Andrea Pezzato

Contrast-enhanced ultrasonography (CEUS) vs. MRI of the small bowel in the evaluation of Crohn’s disease activity

PurposeThe presence of disease activity in Crohn’s disease (CD) is one of the main parameters used to establish whether optimal therapy should be drug therapy or surgery. However, a major problem in monitoring CD is the common mismatch between the patient’s symptoms and imaging objective signs of disease activity. Bowel ultrasonography (US) has emerged as a low-cost, noninvasive technique in the diagnosis and follow-up of patients with CD. Accordingly, the use of contrastenhanced US (CEUS) has made possible an evaluation of the vascular enhancement pattern, similar to the use of magnetic resonance imaging (MRI). The aim of our study was to evaluate the role of CEUS in comparison with small-bowel MRI for assessing Crohn’s disease activity.Materials and methodsWe prospectively enrolled 30 consecutive patients with known CD. Clinical and laboratory data were compared with imaging findings obtained from MRI and CEUS of the small bowel. MRI was performed with a 1.5-T system using phased-array coils and biphasic orally administered contrast agent prior to and after gadolinium chelate administration. We performed US with a 7.5-MHz linear-array probe and a second-generation contrast agent. The parameters analysed in both techniques were the following: lesion length, wall thickness, layered wall appearance, comb sign, fibroadipose proliferation, presence of enlarged lymph nodes and stenosis. We classified parietal enhancement curves into two types in relation to the contrast pattern obtained with the time-intensity curves at MRI and CEUS: (1) quick washin, quick washout, (2) slow washin, plateau with a slow washout.ResultsComparison between Crohn’s disease activity index (CDAI) and MRI showed a low correlation, with an rho=0.398; correlation between CDAI-laboratory data and CEUS activity was low, with rho=0.354; correlation between MRI activity and CEUS activity was good, with rho = 0.791; high correlation was found between CEUS and MRI of the small bowel when assessing wallthickness, lymph nodes and comb sign; good correlation was fund when assessing layered wall appearance, disease extension and fibroadipose proliferation. At MRI, timeintensity curves for 12/30 patients were active, compared with for 14/30 patients at CEUS; therefore there was a poor correlation between curve on CEUS and curve on MRI (r=0.167; p=0.36).ConclusionsThe use of CEUS can be recommended if there is a discrepancy between MRI and clinical/laboratory parameters. MRI of the small bowel remains the most accurate method for evaluating disease activity.RiassuntoObiettivoLa presenza di attività di malattia (CDAI) nel morbo di Crohn (MC) rappresenta un parametro fondamentale per stabilire la strategia medica o chirurgica nel trattamento, tuttavia una delle maggiori difficoltà nel monitoraggio del MC è costituito dalla non concordanza tra sintomatologia e rilievi imaging di attività di malattia. L’ecografia dell’intestino tenue emerge come tecnica a basso costo non invasiva nella diagnosi e nel follow-up dei pazienti con MC, e inoltre lo studio mediante mezzo di contrasto (CEUS) ha reso possibile la valutazione dell’enhancement parietale similmente alla enteroclisi in risonanza magnetica (RM). Lo scopo del nostro studio è valutare il ruolo del CEUS in confronto con RM nella valutazione di attività di malattia nei pazienti con MC.Materiali e metodiAbbiamo selezionato prospetticamente 30 pazienti consecutivi affetti da MC noto. I dati clinici e laboratoristici sono stati confrontati con i rilievi imaging alla RM e al CEUS dell’intestino tenue. L’enteroclisi-RM è stata effettuata con apparecchiatura da 1,5 T con bobine phased-array e mezzo di contrasto (MdC) orale bifasico prima e dopo la somministrazione di chelati del gadolinio endovena. L’ecografia è stata effettuata con soda lineare da 7,5 MHz e MdC ecografico di seconda generazione. I parametri analizzati per entrambe le metodiche sono: lunghezza della lesione, spessore parietale, aspetto striato di parete, segno del pettine, proliferazione fibroadiposa, linfoadenomegalie, stenosi. Abbiamo classificato l’impregnazione di parete post contrasto grafica in due tipi a seconda delle curve intensità tempo ottenute per entrambe le metodiche in: (1) rapida impregnazione e rapida dismissione del MdC; (2) lenta impregnazione e plateau con lenta dismissione del MdC.RisultatiLa correlazione tra CDAI e RM si è dimostrata scarsa con un coefficiente di correlazione Spearman’s (rho)=0,398; la correlazione tra CDAI e dati di laboratorio e attività CEUS si è dimostrata scarsa con un coefficiente di correlazione Spearman’s (rho)=0,354; la correlazione tra attività RM e attività CEUS si è dimostrata buona con un coefficiente di correlazione Spearman’s (rho)=0,791; ottima correlazione tra CEUS e enteroclisi-RM nella valutazione dello spessore parietale, dei linfonodi e segno del pettine; buona correlazione nella valutazione dell’aspetto striato della parete, dell’estensione di malattia e della proliferazione fibro-adiposa. In RM le curve intensità tempo sono risultate essere attive in 12/30 pazienti, in CEUS in 14/30 pazienti, con correlazione curva CEUS / curva RM scarsa (r=0,167 p=0,36).ConclusioniL’uso della CEUS può essere raccomandato in caso di discrepanza tra RM e dati di laboratorio e clinici. L’enteroclisi RM rimane tuttora la metodica imaging non invasiva più accurata per la stima di attività di malattia.

