Jiayin Zhang

Procedural success of CTO recanalization: Comparison of the J-CTO score determined by coronary CT angiography to invasive angiography

OBJECTIVES The J-CTO score is based on invasive angiography, combines several parameters of chronic total coronary occlusions (CTO), and is well established to predict the likelihood of success of percutaneous recanalization. The purpose of this study was to evaluate and validate a J-CTOCT score derived from coronary computed tomography angiography (coronary CTA). METHODS Between April 2011 and December 2014, 159 consecutive patients were retrospectively included. All had at least one CTO in invasive angiography, had coronary CTA performed at an interval of no more than one week from invasive angiography, and had an attempt at percutaneous coronary intervention (PCI) following coronary CTA In parallel to the angiographic J-CTO score, the J-CTOCT score was determined by awarding one point each for a blunt vessel stump, bending > 45°, occlusion length ≥ 20 mm, presence of calcium covering > 50% of any vessel cross-section within the occlusion, or a previously failed attempt at PCI. a. Both scores were compared regarding their ability to predict successful recanalization. RESULTS A total of 171 CTO lesions were analyzed. Intraobserver (k = 0.814, p < 0.001) and interobserver agreement (k = 0.771, p < 0.001) for calculation of the J-CTOCT score were close. The mean occlusion length measured by coronary CTA was significantly shorter than in invasive angiography (27.6 ± 14.8 mm vs. 37.2 ± 18.8 mm, p < 0.001). The J-CTOCT score (mean: 1.9 ± 1.4) correlated closely to the angiographic J-CTO score (mean: 1.8 ± 1.3, r = 0.856, p < 0.001), and in 122/171 lesions (71%), the scores were identical. Both J-CTOCT score (area under curve: 0.882, p < 0.001) and angiographic J-CTO score (area under curve: 0.868, p < 0.001) yielded similarly high predictive value for successful guidewire crossing within 30 min (p = 0.496). CONCLUSIONS While the length of coronary occlusions in coronary CTA is significantly shorter than in invasive angiography, a J-CTOCT score determined by coronary CTA closely correlates to the angiographic J-CTO score. .

Comparison of Myocardial Transmural Perfusion Gradient by Magnetic Resonance Imaging to Fractional Flow Reserve in Patients With Suspected Coronary Artery Disease

The goal of this study was to evaluate the diagnostic accuracy of transmural perfusion gradient (TPG) and transmural perfusion gradient reserve (TPGR) with 3.0 T cardiac magnetic resonance (CMR) against invasively determined fractional flow reserve (FFR) to detect coronary artery stenosis. Quantitative analysis of myocardial perfusion with CMR to diagnosis coronary artery disease (CAD) has been widely accepted. However, traditional transmural myocardial perfusion analysis with CMR neglects that endocardium is more vulnerable to ischemia than epicardium. TPG and TPGR can take the inhomogenous perfusion impairment into account and be more sensitive and specific for diagnosis of CAD. In this study, 71 patients (57 men, age 60.1 ± 6.4 years) with known or suspected CAD referred for invasive angiography study underwent rest and adenosine-induced stress CMR perfusion imaging scan. FFR was attempted to be measured in all major epicardial coronary arteries. FFR ≤0.75 was regarded to indicate a hemodynamic significant coronary lesion. A TPG ≤0.85 predicted significant CAD with sensitivity and specificity of 74.55% and 83.65%, respectively. Sensitivity and specificity of TPGR ≤0.81 were 90.91% and 89.94%, respectively. Area under the receiver-operating curve to detect FFR ≤0.75 was 0.86 for TPG and 0.95 for TPGR. TPGR yielded significantly better sensitivity and specificity for diagnosis of CAD than traditional myocardial blood flow, myocardial perfusion reserve, and TPG (p < 0.0001). In conclusion, TPG and TPGR analyses with MRI are capable of detecting hemodynamic stenosis of coronary artery and superior to traditional myocardial perfusion analysis. Furthermore, TPGR appears to be superior to TPG in the diagnosis of coronary artery stenosis.

