chronic myocardial infarction arrhythmia substrates
F. Fady Dawoud1; K.H. Schuleri1; R. Beinart1; M. Horacek2;
H. Halperin1; A.C. Lardo1
1Johns Hopkins University, Baltimore, United States of America;
2Dalhousie University, Halifax, Canada
Introduction: Chronic myocardial infarction (MI) constitutes a
substrate for ventricular tachyarrhythmias (VT) and its delineation is
important to facilitate catheter ablation procedures. While MI can be
delineated with cardiac CT, electrical propagation can only be
identified with electrophysiological techniques. We investigated the
feasibility of cardiac CT combined with a novel non-invasive electrical
imaging technique (ECGI) to delineate scar and gain insight into VT
Methods: MI was induced in three pigs by LAD occlusion. Whole
body ECG mapping was performed during native rhythm and VT
induction 6 months post MI. Delayed-enhancement CT (DE-CT) was
acquired 7.5-minutes post contrast injection. Inverse electrograms were
reconstructed according to previously developed methodology utilizing
CT-segmented torso- and heart geometries. Regional electrical
activation times were computed and Q-wave integral maps were used to
estimate scar from inverse electrograms.
Results: Figure 1 shows an example of DE-CT volume-rendered
image showing the MI (pink outline, AHA segments 2, 7, 8, 13, 14 in
panel A) and Q-wave integral map from ECGI in pig 1 showing scar
(values \ 0, pink outlined shadowed with black, segments 2, 7, 6, 8,
12, 13, 14 in panel B top) over extending to lateral segments while the
inferior/infero-lateral segments show viable tissue (values [ 0, green
to red, panel B bottom). The reconstructed VT activation map shows
early antero-apical activation at the scar border implying an exit site of
the reentrant VT. Similar patterns were observed in other animals.
Conclusion: We demonstrated a promising application of CT in
combination with ECGI to delineate the location of MI and reconstruct
activation times during VT which can greatly guide planning of
catheter ablation procedures.
Influence of calcium channel blocker usage on results of
123I-mIBG myocardial scintigraphy in heart failure
patients: Diagnostic and prognostic implications
A. Arnold Jacobson1
1GE Healthcare, Princeton, United States of America
Background: Previous studies have suggested that calcium (Ca)
channel blockers may interfere with stimulation of neuronal cell bodies
and may also inhibit release of meta-iodobenzylguanidine (mIBG).
The present analysis examined the influence of Ca channel blocker
usage on 123I-mIBG imaging results and clinical outcomes during
2 years follow-up of HF subjects in the ADMIRE-HFX study.
Methods: Of the 961 HF subjects in ADMIRE-HFX (LVEF B 35%;
83% NYHA II, 17% NYHA III), 78 (8%) were using Ca channel
blockers at the time of 123I-mIBG imaging. Cardiac 123I-mIBG
uptake was quantified as the heart/mediastinum ratio (H/M) on early
(15 minute) and late (4-hour) anterior planar (p) images,
backgroundcorrected washout (WO) rate between the two planar images, and H/M
on OSEM-reconstructed SPECT (s) images. Outcomes determined
during median 2 years follow-up were cardiac death, and all-cause
mortality. Summary statistics were compared using t-tests, while
survival was compared using Kaplan Meier analyses and log-rank tests
(P \ .05 considered significant).
Results: During follow-up, there were 64 cardiac (7%) and 101 total
deaths (11%). In the total population, there was no difference in baseline
123I-mIBG parameters between subjects who were and were not using Ca
channel blockers (With vs without Ca blockers: Mean Early H/Mp: 1.55 vs
1.57 (P = .38); Mean Late H/Mp: 1.41 vs 1.45 (P = .16); Mean WO
Rate: 39.2% vs 37.3% (P = .36); Mean H/Ms: 2.19 vs 2.19 (P = .99)).
However, when subjects were categorized as having either reduced (late
H/Mp \ 1.60) or preserved (late H/Mp C 1.60) myocardial innervation,
those using Ca blockers had lower 2 year all-cause mortality rates (With
vs without Ca blockers: 8.3% vs 16.8% for late H/Mp \ 1.60, 0 vs 3.2%
for late H/Mp C 1.60; P = .002) and lower 2 year cardiac mortality rates
(With vs without Ca blockers: 6.7% vs 11.5% for late H/Mp \ 1.60, 0 vs
3.2% for late H/Mp C 1.60; P = .013).
Conclusions: Although Ca channel blockers had no effect on
population-based measures of myocardial 123I-mIBG uptake, HF subjects
using these medications had lower cardiac and all-cause mortality rates
during 2-year follow-up. In light of the higher mortality rate among
subjects with reduced myocardial innervation, the potential value of
addition of Ca channel blockers to the therapeutic regimen of such
subjects may warrant further investigation.
Epicardial fat volume (EFV) measurement, using cardiac computed
tomography (CT) has been shown to be a reliable marker of coronary
atherosclerosis, and greater EFV is associated with coronary artery
disease (CAD). However, little is known on the relation between the
amount of EAT and the severity of coronary atherosclerosis in
identifying high risk patients with subclinical CAD.
Purpose: The aim of this study was to investigate the relationship
between EFV and severity of coronary artery disease measured by CT.
Methods: We retrospectively analyzed data of 600 individuals who
were referred for evaluation of CAD with cardiac CT from 2007 to
2012. Subjects who had history of primary coronary intervention or
coronary artery by-pass graft were excluded. Thickness of epicardial
adipose tissue (EAT cm3), was measured on noncontrast multiplanar
reformat images with parasternal short axis view at basal,
mid-ventricular and apical levels and horizontal long axis view as the sum of
the EAT areas with 2 mm thick from the whole heart. CAD severity
was determined by, the presence of significant coronary stenosis
([50% luminal narrowing of at least one major coronary artery), high
coronary artery calcium score (CACS [ 100) and plaque
characteristics (any plaque causing significant stenosis and/or vulnerable plaques),
in the subsequent CT angiography.
Results: In the finally studied population of 434 individuals, 155
(35.7%) had atherosclerotic coronary artery disease and 279 (64.3%) of
them were normal. Overall, 75.2% were male; mean age was
58 18 years with a mean EAT 155.54 cm3. Patients with coronary
atherosclerosis had significantly greater mean EAT compared to
normals (P = .011). Linear regression analysis revealed that the incidence
of significant stenosis, atherosclerotic plaque and high calcium score
increased with EFV (P \ .01).
Conclusion: EFV measured by 64-slice CT scanning, was closely
associated with significant CAD and its measurement might be used in
addition to CT angiography as an early indicator of increased risk of
Incidence of coronary artery disease at CT coronary
angiography in patients with hypertrophic cardiomyopathy
presenting with chest pain or angina-equivalent symptoms
M. Shariat1; A.M. Crean1
1University Health Network, Toronto, Canada
Incidence of coronary artery disease at CT coronary angiography in
patients with hypertrophic cardiomyopathy presenting with chest pain
or angina-equivalent symptoms.
Background: Angina is a frequent symptom in patients with
hypertrophic cardiomyopathy (HCM). Many of these patients will present
with exertional chest pain or angina-equivalent symptoms, such as
effort-related breathlessness, which appear indistinguishable from
symptoms in the arteriopathic population.
CT coronary angiography (CTCA) is often regarded as the
non-invasive test of choice to rule out significant coronary artery disease in the
low and medium risk patient group categoryinto which many of
these patients fall.
Objectives: To describe the prevalence of severe coronary artery
disease in patients with HCM referred to CTCA for investigation of
Patients and Methods: We retrospectively reviewed CTCA studies of
93 patients who were known to have HCM or in whom the diagnosis
was unequivocally present based on the CTCA images.
CTCA studies were done on 320 slice CT scanner. Volumetric data
acquisition was done at 0.5 mm slice thickness and 0.25 mm gap. The
coronary arteries were carefully evaluated and any luminal narrowing
more than 70% was labeled severe. Any narrowing less than 50%
was labeled mild and between 50% and 70% was called moderate.
Cases were reviewed by two blinded observers. Disagreements were
arbitrated by a third reader.
Results: The indications for the CTCA included chest pain in 87
patients (93.5%) and shortness of breath in 6 patients (6.5%). Out of 93
patients, 14 (15.1%) had apical HCM, 13 (14%) had concentric
hypertrophy and 66 (70.9%) had asymmetric septal hypertrophy.