Non invasive cardiac vein mapping: Role of multislice CT coronary angiography

PURPOSE Coronary venous anatomy is of primary importance when implanting a cardiac resynchronization therapy device, besides, the coronary sinus can be differently enlarged depending on chronic heart failure. The aim of this study is to evaluate the usefulness of Coronary CTA in describing the coronary venous tree and in particular the coronary sinus and detecting main venous system variants. MATERIALS AND METHODS 301 consecutive patients (196 ♂, mean age 63.74 years) studied for coronary artery disease with 64 slice Coronary CTA were retrospectively examined. The acquisition protocol was the standard acquisition one used for coronary artery evaluation but the cardiac venous system were visualized. The cardiac venous system was depicted using 3D, MPR, cMPR and MIP post-processing reconstructions on an off-line workstation. For each patient image quality, presence and caliber of the coronary sinus (CS), great cardiac vein (GCV), middle vein (MV), anterior interventricular vein (AIV), lateral cardiac vein (LCV), posterior cardiac vein (PCV), small cardiac vein (SCV) and presence of variant of the normal anatomy were examined and recorded. RESULTS CS, GCV, MV and AIV were visualized in 100% of the cases. The LCV was visualized in 255/301 (84%) patients, the PCV in 248/301 (83%) patients and the SCV in 69/301 (23%) patients. Mean diameter of the CS was 8.7 mm in 276/301 (91.7%) patients without chronic heart failure and 9.93 mm in 25/301 (8.3%) patients with chronic heart failure. CONCLUSIONS Coronary CTA allows non invasive mapping of the cardiac venous system and may represent a useful presurgical tool for biventricular pacemaker devices implantation.

Coronary artery anatomy and variants

Variants and congenital anomalies of the coronary arteries are usually asymptomatic, but may present with severe chest pain or cardiac arrest. The introduction of multidetector CT coronary angiography (MDCT-CA) allows the detection of significant coronary artery stenosis. Improved performance with isotropic spatial resolution and higher temporal resolution provides a valid alternative to conventional coronary angiography (CCA) in many patients. MDCT-CA is now considered the ideal tool for three-dimensional visualization of the complex and tortuous anatomy of the coronary arteries. With multiplanar and volume-rendered reconstructions, MDCT-CA may even outperform CCA in determining the relative position of vessels, thus providing a better view of the coronary vascular anatomy. The purpose of this review is to describe the normal anatomy of the coronary arteries and their main variants based on MDCT-CA with appropriate reconstructions.

Diagnostic accuracy in coronary stenosis: comparison between visual score and quantitative analysis (quantitative computed tomographic angiography) in coronary angiography by multidetector computed tomography-coronary angiography and quantitative analysis (quantitative coronary angiography) in conventional coronary angiography.