CT features in the early and late stages of chronic total coronary occlusions

OBJECTIVES To investigate the morphologic characteristics of early and late stages of chronic total coronary artery occlusions (CTO) in coronary computed tomography angiography (coronary CTA). METHODS We retrospectively analyzed patients who underwent coronary CTA and invasive coronary angiography and had at least one CTO with known duration. The following parameters were obtained in coronary CTA: calcification of the occluded segment; stump morphology; lesion length; remodeling index; presence of intra-occlusion linear contrast enhancement; and density of non-calcified CTO components. CT parameters were compared between patients with early (duration ≤ 12 months) and late (duration > 12 months) stage CTO. RESULTS One-hundred and twelve patients with 124 chronically occluded coronary arteries were analyzed. Fifty nine patients had early stage CTOs (62 lesions) and 53 patients had late stage CTOs (62 lesions). Calcification was more severe in late-stage versus early CTOs (Agatston score: early stage, 27.4 ± 46.7 vs. late stage, 58.3 ± 112.4; p = 0.049). Remodeling index was lower in late-stage CTOs (early stage, 0.96 ± 0.2 vs. late stage, 0.88 ± 0.22; p = 0.034). In patients with late stage CTO, the presence of intra-occlusion linear enhancement was more likely (45.2% vs 14.5%, p < 0.001), and the density of non-calcified components was significantly higher (85.4 ± 27.2 HU vs. 65.7 ± 30.1 HU, p < 0.001). Stump morphology was not different between the two groups. CONCLUSIONS Coronary CTA reveals differences between chronic total coronary occlusions of longer and shorter duration. A long duration is associated with focal calcification and negative remodeling, as well as intra-occlusion enhancement and a higher density of non-calcified components.

Relationship of the Duke jeopardy score combined with minimal lumen diameter as assessed by computed tomography angiography to the hemodynamic relevance of coronary artery stenosis

OBJECTIVES To study the diagnostic performance of the ratio between the Duke jeopardy score (DJS) and the minimal lumen diameter (MLD) (DJS/MLDCT ratio) as assessed by coronary computed tomographic angiography (CTA) for differentiating functionally significant from non-significant coronary artery stenoses, with reference to invasive fractional flow reserve (FFR). METHODS Patients who underwent both coronary CTA and FFR measurement during invasive coronary angiography (ICA) within 2 weeks were retrospectively included in the study. Invasive FFR measurement was performed in patients with intermediate to severe coronary stenoseis. DJS/MLDCT ratio and anatomical parameters were recorded. Lesions with FFR ≤0.80 were considered to be functionally significant. RESULTS One hundred and sixty-one patients with 175 lesions were included into the analysis. Diameter stenosis in CT, area stenosis, plaque burden, lesion length (LL), ICA-based stenosis degree, DJS, LL/MLD4 ratio, DJS/MLA ratio as well as DJS/MLD ratio were all significantly different between hemodynamically significant and non-significant lesions (p<0.05 for all). ROC curve analysis determined the optimal cut-off value for DJS/MLDCT ratio to be 1.96 (area under curve = 0.863, 95 % confidence interval = 0.803-0.910), yielding a high diagnostic accuracy (86.9%, 152/175). CONCLUSIONS In coronary artery stenoses detected by coronary CTA, the DJS/MLD ratio is able to predict hemodynamic relevance.

CT morphological index provides incremental value to machine learning based CT-FFR for predicting hemodynamically significant coronary stenosis

AIMS To study the diagnostic performance of the ratio of Duke jeopardy score (DJS) to the minimal lumen diameter (MLD) at coronary computed tomographic angiography (CCTA) and machine learning based CT-FFR for differentiating functionally significant from insignificant lesions, with reference to fractional flow reserve (FFR). METHODS AND RESULTS Patients who underwent both coronary CTA and FFR measurement at invasive coronary angiography (ICA) within 2 weeks were retrospectively included in our study. CT-FFR, DJS/MLDCT ratio, along with other parameters, including minimal luminal area (MLA), MLD, lesion length (LL), diameter stenosis, area stenosis, plaque burden, and remodeling index of lesions, were recorded. Lesions with FFR ≤0.8 were considered to be functionally significant. One hundred and twenty-nine patients with 166 lesions were ultimately included for analysis. The LL, diameter stenosis, area stenosis, plaque burden, DJS and DJS/MLDCT ratio were all significantly longer or larger in the group of FFR ≤ 0.8 (p < 0.001 for all), while smaller MLA, MLD and CT-FFR value were also noted (p < 0.001 for all). CT-FFR and DJS/MLDCT ratio showed the largest AUC among all single parameters (AUC = 0.85 and AUC = 0.83, respectively; p < 0.001 for both) for diagnosing functionally significant stenosis. Combining CT-FFR and DJS/MLDCT ratio provided incremental value for discrimination between flow-limiting and non-flow-limiting coronary lesions and yielded the best diagnostic performance (accuracy of 83.7%). CONCLUSIONS The combination of ML-based CT-FFR and DJS/MLDCT allows accurate non-invasive discrimination between flow-limiting and non-flow-limiting coronary lesions.