54 patients (58%) had completely normal coronary arteries, 31 (33.3%)
had mild disease and 6 (6.5%) had moderate disease. Only 2 patients
(2.2%) had severe disease in at least one segment of the coronary
arteries. The left anterior descending artery was the most commonly
involved vessel. It showed mild disease in 28 patients, moderate
disease in five patients and severe disease in 1 patient. Myocardial
bridging was present in 34 patients (36.6%) and it involved the LAD in
31 patients (33.3%).
Conclusion: Although angina is a common symptom in patients with
HCM, in our study, only 2.2% of these symptomatic patients had
severe coronary artery disease on CTCA. Coronary CTA may be useful
for preventing inappropriate treatment of HCM patients with
antianginal and lipid lowering therapies.
Purpose: Computed tomography coronary angiography (CTA) has
important prognostic value. Additionally, QCT provides a more detailed,
accurate assessment of CAD on CTA. Potentially, a score incorporating
all quantitative stenosis parameters allows for accurate risk stratification.
Therefore, the purpose of this study was to determine if a detailed
automatic assessment of coronary atherosclerosis using QCT combined
into a single risk score allows automatic risk stratification of patients.
Methods: In 300 consecutive patients QCT was performed. First, using
an automatic tree labeling algorithm, segments were labeled according
to the AHA 17-segment model. Second, vessel wall and lumen were
automatically segmented. Finally, an automatic lesion detection
algorithm identified all lesions in the coronary tree. Using QCT, patients
risk was calculated based on plaque extent, severity, composition and
location on a segment basis and integrated into a single score (0-42).
During follow-up, the composite endpoint of all cause mortality, PCI
and non-fatal infarction was recorded.
Results: At present, results are available for 65 of the 300 patients.
Event rate was 12%. In all eight patients with events an automatic,
quantitative assessed significant stenosis was present. Furthermore, in
these patients the median risk score was higher compared to patients
without events (median 8.6 (IQR 4.7-12.8) vs median 0 (IQR 0-4.8)
respectively) (P = .007).
Conclusion: Integration of detailed plaque characteristics on QCT into
a single risk score could provide accurate risk stratification.
Evaluation of nonculprit vulnerable plaque with 64-Slice
multidetector computed tomography in comparison to
Background: Coronary atherosclerotic plaque composition plays an
important role in the progression of future coronary event.
Especially, coronary atherosclerotic plaque with intravascular ultrasound
(IVUS) attenuation might be related to the deterioration of coronary
flow and worse long-term outcomes after coronary artery disease
(CAD) and interventions. Noninvasively characterizing vulnerable
plaque is an important method in risk stratification and following
the progression of coronary plaques. Multidetector computed
tomography (MDCT) is most reliable method to evaluate coronary
plaque composition. The aim of this study is to evaluate possibility
of 64-slice MDCT to detect nonculprit IVUS attenuated plaque
and identification of atherosclerotic plaque with future coronary
Methods and Results: Fifty-seven patients (15 with ACS, 42 with
stable CAD) and 240 plaques were evaluated by 64-slice MDCT. One
hundred sixty-eight nonculprit plaques of the 240 plaques were
evaluated by IVUS. Of the 168 plaques, 59 (47 calcified and 12 mixed
plaques) were excluded from the present analysis. The remaining 109
plaques (40 soft plaques, 30 attenuated plaques, 39 fibrous plaques)
represent the present analysis. In the attenuated plaques, CT density
had significantly higher than soft plaques (70 9 HU vs 40 6 HU;
P \ .001) and lower than fibrous plaques (70 9 HU vs 94 6 HU;
P \ .001). Spotty calcification with lipid pool was more common
(37% vs 13%; P \ .05) in the attenuated plaques compared to the soft
plaques. The attenuated plaques were present significantly more
frequently in patients with lower high-density lipoprotein cholesterol
levels than those without attenuated plaques (40 9 vs 48 9 mg/dL;
P \ .001, 40 9 vs 47 11 mg/dL; P \ .005).
Conclusions: Nonculprit plaque analysis by MDCT would be a useful
method for predicting atherosclerotic plaque with high risk of future
C. Christos Graidis1; T. Christoforidou1; D. Dimitriadis1;
V. Karasavvidis1; K. Gourgiotis1; M. Giannadaki1;
I. Neroladakis1; G. Karakostas1; N. Karadimitras1;
1Euromedica-Blue Cross Hospital, Thessaloniki, Greece
Background: Congenital coronary anomalies are uncommon with an
incidence ranging from 0.17% in autopsy cases to 1.2% in
angiographically evaluated cases. The recent development of ECG-gated
multi-detector row computed tomography (MDCT) coronary
angiography allows accurate and noninvasive depiction of coronary artery
Purpose: The aim of this study was to evaluate the prevalence of
anomalous origin, course and termination of coronary arteries in
consecutive symptomatic patients, who underwent cardiac 64- slice
MDCT coronary angiography.
Methods-Results: This retrospective study included 2572 patients who
underwent coronary 64-slice MDCT coronary angiography from
January 2008 to March 2012. Of the 2572 patients, 60 (2.33%) were
diagnosed with coronary artery anomalies (CAAs), with a mean age of
53.6 11.8 years. High take-off of the RCA was seen in 16 patients
(0.62%), of the left main coronary artery (LMCA) in 2 patients
(0.08%) and both of them in 2 patients (0.08%). Separate origin of the
LAD and Cx from Left Sinus of Valsalva (LSV) was found in 15
patients (an incidence of 0.58%). In 9 patients (0.35%) the RCA arose
from the opposite sinus of Valsalva with a separate ostium. In 6
patients (0.23%) an abnormal origin of LCX from the right sinus of
Valsalva (RSV) was found. A single coronary artery was seen in 3
patients (0.12%). In 2 patients (0.08%) left coronary trunk was found
to originate from the RSV with separate ostium from the RCA. LCA
from the pulmonary artery was seen in one patient (0.04%). A coronary
artery fistula was detected in 4 patients (0.15%).
Conclusion: The results of this study support the use MDCT coronary
angiography as a safe and effective noninvasive imaging modality for
defining CAAs in an appropriate clinical setting, providing detailed
three-dimensional anatomic information that may be difficult to obtain
with invasive angiography.
Aortic valve sclerocalcification (AVSC) and mitral annulus
calcification (MAC) is common with aging and have been considered as a
manifestation of generalized atherosclerosis in elderly population.
However, the significance of these calcifications in younger
populations has not been previously determined. AVSC and MAC can be
easily detected by transthoracic echocardiography (TTE). Recently,
Coronary CT angiography (CTA) has become widely available in
detecting occult coronary atherosclerosis disease (CAD).
Purpose: We hypothesized that in subjects age \ 60 years, AVSC and
MAC would be associated with a higher prevalence of positive CCTA.
Methods: In a prospective, cohort study, we identified patients
younger that 60 years, who all underwent both CCTA and TTE for
various clinical indications. We utilized positive CTA as a surrogate
for angiographically CAD. All known risk factors for atherosclerosis
including age, gender, hypertension, smoking, dyslipidemia, diabetes
and family history were also investigated.
Results: The mean age of our study population included 155 patients
(109 men and 46 women) was 50 4.2 years. When the cohort was
divided by the presence of atherosclerosis, we found that 81 patients
had CAD and 74 had normal coronary arteries (75.8% vs 24.2%). Of
the 81 patients with CAD, 69 had AVSC compared with 22 in the
nonCAD group (P \ .001).Hypertension and MAC were found
significantly more prevalent in the CAD group than in non-CAD group,
respectively (61% vs 39%, with P = .006 and 70.4 vs 29.6, with
P = 0,042). Multivariate analysis identified only AVSC and age as
independent predictors of coronary atherosclerosis. The sensitivity,
specificity, positive and negative predictive values for AVSC in
diagnosing CAD were 72.2.1%, 60%, 81% and 50%, respectively.
Although AVS is highly associated with CAD, it has only modest
sensitivity and specificity (72% and 60%), respectively. Despite a low
negative predictive value (50%), it has a high positive predictive value
(81%) for the presence of significant CAD.
Conclusion: Our study demonstrates that aortic valve
sclerocalcification and coronary atherosclerosis are significantly associated with
each-other, even in a juvenile population. The presence of aortal
sclerocalcifications may help in predicting CAD and should be added
to conventional risk factors.
