Aiden Abidov

SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography

The increasing use of coronary computed tomographyangiography(CCTA)requirestheestablishmentofstandardsmeant to ensure reliable practice methods and qualityoutcomes.TheSocietyofCardiovascularComputedTomog-raphy Guidelines Committeewas formed to develop recom-mendations for acquiring, interpreting, and reporting thesestudies in a standardized fashion. Indications and contrain-dicationsforspecificservicesorproceduresarenotincludedin the scope of these documents. These recommendationswere produced as an educational tool for practitioners toimprove the diagnostic care of patients, in the interest ofdevelopingsystematicstandardsofpracticeforCCTAbasedon the best available data or broad expert consensus. Due tothe highly variable nature of individual medical cases, anapproachtointerpretationorreportingthatdiffersfromtheseguidelinesmayrepresentanappropriatevariationbasedonalegitimate assessment of an individual patient’s needs.The Society of Cardiovascular Computed TomographyGuidelinesCommitteemakeseveryefforttoavoidanyactualorpotentialconflictsofinterestthatmightariseasaresultofan outside relationship or a personal interest of a member ofthe Guidelines Committee or either of its Writing Groups.Specifically, all members of the Guidelines Committee andof both Writing Groups are asked to provide disclosurestatementsofallsuchrelationshipsthatmightbeperceivedasrealorpotentialconflictsofinterestrelevanttothedocumenttopic. The relationships with industry information for Com-mittee members and Writing Group members are published

Adenosine myocardial perfusion single-photon emission computed tomography in women compared with men: Impact of diabetes mellitus on incremental prognostic value and effect on patient management

OBJECTIVESnThis study was designed to assess the incremental prognostic value of adenosine stress myocardial perfusion single-photon emission computed tomography (MPS) in women versus men, and to explore the prognostic impact of diabetes mellitus.nnnBACKGROUNDnLimited data are available regarding the incremental value of adenosine stress MPS for the prediction of cardiac death in women versus men and the impact of diabetes mellitus on post-adenosine MPS outcomes. Of 6,173 consecutive patients who underwent rest thallium-201/adenosine technetium-99m sestamibi MPS, 254 (4.1%) were lost to follow-up, and 586 with early revascularization < or = 60 days after MPS were censored, leaving 2,656 women and 2,677 men.nnnRESULTSnWomen had significantly smaller adenosine stress, rest, and reversible defects than men. During 27.0 +/- 8.8 month follow-up, cardiac death rates were lower in women than men (2.0%/year vs. 2.7%/year, respectively, p < 0.05). Before and after risk adjustment, cardiac death risk increased significantly in both men and women as a function of MPS results. Multivariable models revealed that MPS results provided incremental prognostic value over pre-scan data for the prediction of cardiac death in both genders. Also, while comparative unadjusted rates of early (< or =60 days post-test) coronary angiography (17% vs. 23%) and revascularization (8% vs. 12%) were significantly lower in women (p < 0.05), after adjusting for MPS, these rates were similar in men and women. Importantly, diabetic women had a significantly greater risk of cardiac death compared with other patients. Also, after risk adjustment, patients with insulin-dependent diabetes mellitus (IDDM) had higher risk of cardiac death for any MPS result than patients with non-insulin-dependent diabetes mellitus.nnnCONCLUSIONnThe findings suggest that adenosine MPS has comparable incremental value for prediction of cardiac death in women and men and that MPS is appropriately influencing subsequent invasive management decisions in both genders. Diabetic women and patients with IDDM appear to have greater risk of cardiac death than other patients for any MPS result.

Prognostic Implications of Myocardial Perfusion Single-Photon Emission Computed Tomography in the Elderly