Assessment of Myocardial Bridge by Cardiac CT: Intracoronary Transluminal Attenuation Gradient Derived from Diastolic Phase Predicts Systolic Compression

Objective To study the predictive value of transluminal attenuation gradient (TAG) derived from diastolic phase of coronary computed tomography angiography (CCTA) for identifying systolic compression of myocardial bridge (MB). Materials and Methods Consecutive patients diagnosed with MB based on CCTA findings and without obstructive coronary artery disease were retrospectively enrolled. In total, 143 patients with 144 MBs were included in the study. Patients were classified into three groups: without systolic compression, with systolic compression < 50%, and with systolic compression ≥ 50%. TAG was defined as the linear regression coefficient between intraluminal attenuation in Hounsfield units (HU) and length from the vessel ostium. Other indices such as the length and depth of the MB were also recorded. Results TAG was the lowest in MB patients with systolic compression ≥ 50% (-19.9 ± 8.7 HU/10 mm). Receiver operating characteristic curve analysis was performed to determine the optimal cutoff values for identifying systolic compression ≥ 50%. The result indicated an optimal cutoff value of TAG as -18.8 HU/10 mm (area under curve = 0.778, p < 0.001), which yielded higher sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy (54.1, 80.5, 72.8, and 75.0%, respectively). In addition, the TAG of MB with diastolic compression was significantly lower than the TAG of MB without diastolic compression (-21.4 ± 4.8 HU/10 mm vs. -12.7 ± 8 HU/10 mm, p < 0.001). Conclusion TAG was a better predictor of MB with systolic compression ≥ 50%, compared to the length or depth of the MB. The TAG of MB with persistent diastolic compression was significantly lower than the TAG without diastolic compression.

Calcification Remodeling Index Characterized by Cardiac CT as a Novel Parameter to Predict the Use of Rotational Atherectomy for Coronary Intervention of Lesions with Moderate to Severe Calcification

Objective To assess the feasibility of calcification characterization by coronary computed tomography angiography (CCTA) to predict the use of rotational atherectomy (RA) for coronary intervention of lesions with moderate to severe calcification. Materials and Methods Patients with calcified lesions treated by percutaneous coronary intervention (PCI) who underwent both CCTA and invasive coronary angiography were retrospectively included in this study. Calcification remodeling index was calculated as the ratio of the smallest vessel cross-sectional area of the lesion to the proximal reference luminal area. Other parameters such as calcium volume, regional Agatston score, calcification length, and involved calcium arc quadrant were also recorded. Results A total of 223 patients with 241 calcified lesions were finally included. Lesions with RA tended to have larger calcium volume, higher regional Agatston score, more involved calcium arc quadrants, and significantly smaller calcification remodeling index than lesions without RA. Receiver operating characteristic curve analysis revealed that the best cutoff value of calcification remodeling index was 0.84 (area under curve = 0.847, p < 0.001). Calcification remodeling index ≤ 0.84 was the strongest independent predictor (odds ratio: 251.47, p < 0.001) for using RA. Conclusion Calcification remodeling index was significantly correlated with the incidence of using RA to aid PCI. Calcification remodeling index ≤ 0.84 was the strongest independent predictor for using RA prior to stent implantation.

Natural History of Untreated Coronary Total Occlusions Revealed with Follow-Up Semi-Automated Quantitative Coronary CT Angiography: The Morphological Characteristics of Initial CT Predict Occlusion Shortening

