Bio


Dr Nieman is a cardiologist and associate professor in the departments of medicine/cardiovascular and radiology. He investigates advanced cardiac imaging techniques, and current projects include the development and technical validation of functional CT applications for ischemic heart disease, the validation of cardiac CT in clinical effectiveness trials, and multimodality imaging of cardiomyopathies. He is currently the president of the Society of Cardiovascular Computed Tomography.
Dr Nieman was born in the Netherlands, obtained his medical degree at the Radboud University in Nijmegen (1998), and completed his cardiology training at the Erasmus University Medical Center in Rotterdam (2008). His research in cardiac CT at the Erasmus University resulted in a PhD degree in 2003. In 2004 he performed an imaging fellowship at the Massachusetts General Hospital (Harvard Medical School) in Boston, MA. Dr Nieman joined the staff of the department of cardiology and radiology at the Erasmus University Medical Center in 2008, where he was scientific director of the cardiac CT and MRI group and supervised the intensive cardiac care unit until he joined the staff at Stanford University.

Clinical Focus


  • Cardiology
  • Computed tomography
  • Magnetic resonance imaging
  • Echocardiography
  • Ischemic heart disease
  • Coronary artery disease

Academic Appointments


Boards, Advisory Committees, Professional Organizations


  • Annual Scientific Meeting Program Committee (2019-2020 Chair), Society of Cardiovascular Computed Tomography (2014 - Present)
  • President, Society of Cardiovascular Computed Tomography (2020 - Present)
  • CT Committee Member, Certification and Accreditation Committee, European Association of Cardiovascular Imaging (2016 - Present)
  • Board member, Society of Cardiovascular Computed Tomography (2015 - Present)
  • Board of Directors, International Society of Computed Tomography (2015 - 2019)
  • Board member, Netherlands Vascular Forum (2013 - 2016)
  • Nucleus member CT/Nuc section, European Association of Cardiovascular Imaging (2012 - 2016)
  • Research and innovation committee, European Association of Cardiovascular Imaging (2012 - 2016)
  • Program Committee Member, European Society of Cardiovascular Imaging (2012 - 2015)
  • Board member (Chair 2012-2015), Cardiac CT/MR/Nuc working group of the Dutch Cardiology Association (2009 - 2015)

Professional Education


  • Board Certification: RGS KNMG Dept of Postgraduate Training, Cardiology (2008)
  • PhD Training: Erasmus University Medical Center (2003) Netherlands
  • Fellowship: Massachusetts General Hospital Dept of Radiology (2005) MA United States of America
  • Residency: Erasmus University Medical Center (2008) Netherlands
  • Internship: Radboud University (1998) Netherlands
  • Medical Education: Radboud University (1998) Netherlands
  • Cardiologist, Erasmus University, Rotterdam, NL, Cardiology (2008)
  • PhD, Erasmus University, Rotterdam, NL, Cardiac CT (2003)
  • MD, Radboud University, Nijmegen, NL, Medicine (1998)

Current Research and Scholarly Interests


Current research interests:

Functional cardiac CT applications for the hemodynamic interpretation of coronary artery disease:
- CT myocardial perfusion imaging (SPECIFIC trial).
- CTA derived fractional flow reserve (ADVANCE registry, MACHINE registry, PRECISE trial).

Clinical validation of cardiac CT in cardiovascular medicine:
- Coronary CT angiography for the triage of patients with acute chest pain (BEACON randomized controlled trial).
- Tiered cardiac CT protocols algorithms for comprehensive assessment of patients with stable anginal complaints (CRESCENT and CRESCENT2 randomized controlled trials)

Comprehensive evaluation of patients with symptoms after coronary revascularization.

Multimodality imaging of cardiomyopathies.

Noninvasive characterization of atherosclerotic plaque.

Cardiac CT in structural heart disease.

Contrast media (CT-CON and IsoCOR randomized controlled trials).

Clinical Trials


  • Comprehensive Computed Tomography Guidance of Coronary Bypass Graft Surgery Recruiting

    Apply CT angiography, CT perfusion imaging and advanced image processing techniques to improve revascularization decision-making and surgical strategies in patients undergoing coronary artery bypass graft surgery.

    View full details

  • International Consortium for Multimodality Phenotyping in Adults With Non-compaction Not Recruiting

    Non-compaction cardiomyopathy (NCCM) is a heterogeneous, poorly understood disorder characterized by a prominent inner layer of loose myocardial tissue, and associated with heart failure, stroke, severe rhythm irregularities and death. For a growing population diagnosed with NCCM there is a need for better risk stratification to appropriately allocate (or safely withhold) these impactful preventive measures. The goal of this international consortium is to improve care of patients with non-compaction cardiomyopathy. We hypothesize that comprehensive analysis of clinical, genetic, structural and functional information will improve risk stratification. In addition, we hypothesize that detailed structural analysis will allow for differentiation of pathological and benign patterns of non-compaction. In a large cohort of adult patients with suspected NCCM we will perform in-depth phenotyping, including clinical information, pedigree data, genetics, echocardiography and MRI, and follow patients for up to 3 years. We will apply machine-learning based analytics to develop predictive models and compare their performance to currently used models and treatment criteria. Secondly, in a subset of patients we will perform high-resolution cardiac CT for detailed structural characterization of the myocardial wall. We will investigate associations between myocardial structure and regional contractile function, as assessed by echo and MRI. The aim of this proposal is to identify a structural signature associated with pathological non-compaction and improve developed risk prediction models. Discovery of pathological structural signatures through innovative imaging techniques, in relation to myocardial contractility, will advance our understanding of NCCM.

    Stanford is currently not accepting patients for this trial. For more information, please contact Koen Nieman, MD, PhD, (650) 723 - 7476.

    View full details

Projects


  • SPECIFIC Trial, Stanford University and others (5/1/2016 - Present)

    International, multicenter trial to validate the diagnostic value of dynamic CT myocardial perfusion imaging to identify hemodynamically relevant coronary artery disease, using measured fractional flow reserve as reference.

    Location

    Stanford

    Collaborators

  • ADVANCE registry, Stanford University (7/1/2015)

    International registry on the use and management impact of CT-derived Fractional Flow Reserve, including 5000 patients at 50 sites in Europe, Asia and North America

    Location

    300 Pasteur Drive, Stanford, California

All Publications


  • Temporal changes in FFRCT-Guided Management of Coronary Artery Disease - Lessons from the ADVANCE Registry. Journal of cardiovascular computed tomography Nous, F., Budde, R. P., Fairbairn, T. A., Akasaka, T., Norgaard, B. L., Berman, D. S., Raff, G., Hurwitz-Koweek, L. M., Pontone, G., Kawasaki, T., Sand, N. P., Jensen, J. M., Amano, T., Poon, M., Ovrehus, K. A., Sonck, J., Rabbat, M. G., Mullen, S., De Bruyne, B., Rogers, C., Matsuo, H., Bax, J. J., Leipsic, J., Patel, M. R., Nieman, K. 2020

    Abstract

    BACKGROUND: The ADVANCE registry is a large prospective study of outcomes and resource utilization in patients undergoing coronary computed tomography angiography (CCTA) and CT-based fractional flow reserve (FFRCT). As experience with new technologies and practices develops over time, we investigated temporal changes in the use of FFRCT within the ADVANCE registry.METHODS: 5083 patients with coronary artery disease (CAD) on CCTA were prospectively enrolled in the ADVANCE registry and were divided into 3 equally sized cohorts based on the temporal order of enrollment per site. Demographics, CCTA and FFRCT findings, and clinical outcomes through 1-year follow-up, were recorded and compared between tertiles.RESULTS: The number of patients with a ≥70% stenosis on CCTA was similar over time (33.6%, 30.9%, and 33.8% for cohort 1-3). The rate of positive FFRCT ≤0.80 was higher for cohorts 2 (67.3%) and 3 (74.6%) than for cohort 1 (57.1%, p<0.001). Invasive FFR rates decreased from 25.8% to 22.4% between cohort 1 and 3 (p=0.023). Moreover, patients with a FFRCT ≤0.80 were less frequently referred for invasive coronary angiography (ICA) (from 62.9% to 52.9%, p<0.001), and underwent fewer revascularizations between cohort 1 and 3 (from 41.9% to 32.0%, p<0.001). The prevalence of major events was low (1.2%) and similar between cohorts.CONCLUSIONS: Growing experience with FFRCT improved the likelihood of identifying hemodynamically significant CAD and safely reduced the need for ICA and revascularization in patients with anatomically significant disease even in the instance of an abnormal FFRCT.

    View details for DOI 10.1016/j.jcct.2020.04.011

    View details for PubMedID 32418861

  • Multimodality Imaging for Risk Assessment of Inherited Cardiomyopathies CURRENT CARDIOVASCULAR RISK REPORTS O'Sullivan, J. W., Rhee, J., Hsu, D., Wheeler, M. T., Nieman, K. 2020; 14 (5)
  • Prognostic Value of Subclinical Coronary Artery Disease in Atrial Fibrillation Patients Identified by Coronary Computed Tomography Angiography. The American journal of cardiology Nous, F. M., Budde, R. P., van Dijkman, E. D., Musters, P. J., Nieman, K., Galema, T. W. 2020

    Abstract

    Identifying coronary artery disease (CAD) in atrial fibrillation (AF) patients improves risk stratification and defines clinical management. However, the value of screening for subclinical CAD with cardiac CT in AF patients is unknown. Between 2011 and 2015, 94 consecutive patients without known or suspected CAD (66 (57-73) years, 68% male), who were referred for AF evaluation, underwent a noncontrast-enhanced coronary calcium scan and a coronary computed tomography angiography (CCTA) at our center. We retrospectively evaluated the coronary calcium score, the prevalence of obstructive CAD (≥50% stenosis) determined by CCTA, compared clinical management and 5-year outcome in patients with and without obstructive CAD on CCTA, and examined the potential impact of a coronary calcium score and obstructive CAD on CCTA as a manifestation of vascular disease on the CHA2Ds2VASc score and for the cardiovascular risk stratification of AF patients. The median coronary calcium score was 57 (0-275) and 24 patients (26%) had obstructive CAD on CCTA. At baseline, patients with obstructive CAD more often used statins than those without obstructive CAD (54% vs 26%, p = 0.011). After a median clinical follow-up of 2.4 (0.5-4.5) years, patients with obstructive CAD more frequently used oral anticoagulant and/or antiplatelet drugs, statins, angiotensin-II-receptor blockers and/or angiotensin-converting-enzyme inhibitors, and less often used class I antiarrhythmic drugs than patients without obstructive CAD (all p <0.050). After a median follow-up of 5.7 (4.8-6.8) years, mortality was higher in patients with obstructive CAD than in those without obstructive CAD (29% vs 11%, log-rank test: p = 0.034). Implementation of a coronary calcium score and/or obstructive CAD on CCTA elevated the CHA2Ds2VASc score and cardiovascular risk stratification in 42 patients (p <0.001) and 47 patients (p = 0.006), respectively. In conclusion, we observed a high prevalence of obstructive CAD on CCTA in AF patients without known or suspected CAD. AF patients with obstructive CAD were managed differently and had a worse prognosis than those without obstructive CAD. Cardiac CT could enhance cardiovascular risk stratification of AF patients.