J. Jingjing Gai1; L.Y. Gai1; H.Y. Qiao1; S.Y. Zhang1;
Z.W. Guan2; L. Yang3; Y.D. Chen1
1China PLA General Hospital, Department of Cardiology, Beijing,
Peoples Republic of China; 2China PLA General Hospital,
Department of Nuclear Medicine, Beijing, Peoples Republic of China;
3China PLA General Hospital, Department of Radiology, Beijing,
Peoples Republic of China
Objective: Major adverse cardiac events (MACE) often occur
suddenly resulting in high mortality and morbidity. Analyzing the
characteristics of coronary plaque by Coronary Computed
Tomography Angiography (CCTA) may help forecasting the MACE.
Methods: The patients who underwent CCTA from Jan 2008 to Feb
2010 were consecutively enrolled in the study. The hospital data base
was screened for patients who later developed acute ST elevated
myocardial infarction (STEMI) or non ST elevated acute myocardial
infarction (NSTEMI) or cardiac death. The definition of the plaque
score as follow: 1. Minor plaque, 1 point; 2. Moderate plaque, 2 points;
3. Severe localized stenosis, 3 points; 4. The erosive plaque, 5 points;
5. Calcification, 1 point; 6. DES, 5 points; 7. Plaque with positive remodeling, 3 points; 8. Complete occlusion, 3 points; 9. Diffused moderate lesions, 2 points. Two-way analysis of variance was performed.
Results: A total of 8557 consecutive cases of CCTA were performed in
the institution. Among them 1055 were hospitalized during which 25
patients developed MACE, including 6 cases of deaths, 2 cases of heart
failure, 11 cases of STEMI and 6 cases of NSTEMI. One way ANOVA
analysis showed that advanced age, AF, past history of PCI, low Hb,
tachycardia and high Grace Score contributed to death and heart failure.
The differences were significant, P \ .05. The plaque characteristics of
the plaques were analyzed. The patients who had erosion plaques and
high degree localized lesions had high likelihood of developing MACE,
95% CI: 0.6472-1.538, P = .000. The death and heart failure had the
highest plaque score, 95% CI: 0.4882-1.379, P = .000.
Conclusion: The plaque characteristics identify high risk patients.
Comparation of agatston coronary artery calcium score
using contrast-enhanced CT coronary angiography,
framingham score and multiple blood biomarkers
as predictors of coronary artery stenosis
A. Ana Lanca1; Z. Madzar1; D. Javoran1; V. Bursic1;
V. Pehar-Pejcinovic1; V. Persic1; M. Boban1
1Clinical Hospital Thalassotherapia Opatija, Opatija, Croatia
Purpose: To analyze efficiency of Agatston score, Framingham risk
score, and multiple blood biomarkers as predictors of coronary artery
stenosis in patients with nonspecific chest pain.
Methods: The study included 161 patients (mean age 63 7.7, 70% of
females) with atypical chest pain and unknown coronary heart disease,
who underwent coronary multi detector computed tomography
coronarography and obtained Agatston score. Scanning was done with the
Definition Flash 2 9 128 slice CT scanner by dual source technique,
and the mean received amount radiation was 4.6 1.2 mSv. The mean
heart rate during scanning was 68 9.3/minute, and patients body
mass index (BMI) 27.4 4.3. Patients with known cardiovascular risk
factors, including hypertension (77%), diabetes mellitus (25%),
dyslipidemia (77%) or smoking (28%) and various Framingham risk score
values (0.6-59.9, mean 22.3 12.7) were considered. Blood
biomarkers included glucose, C-reactive protein (CRP), total cholesterol,
LDL-cholesterol, HDL-cholesterol, triglycerides, creatinine, eGFR and
uric acid. Participants were divided in two groups, based on coronary
artery stenosis greater than 50% (40 of participants), and the other with
stenosis smaller than 50% (121 of participants). Frequency of
demographic and clinical characteries, blood biomarkers and risk factors
were tested between the groups by using Chi square test and Student T
test as appropriate. To test for factors associated with predicting
coronary artery stenosis, Likelihood Ratio, and Receiver Operating
Characteristics (ROC) analyses were used. Relative Risk was
calculated in context of developing coronary artery stenosis greater than
50% in participants with Agatston score above 100.
Results: The most accurate predictor of coronary artery stenosis
greater then 50% was Agatstone score (AUC 0.99, P \ .0001).
Agatstone score higher than 100, had relative risk for developing of
coronary stenosis over 50%, 17 times higher than values under 100.
CRP (AUC 0.76), glucose (AUC 0.59), uric acid (AUC 0.61) and
Framingham risk score (AUC 0.57) had high sensitivity but low
specificity for coronary artery stenosis.
Conclusion: Among all considered demographic and clinical
characteristics, blood biomarkers and risk factors, Agatstone score was the
most accurate predictor for developing of coronary artery stenosis.
G. Scrima1; G. Giovanni Bertuccio2
Myocardial bridge is the most frequent congenital coronary
anomaly (about 1.5% of patients already undergone to coronary
Prognosis is quite variable: a negative prognosis could be related to the
so-called type III bridges (deep intra-myocardial course; [ 10 mm
length; [ 75% systolic milking) with myocardial ischemia and
major ventricular arrhythmias (0,6% among Patients pertaining to our
We have considered consecutively all symptomatic patients with type
III myocardial bridge afferent to our department from 01/08 to 01/
11. All of them were submitted to coronary angiography.
We selected 22 patients out of them, 13 with stable angina symptoms
(angina CCS II-III): 11/13 with exercise test positive for ischemia; 2/13
had a positive SPECT with mild/moderate amounts of anterior
ischemia in the absence of specific medical therapy.
The remaining 9 Patients exhibited a clinical SCA (2 antero-lateral
STEMI; 7 anterior/UA NSTEMI) related to the myocardial bridge
All Patients with stable angina symptoms were treated with
betablockers, followed by myocardial SPECT resulted negative for
inducible ischemia in the same site. All of them were asymptomatic to
the clinical follow-up (22 months).
All Patients, with bridge-related SCA, were treated with PTCA and
medicated stent (DES). This procedure in 8/9 Patients was guided by
intracoronary ultrasound (IVUS) that allowed the diameters
optimization and the length of the implanted stent (in-flow and out-flow of the
stent at least 3 mm before and after the intra-myocardial stretch), as
well its final relaxation.
Only the patient submitted to PTCA without IVUS was hospitalized
again for a SCA recurrence 7 months after first procedure, secondary
to the re-stenosis of the medicated stent. The IVUS control
demonstrated an evident under-sizing of the implanted stent compared to the
native vessel; it was solved with a simply re-PTCA using an adequate
diameter NC balloon.
Finally we could affirm that: Patients with myocardial bridge on
IVA with stable angina symptoms have indication to medical therapy
with Beta-blockers or, if not indicated, Ca-antagonist. They should be
subjected to a myocardial SPECT with full therapy to evaluate the
residual functional significance of the bridge during medical
therapy. PTCA is useful with persisting ischemia despite medical treatment.
In SCA bridge-related, IVUS guided percutaneous treatment with
medicated stent appears to be safe and effective because it isnt related
to late thrombotic events (no patient in our casistic) and its associated
with a very low restenosis rate.
Background: Cardiovascular disease is the leading cause of mortality
in the world. An early investigation and management can improve
survival. The non-invasive diagnostic methods in the evaluation of
coronary artery disease have been widely used even those that submit
patients (p) to radiation. If the association of myocardial perfusion
imaging (MPI) and coronary calcium score (CAC) is important in the
management of low to intermediate risk of coronary artery disease
(CAD) patients (p) is not yet well established.
Purpose: The aim of this study was to evaluate if the information of MPI
add value to CAC in a low to intermediate risk of CAD group of patients.
Methods: It was analyzed 212 p that performed CAC and MPI
between 01 and 07 of 2012 without any cardiac procedure in between.
From the total, 166 p (78.3%) were male, mean age of 47 years, 49 p
(23.1%) with diabetes, 122 p (57.5%) with dyslipidemia, 48 p (22.6%)
with hypertension, and none p had known CAD or cardiac symptoms.
The CAC and the sestamibi-Tc-99m MPI were performed by standard
techniques. CAC were divided in zero (101 p), \100 (27 p), 100-400
(44 p) and [400 (40 p). MPI was considered normal if no perfusion
defect and suggestive of ischemia if reversible perfusion defect after
stress phase. Statistical analysis was performed by Fisher exact test,
being considered significant P values B 0.05.