Objective To investigate the morphological changes of coronary chronic total occlusion (CTO) as determined by coronary computed tomography angiography (CCTA) follow-up using semi-automated quantitative analysis. Materials and Methods Thirty patients with 31 CTO lesions confirmed by invasive coronary angiography and baseline/follow-up CCTA were retrospectively included. CTOs were quantitatively analyzed by a semi-automated coronary plaque analysis software (Coronary Plaque Analysis, version 2.0, Siemens) after manually determining the lesion border. Recanalized lumen was defined as the linear-like enhanced opacity traversing the non-opacified occluded segment. Other parameters, such as total occlusion length, total occlusion volume, volume with low attenuation component (< 30 Hounsfield unit [HU]), volume with middle to high attenuation component (30–190 HU) as well as the calcification volume, were also recorded. Results Recanalized lumen was found within 48.4% (15/31) occlusions on the follow-up CCTA, compared to 45.2% (14/31) occlusions on the baseline CCTA. Eleven of 14 lesions (78.6%) with CT-visible recanalized lumen within CTOs had a shorter occlusion length on follow-up compared to only 3 of 17 lesions (17.6%) without CT-visible recanalized lumen (odds ratio, 17.1, p < 0.001). The percentage of low attenuation component of occlusions was smaller on follow-up CCTA compared to baseline value (18.1 ± 20.1% vs. 22.6 ± 19.6%, p = 0.033). Conclusion Coronary computed tomography angiography enables non-invasive characterization of natural progression of untreated CTO lesions. Recanalized lumen within CTOs observed at baseline CCTA was associated with shortening of occlusion length on follow-up. Compared to their earlier stage, occlusions of later stage were presented with higher density of non-calcified components.

Quantitative baseline CT plaque characterization of unrevascularized non-culprit intermediate coronary stenosis predicts lesion volume progression and long-term prognosis: A serial CT follow-up study

AIMS To investigate the quantitative baseline CT plaque characterization of unrevascularized non-culprit intermediate coronary stenosis and its association with lesion volume progression and long-term prognosis. METHODS Patients with baseline coronary CT angiography (CCTA) and invasive coronary angiography (ICA) and at least one unrevascularized non-culprit intermediate coronary stenosis were prospectively enrolled for this study. All patients were followed up by a second CCTA at 1-year to 1.5-year interval. High-risk plaque features as well as other quantitative plaque measurements were recorded. RESULTS 140 patients with 165 unrevascularized non-culprit intermediate lesions were selected. Lesion volume progression was identified in 18 lesions (10.9%, 18/165) at follow-up CCTA and 15 patients experienced major adverse cardiac events (MACE) during a mean follow-up period of 51.5 months. Low attenuation plaque (LAP) was more frequently present in the lesion-progression subgroup and MACE subgroup (lesion-progression VS. non-lesion progression: 55.6% VS. 8.8% and MACE VS. MACE free: 40% VS. 12.8%, both p < 0.05), while other parameters showed no significant differences. Based on stepwise multivariable logistic regression analysis, LAP was an independent predictor (OR = 16.74, 95%CI = 5.02 to 55.84, p < 0.001) for lesion volume progression and MACE (OR = 4.25, 95%CI = 1.03 to 17.53, p = 0.046). CONCLUSIONS The presence of LAP of unrevascularized non-culprit intermediate stenosis is associated with lesion volume progression and an independent predictor for MACE occurrence.

Third generation dual-source CT enables accurate diagnosis of coronary restenosis in all size stents with low radiation dose and preserved image quality

ObjectivesTo investigate the diagnostic performance of low dose stent imaging in patients with large (≥ 3 mm) and small (< 3 mm) calibre stents by third-generation dual-source CT.MethodsSymptomatic patients suspected of having in-stent restenosis (ISR) were prospectively enrolled. Coronary computed tomography angiography (CCTA) and invasive coronary angiography (ICA) were performed within 1 month for correlation. Binary ISR was defined as an in-stent neointimal proliferation with diameter stenosis ≥ 50%. The radiation dose and image quality of CCTA were also assessed.ResultsSixty-nine patients with 140 stents were ultimately included for analysis. The mean total radiation dose of CCTA was 1.3 ± 0.72 mSv in all patients and 0.95 ± 0.17 mSv in patients with high pitch acquisition. The overall diagnostic accuracy of CCTA stent imaging of patient-based, lesion-based and stent-based analysis was 95.7%, 94.1% and 94.3%, respectively. Further, the diagnostic accuracy of CCTA in the small calibre stent group (diameter < 3 mm) was slightly lower than that of the large calibre stent group (diameter ≥ 3 mm) (88.5% versus 98.7%, p = 0.01).ConclusionsThird-generation dual-source CT enables accurate diagnosis of coronary ISR of both large and small calibre stents. Low radiation dose could be achieved with preserved image quality.Key Points• Third-generation DSCT enables accurate diagnosis of coronary ISR of all size stents.• Low radiation dose could be achieved with preserved image quality.• The diagnostic accuracy of CCTA of small calibre stents was 88.5%.