    View details for DOI 10.1016/j.amjcard.2020.03.050

    View details for PubMedID 32345472

  • Society of Cardiovascular Computed Tomography guidance for use of cardiac computed tomography amidst the COVID-19 pandemic Endorsed by the American College of Cardiology. Journal of cardiovascular computed tomography Choi, A. D., Abbara, S., Branch, K. R., Feuchtner, G. M., Ghoshhajra, B., Nieman, K., Pontone, G., Villines, T. C., Williams, M. C., Blankstein, R. 2020

    Abstract

    The world is currently suffering through a pandemic outbreak of severe respiratory syndrome coronavirus 2 (SARS-CoV-2) known as Coronavirus Disease 2019 (COVID-19). The United States (US) Centers for Disease Control and Prevention (CDC) currently advises medical facilities to "reschedule non-urgent outpatient visits as necessary". The European Centre for Disease Prevention and Control, the United Kingdom National Health Service and several other international agencies covering Asia, North America and most regions of the world have recommended similar "social distancing" measures. The Society of Cardiovascular Computed Tomography (SCCT) offers guidance for cardiac CT (CCT) practitioners to help implement these international recommendations in order to decrease the risk of COVID-19 transmission in their facilities while deciding on the timing of outpatient and inpatient CCT exams. This document also emphasizes SCCT's commitment to the health and well-being of CCT technologists, imagers, trainees, and research community, as well as the patients served by CCT.

    View details for DOI 10.1016/j.jcct.2020.03.002

    View details for PubMedID 32317235

  • Anatomic or functional testing in stable patients with suspected CAD: contemporary role of cardiac CT in the ISCHEMIA trial era. The international journal of cardiovascular imaging Rodriguez-Granillo, G. A., Nieman, K., Carrascosa, P., Campisi, R., Ambrose, J. A. 2020

    Abstract

    One of the foundations of the management of patients with suspected coronary artery disease (CAD) is to avoid unnecessary invasive coronary angiography (ICA) referrals. However, the diagnostic yield of ICA following abnormal conventional stress testing is low. The ability of ischemia testing to predict subsequent myocardial infarction and death is currently being challenged, and more than half of cardiac events among stable patients with suspected CAD occur in those with normal functional tests. The optimal management of patients with stable CAD remains controversial and ischemia-driven interventions, though improving anginal symptoms, have failed to reduce the risk of hard cardiovascular events. In this context, there is an ongoing debate whether the initial diagnostic test among patients with stable suspected CAD should be a functional test or coronary computed tomography angiography. Aside from considering the specific characteristics of individual patients and local availability and conditions, the choice of the initial test relates to whether the objective concerns its role as gatekeeper for ICA, prognosis, or treatment decision-making. Therefore, the aim of this review is to provide a contemporary overview of these issues and discuss the emerging role of CCTA as the upfront imaging tool for most patients with suspected CAD.

    View details for DOI 10.1007/s10554-020-01815-7

    View details for PubMedID 32180079

  • Impact of machine-learning CT-derived fractional flow reserve for the diagnosis and management of coronary artery disease in the randomized CRESCENT trials. European radiology Nous, F. M., Budde, R. P., Lubbers, M. M., Yamasaki, Y., Kardys, I., Bruning, T. A., Akkerhuis, J. M., Kofflard, M. J., Kietselaer, B., Galema, T. W., Nieman, K. 2020

    Abstract

    OBJECTIVE: To determine the potential impact of on-site CT-derived fractional flow reserve (CT-FFR) on the diagnostic efficiency and effectiveness of coronary CT angiography (CCTA) in patients with obstructive coronary artery disease (CAD) on CCTA.METHODS: This observational cohort study included patients with suspected CAD who had been randomized to cardiac CT in the CRESCENT I and II trials. On-site CT-FFR was blindly performed in all patients with at least one ≥50% stenosis onCCTA and no exclusion criteria for CT-FFR. We retrospectively assessed the effect of adding CT-FFR to the CT protocol in patients with a stenosis ≥50% on CCTA in terms of diagnostic effectiveness, i.e., the number of additional tests required to determine the final diagnosis, reclassification of the initial management strategy, and invasive coronary angiography (ICA) efficiency, i.e., ICA rate without ≥50% CAD.RESULTS: Fifty-three patients out of the 372 patients (14%) had at least one ≥50% stenosis on CCTA of whom 42/53 patients (79%) had no exclusion criteria for CT-FFR. CT-FFR showed a hemodynamically significant stenosis (≤0.80) in 27/53 patients (51%). The availability of CT-FFR would have reduced the number of patients requiring additional testing by 57%-points compared with CCTA alone (37/53 vs. 7/53, p<0.001). The initial management strategy would have changed for 30 patients (57%, p<0.001). Reserving ICA for patients with a CT-FFR ≤0.80 would have reduced the number of ICA following CCTA by 13%-points (p=0.016).CONCLUSION: Implementation of on-site CT-FFR may change management and improve diagnostic efficiency and effectiveness in patients with obstructive CAD on CCTA.KEY POINTS: The availability of on-site CT-FFR in the diagnostic evaluation of patients with obstructive CAD on CCTA would have significantly reduced the number of patients requiring additional testing compared with CCTA alone. The implementation of on-site CT-FFR would have changed the initial management strategy significantly in the patients with obstructive CAD on CCTA. Restricting ICA to patients with a positive CT-FFR would have significantly reduced the ICA rate in patients with obstructive CAD on CCTA.

    View details for DOI 10.1007/s00330-020-06778-w

    View details for PubMedID 32166492

  • Diagnostic CMR Imaging Criteria in Noncompaction Cardiomyopathy and the Yield of Genetic Testing. The Canadian journal of cardiology van Waning, J. I., Caliskan, K., Chelu, R. G., van der Velde, N., Pezzato, A., Michels, M., van Slegtenhorst, M. A., Boersma, E., Nieman, K., Majoor-Krakauer, D., Hirsch, A. 2020

    Abstract

    Noncompaction cardiomyopathy (NCCM) is characterized by a thickened myocardial wall with excessive trabeculations of the left ventricle and around 30% is explained by a (likely) pathogenic variant ((L)PV) in a cardiomyopathy gene. Diagnosing a (L)PV is important because it allows to identify accurately which relatives are at risk and helps predicting prognosis. The goal of the study was to assess which specific clinical and morphological characteristics of the myocardium may predict a (L)PV and which of the Cardiovascular Magnetic Resonance Imaging (CMR) diagnostic criteria for NCCM can best be used for that purpose.Sixty-two NCCM patients, diagnosed by echocardiographic Jenni criteria, had a CMR that was evaluated according the Petersen, Stacey, Jacquier, Captur and Choi diagnostic CMR criteria for NCCM. Patients also underwent DNA testing, and were stratified according to having a (L)PV.Thirty-three (53%) NCCM patients had a (L)PV. The apical and mid-lateral segments were the dominant locations for meeting Petersen and/or Stacey criteria. Correlation between different CMR criteria varied from moderate to very strong. In multivariate binary logistic regression analysis with CMR and non-CMR parameters, independent positive predictors for a (L)PV were familial cardiomyopathy, trabecular mass, and meeting Petersen criteria in ≥2 out of 3 long axis views, while left bundle branch block and hypertension were negative predictors. The ROC-curve of this multivariate model had an area under the curve of 0.89 (95%CI 0.82-0.97).CMR criteria together with family history help to distinguish those patients in whom a (L)PV can be identified, consequently leading to referral for genetic diagnostics and cascade screening.

    View details for DOI 10.1016/j.cjca.2020.05.021

    View details for PubMedID 32445794

  • 1-Year Impact on Medical Practice and Clinical Outcomes of FFRCT The ADVANCE Registry JACC-CARDIOVASCULAR IMAGING Patel, M. R., Norgaard, B., Fairbairn, T. A., Nieman, K., Akasaka, T., Berman, D. S., Raff, G. L., Koweek, L., Pontone, G., Kawasaki, T., Sand, N., Jensen, J. M., Amano, T., Poon, M., Ovrehus, K. A., Sonck, J., Rabbat, M. G., Mullen, S., De Bruyne, B., Rogers, C., Matsuo, H., Bax, J. J., Leipsic, J. 2020; 13 (1): 97–105
  • Computed Tomographic Angiography-Based Fractional Flow Reserve Compared With Catheter-Based Dobutamine-Stress Diastolic Fractional Flow Reserve in Symptomatic Patients With a Myocardial Bridge and No Obstructive Coronary Artery Disease. Circulation. Cardiovascular imaging Jubran, A., Schnittger, I., Tremmel, J., Pargaonkar, V., Rogers, I., Becker, H. C., Yang, S., Mastrodicasa, D., Willemink, M., Fleischmann, D., Nieman, K. 2020; 13 (2): e009576

    View details for DOI 10.1161/CIRCIMAGING.119.009576

    View details for PubMedID 32069114

  • Opportunities and challenges of implementing computed tomography fractional flow reserve into clinical practice. Heart (British Cardiac Society) Nazir, M. S., Mittal, T. K., Weir-McCall, J., Nieman, K., Channon, K., Nicol, E. D. 2020

    Abstract

    CT-derived fractional flow reserve (CT-FFR) uses computational fluid dynamics to derive non-invasive FFR to determine the haemodynamic significance of coronary artery lesions. Studies have demonstrated good diagnostic accuracy of CT-FFR and reassuring short-term clinical outcome data.As a prerequisite, high-quality CT coronary angiography (CTCA) images are required with good heart rate control and pre-treatment with glyceryl trinitrate, which would otherwise render CTCA as unsuitable for CT-FFR. CT-FFR can determine the functional significance of CAD lesions, and there are supportive data for its use in clinical decision-making. However, the downstream impact on myocardial ischaemic burden or viability cannot be obtained.Several challenges remain with implementation of CT-FFR, including interpretation, training, availability, resource utilisation and funding. Further research is required to determine which cases should be considered for clinical CT-FFR analysis, with additional practical guidance on how to implement this emerging technique in clinical practice. Furthermore, long-term prognostic data are required before widespread clinical implementation of CT-FFR can be recommended.While there are several potential opportunities for CT-FFR, at present there remain important systemic and technical limitations and challenges that need to be overcome prior to routine integration of CT-FFR into clinical practice.

    View details for DOI 10.1136/heartjnl-2019-315607

    View details for PubMedID 32561589

  • Highlights of the fourteenth annual scientific meeting of the Society of Cardiovascular Computed Tomography. Journal of cardiovascular computed tomography Weir-McCall, J. R., Nicol, E., Abbara, S., Branch, K., Choi, A. D., Ghoshhajra, B. B., Leipsic, J., Nieman, K., Shaw, L. J., Blankstein, R. 2019

    Abstract

    The 14th Annual Scientific Meeting of the SCCT, held from July 11 to July 14 in Baltimore, MA, was attended by 830 attendees from 31 countries, with a program that included 45 sessions, and 26 exhibitors. This article summarizes several of the key themes and topics that were presented at this meeting, and provides an overview of the technical advances that are likely to impact future clinical practice in cardiovascular computed tomography.