Background: Multidetector computed tomography-coronary angiography allows quantification of coronary stenosis with a high level of accuracy; however, the inherent inaccuracy of visual score still remains. Computed quantitative vessel analysis systems (quantitative computed tomographic angiography [QCTA]) aim to overcome this limitation. The aim of our study was to evaluate the accuracy of QCTA in comparison with quantitative coronary angiography (QCA) and visual score using the QCA. Materials and Methods: Two operators visually scored 30 consecutive patients referred for multidetector computed tomography-coronary angiography to assess stenotic segments according to a modified 17-segment American Heart Association classification model. Coronary angiography was performed within 1 week. The degree of stenosis was classified as 0%, lower than 20% (wall irregularities), lower than 50% (without significant disease), and higher than 50% (significant disease). Each segment was then analyzed using electronic calipers of the QCTA system. Data were compared with QCA results. Each segment was finally classified as fibrofatty, mixed, and calcified. Comparisons between QCTA results, visual score, and QCA were performed by means of Spearman rank correlation. Interobserver variability is calculated using &kgr; statistics. Results: From a total of 870 segments, 69 were diseased. Interobserver agreement between the 2 operators resulted very high (&kgr; = 0.97). A good correlation was found between visual score and QCA (&rgr; = 0.932, P < 0.0001) and between visual score and QCTA (&rgr; = 0.845, P < 0.0001). A moderate correlation was found between QCTA and QCA (&rgr; = 0.810, P < 0.0001). Conclusions: The accuracy of QCTA is comparable with that of QCA and visual score especially in noncalcified vessels. Editing of the vessel contours in case of calcified vessels is helpful in correctly estimating the right percentage of stenosis.

Normal anatomy and variants of the venous cardiac system in MDCT coronary angiography

Three separate venous systems drain the blood returning from the heart walls. These veins are characterised by remarkable variability in terms of frequency, size and course. The knowledge of cardiac venous anatomy is of primary importance during interventional cardiac procedures that require catheterisation of cardiac veins. Some anatomical variants may hinder or contraindicate access to target veins. Coronary angiography (CA) with multidetector computed tomography (MDCT-CA) and multiplanar reformations (MPR), maximum intensity projection (MIP) and 3D reconstructions provides noninvasive visualisation of normal cardiac veins and anatomical variants. The purpose of this pictorial review is to describe by MDCT-CA the anatomy and main variants of the cardiac venous system.RiassuntoIl sangue refluo dal cuore è raccolto da tre sistemi di vene caratterizzate da una notevole variabilità in termini di frequenza, calibro e decorso. Conoscere l’anatomia venosa cardiaca è importante in relazione a manovre di cardiologia interventistica che richiedono la cateterizzazione delle vene cardiache, dal momento che alcune varianti anatomiche possono ostacolare o controindicare l’accesso alle vene target. L’angiografia coronarica mediante tomografia computerizzata multistrato (TCMS) permette, tramite ricostruzioni 3D, ricostruzioni multiplanari (MPR), MPR curve e proiezioni di massima intensità (MIP), la visualizzazione dell’anatomia venosa cardiaca normale e delle sue varianti in modo non invasivo, fornendo una valida alternativa alla venografia retrograda. Lo scopo di questo pictorial consiste nella descrizione mediante immagini TCMS con ricostruzioni 3D dell’anatomia e delle principali varianti delle vene cardiache.

MDCT coronary angiography vs 2D echocardiography for the assessment of left ventricle functional parameters