Background— The goal of this study was to assess the clinical value of stress myocardial perfusion scintigraphy (MPS) in elderly patients (≥75 years of age). Methods and Results— We followed up 5200 elderly patients (41% exercise) after dual-isotope MPS over 2.8±1.7 years (362 cardiac deaths [CDs], 7.0%, 2.6%/y) and a subset with extended follow-up (684 patients for 6.2±2.9 years; 320 all-cause deaths). Survival modeling of CD revealed that both MPS-measured ischemia and fixed defect added incrementally to pre-MPS data in both adenosine and exercise stress patients. Modeling a subset with gated MPS (n=2472) revealed that ejection fraction and perfusion data added incrementally to each other, further enhancing risk stratification. Unadjusted, annualized post-normal MPS CD rate was 1.3% but <1% in patients with normal rest ECG, exercise stress, or age of 75 to 84 years and was 2.3% to 3.7% in patients ≥85 years of age or undergoing pharmacological stress. However, compared with age-matched US population CD rates (75 to 84 years of age, 1.5%; ≥85 years, 4.8%), normal MPS CD rates were approximately one-third lower than the baseline risk of US individuals (both P<0.05). Modeling of all-cause death in 684 patients with extended follow-up revealed that after risk adjustment, an interaction between early treatment and ischemia was present; increasing ischemia was associated with increasing survival with early revascularization, whereas in the setting of little or no ischemia, medical therapy had improved outcomes. Conclusions— Stress MPS effectively stratifies CD risk in elderly patients and may identify optimal post-MPS therapy. CD rates after normal MPS are low in all subsets in relative terms compared with the age-matched US population.

Prognostic Impact of Hemodynamic Response to Adenosine in Patients Older Than Age 55 Years Undergoing Vasodilator Stress Myocardial Perfusion Study

Background The prognostic importance of various hemodynamic responses to adenosine infusion in patients undergoing adenosine stress myocardial perfusion stress (MPS) has not been defined. Methods and Results We identified 3444 unique patients (53.5% women, mean age 74.0±8.4 years) who underwent adenosine (with no additional exercise) stress myocardial perfusion single photon emission computed tomography (MPS) and were followed up for 2.0±0.8 years. Multivariable Cox proportional hazards analysis was used to assess the prognostic value of hemodynamic variables in predicting cardiac death (CD). Two hundred twenty‐four CDs (6.5%) occurred during follow‐up. By multivariable analysis, higher rest heart rate (HR) and to a lesser extent lower peak HR were markers of CD. When added to the multivariable model in place of peak and rest HR, the peak/rest HR ratio was an independent predictor of CD. Peak/rest HR ratio additionally risk‐stratified patients within each MPS category. A significant interaction was found between gender and peak systolic blood pressure (SBP), in which there was an increased risk associated with a low peak SBP (<90 mmHg at end of adenosine infusion) in men but not in women. Conclusions Patients undergoing adenosine stress MPS with high rest HR and low peak/rest HR ratio have increased risk of CD, as do male patients with a low peak SBP. Assessment of the hemodynamic response to adenosine adds incremental prognostic value to MPS results and enhances identification of patients at risk for CD. (Circulation. 2003; 107:2894‐2899.)

Gated SPECT in assessment of regional and global left ventricular function: Major tool of modern nuclear imaging

Over the last few decades, the assessment of myoial perfusion from stress and rest myocardial perfusingle photon emission computed tomography ECT) (MPS) has become central to the management patients with known or suspected coronary artery ase (CAD). More recently, electrocardiography G)–gated SPECT, with the ability to measure left tricular (LV) ejection fraction (EF) and ventricular umes, as well as to evaluate presence of regional wall tion abnormalities (RWMAs), has become a routine t of clinical protocols, expanding the clinical utility of S. Recent American College of Cardiology/American rt Association/American Society of Nuclear Cardiolguidelines for the clinical use of cardiac radionuclide ging consider ECG-gated SPECT as the “current e of the art” and indicate the following: “The ability observe myocardial contraction in segments with arent fixed perfusion defects permits the nuclear test er to discern attenuation artifacts from true perfusion ormalities. The ability of gated SPECT to provide surement of LVEF, segmental wall motion, and olute LV volumes also adds to the prognostic inforion that can be derived from a SPECT study.” Gated SPECT is now performed in over 90% of all S studies in the United States. This review is nded to describe the major milestones in which tricular function assessment has emerged and added perfusion assessment by use of gated SPECT. The ortant developments relating to perfusion parameters MPS are not covered in this review.

Cardiovascular Magnetic Resonance of Primary Tumors of the Heart: A Review

Overall, the prevalence of primary cardiac neoplasms is approximately 0.3% and these masses should be distinguished from the myriad of other primary and secondary processes that can occur in the heart. Tumors within, attached to, or near the heart can cause direct cardiac damage, can result in thrombus formation, can compromise blood flow and can embolize distally. Hence, proper diagnosis is clinically important. It has been suggested that cardiovascular magnetic resonance (CMR) imaging is a useful tool for diagnosing and characterizing cardiac tumors. In this report, we present a case example of a patient with a large, mobile right atrial myxoma imaged by CMR with results of histopathologic analysis after excision. We also demonstrate the utilization of CMR for characterization of cardiac lesions, review the basic characteristics of primary cardiac neoplasms, provide an overview of published cases describing use of CMR, and give suggested guidelines for imaging of cardiac masses with emphasis on diagnosis of cardiac tumors. CMR is an important technique for diagnosing and characterizing cardiac tumors.