    View details for DOI 10.1016/j.jcct.2019.12.034

    View details for PubMedID 31883903

  • Society of cardiovascular computed tomography expert consensus document on myocardial computed tomography perfusion imaging. Journal of cardiovascular computed tomography Patel, A. R., Bamberg, F., Branch, K., Carrascosa, P., Chen, M., Cury, R. C., Ghoshhajra, B., Ko, B., Nieman, K., Pugliese, F., Schoepf, J., Blankstein, R. 2019

    View details for DOI 10.1016/j.jcct.2019.10.003

    View details for PubMedID 32122795

  • The global social media response to the 14th annual Society of Cardiovascular Computed Tomography scientific sessions. Journal of cardiovascular computed tomography Choi, A. D., Parwani, P., Michos, E. D., Lee, J., Singh, V., Fentanes, E., Lopez-Mattei, J., Gulati, M., Nasir, K., Nieman, K., Shaw, L. J., Blankstein, R. 2019

    Abstract

    The 2019 Society of Cardiovascular Computed Tomography (SCCT) Annual Scientific Meeting (ASM) was perhaps the most impactful meeting in recent memory for the field of cardiovascular CT. Beyond just being the highest attended ASM meeting in the society's history, the virtual impact of the meeting extended farther than ever before due to coordinated social media coverage and participation. As a result, the ASM reinforced the fact that the educational paradigm and audience of scientific meetings has changed. Bound through the hashtag #SCCT2019, social media allowed the research, education, networking and trends from this year's ASM to extend beyond the walls of the meeting with a record setting level of digital global reach. Using posts from Twitter as a prism of interests and response of the global cardiovascular CT community, this article presents the topics with the highest social media engagement from the 14th ASM.

    View details for DOI 10.1016/j.jcct.2019.12.003

    View details for PubMedID 31843522

  • Coronary artery calcium: A technical argument for a new scoring method JOURNAL OF CARDIOVASCULAR COMPUTED TOMOGRAPHY Willemink, M. J., van der Werf, N. R., Nieman, K., Greuter, M. W., Koweek, L. M., Fleischmann, D. 2019; 13 (6): 347–52
  • Impact of iodine concentration and iodine delivery rate on contrast enhancement in coronary CT angiography: a randomized multicenter trial (CT-CON) EUROPEAN RADIOLOGY Rengo, M., Dharampal, A., Lubbers, M., Kock, M., Wildberger, J. E., Das, M., Niezen, A., van Tilborg, F., Kofflard, M., Laghi, A., Krestin, G., Nieman, K. 2019; 29 (11): 6109–18
  • Dynamic CT myocardial perfusion imaging. Journal of cardiovascular computed tomography Nieman, K., Balla, S. 2019

    Abstract

    Cardiac CT offers several approaches to establish the hemodynamic severity of coronary artery obstructions. Dynamic myocardial perfusion CT (MPICT) is based on serial CT imaging to measure the inflow of contrast medium into the myocardium and calculate absolute measures of myocardial perfusion. This review describes the MPICT acquisition protocol, post-image acquisition processing and calculation of quantitative parameters, the diagnostic performance of MPICT and the potential incremental value of this technique in comparison to alternative approaches. Further technical innovation using different scanner platforms and establishment of reproducible diagnostic thresholds to differentiate significant coronary artery disease will be crucial in the path to broader clinical implementation.

    View details for DOI 10.1016/j.jcct.2019.09.003

    View details for PubMedID 31540820

  • The feasibility, findings and future of CT-FFR in the emergency ward. Journal of cardiovascular computed tomography Nieman, K. 2019

    View details for DOI 10.1016/j.jcct.2019.08.008

    View details for PubMedID 31477560

  • Cardiac CT After Coronary Revascularization: Enough to Make a Difference? JACC. Cardiovascular imaging Nagel, E., Nieman, K. 2019

    View details for DOI 10.1016/j.jcmg.2019.07.006

    View details for PubMedID 31422144

  • Influence of Coronary Calcium on Diagnostic Performance of Machine Learning CT-FFR: Results From MACHINE Registry. JACC. Cardiovascular imaging Tesche, C., Otani, K., De Cecco, C. N., Coenen, A., De Geer, J., Kruk, M., Kim, Y., Albrecht, M. H., Baumann, S., Renker, M., Bayer, R. R., Duguay, T. M., Litwin, S. E., Varga-Szemes, A., Steinberg, D. H., Yang, D. H., Kepka, C., Persson, A., Nieman, K., Schoepf, U. J. 2019

    Abstract

    OBJECTIVES: This study was conducted to investigate the influence of coronary artery calcium (CAC) score on the diagnostic performance of machine-learning-based coronary computed tomography (CT) angiography (cCTA)-derived fractional flow reserve (CT-FFR).BACKGROUND: CT-FFR is used reliably to detect lesion-specific ischemia. Novel CT-FFR algorithms using machine-learning artificial intelligence techniques perform fast and require less complex computational fluid dynamics. Yet, influence of CAC score on diagnostic performance of the machine-learning approach has not been investigated.METHODS: Four hundred eighty-two vessels from 314 patients (62.3 ± 9.3 years, 77% male) who underwent cCTA followed by invasive FFR were investigated from the MACHINE (Machine Learning based CT Angiography derived FFR: a Multi-center Registry) registry data. CAC scores were quantified using the Agatston convention. The diagnostic performance of CT-FFR to detect lesion-specific ischemia was assessed across all Agatston score categories (CAC 0, >0 to<100, 100 to<400, and≥400) on a per-vessel level with invasive FFR as the reference standard.RESULTS: The diagnostic accuracy of CT-FFR versus invasive FFR was superior to cCTA alone on a per-vessel level (78% vs. 60%) and per patient level (83% vs. 73%) across all Agatston score categories. No statistically significant differences in the diagnostic accuracy, sensitivity, or specificity of CT-FFR were observed across the categories. CT-FFR showed good discriminatory power in vessels with high Agatston scores (CAC≥ 400) and high performance in low-to-intermediate Agatston scores (CAC >0 to<400) with a statistically significant difference in the area under the receiver-operating characteristic curve (AUC) (AUC: 0.71 [95% confidence interval (CI): 0.57-0.85] vs. 0.85 [95%CI: 0.82-0.89], p=0.04). CT-FFR showed superior diagnostic value over cCTA in vessels with high Agatston scores (CAC≥ 400: AUC 0.71 vs. 0.55, p=0.04) and low-to-intermediate Agatston scores (CAC >0 to<400: AUC 0.86 vs. 0.63, p<0.001).CONCLUSIONS: Machine-learning-based CT-FFR showed superior diagnostic performance over cCTA alone in CAC with a significant difference in the performance of CT-FFR as calcium burden/Agatston calcium score increased. (Machine Learning Based CT Angiography Derived FFR: a Multicenter, Registry [MACHINE] NCT02805621).

    View details for DOI 10.1016/j.jcmg.2019.06.027

    View details for PubMedID 31422141

  • Effect of Tube Voltage on Diagnostic Performance of Fractional Flow Reserve Derived From Coronary CT Angiography With Machine Learning: Results From the MACHINE Registry AMERICAN JOURNAL OF ROENTGENOLOGY De Geer, J., Coenen, A., Kim, Y., Kruk, M., Tesche, C., Schoepf, U., Kepka, C., Yang, D., Nieman, K., Persson, A. 2019; 213 (2): 325–31
  • Functional Interpretation of CoronaryStenoses by Cardiac CT andthe Many Ways to SkinThat Cat. JACC. Cardiovascular imaging Nieman, K., Chandrashekhar, Y. 2019; 12 (8 Pt 1): 1599–1600

    View details for DOI 10.1016/j.jcmg.2019.07.001

    View details for PubMedID 31395251

  • Controversies in Diagnostic Imaging of Patients With Suspected Stable and Acute Chest Pain Syndromes. JACC. Cardiovascular imaging Shaw, L. J., Blankstein, R., Brown, D. L., Dhruva, S. S., Douglas, P. S., Genders, T. S., Gibbons, R. J., Greenwood, J. P., Kwong, R., Leipsic, J., Mahmarian, J. J., Maron, D., Nagel, E., Nicol, E., Nieman, K., Pellikka, P. A., Redberg, R. F., Weir-McCall, J., Williams, M. C., Chandrasekhar, Y. 2019; 12 (7 Pt 1): 1254–78

    Abstract

    There has been a tremendous growth quantity of high-quality imaging evidence in the area of acute and stable ischemic heart disease (SIHD). A number of recent comparative effectiveness trials have spurned significant controversies in the field of cardiovascular imaging. The result of this evidence is that many health care policies and national guidelines have undergone significant revisions. With all of this evidence, many challenges remain and the optimal evaluation strategy for evaluation of patients presenting with chest pain remains ill-defined. This paper enlisted the guidance of numerous experts in the field of cardiovascular imaging to garner their perspective on available imaging research in chest pain syndromes. Each of these vignettes represent editorial perspectives and diverse opinions as to which, if any, shouldbethe primary test in the evaluation of stable chest pain. These perspectives are not meant to be all inclusive but to highlight many of the commonly discussed controversies in the evaluation of chest pain symptoms. Theseperspectives are presented as a pre-amble to an upcoming American College of Cardiology/American Heart Association clinical practice guideline that is undergoing revision from the previous report published in 2012. Theevidence has changed considerably since the 2012SIHD guideline, and the current perspectives represent thediversity of availableevidence as to the optimal imagingstrategy for evaluation of the symptomatic patient.

    View details for DOI 10.1016/j.jcmg.2019.05.009

    View details for PubMedID 31272608

  • Clinical applications of machine learning in cardiovascular disease and its relevance to cardiac imaging EUROPEAN HEART JOURNAL Al'Aref, S. J., Anchouche, K., Singh, G., Slomka, P. J., Kolli, K. K., Kumar, A., Pandey, M., Maliakal, G., van Rosendael, A. R., Beecy, A. N., Berman, D. S., Leipsic, J., Nieman, K., Andreini, D., Pontone, G., Schoepf, U., Shaw, L. J., Chang, H., Narula, J., Bax, J. J., Guan, Y., Min, J. K. 2019; 40 (24): 1975-+
  • The role of coronary CT angiography for acute chest pain in the era of high-sensitivity troponins. Journal of cardiovascular computed tomography Yang, S., Manjunath, L., Willemink, M. J., Nieman, K. 2019

    Abstract

    Accurate and efficient diagnostic triage for acute chest pain (ACP) remains one of the most challenging problems in the emergency department (ED). While the proportion of patients that present with myocardial infarction (MI), aortic dissection, or pulmonary embolism is relatively low, a missed diagnosis can be life threatening. Coronary computed tomography angiography (CCTA) has developed into a robust diagnostic tool in the triage of ACP over the past decade, with several trials showing that it can reliably identify patients at low risk of major adverse cardiovascular events, shorten the length of stay in the ED, and reduce cost associated with the triage of patients with undifferentiated chest pain. Recently, however, high-sensitivity troponin assays have been increasingly incorporated as a rapid and efficient diagnostic test in the triage of ACP due to their higher sensitivity and negative predictive value of myocardial infarction. As more EDs adopt high-sensitivity troponin assays into routine clinical practice, the role of CCTA will likely change. In this review, we provide an overview of CCTA and high-sensitivity troponins for evaluation of patients with suspected ACS in the ED. Moreover, we discuss the changing role of CCTA in the era of high-sensitivity troponins.