PurposeThis study was done to compare the parameters of left ventricular (LV) function obtained by multidetector computed tomography coronary angiography (MDCT-CA) using 64-slice equipment with those obtained using twodimensional echocardiography (2D-SE) considered as reference standard.Materials and methodsBetween April 2008 and September 2009, 116 consecutive patients were studied with both techniques. We analysed the parameters commonly sampled in echocardiography and related them with those retrieved with MDCT-CA: septal thickness, posterior wall thickness, diameter of ascending aorta, diameter and volumes in end-systolic and end-diastolic phase, ejection fraction, stroke volume, cardiac output and heart mass.ResultsGood correlation was found measuring septal thickness (r=0.470; p=0.001), and diameters of the ascending aorta. Correlation between systolic and diastolic diameters obtained with the two techniques was good. Poor correlation was attained measuring thickness of the posterior wall (r=0.243; p=0.104). MDCT-CA consistently overestimated the average volumes; diastolic and systolic volumes showed significant correlation (r=0.0456; p= 0.002; r=0.640; p<0.001). Ejection fraction agreement showed a significant correlation (r=0.626; p<0.001).ConclusionsMDCT-CA provides parameters of cardiac function comparable to those found in echocardiography. MDCT-CA although used primarily for coronary noninvasive imaging can provide additional information on ventricular function useful to the diagnostic workup of cardiac patients.RiassuntoObiettivoScopo del nostro studio è stato comparare i parametri della funzione ventricolare ottenuti mediante angiografia coronarica mediante tomografia computerizzata multistrato (AC-TCMS) a 64 strati con quelli ottenuti mediante ecocardiografia bidimensionale (2DSE), considerata come standard di riferimento.Materiali e metodiTra aprile 2008 e settembre 2009, 116 pazienti consecutivi sono stati studiati con entrambe le tecniche. Sono stati analizzati per entrambe le metodiche i seguenti parametri comunemente campionati in ecocardiografia e correlati con quelli ottenuti in ACTCMS: spessore del setto, spessore della parete posteriore, diametro dell’aorta ascendente, diametro e volume tele sistolico e tele diastolico, frazione di eiezione, stroke volume, gittata cardiaca e massa cardiaca.RisultatiÈ stata riscontrata una buona correlazione tra le misure dello spessore del setto (r=0,470 e p=0,001) e del diametro dell’aorta ascendente (r=0,777 e p<0,001) in ecografia e in TC, mentre una scarsa correlazione tra le misure dello spessore della parete posteriore (r=0,243 e p=0,104). La correlazione tra i diametri tele diastolico (r=0,375 e p=0,054) e tele sistolico (r=0,703 e p<0,001) ottenuti con le due tecniche è risultata buona. La TCMS ha sovrastimato in modo consistente i valori medi dei volumi rispetto all’ecocardiografia ma i volumi tele diastolico e tele sistolico derivati dalla 2DSE e dalla ACTCMS hanno mostrato una correlazione significativa (rispettivamente r=0,456 e p=0,002; r=0,640 e p<0,001). Come indicatore di funzione sistolica globale del ventricolo sinistro (VS), la frazione di eiezione (FE) misurata tramite TCMS o ecocardiografia ha mostrato un’eccellente correlazione (r=0,626 e p<0,001).ConclusioniLa AC-TCMS fornisce parametri della funzione cardiaca comparabili a quelli riscontrati in ecocardiografia. La AC-TCMS sebbene utilizzata prevalentemente per l’imaging non invasivo delle arterie coronarie, può fornire informazioni aggiuntive allo studio delle coronarie utili al work up diagnostico dei pazienti con patologie coronariche e cardiache.

Role of MDCT coronary angiography in the clinical setting: economic implications.