Results: In the group of CAC zero 2 p (1.9%) had presented ischemia on
MPI. In the other groups with CAC \ 100, CAC 100-400 and
CAC [ 400, 1 p (3.7%), 6 p (13.6%) and 14 p (35%) had presented
ischemia on MPI, respectively (P B 0.05). The three patients who
presented ischemia on MPI and had CAC zero or \100 had suggestive of
soft plaque on coronary tomography. Male gender and presence of
diabetes were associated with ischemia in the group of patients with
CAC 100-400 (P \ 0.05). In the group with CAC [ 400 only diabetes
was associated with presence of ischemia on the MPI (P \ 0.05).
Conclusion: The obtained results may suggested that MPI can add
diagnostic information to CAC in a low to intermediate risk of CAD group
of patients because of the detection of ischemia in p with soft plaques.
Aim: To characterize coronary artery calcification in patients with
giant coronary aneurysms (GAA) caused by Kawasaki disease (KD)
using multi-detector x-ray computed tomography (MDCT).
Methods: Subjects were 25 pediatric and young adult patients (19 male
and 6 female) with history of KD who had GAA with [8.0 mm of
coronary artery diameter confirmed by coronary angiography (CAG).
Using MDCT, calcification of the coronary arteries was identified and
classified according to the degree of circumferential calcification; Type
A, \90 ; B 90180 ; C, 180-359 ; D, 360 ; E, luminal occlusion and
internal lumen was evaluated at these calcified segments.
Results: Patients age at onset and at study were 2.6 2.8 and
23.5 7.1 (10.8-40.4) years old, with median of 20.8 (9.8-40.1) years
after the onset. In these 25 patients, 11 (44%) underwent either catheter
or surgical interventions for coronary stenosis.
On MDCT, all 25 patients showed calcification of the coronary arteries
in total of 47 segments (1.9, range 1-4 segments for each patient). In
these 47 segments, GAA presented in 36 (77%) segments, small to
moderate aneurysms with diameter \8.0 mm in 11 (23%).
Calcification was located at #1 in 15, #2 in 5, #3 in 5, #5 in 5, #6 in 12, and #11
in 15 patients. Degree of calcification was calcified as Type A, 28%; B,
6%; C, 17%; D, 34%; E, 15%. Among 29 segments where calcification
presented with patent coronary lumen, we could evaluate the degree of
stenosis in 18 of 19 (95%) segments of Type A, B, and C, but it was
possible only 3 of 10 (30%) segments of Type D with complete
Conclusions: All patients with GAA after KD showed calcification at
more than 10 years after the onset at proximal coronary segments, even
at segments with small to moderate coronary aneurysms. Complete
circumferential calcification present in one third of segments and
preclude accurate evaluation of the internal lumen with current setting
of the MDCT, hence other modalities including CAG or cardiac
magnetic resonance imaging must be the choice of diagnostic test in
Multi-slice computed tomography (MSCT) offers possibility to
visualize the relations between left circumflex artery (LCx) and coronary
sinus (CS) before percutaneous mitral annuloplasty (PMA) to exclude
patients with potentially dangerous relations LCx/CS. There are no
data available showing quality of visualization both vessels in MSCT.
Methods: MSCT (Aquilion64) in 196 pts. (109 M; aged 56 11) with
suspected CAD was performed using retrospective scan with
ECGgating. In each case 3D VR and 2D MPR reconstructions were created
(0.5 mm). A subjective assessment of the quality of visualization to
find the optimal phases of visualization for LCx, CS and both vessels
together (relations) was used. The quality of visualization was graded
by 2 experts on 6-points scale: 0 = lack of vessel; 1 = image not
diagnostic; 5 = smoothly bordered vascular structure. Independent
2 mm reconstructions optimized for the LCx (diastolic 70-80-90% RR)
and CS (systolic 30-40-50% RR) were also performed.
Results: In parallel visualization of LCx and CS optimal image quality
(score 5 and 4) was obtained in diastolic phases (70-80%)72 cases
(36.7%). Exact scoring for independent visualization in optimal phases
is presented in the table below (n; %). Optimal score was achieved in
85 cases (43.4%) for LCx and in 133 cases (67.9%) for CS. Not
diagnostic images (score 1) was obtained in 7 (3.6%) cases (LCx: 2;
1.0% CS: 5; 2.5%).
Conclusions: Quality of parallel as well as independent visualization
of LCx and CS confirm potential role of MSCT before PMA
procedures. Parallel visualization should be performed in diastolic phases as
an addition for independent visualization.
Quality of visualization
Score 2 Score 1
Quality of visualization LCx
Phase 70% 17; 9.7% 12; 6.8%
Phase 80% 25; 14.2% 23; 13.1%
Phase 90% 5; 2.8% 3; 1.7%
Quality of visualization CS
Phase 30% 19; 10.8% 9; 5.1%
Phase 40% 61; 34.6% 31; 17.6%
Phase 50% 8; 4.5% 5; 2.8%
LCx, Left circumflex artery; CS, coronary sinus.
Table of the abstract 373
R. Mlynarski1; A. Mlynarska2; M. Sosnowski3
1Upper-Silesian Cardiology Center, Katowice, Poland;
2Medical University of Silesia, Katowice, Poland;
3Medical University of Slesia, Katowice, Poland
Cardiac imaging is almost mandatory in techniques like percutaneous
mitral annuloplasty (PMA). During PMA the relationship between
coronary sinus (CS) and circumflex artery (Cx) in relations to mitral
valve (MV) is of special importance. In such circumstances, a new
image reconstruction algorithm might be potentially useful.
Methods: In 46 pts (24 M) a 64 slice computed tomography (Aquilion
64) was performed. Pts with critical changes in LCx were excluded. A
scan with ECG-gating was performed using: slice 0.5 mm, helical pitch
12.8 and tube voltage 135 kV (380 mA). 100 ml of non-ionic contrast
agent at a rate of 4.5 mL/second was given. In each case 3D VR and 2D
MPR reconstructions were created (Vitrea 2). In all pts various
visualization modes were tested (MPR measurements and visualizations) to
create optimal visualization LCx/CS/MV, defined as a consensus
between 2 experienced observers to fulfill PMA requirements.
Results: The following stages in post-processing were recognized as
optimal: 3DVR visualization of lateral view of the heart (Figure A); 3x
(10 ) virtual cutting of the of the heart (Figure B); digital analysis
(own projectFigure C) of the relations LCx/CS/MV. Examples of
image preparation are presented on the figures below. Presented
method was applicable in all patients. Selected 2D measurements
vessels of interest (Figure C) were as follow: LCx diameter
3.7 0.7 mm, CS diameter 4.9 1.5 mm, LCx-MVd diameter
44.5 7.9 mm, and CS-MVd diameter 42.8 6.6 mm. In 26 pts
(56.5%) the LCx run closer to the MVit potentially cause problems
(LCx occlusion) after PMA device implantation.
Conclusions: Presented method may be useful for visualization of
LCx/CS/MV in cardiac CT in patients before PMA, however
applicability of this method requires verification in further clinical studies.
Scheme of CT image post-processing
Usefulness of computed tomography coronary angiography
in screening patients in the presence of atypical chest pain
and risk factors for coronary disease
R. Moran1; O. Rana1; R. Patel1; R. Swallow1; J. Kingston1;
1Royal Bournemouth Hospital, Bournemouth, United Kingdom
Purpose: Assessment of patients with chest pain and risk factors for
coronary artery disease (CAD) in the presence of atypical symptoms
can be difficult. Such patients often have equivocal exercise tolerance
tests or cannot perform one. Consequently they undergo quantitative
coronary angiography to exclude significant CAD, with normal results
in up to 25%. Non-invasive imaging modalities such as computed
tomography coronary angiography (CTCA) have emerged as
alternatives. We performed a retrospective review to assess the hypothesis
that CTCA is diagnostically useful in this cohort.
Methods: We examined the referral pathway of 168 consecutive
patients (58.4 11.3 years) over 14 months who had been referred to
3 cardiologists for possible CAD. All had atypical chest pain with
coexisting risk factors (see table) and either had an equivocal exercise
tolerance test or were unable to perform one. The cohort had an
intermediate pre-test probability of CAD (52.1% 26.4) derived from
the United Kingdom national guidelines. All patients underwent CTCA
(Aquilion 1 Toshiba, Japan) and proceeded to invasive coronary
angiography only if CTCA showed significant CAD (defined as at least
one moderate lesion, [50% stenosis).