    View details for DOI 10.1016/j.jcct.2019.05.007

    View details for PubMedID 31235403

  • Coronary CT in Patients with a History of PCI or CABG: Helpful or Harmful? CURRENT CARDIOVASCULAR IMAGING REPORTS Jubran, A., Willemink, M. J., Nieman, K. 2019; 12 (6)
  • 1-Year Impact on Medical Practice and Clinical Outcomes of FFRCT: The ADVANCE Registry. JACC. Cardiovascular imaging Patel, M. R., Norgaard, B. L., Fairbairn, T. A., Nieman, K., Akasaka, T., Berman, D. S., Raff, G. L., Hurwitz Koweek, L. M., Pontone, G., Kawasaki, T., Sand, N. P., Jensen, J. M., Amano, T., Poon, M., Ovrehus, K. A., Sonck, J., Rabbat, M. G., Mullen, S., De Bruyne, B., Rogers, C., Matsuo, H., Bax, J. J., Leipsic, J. 2019

    Abstract

    OBJECTIVES: The 1-year data from the international ADVANCE (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) Registry of patients undergoing coronary computed tomography angiography (CTA) was used to evaluatethe relationship of fractional flow reserve derived from coronary CTA (FFRCT) with downstream care and clinical outcomes.BACKGROUND: Guidelines for management of chest pain using noninvasive imaging pathways are based on short- to intermediate-term outcomes.METHODS: Patients (N= 5,083) evaluated for clinically suspected coronary artery disease and in whom atherosclerosis was identified by coronary CTA were prospectively enrolled at 38 international sites from July 15, 2015, to October 20, 2017. Demographics, symptom status, coronary CTA and FFRCT findings and resultant site-based treatment plans, and clinical outcomes through 1 year were recorded and adjudicated by a blinded core laboratory. Major adverse cardiac events (MACE), death, myocardial infarction (MI), and acute coronary syndrome leading to urgent revascularization were captured.RESULTS: At 1 year, 449 patients did not have follow-up data. Revascularization occurred in 1,208 (38.40%) patientswith an FFRCT≤0.80 and in 89 (5.60%) with an FFRCT >0.80 (relative risk [RR]: 6.87; 95% confidence interval [CI]: 5.59to 8.45; p< 0.001). MACE occurred in 55 patients, 43 events occurred in patients with an FFRCT≤0.80 and 12occurred in those with an FFRCT >0.80 (RR: 1.81; 95% CI: 0.96 to 3.43; p= 0.06). Time to first event (all-cause death orMI) occurred in 38 (1.20%) patients with an FFRCT≤0.80 compared with 10 (0.60%) patients with an FFRCT >0.80 (RR: 1.92; 95% CI: 0.96 to 3.85; p= 0.06). Time to first event (cardiovascular death or MI) occurred cardiovascular death or MI occurred more in patients with an FFRCT≤0.80 compared with patients with an FFRCT >0.80 (25 [0.80%] vs. 3 [0.20%]; RR: 4.22; 95% CI: 1.28 to13.95; p= 0.01).CONCLUSIONS: The 1-year outcomes from the ADVANCE FFRCT Registry show low rates of events in all patients, withless revascularization and a trend toward lower MACE and significantly lower cardiovascular death or MI in patientswith a negative FFRCT compared with patients with abnormal FFRCT values. (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Wave [ADVANCE]; NCT02499679).

    View details for PubMedID 31005540

  • Intermodality variation of aortic dimensions: How, where and when to measure the ascending aorta INTERNATIONAL JOURNAL OF CARDIOLOGY Bons, L. R., Duijnhouwer, A. L., Boccalini, S., van den Hoven, A. T., van der Vlugt, M. J., Chelu, R. G., McGhie, J. S., Kardys, I., van den Bosch, A. E., Siebelink, H. J., Nieman, K., Hirsch, A., Broberg, C. S., Budde, R. J., Roos-Hesselink, J. W. 2019; 276: 230–35
  • Impact of iodine concentration and iodine delivery rate on contrast enhancement in coronary CT angiography: a randomized multicenter trial (CT-CON). European radiology Rengo, M., Dharampal, A., Lubbers, M., Kock, M., Wildberger, J. E., Das, M., Niezen, A., van Tilborg, F., Kofflard, M., Laghi, A., Krestin, G., Nieman, K. 2019

    Abstract

    To compare the effect of contrast medium iodine concentration on contrast enhancement, heart rate, and injection pressure when injected at a constant iodine delivery rate in coronary CT angiography (CTA).One thousand twenty-four patients scheduled for coronary CTA were prospectively randomized to receive one of four contrast media: iopromide 300 mg I/ml, iohexol 350 mg I/ml, iopromide 370 mg I/ml, or iomeprol 400 mg I/ml. Contrast media were delivered at an equivalent iodine delivery rate of 2.0 g I/s. Intracoronary attenuation was measured and compared (per vessel and per segment). Heart rate before and after contrast media injection was documented. Injection pressure was recorded (n = 403) during contrast medium injection and compared between groups.Intracoronary attenuation values were similar for the different contrast groups. The mean attenuation over all segments ranged between 384 HU for 350 mg I/ml and 395 HU for 400 mg I/ml (p = 0.079). Dose-length product (p = 0.8424), signal-to-noise ratio (all p > 0.05), time to peak (p = 0.324), and changes in heart rate (p = 0.974) were comparable between groups. The peak pressures differed: 197.4 psi for 300 mg I/ml (viscosity 4.6 mPa s), 229.8 psi for 350 mg I/ml (10.4 mPa s), 216.1 psi for 370 mg I/ml (9.5 mPa s), and 243.7 psi for 400 mg I/ml (12.6 mPa s) (p < 0.0001).Intravascular attenuation and changes in heart rate are independent of iodine concentration when contrast media are injected at the same iodine delivery rate. Differences in injection pressures are associated with the viscosity of the contrast media.• The contrast enhancement in coronary CT angiography is independent of the iodine concentration when contrast media are injected at body temperature (37 °C) with the same iodine delivery rate. • Iodine concentration does not influence the change in heart rate when contrast media are injected at identical iodine delivery rates. • For a fixed iodine delivery rate and contrast temperature, the viscosity of the contrast medium affects the injection pressure.

    View details for PubMedID 31016447

  • Gender differences in the diagnostic performance of machine learning coronary CT angiography-derived fractional flow reserve -results from the MACHINE registry. European journal of radiology Baumann, S., Renker, M., Schoepf, U. J., De Cecco, C. N., Coenen, A., De Geer, J., Kruk, M., Kim, Y. H., Albrecht, M. H., Duguay, T. M., Jacobs, B. E., Bayer, R. R., Litwin, S. E., Weiss, C., Akin, I., Borggrefe, M., Yang, D. H., Kepka, C., Persson, A., Nieman, K., Tesche, C. 2019; 119: 108657

    Abstract

    This study investigated the impact of gender differences on the diagnostic performance of machine-learning based coronary CT angiography (cCTA)-derived fractional flow reserve (CT-FFRML) for the detection of lesion-specific ischemia.Five centers enrolled 351 patients (73.5% male) with 525 vessels in the MACHINE (Machine leArning Based CT angiograpHy derIved FFR: a Multi-ceNtEr) registry. CT-FFRML and invasive FFR ≤ 0.80 were considered hemodynamically significant, whereas cCTA luminal stenosis ≥50% was considered obstructive. The diagnostic performance to assess lesion-specific ischemia in both men and women was assessed on a per-vessel basis.In total, 398 vessels in men and 127 vessels in women were included. Compared to invasive FFR, CT-FFRML reached a sensitivity, specificity, positive predictive value, and negative predictive value of 78% (95%CI 72-84), 79% (95%CI 73-84), 75% (95%CI 69-79), and 82% (95%CI: 76-86) in men vs. 75% (95%CI 58-88), 81 (95%CI 72-89), 61% (95%CI 50-72) and 89% (95%CI 82-94) in women, respectively. CT-FFRML showed no statistically significant difference in the area under the receiver-operating characteristic curve (AUC) in men vs. women (AUC: 0.83 [95%CI 0.79-0.87] vs. 0.83 [95%CI 0.75-0.89], p = 0.89). CT-FFRML was not superior to cCTA alone [AUC: 0.83 (95%CI: 0.75-0.89) vs. 0.74 (95%CI: 0.65-0.81), p = 0.12] in women, but showed a statistically significant improvement in men [0.83 (95%CI: 0.79-0.87) vs. 0.76 (95%CI: 0.71-0.80), p = 0.007].Machine-learning based CT-FFR performs equally in men and women with superior diagnostic performance over cCTA alone for the detection of lesion-specific ischemia.

    View details for DOI 10.1016/j.ejrad.2019.108657

    View details for PubMedID 31521876

  • A novel therapy for an unusual problem: IL-1 receptor antagonist for recurrent post-transplant pericarditis. Clinical transplantation Parizo, J. T., Moayedi, Y., Nieman, K., Town, K., Teuteberg, J. J., Khush, K. K. 2019

    Abstract

    Heart transplant (HTx) recipients are at increased risk of pericardial disease. Idiopathic recurrent pericarditis has not been previously described following HTx. We describe a 35-year-old male who was admitted with pericarditis and moderate pericardial effusion ten months after HTx. Two weeks before his admission, his prednisone had been tapered off. A thorough infectious workup and endomyocardial biopsy was unrevealing. He was started on colchicine with the addition of tapering prednisone regimen of 40 mg daily due to unresolved pain. Over the next several years he had three recurrent episodes of pericarditis requiring re-initiation of prednisone with extensive investigations negative for rejection, autoimmune and infectious causes. Cardiac MRI confirmed pericardial inflammation. Due to his recurrent course and inability to wean off prednisone, anakinra, an IL-1 receptor antagonist, was started at 100 mg sc daily. This allowed successful discontinuation of prednisone. He is now 34 months post-transplant without recurrence on anakinra and colchicine maintenance. Due to the overlap between idiopathic recurrent pericarditis and auto-inflammatory diseases, there is growing evidence for utilizing IL-1 receptor antagonists in this condition. While pericarditis is common in the HTx population, this is the first report of successful use of an IL-1 receptor blocker for pericarditis in this population. This article is protected by copyright. All rights reserved.