PurposeThis study evaluated the incremental value and cost-effectiveness ratio of introducing coronary angiography (CA) with multidetector computed tomography (MDCT-CA) in the diagnostic management of patients with suspected coronary artery disease (CAD) compared with the traditional diagnostic workup.Material and methodsFive hundred and fifty consecutive patients who underwent MDCT-CA between January 2009 and June 2011 were considered. Patients with atypical chest pain and suspected obstructive CAD were directed to one of two diagnostic pathways: the traditional protocol (examination, stress test, CA) and the current protocol (examination, stress test, MDCT-CA, and CA, if necessary). The costs of each protocol and for the individual method were calculated. Based on the results, the cost-effectiveness ratio of the two diagnostic pathways was compared. A third, modified, diagnostic pathway has been proposed with its relative cost-effectiveness ratio (examination, MDCT-CA, stress test, and CA, if necessary).ResultsStress test vs. MDCT-CA had an accuracy of 66%, a sensitivity and specificity of 21% and 87%, respectively, and a positive (PPV) and negative (NPV) predictive value of 40% and 70%, respectively. Comparison between conventional CA (CCA) and MDCT-CA showed a sensitivity and specificity of 92% and 89%, respectively, a PPV and NPV of 89%, and an accuracy of 92%. The traditional protocol has higher costs than the second protocol: 1,645 euro against 322 euro (mean), but it shows a better cost-effectiveness ratio. The new proposed protocol has lower costs, mean 261 euro, with a better costeffectiveness ratio than the traditional protocol.ConclusionsThe diagnostic protocol for patients with suspected CAD has been modified by the introduction of MDCT-CA. Our study confirms the greater diagnostic performance of MDCT-CA compared with stress test and its similar accuracy to CCA. The use of MDCT-CA to select patients for CCA has a favourable cost-effectiveness profile.RiassuntoObiettivoScopo del presente lavoro è stato valutare il valore incrementale dell’introduzione della angiografia coronarica mediante tomografia computerizzata multistrato (AC-TCMS) nella gestione diagnostica del paziente con sospetta malattia coronarica (CAD) rispetto al tradizionale workup diagnostico in termini di rapporto costo/efficacia.Materiali e metodiSono stati considerati 550 pazienti consecutivi sottoposti ad AC-TCMS tra gennaio 2009 e giugno 2011. Sono stati considerati due percorsi diagnostici per pazienti con dolore toracico atipico e sospetta coronaropatia ostruttiva: il protocollo tradizionale (visita, stress test, coronarografia) e il protocollo attuale, (visita, stress test, AC-TCMS ed eventuale coronarografia). è stato calcolato il costo di ogni protocollo come la somma dei costi delle singole metodiche. Sulla base dei risultati i due percorsi diagnostici sono stati confrontati dal punto di vista del rapporto costo/efficacia. è stato proposto un terzo percorso diagnostico modificato con relativo rapporto costo/efficacia (visita, AC-TCMS, stress test, eventuale coronarografia).RisultatiLo stress test nei confronti dell’AC-TCMS ha attenuto valori di accuratezza del 66% con sensibilità e specificità del 21% e 87% e valore predittivo positivo (VPP) e valore predittivo negativo (VPN) di 40% e 70%. Il confronto tra ACC e AC-TCMS ha rilevato una sensibilità e specificità pari a 92% e 89%, un VPP e VPN pari a 89% per un’accuratezza complessiva del 92%. Il protocollo tradizionale è risultato avere costi più elevati rispetto a quello modificato dalla AC-TCMS, 1645 euro contro 322 euro (media), ma dimostra un miglior rapporto costo/ efficacia. Il nuovo protocollo proposto risulta avere costi minori, 261 euro in media, con un miglior rapporto costo/ efficacia, rispetto al protocollo tradizionale.ConclusioniIl protocollo diagnostico di un paziente con sospetta CAD ha subito variazioni con l’introduzione dell’AC-TCMS. Il nostro studio conferma una maggior performance diagnostica dell’AC-TCMS nei confronti del test da sforzo ed un’accuratezza simile a quella della coronarografia. Dai nostri dati, l’utilizzazione di un protocollo che prevede l’AC-TCMS come spartiacque principale per i pazienti da inviare alla coronarografia, risulta vantaggioso in termini di costo e di efficacia diagnostica.

Learning curve in multidetector CT coronary angiography (MDCT-CA).