Results: Of 168 patients, 123 (73.2%) were normal (63, 37.5%) or had
non-significant CAD (60, 35.7%) based on CTCA. The remaining 45
patients (26.8%) underwent quantitative coronary angiography,
revealing severe CAD ([70% stenosis) in only 13 patients (7.7%). All
13 had been correctly identified by CTCA. Moderate CAD (50-70%
stenosis) was seen in the other 32 (19%), CTCA being concordant with
this in 28 patients (88%). CTCA overestimated CAD severity in the
other 4 (12%).
Conclusions: Our data suggest CTCA is an alternative to quantitative
coronary angiography in screening patients with atypical chest pain
and equivocal exercise tolerance tests, despite the presence of risk
factors for CAD. Risk scores appear to overestimate the true incidence
of significant CAD.
Frequency of CAD risk factors (%)
M.J. Moncy Jacob Oommen1; L. Nazar1
1Division of Cardiology, RIPAS Hospital, Brunei, BANDER SERI
BEGAWAN, Brunei Darussalam
Introduction: Patients with inconclusive stress tests and suspected
CAD often present a diagnostic challenge in a non interventional
cardiac centre. In deed the yield of invasive CAG in this group of
patients is not significant. Coronary CTA in patients with equivocal
stress test is considered as an appropriate indication.
Objectives: We attempted to determine the clinical events of the
patients who had the inconclusive stress tests and CTA, tried to classify
these a patients based on the risk factors, severity of CAD by CTA and
tried to find the significance of the risk factors and CTA results with
the clinical events during this period.
Methods: We studied 175 patients who had suspected CAD and
inconclusive stress tests done from April 2007 to December 2009. All
these patients had 64 slice cardiac CTA. Patients are classified based
on age, sex risk profile, CCS and CTA results of the CAD severity.
Patients are reviewed for the cardiac events in the followup clinic. The
primary outcome of the study was all cause mortality, cardiac
admissions for ACS or for CAG and PCI. However only 139 patients were
followed up in the clinic and by telephonic interview till date.
Results: 43% of the patients were in the age group 50 to 69, 53% were
females, 69% has hypertension 44% hyperlidaemia. 40% had atypical
chest pain, 70% had CCS less than 100. CTA results showed no CAD
in 54% patients. Follow up of these patients with significant CAD once
in six months till date showed 69% of these patients had no cardiac
events, there was one death (0.7%, 8 (5.6%) admissions for ACS, 34
(24%) patients had CAG and PCI.
Conclusion: Among patients with inconclusive stress tests, a
significant number did not show any obstructive CAD by CTA. During the
follow up study, clinical events are higher in patients with increasing
severity of CAD by CTA. This clinical approach based on CTA is
useful for short term prognostic assessment in this group of patients
especially in a non interventional cardiac centre.
Purpose: Fractional flow reserve (FFR) is an easily obtained index of
the physiologic significance of coronary stenosis that can optimize
treatment strategy. The purpose of this work was to compare diagnostic
performance of noninvasive computed FFR (FFRct) with standard
invasive FFR angiogram patient data and to assess the impact of FFRct
on diagnostic improvement in borderline coronary lesions.
Methods: Three patients admitted for coronary artery disease
underwent coronary CT angiography (Siemens 256-slice SOMATOM
Definition CT scanner) and cardiac catheterization with FFR
assessment. Internally designed software was used for computer simulation
of FFR based on the coronary CT angiogram. The 3D blood flow was
described by the Navier-Stokes equations, in conjunction with the
continuity equation. A parabolic flow waveform was applied at the
location of aortic root, while outlet boundary conditions were
configured to an inverse resistance of the corresponding diameter.
Results: Coronary CT angiography discovered that two patients had
single vessel CAD with significant stenosis ([50%) observed on ACD
and LAD respectively, and one patient had triple vessel CAD. There
was no difference between the FFR and FFRct values (P [ .22).
Coronary CT angiogram designated 2 (66%) lesions as significant and
after performing FFRct none of these lesions proved to be
hemodynamically significant. Coronary CT angiogram tended to overestimate
the degree of stenosis but with no statistical difference compared to
coronary angiography (P = .75).
Conclusions: We found a solid correlation between standard FFR and
FFRct results. Computer simulation may offer distinct advantage due
to non-invasive nature of the analysis, and as such may prove to be of
particular benefit when assessing borderline cardiac patients.
Assessment of coronary vessels surrounding left ventricle in the
atrioventricular sulcus is an important step before percutaneous mitral
annuloplasty (PMA). There are no research evidencing whether and
how the presence of flow-limiting stenosis in the left circumflex artery
(LCx) influence the venous circulation of the heart.
Methods: In 66 consecutive patients (41 M, aged 61.7 10.4), a
64-slice CT (Aquilion 64) was performed due to a CAD suspicion. Pts
were divided into two groups according to the presence of stenosis in
LCx: 38 pts with LCx stenosis (stenosis) and 28 pts without changes in
LCx (control). A scan with ECG-gating was performed using: slice
0.5 mm; helical pitch: 12.8; rotation time: 0.4 seconds and average
tube voltage: 135 kV at 380 mA. 100 mL of non-ionic contrast agent
at a rate of 4-5 mL/second was given. All measurements were
performed on 2D MPR and VR reconstructions. Following measurements
were made: CS ostium diameter (mm), angle of entrance CS to RA (8),
average LCx diameter (mm), average CS diameter (mm), max distance
between CS and LCx (mm), minimal distance between CS and LCx
(mm), distance between LAD and CS/LCx intersection (mm)
examples Fig below.
Results: A significant reduction of angle of entrance CS to the right atrium
was observed in the group with LCx stenosis: 102.3 8.5 (stenosis) vs
110.5 8.3 (control); P \ .001. In this group, a significant increase of the
maximum distance between CS and LCx was also observed: 16.9 4.9
(stenosis) vs 13.6 4.4 (control); P \ .01. Differences in the other
analyzed parameters did not reach statistical significance.
Conclusions: Presence of stenosis in the left circumflex branch of left
coronary artery influence the anatomy of coronary sinus, however
further studies are necessary to explore clinical significance of our
Example of measurements
S. Huidu1; D. Dimulescu1; A. Popescu1; S. Lacau1; S. Barsan1;
L. Ionescu1; I. Stanca1; L. Arama1
1Elias Emergency Universitary Hospital, Bucharest, Romania
Purpose: We evaluated the feasibility and image quality of coronary
CT to 120 patients screening for CT angiography in Elias-Prolife
Hospital between 2010 and 1012.
Method: All patients were symptomatic with low or intermediate
probability of having severe coronary stenosis. Other patients had
known coronary heart disease and CT were performed to check for
patency of coronary stents or by-passes.
120 patients were screen.
Were excluded those who had renal insufficiency or allergy to contrast
Inclusion criteria were: age over 29 years, weight less than 100 kg,
heart rate below 60 bpm after administration of premedication
It is known that about 60 bpm heart rate allows a better image quality
in CT angiography.
It influences body weight and image quality.
Of the 120 patients, 11 were excluded by the inability to obtain a heart
rate below 60/minute after 100 mg of atenolol 10-20 mg metoprolol
IV, 5 were excluded by the presence of renal insufficiency, 4 because
of marked obesity. To 100 patients were performed CT angiographies.
Among patients who carried angio CT all 100 images were good
results without having no interpretable.
32% of patients were women and 68% men;
46 patients were aged below 60 years.
Results: Calcium score was 0 in 26% patients.
9% had PCI with stent in one or two coronary arteries prior CT and 2%
CABG 2, 3 coronary arteries.
All the stenosis more than 50% was considered significant stenosis.
One patient had a significant lesion on LM segment, 18 cases had LAD
stenosis, 8 cases CD and 13 casescircumflex artery. 11 patients had
two or more coronary arteries with stenosis.
76% patients had insignificant coronary stenosis. Of all patients, 24
were sent for coronary lesions confirmation to CG, and one single false
positive result was found. 12 patients had confirmed the lesions
through CG. 11 patients had indication to perform CG because of
significant stenosis but did not complete it.
Conclusion: Angio CT remains a noninvasive method for assessing
coronary stenosis that is recommended to patients with low or
moderate probability of significant coronary stenosis and provides excellent
image quality for non-obese patients with AV below 60/minute.
W. Wilson Pimentel1; W. Custodio1; J. Buchler1; S. Assis1; M.
Macedo Soares1; E. Bocchi1
1Beneficencia Portuguesa Hospital, Sao Paulo, Brazil
Aims: The aim of this study was to evaluate the diagnostic
performance of coronary computed tomographic angiography (CCTA) and
its influence on modification of percutaneous coronary interventions
(PCI) strategies that means, we discuss the potential application of
CCTA for the guidance of PCI.