    View details for DOI 10.1111/ctr.13699

    View details for PubMedID 31437316

  • Effect of Tube Voltage on Diagnostic Performance of Fractional Flow Reserve Derived From Coronary CT Angiography With Machine Learning: Results From the MACHINE Registry. AJR. American journal of roentgenology De Geer, J., Coenen, A., Kim, Y. H., Kruk, M., Tesche, C., Schoepf, U. J., Kepka, C., Yang, D. H., Nieman, K., Persson, A. 2019: 1–7

    Abstract

    OBJECTIVE. Coronary CT angiography (CCTA)-based methods allow noninvasive estimation of fractional flow reserve (cFFR), recently through use of a machine learning (ML) algorithm (cFFRML). However, attenuation values vary according to the tube voltage used, and it has not been shown whether this significantly affects the diagnostic performance of cFFR and cFFRML. Therefore, the purpose of this study is to retrospectively evaluate the effect of tube voltage on the diagnostic performance of cFFRML. MATERIALS AND METHODS. A total of 525 coronary vessels in 351 patients identified in the MACHINE consortium registry were evaluated in terms of invasively measured FFR and cFFRML. CCTA examinations were performed with a tube voltage of 80, 100, or 120 kVp. For each tube voltage value, correlation (assessed by Spearman rank correlation coefficient), agreement (evaluated by intraclass correlation coefficient and Bland-Altman plot analysis), and diagnostic performance (based on ROC AUC value, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy) of the cFFRML in terms of detection of significant stenosis were calculated. RESULTS. For tube voltages of 80, 100, and 120 kVp, the Spearman correlation coefficient for cFFRML in relation to the invasively measured FFR value was ρ = 0.684, ρ = 0.622, and ρ = 0.669, respectively (p < 0.001 for all). The corresponding intraclass correlation coefficient was 0.78, 0.76, and 0.77, respectively (p < 0.001 for all). Sensitivity was 100.0%, 73.5%, and 85.0%, and specificity was 76.2%, 79.0%, and 72.8% for tube voltages of 80, 100, and 120 kVp, respectively. The ROC AUC value was 0.90, 0.82, and 0.80 for 80, 100, and 120 kVp, respectively (p < 0.001 for all). CONCLUSION. CCTA-derived cFFRML is a robust method, and its performance does not vary significantly between examinations performed using tube voltages of 100 kVp and 120 kVp. However, because of rapid advancements in CT and postprocessing technology, further research is needed.

    View details for PubMedID 31039021

  • Determinants of Rejection Rate for Coronary CT Angiography Fractional Flow Reserve Analysis. Radiology Pontone, G., Weir-McCall, J. R., Baggiano, A., Del Torto, A., Fusini, L., Guglielmo, M., Muscogiuri, G., Guaricci, A. I., Andreini, D., Patel, M., Nieman, K., Akasaka, T., Rogers, C., Nørgaard, B. L., Bax, J., Raff, G. L., Chinnaiyan, K., Berman, D., Fairbairn, T., Koweek, L. H., Leipsic, J. 2019: 182673

    Abstract

    Background Coronary artery fractional flow reserve (FFR) derived from CT angiography (FFTCT) enables functional assessment of coronary stenosis. Prior clinical trials showed 13%-33% of coronary CT angiography studies had insufficient quality for quantitative analysis with FFRCT. Purpose To determine the rejection rate of FFRCT analysis and to determine factors associated with technically unsuccessful calculation of FFRCT. Materials and Methods Prospectively acquired coronary CT angiography scans submitted as part of the Assessing Diagnostic Value of Noninvasive FFRCT in Coronary Care (ADVANCE) registry (https://ClinicalTrials.gov: NCT02499679) and coronary CT angiography series submitted for clinical analysis were included. The primary outcome was the FFRCT rejection rate (defined as an inability to perform quantitative analysis with FFRCT). Factors that were associated with FFRCT rejection rate were assessed with multiple linear regression. Results In the ADVANCE registry, FFRCT rejection rate due to inadequate image quality was 2.9% (80 of 2778 patients; 95% confidence interval [CI]: 2.1%, 3.2%). In the 10 621 consecutive patients who underwent clinical analysis, the FFRCT rejection rate was 8.4% (n = 892; 95% CI: 6.2%, 7.2%; P < .001 vs the ADVANCE cohort). The main reason for the inability to perform FFRCT analysis was the presence of motion artifacts (63 of 80 [78%] and 729 of 892 [64%] in the ADVANCE and clinical cohorts, respectively). At multivariable analysis, section thickness in the ADVANCE (odds ratio [OR], 1.04; 95% CI: 1.001, 1.09; P = .045) and clinical (OR, 1.03; 95% CI: 1.02, 1.04; P < .001) cohorts and heart rate in the ADVANCE (OR, 1.05; 95% CI: 1.02, 1.08; P < .001) and clinical (OR, 1.06; 95% CI: 1.05, 1.07; P < .001) cohorts were independent predictors of rejection. Conclusion The rates for technically unsuccessful CT-derived fractional flow reserve in the ADVANCE registry and in a large clinical cohort were 2.9% and 8.4%, respectively. Thinner CT section thickness and lower patient heart rate may increase rates of completion of CT fractional flow reserve analysis. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Sakuma in this issue.

    View details for DOI 10.1148/radiol.2019182673

    View details for PubMedID 31335283

  • Comparison of the Diagnostic Performance of Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve in Patients With Versus Without Diabetes Mellitus (from the MACHINE Consortium). The American journal of cardiology Nous, F. M., Coenen, A., Boersma, E., Kim, Y., Kruk, M. B., Tesche, C., de Geer, J., Yang, D. H., Kepka, C., Schoepf, U. J., Persson, A., Kurata, A., Budde, R. P., Nieman, K. 2018

    Abstract

    Coronary computed tomography angiography-derived fractional flow reserve (CT-FFR) is a noninvasive application to evaluate the hemodynamic impact of coronary artery disease by simulating invasively measured FFR based on CT data. CT-FFR is based on the assumption of a normal coronary microvascular response. We assessed the diagnostic performance of a machine-learning based application for on-site computation of CT-FFR in patients with and without diabetes mellitus with suspected coronary artery disease. The study population included 75 diabetic and 276 nondiabetic patients who were enrolled in the MACHINE consortium. The overall diagnostic performance of coronary CT angiography alone and in combination with CT-FFR were analyzed with direct invasive FFR comparison in 110 coronary vessels of the diabetic group and in 415 coronary vessels of the nondiabetic group. Per-vessel discrimination of lesion-specific ischemia by CT-FFR was assessed by the area under the receiver operating characteristic curves. The overall diagnostic accuracy of CT-FFR in diabetic patients was 83% and in nondiabetic patients 75% (p = 0.088), showing improvement over the diagnostic accuracy of coronary CT angiography, which was 58% and 65% (p = 0.223), respectively. In addition, the diagnostic accuracy of CT-FFR was similar between diabetic and nondiabetic patients per stratified CT-FFR group (CT-FFR < 0.6, 0.6 to 0.69, 0.7 to 0.79, 0.8 to 0.89, ≥0.9). The area under the curves for diabetic and nondiabetic patients were also comparable, 0.88 and 0.82 (p = 0.113), respectively. In conclusion, on-site machine-learning CT-FFR analysis improved the diagnostic performance of coronary CT angiography and accurately discriminated lesion-specific ischemia in both diabetic and nondiabetic patients suspected of coronary artery disease.

    View details for PubMedID 30553510

  • Comprehensive Cardiac CT With Myocardial Perfusion Imaging Versus Functional Testing in Suspected CoronaryArtery Disease: The Multicenter, Randomized CRESCENT-II Trial. JACC. Cardiovascular imaging Lubbers, M., Coenen, A., Kofflard, M., Bruning, T., Kietselaer, B., Galema, T., Kock, M., Niezen, A., Das, M., van Gent, M., van den Bos, E., van Woerkens, L., Musters, P., Kooij, S., Nous, F., Budde, R., Hunink, M., Nieman, K. 2018; 11 (11): 1625–36

    Abstract

    OBJECTIVES: This study sought to assess the effectiveness, efficiency, and safety of a tiered, comprehensive cardiac computed tomography (CT) protocol in comparison with functional testing.BACKGROUND: Although CT angiography accurately rules out coronary artery disease (CAD), incorporation of CT myocardial perfusion imaging as part of a tiered diagnostic approach could improve the clinical value and efficiency of cardiac CT in the diagnostic work-up of patients with angina pectoris.METHODS: Between July 2013 and November 2015, 268 patients (mean age 58 years; 49% female) with stable angina (mean pre-test probability 54%) were prospectively randomized between cardiac CT and standard guideline-directed functional testing (95% exercise electrocardiography). The tiered cardiac CT protocol included a calcium scan, followed by CT angiography if calcium was detected. Patients with≥50% stenosis on CT angiography underwent CT myocardial perfusion imaging.RESULTS: By 6 months, the primary endpoint, the rate of invasive coronary angiograms without a European Society ofCardiology class I indication for revascularization, was lower in the CT group than in the functional testing group (2of130 [1.5%] vs. 10 of 138 [7.2%]; p= 0.035), whereas the proportion of invasive angiograms with a revascularization indication was higher (88% vs. 50%; p= 0.017). The median duration until the final diagnosis was 0 (0 of 0) days in the CTgroup and 0 (0 of 17) in the functional testing group (p< 0.001). Overall, 13% of patients randomized to CT required further testing, compared with 37% in the functional testing group (p< 0.001). The adverse event rate was similar (3%vs. 3%; p= 1.000), although the median cumulative radiation dose was higher for the CT group (3.1 mSv [interquartilerange: 1.6 to 7.8] vs. 0 mSv [interquartile range: 0.0 to 7.1]; p< 0.001).CONCLUSIONS: In patients with suspected stable CAD, a tiered cardiac CT protocol with dynamic perfusion imaging offers a fast and efficient alternative to functional testing. (Comprehensive Cardiac CT Versus Exercise Testing in SuspectedCoronary Artery Disease 2 [CRESCENT2]; NCT02291484).

    View details for PubMedID 29248657

  • Cardiac Computed Tomography 2.0: Adding Physiology to Anatomy. JACC. Cardiovascular imaging Nieman, K., Shaw, L. J., Chandrashekhar, Y. 2018; 11 (11): 1733–35

    View details for PubMedID 30409333

  • Highlights of the thirteenth annual scientific meeting of the Society of Cardiovascular Computed Tomography. Journal of cardiovascular computed tomography Weir-McCall, J. R., Madan, N., Villines, T. C., Shaw, L. J., Abbara, S., Ferencik, M., Nieman, K., Blankstein, R., Ghoshhajra, B. B., Choi, A. D., Nicol, E. 2018

    Abstract

    The 13th Annual Scientific Meeting of the SCCT, held from July 13 to July 15 in Dallas, TX, was attended by 690 attendees from 39 countries, 55 sessions with 140 speakers, and 18 exhibitors with the abstracts of all scientific posters published in the Journal of the Cardiovascular Computed Tomography. This article summarizes the many themes and topics of presentation and discussion in this meeting, and the many technical advances that are likely to impact future clinical practice in cardiac computed tomography and feature in future meetings.