PurposeCoronary angiography using multidetector computed tomography (MDCT-CA) is a recent technique for the nonivasive study of coronary arteries. This study assessed the diagnostic accuracy of coronary artery stenosis evaluation obtained by three readers at different levels of training or at different points of the learning curve proposed by the international guidelines.Materials and methodsThree radiologists in training with different levels of experience in MDCT-CA scored 50 cases at various time points of the learning curve: baseline, 4 weeks, 8 weeks and 6 months. The trainee radiologists evaluated the degree of stenosis on each coronary segment, and overall accuracy was calculated on a per-segment, pervessel and per-patient basis.ResultsAll readers improved analysis accuracy per segment (range, 73–90%); sensitivity reached 45% per segment, 84% per vessel and 93% per patient; specificity was 99% per segment and vessel and 98% per patient. Positive and negative predictive values increased to 94% and 92%, respectively.ConclusionsAlthough all readers improved in diagnostic performance with growing experience with MDCT-CA, a longer training period may be necessary to achieve adequate levels of expertise in MDCT-CA to be able to perform as independent readers.RiassuntoObiettivoValutare l’accuratezza diagnostica nella stima di stenosi coronarica con l’angiografia coronarica mediante TCMS (AC-TCMS) ottenuta da tre lettori nei vari livelli di training proposti dalle linee guida internazionali come curva di apprendimento.Materiali e metodiTre lettori medici in formazione con esperienza in AC-TCMS differente hanno eseguito l’analisi sistematica delle AC-TCMS di 50 pazienti in diversi step della curva di apprendimento: iniziale, a 4 settimane, 8 settimane, 6 mesi. Per ogni segmento è stato valutato il grado di stenosi ed è stata calcolata l’accuratezza globale mediante analisi per segmento, vaso e paziente.RisultatiTutti i lettori hanno incrementato la loro accuratezza (range 73–90%) nell’analisi per segmento; la sensibilità con valori massimi per segmento pari a 45%, per vaso a 84% e per paziente a 93%; la specificità con valori massimi per l’analisi per segmento e vaso pari a 99% e per paziente pari a 98%. Anche i valori di predittività positiva e negativa sono incrementati raggiungendo valori rispettivamente pari a 94% e 92%.ConclusioniSebbene tutti i lettori abbiano migliorato la loro performance diagnostica aumentando la loro esperienza in AC-TCMS, può essere necessario un tempo più lungo per raggiungere un’esperienza adeguata in ACTCMS tale da consentire una valutazione indipendente.

Role of coronary angiography MDCT in the clinical setting: changes in diagnostic workup in the real world.

PurposeThe authors sought to evaluate the incremental value of introducing coronary angiography with multidetector computed tomography (MDCT-CA) compared with the conventional diagnostic workup in managing patients with suspected coronary artery disease (CAD) workup.Materials and methodsA total of 531 consecutive patients underwent MDCT-CA between April 2008 and August 2010. For each patient the pretest probability of CAD was obtained by using the Morise score as well as the diagnostic performance of the exercise test and of MDCT-CA, considering conventional coronary angiography (CCA) as the gold standard. Based on these results, we calculated the posttest likelihood of CAD after stress testing, comparing the incremental diagnostic value for each category of cardiovascular risk with data obtained with MDCT-CA. The conventional diagnostic workup (without MDCT-CA) was then compared with the modified workup (including MDCT-CA).ResultsThe diagnostic performance of the exercise test for identifying patients with significant lesions had a sensitivity and specificity of 20% and 88%, respectively, with positive (PPV) and negative (NPV) predictive value of 41% and 72%, respectively. Taking CA as the gold standard, MDCT-CA had 93% sensitivity, 89% specificity, 88% PPV and 93% NPV compared with CCA in evaluating significant stenoses in the per-patient analysis. The overall diagnostic accuracy of MDCT-CA was 91%. The exercise tests provided no significant incremental diagnostic value compared with cardiovascular history in patients with a low to intermediate risk. Comparison of the diagnostic accuracy of these protocols showed improved performance results for the modified protocol.ConclusionsMDCT-CA is the reference modality for the noninvasive exclusion of critical CAD. It provides a very high incremental diagnostic value compared with exercise testing in patients with a low to intermediate risk of CAD. The use of diagnostic protocols based on MDCT-CA ensures improved diagnostic performance compared with those involving conventional exercise electrocardiograms.RiassuntoObiettivoScopo del nostro lavoro è valutare il valore incrementale dell’introduzione della angiografia coronarica mediante tomografia assiale multistrato (AC-TCMS) nella gestione diagnostica del paziente con sospetta malattia coronarica (CAD) rispetto al tradizionale workup diagnostico.Materiali e metodiSono stati presi in considerazione 531 pazienti consecutivi sottoposti ad AC-TCMS tra marzo 2008 e agosto 2010. Per ogni paziente è stato calcolata la probabilità pre-test di CAD mediante Morise score e la performance diagnostica del cicloergometro e della ACTCMS considerando l’AC come standard di riferimento; Sulla base dei risultati è stata calcolata la probabilità post-test di CAD dopo stress test, confrontandone il valore diagnostico incrementale per ogni categoria di rischio cardiovascolare con i dati ottenuti dalla AC-TCMS. è stato confrontato il percorso diagnostico tradizionale senza ACTCMS, con quello modificato dall’introduzione dell’ACTCMS.RisultatiLa performance diagnostica dello stress test nella individuazione dei pazienti con lesioni significative ha dimostrato una sensibilità e specificità del 20% e 88% con valore predittivo positivo (VPP) e valore predittivo negativo (VPN) di 41% e 72%. Considerando come standard di riferimento la AC il confronto tra AC e ACTCMS nella valutazione di stenosi significative mediante analisi per paziente ha rilevato una sensibilità pari a 93%, una specificità pari a 89%, un VPP e VPN pari a 88 % e 93%. L’accuratezza diagnostica globale della metodica è risultata essere pari a 91%. Lo stress test ha dimostrato di non fornire un significativo valore diagnostico incrementale rispetto all’anamnesi cardiovascolare nei pazienti a basso-medio rischio. Il confronto tra l’accuratezza diagnostica dei protocolli ha dimostrato una migliore performance del protocollo che prevede l’introduzione dell’ACTCMS nei confronti del protocollo tradizionale.ConclusioniLa AC-TCMS è una metodica di riferimento non invasiva per l’esclusione di coronaropatia critica. Fornisce un valore diagnostico incrementale molto elevato rispetto allo stress test nei pazienti a basso-medio rischio. L’utilizzazione del protocollo diagnostico che prevede l’utilizzo dell’AC-TCMS garantisce una migliore perfomance diagnostica rispetto al protocollo tradizionale.