Methods and Results: The study included two groups of patients: a
main group (MG), including 200 patients screened with a suspect of
severe CAD by CCTA and indication for coronary cineangiography
(CINE), and a control group (CG) for comparison, including 200
patients selected during the same period, with indication for CINE
according to clinical criteria or by positive functional tests. We
evaluated the performance of CCTA for the diagnosis of lesions [50% in
coronary segments, arteries and patients and the revascularization
Results: The sensitivity, specificity and positive and negative
predictive values of CCTA were 85%, 85%, 71% and 98% for the coronary
segments, 90%, 91%, 82% and 100% for the coronary arteries and
100%, 88%, 96% and 98% for patients, respectively. In the MG,
percutaneous coronary intervention (PCI) was performed in 90% of the
patients, whereas in the CG, percutaneous coronary intervention was
performed in 43% of the patients (P = .01).
Conclusions: CCTA had a high diagnostic performance in detecting
CAD and allowed ad hoc PCI to be performed in 90% of the patients.
This strategy, however, must await randomized studies to confirm
Superiority of CT coronary angiography over catheter
angiography in detection of variants/anomalies/disease of the
coronary arteries: A problem solver
A. Abhishek Bansal1; M.M. Dsouza1; H. Wardhan2;
R. Sharma1; P.K. Chugh1; R.P. Tripathi1
1Institute of Nuclear Medicine and Allied Sciences, New Delhi, India;
2Dr. Ram Manohar Lohia Hospital, New Delhi, India
Purpose: To describe various coronary artery variants/ anomalies and
diseases that were identified on coronary CT angiography (CCTA), and
better delineated and characterized than on the catheter angiography
(CAG), thus, emphasizing the increasing role of CCTA in accurately
diagnosing such conditions which went unnoticed previously.
Methods: We retrospectively studied 94 patients who had undergone
CCTA at our institute. Out of these, we identified 10 patients showing
variations/anomalies/disease of the coronary arteries, which were not
adequately assessed on CAG. The CCTA was then performed on a
40-slice MDCT scanner (SOMATOM Sensation, Siemens Medical
Systems). Informed consent was taken from each patient.
Results: Patients ranged in age from 22-64 years. Out of 10 patients, 4
were females and 6 were males. In 2 patients, the right coronary artery
(RCA) showed an intra-atrial course in the right atrium for variable
lengths, which was not identified on CAG. A patient with Tetralogy of
Fallot demonstrated markedly tortuous and dilated coronary arteries
with multiple coronary-cameral fistulae. CCTA also depicted all the
characteristic abnormalities namely, ventricular septal defect,
overriding of aorta, infundibular pulmonary stenosis and right ventricular
hypertrophy. 1 patient with single coronary artery arising from the
right coronary sinus was identified. The exact course of all the
branches was delineated accurately on CCTA only. In another patient, the
RCA was seen arising from the ascending aorta anteriorly, which was
not identified on the CAG. 1 patient had the left main coronary artery
(LMCA) arising from the non-coronary sinus. In another patient, CAG
showed complete occlusion of the RCA in its proximal part, the cause
of which- an intra-luminal thrombus and its exact extent was identified
on CCTA only. In another patient the LAD had an aberrant course on
CAG, the cause of which was identified as marked dilatation of the
right atrium and ventricle exerting pressure effects over the LAD on
CCTA. 1 patient showed a non-enhancing mass in the left ventricular
cavity, diagnosed as a cystic thrombus on CCTA. In 1 patient the RCA
showed focal long segment ectatic dilatation.
Conclusions: This study illustrates the utility of CCTA in depiction of
coronary artery anomalies/variants and its superiority over CAG. It is
highly likely that such anomalies/variants of the coronary arteries were
missed in the past due to the availability of only CAG. CCTA allows
simultaneous depiction of coronary arteries, surrounding tissue and
cardiac chambers and comprehensive evaluation of the arterial course
in multiple planes.
Multidetector ct angiography as a noninvasive tool to assess
graft patency of surgically reconstructed diffusely diseased
A. Rezk1; M. Bazid1; Z. Saad2
1King Fahad Military Hospital, Southern Region, Kamis Mushyat,
Saudi Arabia; 2Aseer Central Hospital, Abha, Saudi Arabia
Background: Long reconstruction of the diffusely diseased vessel may be
a useful surgical option for patients with diffuse coronary artery disease.
Close and careful follow up of such subgroup of patients is mandatory.
Invasive graft angiography serves as the diagnostic standard for follow up
of graft patency for such extensive procedure; however, because of the
risks, discomfort, and costs of a hospital stay, a noninvasive diagnostic
tool is desirable. The purpose of current study is to evaluate the results of
extensive reconstruction of the diffusely diseased left anterior descending
coronary artery (LAD) using an left internal thoracic artery (LITA) graft
and assess the reliability of multidetector computed tomography (MDCT)
angiography as a noninvasive and safe alternative to assess graft patency
in asymptomatic patients after (coronary artery bypass surgery (CABG)
with reconstructed diffusely diseased vessels.
Methods: 25 patients with the diffusely diseased LAD underwent a
long-segmental reconstruction procedure with a LITA graft. The
diffusely diseased LAD was extensively incised, additional
endarterectomy was performed if necessary, and then the LAD was
reconstructed with an ITA graft in a long on-lay fashion. Postoperative
MDCT angiography as a non-invasive single tool was performed in 25
asymptomatic patients to assess graft patency.
Results: The cohort consisted of 23 men (92%) and 2 women (8%).
The mean age was 58.5 9.2 years. The mean length of the
arteriotomy incision was 3.5 1.2 cm. Endarterectomy was performed in 3
patients (12%). Preoperative MI was recorded among 1 patient (4%).
While all arterial grafts 27 (100%) were classified as patent, 51 venous
grafts (89%) were considered as patent where 11% of venous grafts
were considered as non patent. All the significant stenosis were found
in the body of venous graft.
Conclusion: Extensive reconstruction of the diffusely diseased LAD
using an ITA graft could be performed safely with very encouraging
results. MDCT angiography is an excellent non invasive tool not only
to evaluate graft patency in the reconstructed LAD but also to detect
other findings in asymptomatic patients with diffuse coronary artery
disease for better and more close follow up.
Non-invasive assessment by Cardiac CT of bypass grafts and
native coronary versus invasive coronary angiography
N. Nieves Romero Rodriguez1; F.J. Guerrero Marquez1;
P. Cristobo Sainz1; S. Navarro Herrero1; M.P. Serrano
Gotarredona1; J.L. Martos Maine1; A. Martinez Martinez1
1Virgen del Rocio University Hospital, Seville, Spain
Introduction: Cardiac CT has proven usefulness in the study of
coronary patients, especially with low and intermediate risk profile.
However there are few published studies on its usefulness in the
diagnosis of patients who have underwent coronary bypass graft. This
study attempts to determine its diagnostic accuracy in this area.
Methods: From October 2008 to January 2012 a total of 632 coronary
CT have been performed in our center of which 12 occurred in patients
with coronary bypass. Finally 9 of them underwent coronary
angiography, on which this study is based. We analyzed the diagnostic
accuracy in the evaluation of both types of grafts and in the assessment
of segments distal to the anastomosis.
Results: A total of 8 males were included with 23 aortocoronary grafts
(12 arterial and 11 venous). 18 were visualized by CT angiography
with a sensitivity of 100% and specificity of 90.9% and with positive
and negative predictive values of 75% and 100% respectively. We also
analyzed the 18 vessels distal to the anastomosis detected (11 anterior
descending, 5 circumflex and 3 right coronary artery), with a sensitivity
of 100%, specificity of 91.6%, negative predictive value of 66.7% and
positive predictive value of 100%.
Conclusions: Cardiac CT has a high sensitivity in the assessment of
coronary grafts and native arteries in this setting.
Does the pre-test probability of CAD improve prediction of
coronary artery calcification and stenosis on CTA?
M.C. Maria Cecilia Ziadi1; R.L.V. Villavicencio1
1Diagnostico Medico Orono, Rosario, Argentina
Objective: Computed tomography angiography (CTA) is mainly
applied to patients (pts) with low to intermediate risk of coronary
artery disease (CAD). Our goal was to assess how the clinical pre-test
categorization impacts on the coronary calcium score (CCS) and the
presence of severe CAD evaluated with non-invasive CTA.