    View details for PubMedID 30292790

  • Computed tomography myocardial perfusion imaging vs. computed tomography-derived fractional flow reserve, which way forward? European heart journal cardiovascular Imaging Nieman, K. 2018

    View details for PubMedID 30239647

  • Evaluation of atrial septal defects with 4D flow MRI-multilevel and inter-reader reproducibility for quantification of shunt severity. Magma (New York, N.Y.) Chelu, R. G., Horowitz, M., Sucha, D., Kardys, I., Ingremeau, D., Vasanawala, S., Nieman, K., Paul, J., Hsiao, A. 2018

    Abstract

    PURPOSE: With the hypothesis that 4D flow can be used in evaluation of cardiac shunts, we seek to evaluate the multilevel and interreader reproducibility of measurements of the blood flow, shunt fraction and shunt volume in patients with atrial septum defect (ASD) in practice at multiple clinical sites.MATERIALS AND METHODS: Four-dimensional flow MRI examinations were performed at four institutions across Europe and the US. Twenty-nine patients (mean age, 43years; 11 male) were included in the study. Flow measurements were performed at three levels (valve, main artery and periphery) in both the pulmonary and systemic circulation by two independent readers and compared against stroke volumes from 4D flow anatomic data. Further, the shunt ratio (Qp/Qs) was calculated. Additionally, shunt volume was quantified at the atrial level by tracking the atrial septum.RESULTS: Measurements of the pulmonary blood flow at multiple levels correlate well whether measuring at the valve, main pulmonary artery or branch pulmonary arteries (r=0.885-0.886). Measurements of the systemic blood flow show excellent correlation, whether measuring at the valve, ascending aorta or sum of flow from the superior vena cava (SVC) and descending aorta (r=0.974-0.991). Intraclass agreement between the two observers for the flow measurements varies between 0.96 and 0.99. Compared with stroke volume, pulmonic flow is underestimated with 0.26l/min at the main pulmonary artery level, and systemic flow is overestimated with 0.16l/min at the ascending aorta level. Direct measurements of ASD flow are feasible in 20 of 29 (69%) patients.CONCLUSION: Blood flow and shunt quantification measured at multiple levels and performed by different readers are reproducible and consistent with 4D flow MRI.

    View details for DOI 10.1007/s10334-018-0702-z

    View details for PubMedID 30171383

  • Intermodality variation of aortic dimensions: How, where and when to measure the ascending aorta. International journal of cardiology Bons, L. R., Duijnhouwer, A. L., Boccalini, S., van den Hoven, A. T., van der Vlugt, M. J., Chelu, R. G., McGhie, J. S., Kardys, I., van den Bosch, A. E., Siebelink, H. J., Nieman, K., Hirsch, A., Broberg, C. S., Budde, R. P., Roos-Hesselink, J. W. 2018

    Abstract

    BACKGROUND: No established reference-standard technique is available for ascending aortic diameter measurements. The aim of this study was to determine agreement between modalities and techniques.METHODS: In patients with aortic pathology transthoracic echocardiography, computed tomography angiography (CTA) and magnetic resonance angiography (MRA) were performed. Aortic diameters were measured at the sinus of Valsalva (SoV), sinotubular junction (STJ) and tubular ascending aorta (TAA) during mid-systole and end-diastole. In echocardiography both the inner edge-to-inner edge (I-I edge) and leading edge-to‑leading edge (L-L edge) methods were applied, and the length of the aortic annulus to the most cranial visible part of the ascending aorta was measured. In CTA and MRA the I-I method was used.RESULTS: Fifty patients with bicuspid aortic valve (36 ± 13 years, 26% female) and 50 Turner patients (35 ± 13 years) were included. Comparison of all aortic measurements showed a mean difference of 5.4 ± 2.7 mm for the SoV, 5.1 ± 2.0 mm for the STJ and 4.8 ± 2.1 mm for the TAA. The maximum difference was 18 mm. The best agreement was found between echocardiography L-L edge and CTA during mid-systole. CTA and MRA showed good agreement. A mean difference of 1.5 ± 1.3 mm and 1.8 ± 1.5 mm was demonstrated at the level of the STJ and TAA comparing mid-systolic with end-diastolic diameters. The visible length of the aorta increased on average 5.3 ± 5.1 mmW during mid-systole.CONCLUSIONS: MRA and CTA showed best agreement with L-L edge method by echocardiography. In individual patients large differences in ascending aortic diameter were demonstrated, warranting measurement standardization. The use of CTA or MRA is advised at least once.

    View details for PubMedID 30213599

  • Clinical applications of machine learning in cardiovascular disease and its relevance to cardiac imaging. European heart journal Al'Aref, S. J., Anchouche, K., Singh, G., Slomka, P. J., Kolli, K. K., Kumar, A., Pandey, M., Maliakal, G., van Rosendael, A. R., Beecy, A. N., Berman, D. S., Leipsic, J., Nieman, K., Andreini, D., Pontone, G., Schoepf, U. J., Shaw, L. J., Chang, H., Narula, J., Bax, J. J., Guan, Y., Min, J. K. 2018

    Abstract

    Artificial intelligence (AI) has transformed key aspects of human life. Machine learning (ML), which is a subset of AI wherein machines autonomously acquire information by extracting patterns from large databases, has been increasingly used within the medical community, and specifically within the domain of cardiovascular diseases. In this review, we present a brief overview of ML methodologies that are used for the construction of inferential and predictive data-driven models. We highlight several domains of ML application such as echocardiography, electrocardiography, and recently developed non-invasive imaging modalities such as coronary artery calcium scoring and coronary computed tomography angiography. We conclude by reviewing the limitations associated with contemporary application of ML algorithms within the cardiovascular disease field.

    View details for PubMedID 30060039

  • Diagnostic Accuracy of a Machine-Learning Approach to Coronary Computed Tomographic Angiography-Based Fractional Flow Reserve Result From the MACHINE Consortium CIRCULATION-CARDIOVASCULAR IMAGING Coenen, A., Kim, Y., Kruk, M., Tesche, C., De Geer, J., Kurata, A., Lubbers, M. L., Daemen, J., Itu, L., Rapaka, S., Sharma, P., Schwemmer, C., Persson, A., Schoepf, U., Kepka, C., Yang, D., Nieman, K. 2018; 11 (6): e007217

    Abstract

    Coronary computed tomographic angiography (CTA) is a reliable modality to detect coronary artery disease. However, CTA generally overestimates stenosis severity compared with invasive angiography, and angiographic stenosis does not necessarily imply hemodynamic relevance when fractional flow reserve (FFR) is used as reference. CTA-based FFR (CT-FFR), using computational fluid dynamics (CFD), improves the correlation with invasive FFR results but is computationally demanding. More recently, a new machine-learning (ML) CT-FFR algorithm has been developed based on a deep learning model, which can be performed on a regular workstation. In this large multicenter cohort, the diagnostic performance ML-based CT-FFR was compared with CTA and CFD-based CT-FFR for detection of functionally obstructive coronary artery disease.At 5 centers in Europe, Asia, and the United States, 351 patients, including 525 vessels with invasive FFR comparison, were included. ML-based and CFD-based CT-FFR were performed on the CTA data, and diagnostic performance was evaluated using invasive FFR as reference. Correlation between ML-based and CFD-based CT-FFR was excellent (R=0.997). ML-based (area under curve, 0.84) and CFD-based CT-FFR (0.84) outperformed visual CTA (0.69; P<0.0001). On a per-vessel basis, diagnostic accuracy improved from 58% (95% confidence interval, 54%-63%) by CTA to 78% (75%-82%) by ML-based CT-FFR. The per-patient accuracy improved from 71% (66%-76%) by CTA to 85% (81%-89%) by adding ML-based CT-FFR as 62 of 85 (73%) false-positive CTA results could be correctly reclassified by adding ML-based CT-FFR.On-site CT-FFR based on ML improves the performance of CTA by correctly reclassifying hemodynamically nonsignificant stenosis and performs equally well as CFD-based CT-FFR.

    View details for PubMedID 29914866

  • Round-the-clock performance of coronary CT angiography for suspected acute coronary syndrome: Results from the BEACON trial EUROPEAN RADIOLOGY Lubbers, M. M., Dedic, A., Kurata, A., Dijkshoorn, M., Schaap, J., Lammers, J., Lamfers, E. J., Rensing, B. J., Braam, R. L., Nathoe, H. M., Post, J. C., Rood, P. P., Schultz, C. J., Moelker, A., Ouhlous, M., van Dalen, B. M., Boersma, E., Nieman, K. 2018; 28 (5): 2169–75

    Abstract

    To assess the image quality of coronary CT angiography (CCTA) for suspected acute coronary syndrome (ACS) outside office hours.Patients with symptoms suggestive of an ACS underwent CCTA at the emergency department 24 hours, 7 days a week. A total of 118 patients, of whom 89 (75 %) presented during office hours (weekdays between 07:00 and 17:00) and 29 (25 %) outside office hours (weekdays between 17:00 and 07:00, weekends and holidays) underwent CCTA. Image quality was evaluated per coronary segment by two experienced readers and graded on an ordinal scale ranging from 1 to 3.There were no significant differences in acquisition parameters, beta-blocker administration or heart rate between patients presenting during office hours and outside office hours. The median quality score per patient was 30.5 [interquartile range 26.0-33.5] for patients presenting during office hours in comparison to 27.5 [19.75-32.0] for patients presenting outside office hours (p=0.043). The number of non-evaluable segments was lower for patients presenting during office hours (0 [0-1.0] vs. 1.0 [0-4.0], p=0.009).Image quality of CCTA outside office hours in the diagnosis of suspected ACS is diminished.• Quality scores were higher for coronary-CTA during office hours. • There were no differences in acquisition parameters. • There was a non-significant trend towards higher heart rates outside office hours. • Coronary-CTA on the ED requires state-of-the-art scanner technology and sufficiently trained staff. • Coronary-CTA on the ED needs preparation time and optimisation of the procedure.