Are Shades of Gray Prognostically Useful in Reporting Myocardial Perfusion Single-Photon Emission Computed Tomography?

Background —Many have advocated the use of a five category normal, probably normal, equivocal, probably abnormal and definitely abnormal approach to final interpretation of myocardial perfusion SPECT. The prognostic value of expressing levels of certainty compared to a dichotomous normal/abnormal classification or categories for summed stress scores is unclear. Methods and Results —Myocardial perfusion SPECT (MPS) was visually assessed using a standard semiquantitative approach, yielding summed scores which were used for preliminary interpretation using 5 levels of certainty. The interpreter was permitted to then shift the level of certainty in the final interpretation by one degree based on non-perfusion MPS variables and available clinical information. nTo examine the prognostic value of expressing levels of clinical certainty, we evaluated 20,740 unique consecutive patients who underwent rest Tl-201/stress Tc-99m sestamibi MPS (34.3% vasodilator stress), of whom 845 (4.4%) were lost to follow-up, and 1,695 were excluded from prognostic analysis due to an early revascularization (<60 days after MPS). The remaining 18,200 patients (59.1% men; age 65±13) were followed-up for cardiac death (CD) for a mean of 2.7±1.7 yr. nDuring the follow-up, total of 591 CD events occurred. By univariable analysis, there were substantial differences in the distribution of follow-up cardiac events by the clinical certainty of the MPS results. The final level of clinical certainty of the MPS interpretation was found to be an independent multivariable predictor of cardiac death in the study population and better identified patients at the increased risk of cardiac death than the approach based solely on the standard categories of summed perfusion scores.n Conclusions —The use of multicategory reporting of MPS results incorporating non-perfusion MPS results and clinical information enhances risk stratification compared to both a dichotomous normal/abnormal approach or an approach based solely on summed perfusion scores. Whether this enhanced risk-stratification based on the clinical certainty of the MPS interpretation leads to a more effective therapeutic regimen, tailored to the individual patient’s need, requires further prospective evaluation.Background—We have advocated the use of a 5-category “normal,” “probably normal,” “equivocal,” “probably abnormal,” and “definitely abnormal” approach to final interpretation of myocardial perfusion single-photon emission computed tomography (SPECT). The prognostic value of expressing levels of certainty compared with a dichotomous normal/abnormal classification or categories for summed stress scores is unclear. Methods and Results—Myocardial perfusion SPECT (MPS) was visually assessed using a standard semiquantitative approach, yielding summed scores that were used for preliminary interpretation using 5 levels of certainty. The interpreter was permitted to then shift the level of certainty in the final interpretation by 1 degree, based on nonperfusion MPS variables and available clinical information. To examine the prognostic value of expressing levels of clinical certainty, we evaluated 20 740 unique consecutive patients who underwent rest Tl-201/stress Tc-99m sestamibi MPS (34.3% vasodilator stress), of whom 845 (4.4%) were lost to follow-up and 1695 were excluded from prognostic analysis due to an early revascularization (<60 days after MPS). The remaining 18 200 patients (59.1% men; age, 65±13 years) were followed up for cardiac death for a mean of 2.7±1.7 years. During the follow-up, a total of 591 cardiac death events occurred. By univariable analysis, there were substantial differences in the distribution of follow-up cardiac death by the category of clinical MPS certainty. The clinical certainty was found to be an independent multivariable predictor of cardiac death in the study population and better identified patients at increased risk of cardiac death than the approaches based solely on the standard categories of summed perfusion scores or based solely on categories of segmental perfusion scores. Conclusions—The use of multicategory reporting of MPS results incorporating nonperfusion MPS results and clinical information enhances risk stratification compared with both a dichotomous normal/abnormal approach or approaches based solely on segmental categories of perfusion scores. Whether this enhanced risk stratification based on the clinical certainty of the MPS interpretation leads to a more effective therapeutic regimen, tailored to the individual patient’s need, requires further prospective evaluation.