Methods: We identified 133 consecutive adult pts with suspected
CAD, who underwent CTA. According to the pre-test likelihood of
CAD, pts were divided into 3 groups: I (low), II (intermediate) and III
(high). CCS was categorized as follows: 0, 1-100, 101-400 and [400.
Coronary artery lumen was classified into normal = 0%, mild =
149%, moderate = 50-69% and severe C70% stenosis.
Results: Mean age was 57 (14) years old, 56% were males.
A CCS = 0 was present in 43 of 65 (66%) and in 15 of 48 (31%) pts
from groups I and II, respectively. Conversely, none of the pts from
group III had a CCS = 0, but 70% (14/20) presented with CCS [ 400
(P \ .05). The prevalence of severe obstructive CAD was 3.1%
(n = 2) in group I, 8.3% (n = 4) in group II and it was significantly
higher in pts from group III, 65% (n = 13), (P \ .05) (Figure). CTA
ruled out obstructive CAD in 95.4% of pts in group I and in 79.2% of
pts in group II. Regardless of the pre-test likelihood of CAD, C70%
stenosis was present 1 of 58 (1.7%) pts with CCS = 0, in 2 of 33
(6.1%) pts with CCS B 100, in 5 of 16 (31.2%) pts with CCS =
100400 and in 11 of 26 (42.3%) pts with CCS [ 400, (P \ .05).
Conclusions: There is a direct correlation between the clinical
probability of CAD and the calcified atherosclerotic burden. Pre-test
likelihood assessment facilitates prediction of severe coronary stenosis
with non-invasive CTA. These findings underscore the role of clinical
categorization for appropriate selection of pts referred for CTA.
Pre-test probability vs CTA lumen
Predictors of significant coronary lesions in patients with
abnormal myocardial single photon emission computed
V.A. Vadim Kuznetsov1; E.I. Yaroslavskaya1;
D.V. Krinochkin1; G.V. Kolunin1; E.A. Gorbatenko1
1Tyumen Cardiology Center, Tyumen, Russian Federation
Background: It is difficult often to detect coronary artery disease
(CAD) without coronary angiography (CAG) in atypical patients by
clinical and echocardiography and single photon emission computed
tomography (SPECT) data.
Purpose: The present study aimed to reveal predictors of significant
coronary lesions in patients with myocardial perfusion abnormalities
Methods: From 13,283 consecutive patients suspected CAD we
selected patients after (99)Tc(m)-methoxyisobutylisonitrile (MIBI)
gated SPECT and CAG who had no more than 3 months between the
tests. There were 47 patients among them who had abnormal SPECT.
We divided these patients in two groups: with significant coronary
lesions (C50% of lumen) on CAG and without.
Results: In 16 patients (34%) with abnormal SPECT and CAD
compared to patient without CAD we observed more often acute
myocardial infarction (37.1% vs 6.5%, P = .005) and higher level of
serum glucose (6.9 2.5 vs 5.3 0.8 mmol/L, P = .007). Reduced
left ventricular (LV) systolic function (LV ejection fraction \ 50%)
was more frequent in these patients (17.4% vs 7.4%, P \ .001), as well
as mild, moderate or severe mitral regurgitation (81.3% vs 59.4%,
P = .026). They had higher extent and index of LV wall motion
abnormalities (20.8% 18.0% vs 2.0% 5.5%, 20.8% 18.0% vs
2.0% 5.5%, respectively), and only patients of this group had signs of
myocardial scars detected by echocardiography (31.3%, all P \ .001).
According to the results of discriminant analysis, CAD was associated
with index of LV wall motion abnormalities and mitral regurgitation.
The obtained sensitivity, specificity, and positive predictivity were
80.6%, 81.8%, and 80.9%, respectively.
Conclusion: An extent of LV wall motion abnormalities and mitral
regurgitation are independent predictors of CAD in patients suspected
CAD with abnormal SPECT.
A. Andrea Peter1; S. Lucic1; M. Lucic1; R. Jung2; S. Tadic2;
S. Stojsic2; M. Stefanovic2
1Institute of Oncology of Vojvodina, Sremska Kamenica, Serbia;
2Institute of Cardiovascular Diseases of Vojvodina, Sremska
Introduction: Noninvasive coronary angiography (CTA) using
multidetector computed tomography is used to detect anatomical coronary
artery stenosis in patients who are suspected to have coronary artery
disease (CAD) with an intermediate to high pretest likelihood. Stress
myocardial perfusion imaging (MPI) is an important diagnostic tool
since it provides information about the functional severity of the
detected coronary artery lesion.
Aim of the Study: To evaluate the findings of MPI after CTA detected
coronary artery lesions and follow up of these patients in terms of
therapeutic decision making and potential cardiac events.
Material and Methods: In 25 patients MPI was performed after CT
coronarography detected coronary artery stenoses. A two-day protocol,
dipyridamole stress/ rest Tc-99m-MIBI myocardial perfusion imaging
(MPI) was performed. Myocardial perfusion images were analyzed
quantitatively, perfusion scores (Summed Stress ScoreSSS and
Summed Difference ScoreSDS), ejection fraction (EF) and the
percentage of affected left ventricle myocardium was calculated using
4DMSPECT commercial software package.
Results: Average age in the examined group was 67.78 8.22 years.
A total number of 46 coronary stenoses were verified during CT
coronarography and the majority had two or mutlivessel coronary artery
disease. The percentage of coronary stenoses detected on CT
coronarography ranged from a minimal of 30% to a maximal narrowing of
98%. The findings of stress MPI showed normal perfusion of the left
ventricle in 22 patients (88%) and reversible ischemia was detected in
3 patients (12%). The group with normal MPI finding had an average
follow up period of 29.20 9.75 month and out of this group only one
patient was admitted to the hospital because of suspected acute
coronary syndrome and coronarography was performed, non-significant
narrowings were found on the coronary arteries. Out of the group with
reversible ischemia all of them underwent coronarography and have
been treated with stent implantation on coronary arteries that had
functionaly significant stenosis on stress MPI. The average follow up
period in this group was 18.20 3.65 months and during this period
they had no symptoms and were without any major cardiovascular
Conclusion: The evaluation of functional significance of coronary
artery lesions with stress MPI is a very important tool in the diagnostic
algorithm of stenoses verified on CT coronarography. Stress MPI
successfully identifies patients with coronary artery lesions that need
Introduction: The aim of this analysis is to evaluate the
reproducibility of CAC calculated on different commercial softwares.
Methods: We included 159 patients who underwent CAC scoring with
use of 64-slice multidetector computed tomography (CT) with
prospective electrocardiographic gating for clinical reasons. The data sets
were evaluated on two different commercially available softwares
(4DM from INVIA, Ann Arbor, MI (software A) and Smart score from
General Electric, Milwaukee, WI (software B)) by two blinded
independent readers using the method of Agatston with a threshold of 130
Hounsfield units. Comparative analysis of CAC scores between the
different software was performed by using Spearman rank correlation
and Bland Altman analysis.
Results: Each software produced different absolute numeric results for
Agatston score. CAC was detected on 107 scan on both softwares. A
total of 59 scans (37%) had the same reading of which 50 patients are
without detected calcium. In contrast, CAC reading were within 10
units in 86 scans (52%) There was excellent statistical correlation
between the two softwares (r = 0.948, p400), 132 (87%) of the scans
were in the same group by both softwares.
Conclusion: Our analysis shows that there is a close correlation
between the different software calculation of CAC although the
different CAC software different absolute CAC scores. The two softwares
concordantly classified 87% of the study population prognostically.