    View details for PubMedID 29247351

    View details for PubMedCentralID PMC5882623

  • Strategies for radiation dose reduction in nuclear cardiology and cardiac computed tomography imaging: a report from the European Association of Cardiovascular Imaging (EACVI), the Cardiovascular Committee of European Association of Nuclear Medicine (EANM), and the European Society of Cardiovascular Radiology (ESCR) EUROPEAN HEART JOURNAL Gimelli, A., Achenbach, S., Buechel, R. R., Edvardsen, T., Francone, M., Gaemperli, O., Hacker, M., Hyafil, F., Kaufmann, P. A., Lancellotti, P., Nieman, K., Pontone, G., Pugliese, F., Verberne, H. J., Gutberlet, M., Bax, J. J., Neglia, D. 2018; 39 (4): 286–94

    View details for PubMedID 29059384

  • Iodixanol versus lopromide at Coronary CT Angiography: Lumen Opacification and Effect on Heart Rhythm-the Randomized IsoCOR Trial RADIOLOGY Lubbers, M. M., Kock, M., Niezen, A., Galema, T., Kofflard, M., Bruning, T., Kooij, H. S., van Valen, H., Dijkshoorn, M., Booij, R., Padmos, A., Vogels, A., Budde, R. J., Nieman, K. 2018; 286 (1): 71–80

    Abstract

    Purpose To show that equal coronary lumen opacification can be achieved with iso- and low-osmolar contrast media when it is injected at the same iodine delivery rate with contemporary cardiac computed tomographic (CT) protocols and to investigate the cardiovascular effect of iso-osmolar contrast media and the image quality achieved. Materials and Methods Institutional review board approval and written informed consent were obtained for the Effect of Iso-osmolar Contrast Medium on Coronary Opacification and Heart Rhythm in Coronary CT Angiography, or IsoCOR, trial. Between November 2015 and August 2016, 306 patients (167 [55%] women) at least 18 years old (weight range, 50-125 kg), were prospectively randomized to receive iso-osmolar iodixanol 270 or low-osmolar iopromide 300 contrast media. All coronary segments were assessed for intraluminal opacification and image quality and were compared by using the Student t test. Heart rate, arrhythmia, patient discomfort, and adverse events also were monitored. Results Mean measured coronary attenuation values ± standard deviation were comparable between the iodixanol 270 and iopromide 300 contrast media groups (469 HU ± 167 vs 447 HU ± 166, respectively [P = .241]; 95% confidence interval: -15.1, 60.0), including those from subanalyses. Adjusted for the lower iodine concentration, the mean iodixanol 270 bolus was larger compared with that of iopromide 300 (76.8 mL ± 11.6 vs 69.7 mL ± 10.8, respectively; P < .001). The higher injection rate was associated with higher pressure (777 kPa ± 308 vs 630 kPa ± 252, respectively; P < .001). Although in the iodixanol 270 group patients experienced less heat discomfort (72% vs 86%, respectively; P < .001), no differences in heart rate or rhythm were observed. Conclusion If injected at comparable iodine delivery rates, the iso-osmolar contrast medium iodixanol 270 is not inferior to low-osmolar contrast medium iopromide 300 for assessment of coronary opacification. Iodixanol 270 was associated with less heat discomfort, but did not affect heart rate differently compared with iopromide 300. © RSNA, 2017 Online supplemental material is available for this article.

    View details for DOI 10.1148/radiol.2017162779

    View details for Web of Science ID 000422905200011

    View details for PubMedID 28809582

  • Coronary artery calcium: A technical argument for a new scoring method. Journal of cardiovascular computed tomography Willemink, M. J., van der Werf, N. R., Nieman, K., Greuter, M. J., Koweek, L. M., Fleischmann, D. 2018

    Abstract

    Coronary artery calcium (CAC) is a strong predictor for future cardiovascular events. Traditionally CAC has been quantified using the Agatston score, which was developed in the late 1980s for electron beam tomography (EBT). While EBT has been completely replaced by modern multiple-detector row CT technology, the traditional CAC scoring method by Agatston remains in use, although the literature indicates suboptimal reproducibility and subjects being incorrectly classified. The traditional Agatston scoring method counteracts the technical advances of CT technology, and prevents the use of thinner sections, obtained at lower tube voltage and overall decreased radiation exposure that has become available to other CT applications. Moreover, recent studies have shown that not only the total amount of CAC, but also its density and distribution in the coronary arterial tree may be of prognostic value. Acquisition and reconstruction techniques thus need to be adapted for modern CT technology and optimized for CAC quantification. In this review we describe the technical limitations of the Agatston score followed by our suggestions for developing a new and more robust CAC quantification method.

    View details for PubMedID 30366859

  • Highlights of the Twelfth Annual Scientific Meeting of the Society of Cardiovascular Computed Tomography JOURNAL OF CARDIOVASCULAR COMPUTED TOMOGRAPHY Weir-McCall, J. R., Villines, T. C., Shaw, L. J., Abbara, S., Ferencik, M., Nieman, K., Achenbach, S., Nicol, E. 2018; 12 (1): 3–7

    Abstract

    The 12th Annual Scientific Meeting of the SCCT, held from July 6 to July 9 in Washington, DC, was one of the largest to date with 724 attendants from 34 countries, 130 invited talks, 4 "Read with the Experts" sessions, 42 oral abstracts presented, 20 rapid fire posters and 164 poster presentations with the abstracts of all of these published in the JCCT. This article summarises the many themes and topics of presentation and discussion in this meeting, and the many technical advances that are likely to impact future clinical practice and feature in future meetings.

    View details for PubMedID 29174217

  • Diagnostic Value of Transluminal Attenuation Gradient for the Presence of Ischemia as Defined by Fractional Flow Reserve and Quantitative Positron Emission Tomography. JACC. Cardiovascular imaging Bom, M. J., Driessen, R. S., Stuijfzand, W. J., Raijmakers, P. G., Van Kuijk, C. C., Lammertsma, A. A., van Rossum, A. C., van Royen, N., Knuuti, J., Maki, M., Nieman, K., Min, J. K., Leipsic, J. A., Danad, I., Knaapen, P. 2017

    Abstract

    OBJECTIVES: The aim of this study was to investigate the incremental diagnostic value of transluminal attenuation gradient (TAG), TAG with corrected contrast opacification (TAG-CCO), and transluminal diameter gradient (TDG) over coronary computed tomography angiography (CTA)-derived diameter stenosis alone for the identification of ischemia as defined by both the invasive reference standard fractional flow reserve (FFR) and the noninvasive reference standard quantitative positron emission tomography (PET).BACKGROUND: In addition to anatomic information obtained by coronary CTA, several functional CT parameters have been proposed to identify hemodynamically significant lesions more accurately, such as TAG, TAG-CCO, and more recently TDG. However, clinical validation studies have reported conflicting results, and a recent study has suggested that TAG may be affected by changes in vessel diameter.METHODS: Patients with suspected coronary artery disease underwent coronary CTA and [15O]H2O PET followed by invasive coronary angiography with FFR of all major coronary arteries. TAG, TAG-CCO, and TDG were assessed, and the incremental diagnostic value of these parameters over coronary CTA-derived diameter stenosis alone for ischemia as defined by PET (hyperemic myocardial blood flow≤2.30 ml/min/g) and FFR (≤0.80) was determined.RESULTS: A total of 557 (91.9%) coronary arteries of 201 patients were included for analysis. TAG, TAG-CCO, and TDG did not discriminate between vessels with or without ischemia as defined by either PET or FFR. Furthermore, these parameters did not have incremental diagnostic accuracy over coronary CTA alone for the presence of ischemia as defined by PET and FFR. There was a significant correlation between TDG and TAG (r= 0.47; p< 0.001) and between TDG and TAG-CCO (r= 0.37; p< 0.001).CONCLUSIONS: TAG, TAG-CCO, and TDG do not provide incremental diagnostic value over coronary CTA alone for the presence of ischemia as defined by [15O]H2O PET and/or FFR. The lack of diagnostic value of contrast enhancement-based flow estimations appears related to coronary luminal dimension variability.

    View details for DOI 10.1016/j.jcmg.2017.10.009

    View details for PubMedID 29248645

  • Is there still a role for cardiac CT in the emergency department in the era of highly-sensitive troponins? Minerva cardioangiologica Dedic, A., Nieman, K., Hoffmann, U., Ferencik, M. 2017; 65 (3): 214-224

    Abstract

    Physicians practicing cardiovascular medicine are every day confronted with patients presenting with symptoms suggestive of an acute coronary syndrome (ACS). Over the years, there have been substantial technical advances, such as the introduction of new non-invasive imaging techniques and the introduction of new highly sensitive cardiac biomarkers. Physicians have adopted these new assets and have become more experienced with them thus improving medical care. Nevertheless, the search for an efficient, yet safe diagnostic work-up for patients presenting with symptoms suggestive of ACS is ongoing. A large proportion of patients will require some form of non-invasive testing and the choice for the diagnostic modality as well as its timing are important steps in this process. Cardiac computed tomography (CT), a non-invasive imaging technique that rapidly provides visualization of the coronary artery tree, is an attractive option, with its unparalleled negative predictive value for obstructive coronary artery disease (CAD). With the introduction of highly-sensitive troponins (hsTn), the role of non-invasive testing, including cardiac CT, has changed. This review will provide an oversight on what is known about cardiac CT in acute chest presentations. Furthermore, we will discuss the changing role of cardiac CT in the era of hsTn and the possibility of their combined use in the work-up of suspected ACS patients. hsTn is currently an established tool for the diagnosis and triage of patients with suspected ACS. The role of cardiac CT has shifted now to a secondary, comprehensive rule-out test in patients with inconclusive biomarker status, providing information on stenosis severity, plaque burden, high-risk features and the presence of other serious conditions that can also give rise to hsTn.

    View details for DOI 10.23736/S0026-4725.16.04291-2

    View details for PubMedID 27886161

  • Calcium Imaging in the Emergency Department: Between a Rock and a Hard Place CIRCULATION-CARDIOVASCULAR IMAGING Nieman, K. 2017; 10 (5)
  • Sex Differences in the Performance of Cardiac Computed Tomography Compared With Functional Testing in Evaluating Stable Chest Pain: Subanalysis of the Multicenter, Randomized CRESCENT Trial (Calcium Imaging and Selective CT Angiography in Comparison to Functional Testing for Suspected Coronary Artery Disease). Circulation. Cardiovascular imaging Lubbers, M., Coenen, A., Bruning, T., Galema, T., Akkerhuis, J., Krenning, B., Musters, P., Ouhlous, M., Liem, A., Niezen, A., Dedic, A., van Domburg, R., Hunink, M., Nieman, K. 2017; 10 (2)

    Abstract

    Cardiac computed tomography (CT) represents an alternative diagnostic strategy for women with suspected coronary artery disease, with potential benefits in terms of effectiveness and cost-efficiency.The CRESCENT trial (Calcium Imaging and Selective CT Angiography in Comparison to Functional Testing for Suspected Coronary Artery Disease) prospectively randomized 350 patients with stable angina (55% women; aged 55±10 years), mostly with an intermediate coronary artery disease probability, between cardiac CT and functional testing. The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. Sex differences were studied as a prespecified subanalysis. Enrolled women presented more frequently with atypical chest pain and had a lower pretest probability of coronary artery disease compared with men. Independently of these differences, cardiac CT led in both sexes to a fast final diagnosis when compared with functional testing, although the effect was larger in women (P interaction=0.01). The reduced need for further testing after CT, compared with functional testing, was most evident in women (P interaction=0.009). However, no sex interaction was observed with respect to changes in angina and quality of life, cumulative diagnostic costs, and applied radiation dose (all P interactions≥0.097).Cardiac CT is more efficient in women than in men in terms of time to reach the final diagnosis and downstream testing. However, overall clinical outcome showed no significant difference between women and men after 1 year.URL: http://www.clinicaltrials.gov. Unique identifier: NCT01393028.