Conventional Autopsy versus Minimally Invasive Autopsy with Postmortem MRI, CT, and CT-guided Biopsy: Comparison of Diagnostic Performance

Purpose To compare the diagnostic performance of minimally invasive autopsy with that of conventional autopsy. Materials and Methods For this prospective, single-center, cross-sectional study in an academic hospital, 295 of 2197 adult cadavers (mean age: 65 years [range, 18-99 years]; age range of male cadavers: 18-99 years; age range of female cadavers: 18-98 years) who died from 2012 through 2014 underwent conventional autopsy. Family consent for minimally invasive autopsy was obtained for 139 of the 295 cadavers; 99 of those 139 cadavers were included in this study. Those involved in minimally invasive autopsy and conventional autopsy were blinded to each others findings. The minimally invasive autopsy procedure combined postmortem MRI, CT, and CT-guided biopsy of main organs and pathologic lesions. The primary outcome measure was performance of minimally invasive autopsy and conventional autopsy in establishing immediate cause of death, as compared with consensus cause of death. The secondary outcome measures were diagnostic yield of minimally invasive autopsy and conventional autopsy for all, major, and grouped major diagnoses; frequency of clinically unsuspected findings; and percentage of answered clinical questions. Results Cause of death determined with minimally invasive autopsy and conventional autopsy agreed in 91 of the 99 cadavers (92%). Agreement with consensus cause of death occurred in 96 of 99 cadavers (97%) with minimally invasive autopsy and in 94 of 99 cadavers (95%) with conventional autopsy (P = .73). All 288 grouped major diagnoses were related to consensus cause of death. Minimally invasive autopsy enabled diagnosis of 259 of them (90%) and conventional autopsy 224 (78%); 200 (69%) were found with both methods. At clinical examination, the cause of death was not suspected in 17 of the 99 cadavers (17%), and 124 of 288 grouped major diagnoses (43%) were not established. There were 219 additional clinical questions; 189 (86%) were answered with minimally invasive autopsy and 182 (83%) were answered with conventional autopsy (P = .35). Conclusion The performance of minimally invasive autopsy in the detection of cause of death was similar to that of conventional autopsy; however, minimally invasive autopsy has a higher yield of diagnoses.