Bland Altman plot of the abstract 388
Coronary artery calcium scores on admission trauma CT
scans and their Association with in-hospital survival
H.D. Death1; K. Oakland1; C. Davies1; K. Brohi1
1Royal London Hospital, London, United Kingdom
Purpose: The presence of coronary artery calcium on Computerised
Tomography (CT) scans is indicative of Coronary Heart Disease
(CHD). Formal scoring of coronary artery calcium in patients with
heart disease is a useful prognostic tool, and is predictive of future
adverse cardiac events and survival. The ability to estimate coronary
artery calcium scores (CACS) on CT scans undertaken in trauma
patients has not been explored. The purpose of this study was to
determine the feasibility of estimating CACS on trauma triage scans,
and thereby determine the incidence of heart disease in injured
patients. Finally, the study aimed to explore the relationship
between coronary artery calcium and in-hospital mortality following
Methods: A single centre retrospective cohort study of all injured
patients aged 45 years or over presenting to a trauma centre between
2009 and 2011. Two observers estimated and graded CACS (none,
mild, moderate, severe and extensive) on admission CT scans of the
thorax, and the relationship with in-hospital mortality was
Results: Four hundred and seventy four trauma patients had a CT scan
of the thorax, of which the calcium scores of 432 (91%) were
interpretable. No coronary artery calcium on CT was found in 137 (32%),
whilst 292 (68%) patients had evidence of calcium. Patients with
coronary calcium were older (60 years vs 50, P \ .001) and had more
co-morbidities (132 vs 46, P = .03, respectively). Of the patients with
calcium, 139 (32%) had a mild score, 75 (17%) moderate, 64 (15%)
severe and 17 (4%) had evidence of extensive coronary artery calcium.
Only patients with severe coronary artery calcification had higher
death rates (OR 2.4, 95% CI 1.1-4.9), whilst patients with mild,
moderate and extensive calcium scores had similar death rates to those
without evidence of calcification. Inter-observer agreement for calcium
grading was substantial (j = 0.74).
Conclusions: Admission trauma CT scans of injured patients may be
used to determine CACS. These estimates demonstrated that the
incidence of CHD approaches 70% in trauma patients aged C45 years.
Only evidence of severe coronary artery calcium placed patients at an
increased risk of in-hospital death following injury.
Coronary artery disease among patients with low coronary
calcium score: A call for definition of low coronary artery
calcium score-Multi-Detector Computed Tomography ANIN
E. Edyta Kaczmarska1; C. Kepka1; Z. Dzielinska1; R. Pracon1;
K. Kryczka1; J. Pregowski2; M. Kruk1; M. Demkow1
1National Institute of Cardiology, Department of Coronary Heart
Disease, Warsaw, Poland; 2Department of Interventional Cardiology
and Angiology Institute of Cardiology, Warsaw, Poland
Objectives: The prospective study was conducted to find the cut-off
point for low CAC score and evaluated the incidence of CAD in
relation to the low CAC score among patients with intermediate
probability of CAD.
Methods: Consecutive patients (n = 1132) were included to the
analysis (58.7 10.9 years, 46.7% males). Coronary computed
tomography (CCT) angiography was performed by multi-detector
computed tomography scanner. CAC score was calculated by Agatston
method. CAD was defined as presence of coronary artery stenosis
C50% on CCT angiography.
Results: CAD was diagnosed in nearly one-fourth of patients
(n = 272, 24%). CAD in subjects with CAC score B10 and B100 were
detected in 4.9% (56 patients) and 12.4% (140 patients), respectively.
In the ROC curve analysis, CAC score of 10 presented as optimal
cutoff point for the discriminating the CAD (sensitivity 0.79, specificity
0.75, P \ .0001). Whereas for CAC score of 100, the sensitivity and
specificity was 0.48 and 0.92, respectively.
Conclusions: The cut-off point of 10 for CAC score with the best
sensitivity and specificity determined patients with CAD. Furthermore,
CAC score \ 10 better defined patients with high risk obstructive
plaque prone to rupture (non- or low calcified obstructive plaque) than
CAC score 100. CAC score \ 10 should be classified as low.
Several studies have been suggested that the presence of multiple
extracoronary sites with calcium deposits would infer a greater risk for
CAD. But, most of them are based in echocardiographic studies that
used categorical variables with poor reproducibility and does not
quantify calcium. Cardio-vascular calcium screening with the use of
EBCT is emerging as a potentially useful test to diagnose
Purpose: The aim of this study was to determine whether there is a
significant association between calcification of the aortic/mitral
annulus and/or thoracic aortic calcified plaques and coronary artery disease
(CAD) in patients undergoing 64-slices angio-CT scan. If an
association could be established between cardiovascular calcifications and
CAD, their presence might be used as a marker of coronary
Methods: We identified the presence, absence and amount of
calcification in each of the three extracoronary calcification (ECC) sites:
aortic root, mitral annulus and ascending aorta, using Agatston calcium
score. We applied a digitized method to quantify ECC so we had a
good reproducibility in identifying them. All known cardiac risk
factors for atherosclerosis including age, gender, hypertension,
smoking, dyslipidemia, diabetes and family history were investigated.
Results: The mean age of our study population included 305 patients
(184 men and 121 women) was 57 11.28 years. These patients were
divided in two groups, age and sex-matched 166 (58.7%) in the ECC
group and 139 (41.3%) in the control group. The ECC group had a
higher prevalence of positive CT for the presence of CAD (75.8 vs
19%, with P \ .001). Multivariate analysis identified only ECC and
age as independent predictors of coronary atherosclerosis. Logistic
regression analysis showed also that ECC was strongly and
significantly associated with CAD after adjusting for all coronary risk factors,
except age (OR = 6.637; 95% CI 2.5-7.464, P \ .001), hence patients
with ECC had a sixfold higher risk for CAD than those without. The
sensitivity, specificity, positive and negative predictive values for ECC
in diagnosing CAD were 85.1%, 70%, 76% and 91%, respectively.
Conclusion: Calcium deposits at two or more sites may help in
identifying patients with atherosclerosis. Their absence is a stronger
predictor for absence also of CAD. Measuring extracoronary
calcification using CTA is accurate, reproducible and may be clinically
Coronary calcification is generally recognised as a form of subclinical
atherosclerosis and has been found, in various severities, in
asymptomatic populations. Its relevance in predicting significant coronary
artery (CA) stenosis in symptomatic patients remains uncertain. We
retrospectively studied 360 patients, mean age 65, 58% males, who
presented with angina-like symptoms and who underwent CT coronary
calcium scoring CAC, conventional angiography and exercise
tolerance testing (ETT). A CAC score [ 0 was superior to ETT for
prediction of significant coronary artery stenosis (C50% narrowing),
with sensitivity 97% vs 39% (P \ .001) but specificity was only 26%
vs 70% (P \ .001). Patients aged C70 had higher sensitivity of
CAC C 400 in predicting CA stenosis C 50% compared to those aged
\70 (62% vs 26%, P = .018) and in predicting single vessel disease
(SVD) (65% vs 28%, P = .008) and multivessel disease (MVD) (74%
vs 28%, P = .039). The respective specificities for CAC [ 0 were
significantly lower in those aged C70 compared to age \ 70 for SVD
(9% vs 60%, P = .052) and MVD (5% vs 26%, P = .018). ROC curve
analysis showed a CAC score of 46.5 as having the highest sensitivity
and specificity (83% and 62%, respectively, P \ .001) for predicting
[50% CA stenosis with area under the curve (AUC) of 76%.
Conclusion: In symptomatic patients, coronary artery calcium score is
more accurate in predicting the presence of significant stenosis but
exercise tolerance testing is more specific in excluding significant
Qiao, H.Y., 366
Queneau, M., 77
Qureshi, W., 207, 348
Xhabija, N.X.H., 365, 392
Index of topics
Acute ischaemia/Acute ischaemic syndromes/
Injury imaging, 160, 163, 217, 258, 295, 297,
Arrhythmias and sudden death, 142, 358
Attenuation correction clinical, 38, 61, 62,
CAD and diabetes, renal disease, gender risk
factors, 137, 145, 224, 225, 233, 238, 243,
244, 245, 246, 247, 248, 249, 250, 252,
253, 254, 256
Calcium scoring, 39, 344, 348, 388, 390,
391, 392, 393
Comparative techniques clinical, 83, 86,
92, 257, 271, 272, 288, 290, 355, 368,
Congestive heart failure, 110, 216, 277,
Coronary revascularisation, 87, 283, 302
Cost effectiveness, health economics, quality
assurance and guidelines, 223, 234
CT angiography, 71, 79, 80, 82, 90, 117,
229, 286, 292, 299, 345, 346, 347, 353,
354, 357, 361, 364, 366, 371, 375, 376,
379, 382, 383, 385
CT - Other, 99, 218, 360, 363, 373, 374
Diagnosis of CAD, 222, 235, 236, 239, 240,
242, 263, 268, 350, 352, 356, 369, 370,
378, 380, 386
Exercise ECG, 227, 232
Free fatty acid imaging, 213
Image patterns, artifact, 84
Instrumentation - other, 105
Instrumentation, software and image
processing, 63, 72, 78, 88, 89, 91, 97, 103