Are shades of gray prognostically useful in reporting myocardial perfusion SPECT

Background —Many have advocated the use of a five category normal, probably normal, equivocal, probably abnormal and definitely abnormal approach to final interpretation of myocardial perfusion SPECT. The prognostic value of expressing levels of certainty compared to a dichotomous normal/abnormal classification or categories for summed stress scores is unclear. Methods and Results —Myocardial perfusion SPECT (MPS) was visually assessed using a standard semiquantitative approach, yielding summed scores which were used for preliminary interpretation using 5 levels of certainty. The interpreter was permitted to then shift the level of certainty in the final interpretation by one degree based on non-perfusion MPS variables and available clinical information. nTo examine the prognostic value of expressing levels of clinical certainty, we evaluated 20,740 unique consecutive patients who underwent rest Tl-201/stress Tc-99m sestamibi MPS (34.3% vasodilator stress), of whom 845 (4.4%) were lost to follow-up, and 1,695 were excluded from prognostic analysis due to an early revascularization (<60 days after MPS). The remaining 18,200 patients (59.1% men; age 65±13) were followed-up for cardiac death (CD) for a mean of 2.7±1.7 yr. nDuring the follow-up, total of 591 CD events occurred. By univariable analysis, there were substantial differences in the distribution of follow-up cardiac events by the clinical certainty of the MPS results. The final level of clinical certainty of the MPS interpretation was found to be an independent multivariable predictor of cardiac death in the study population and better identified patients at the increased risk of cardiac death than the approach based solely on the standard categories of summed perfusion scores.n Conclusions —The use of multicategory reporting of MPS results incorporating non-perfusion MPS results and clinical information enhances risk stratification compared to both a dichotomous normal/abnormal approach or an approach based solely on summed perfusion scores. Whether this enhanced risk-stratification based on the clinical certainty of the MPS interpretation leads to a more effective therapeutic regimen, tailored to the individual patient’s need, requires further prospective evaluation.Background—We have advocated the use of a 5-category “normal,” “probably normal,” “equivocal,” “probably abnormal,” and “definitely abnormal” approach to final interpretation of myocardial perfusion single-photon emission computed tomography (SPECT). The prognostic value of expressing levels of certainty compared with a dichotomous normal/abnormal classification or categories for summed stress scores is unclear. Methods and Results—Myocardial perfusion SPECT (MPS) was visually assessed using a standard semiquantitative approach, yielding summed scores that were used for preliminary interpretation using 5 levels of certainty. The interpreter was permitted to then shift the level of certainty in the final interpretation by 1 degree, based on nonperfusion MPS variables and available clinical information. To examine the prognostic value of expressing levels of clinical certainty, we evaluated 20 740 unique consecutive patients who underwent rest Tl-201/stress Tc-99m sestamibi MPS (34.3% vasodilator stress), of whom 845 (4.4%) were lost to follow-up and 1695 were excluded from prognostic analysis due to an early revascularization (<60 days after MPS). The remaining 18 200 patients (59.1% men; age, 65±13 years) were followed up for cardiac death for a mean of 2.7±1.7 years. During the follow-up, a total of 591 cardiac death events occurred. By univariable analysis, there were substantial differences in the distribution of follow-up cardiac death by the category of clinical MPS certainty. The clinical certainty was found to be an independent multivariable predictor of cardiac death in the study population and better identified patients at increased risk of cardiac death than the approaches based solely on the standard categories of summed perfusion scores or based solely on categories of segmental perfusion scores. Conclusions—The use of multicategory reporting of MPS results incorporating nonperfusion MPS results and clinical information enhances risk stratification compared with both a dichotomous normal/abnormal approach or approaches based solely on segmental categories of perfusion scores. Whether this enhanced risk stratification based on the clinical certainty of the MPS interpretation leads to a more effective therapeutic regimen, tailored to the individual patient’s need, requires further prospective evaluation.

Uptake of FDG in the area of a recently implanted bioprosthetic mitral valve.

AbstractA 74-year-old woman with history of melanoma, left breast cancer and status post left mastectomy, underwent FDG PET scanning as a part of a pulmonary nodule assessment. Two months before the scan the patient had undergone mitral valve replacement using a Hancock-2 porcine prosthesis due to s

Direct quantitative in vivo comparison of calcified atherosclerotic plaque on vascular MRI and CT by multimodality image registration

To investigate direct volumetric in vivo correspondence of calcified atherosclerotic plaque lesions in MRI and CT images of the thoracic aorta by multimodality image registration and fusion.