    View details for DOI 10.1161/CIRCIMAGING.116.005295

    View details for PubMedID 28174196

  • Cloud-processed 4D CMR flow imaging for pulmonary flow quantification. European journal of radiology Chelu, R. G., Wanambiro, K. W., Hsiao, A., Swart, L. E., Voogd, T., van den Hoven, A. T., van Kranenburg, M., Coenen, A., Boccalini, S., Wielopolski, P. A., Vogel, M. W., Krestin, G. P., Vasanawala, S. S., Budde, R. P., Roos-Hesselink, J. W., Nieman, K. 2016; 85 (10): 1849-1856

    Abstract

    In this study, we evaluated a cloud-based platform for cardiac magnetic resonance (CMR) four-dimensional (4D) flow imaging, with fully integrated correction for eddy currents, Maxwell phase effects, and gradient field non-linearity, to quantify forward flow, regurgitation, and peak systolic velocity over the pulmonary artery.We prospectively recruited 52 adult patients during one-year period from July 2014. The 4D flow and planar (2D) phase-contrast (PC) were acquired during same scanning session, but 4D flow was scanned after injection of a gadolinium-based contrast agent. Eddy-currents were semi-automatically corrected using the web-based software. Flow over pulmonary valve was measured and the 4D flow values were compared against the 2D PC ones.The mean forward flow was 92 (±30) ml/cycle measured with 4D flow and 86 (±29) ml/cycle measured with 2D PC, with a correlation of 0.82 and a mean difference of -6ml/cycle (-41-29). For the regurgitant fraction the correlation was 0.85 with a mean difference of -0.95% (-17-15). Mean peak systolic velocity measured with 4D flow was 92 (±49) cm/s and 108 (±56) cm/s with 2D PC, having a correlation of 0.93 and a mean difference of 16cm/s (-24-55).4D flow imaging post-processed with an integrated cloud-based application accurately quantifies pulmonary flow. However, it may underestimate the peak systolic velocity.

    View details for DOI 10.1016/j.ejrad.2016.07.018

    View details for PubMedID 27666627

  • Calcium imaging and selective computed tomography angiography in comparison to functional testing for suspected coronary artery disease: the multicentre, randomized CRESCENT trial EUROPEAN HEART JOURNAL Lubbers, M., Dedic, A., Coenen, A., Galema, T., Akkerhuis, J., Bruning, T., Krenning, B., Musters, P., Ouhlous, M., Liem, A., Niezen, A., Hunink, M., de Feijter, P., Nieman, K. 2016; 37 (15): 1232-1243

    Abstract

    To compare the effectiveness and safety of a cardiac computed tomography (CT) algorithm with functional testing in patients with symptoms suggestive of coronary artery disease (CAD).Between April 2011 and July 2013, 350 patients with stable angina, referred to the outpatient clinic of four Dutch hospitals, were prospectively randomized between cardiac CT and functional testing (2 : 1 ratio). The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. By 1 year, fewer patients randomized to cardiac CT reported anginal complaints (P = 0.012). The cumulative radiation dose was slightly higher in the CT group (6.6 ± 8.7 vs. 6.1 ± 9.3 mSv; P < 0.0001). After 1.2 years, event-free survival was 96.7% for patients randomized to CT and 89.8% for patients randomized to functional testing (P = 0.011). After CT, the final diagnosis was established sooner (P < 0.0001), and additional downstream testing was required less frequently (25 vs. 53%, P < 0.0001), resulting in lower cumulative diagnostic costs (€369 vs. €440; P < 0.0001).For patients with suspected stable CAD, a tiered cardiac CT protocol offers an effective and safe alternative to functional testing. Incorporating the calcium scan into the diagnostic workup was safe and lowered diagnostic expenses and radiation exposure.

    View details for DOI 10.1093/eurheartj/ehv700

    View details for Web of Science ID 000373985800015

    View details for PubMedID 26746631

  • 'Prognostic implications of non-culprit plaques in acute coronary syndrome: non-invasive assessment with coronary CT angiography'. European heart journal cardiovascular Imaging Dedic, A., Kurata, A., Lubbers, M., Meijboom, W. B., van Dalen, B. M., Snelder, S., Korbee, R., Moelker, A., Ouhlous, M., Van Domburg, R., de Feijter, P. J., Nieman, K. 2016; 17 (4): 392-?

    View details for DOI 10.1093/ehjci/jew002

    View details for PubMedID 26912666

  • Qualitative grading of aortic regurgitation: a pilot study comparing CMR 4D flow and echocardiography INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING Chelu, R. G., van den Bosch, A. E., van Kranenburg, M., Hsiao, A., van den Hoven, A. T., Ouhlous, M., Budde, R. P., Beniest, K. M., Swart, L. E., Coenen, A., Lubbers, M. M., Wielopolski, P. A., Vasanawala, S. S., Roos-Hesselink, J. W., Nieman, K. 2016; 32 (2): 301-307

    Abstract

    Over the past 10 years there has been intense research in the development of volumetric visualization of intracardiac flow by cardiac magnetic resonance (CMR).This volumetric time resolved technique called CMR 4D flow imaging has several advantages over standard CMR. It offers anatomical, functional and flow information in a single free-breathing, ten-minute acquisition. However, the data obtained is large and its processing requires dedicated software. We evaluated a cloud-based application package that combines volumetric data correction and visualization of CMR 4D flow data, and assessed its accuracy for the detection and grading of aortic valve regurgitation using transthoracic echocardiography as reference. Between June 2014 and January 2015, patients planned for clinical CMR were consecutively approached to undergo the supplementary CMR 4D flow acquisition. Fifty four patients(median age 39 years, 32 males) were included. Detection and grading of the aortic valve regurgitation using CMR4D flow imaging were evaluated against transthoracic echocardiography. The agreement between 4D flow CMR and transthoracic echocardiography for grading of aortic valve regurgitation was good (j = 0.73). To identify relevant,more than mild aortic valve regurgitation, CMR 4D flow imaging had a sensitivity of 100 % and specificity of 98 %. Aortic regurgitation can be well visualized, in a similar manner as transthoracic echocardiography, when using CMR 4D flow imaging.

    View details for DOI 10.1007/s10554-015-0779-7

    View details for Web of Science ID 000369810300011

    View details for PubMedCentralID PMC4737795

  • Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins: Randomized Multicenter Study. Journal of the American College of Cardiology Dedic, A., Lubbers, M. M., Schaap, J., Lammers, J., Lamfers, E. J., Rensing, B. J., Braam, R. L., Nathoe, H. M., Post, J. C., Nielen, T., Beelen, D., le Cocq d'Armandville, M., Rood, P. P., Schultz, C. J., Moelker, A., Ouhlous, M., Boersma, E., Nieman, K. 2016; 67 (1): 16-26

    Abstract

    It is uncertain whether a diagnostic strategy supplemented by early coronary computed tomography angiography (CCTA) is superior to contemporary standard optimal care (SOC) encompassing high-sensitivity troponin assays (hs-troponins) for patients suspected of acute coronary syndrome (ACS) in the emergency department (ED).This study assessed whether a diagnostic strategy supplemented by early CCTA improves clinical effectiveness compared with contemporary SOC.In a prospective, open-label, multicenter, randomized trial, we enrolled patients presenting with symptoms suggestive of an ACS at the ED of 5 community and 2 university hospitals in the Netherlands. Exclusion criteria included the need for urgent cardiac catheterization and history of ACS or coronary revascularization. The primary endpoint was the number of patients identified with significant coronary artery disease requiring revascularization within 30 days.The study population consisted of 500 patients, of whom 236 (47%) were women (mean age 54 ± 10 years). There was no difference in the primary endpoint (22 [9%] patients underwent coronary revascularization within 30 days in the CCTA group and 17 [7%] in the SOC group [p = 0.40]). Discharge from the ED was not more frequent after CCTA (65% vs. 59%, p = 0.16), and length of stay was similar (6.3 h in both groups; p = 0.80). The CCTA group had lower direct medical costs (€337 vs. €511, p < 0.01) and less outpatient testing after the index ED visit (10 [4%] vs. 26 [10%], p < 0.01). There was no difference in incidence of undetected ACS.CCTA, applied early in the work-up of suspected ACS, is safe and associated with less outpatient testing and lower costs. However, in the era of hs-troponins, CCTA does not identify more patients with significant CAD requiring coronary revascularization, shorten hospital stay, or allow for more direct discharge from the ED. (Better Evaluation of Acute Chest Pain with Computed Tomography Angiography [BEACON]; NCT01413282).

    View details for DOI 10.1016/j.jacc.2015.10.045

    View details for PubMedID 26764061

  • Diagnostic value of transmural perfusion ratio derived from dynamic CT-based myocardial perfusion imaging for the detection of haemodynamically relevant coronary artery stenosis. European radiology Coenen, A., Lubbers, M. M., Kurata, A., Kono, A., Dedic, A., Chelu, R. G., Dijkshoorn, M. L., Rossi, A., van Geuns, R. M., Nieman, K. 2016

    Abstract

    To investigate the additional value of transmural perfusion ratio (TPR) in dynamic CT myocardial perfusion imaging for detection of haemodynamically significant coronary artery disease compared with fractional flow reserve (FFR).Subjects with suspected or known coronary artery disease were prospectively included and underwent a CT-MPI examination. From the CT-MPI time-point data absolute myocardial blood flow (MBF) values were temporally resolved using a hybrid deconvolution model. An absolute MBF value was measured in the suspected perfusion defect. TPR was defined as the ratio between the subendocardial and subepicardial MBF. TPR and MBF results were compared with invasive FFR using a threshold of 0.80.Forty-three patients and 94 territories were analysed. The area under the receiver operator curve was larger for MBF (0.78) compared with TPR (0.65, P = 0.026). No significant differences were found in diagnostic classification between MBF and TPR with a territory-based accuracy of 77 % (67-86 %) for MBF compared with 70 % (60-81 %) for TPR. Combined MBF and TPR classification did not improve the diagnostic classification.Dynamic CT-MPI-based transmural perfusion ratio predicts haemodynamically significant coronary artery disease. However, diagnostic performance of dynamic CT-MPI-derived TPR is inferior to quantified MBF and has limited incremental value.• The transmural perfusion ratio from dynamic CT-MPI predicts functional obstructive coronary artery disease • Performance of the transmural perfusion ratio is inferior to quantified myocardial blood flow • The incremental value of the transmural perfusion ratio is limited.

    View details for DOI 10.1007/s00330-016-4567-0

    View details for PubMedID 27704198

  • Qualitative grading of aortic regurgitation: a pilot study comparing CMR 4D flow and echocardiography. The international journal of cardiovascular imaging Chelu, R. G., van den Bosch, A. E., van Kranenburg, M., Hsiao, A., van den Hoven, A. T., Ouhlous, M., Budde, R. P., Beniest, K. M., Swart, L. E., Coenen, A., Lubbers, M. M., Wielopolski, P. A., Vasanawala, S. S., Roos-Hesselink, J. W., Nieman, K. 2016; 32 (2): 301–7

    Abstract

    Over the past 10 years there has been intense research in the development of volumetric visualization of intracardiac flow by cardiac magnetic resonance (CMR).This volumetric time resolved technique called CMR 4D flow imaging has several advantages over standard CMR. It offers anatomical, functional and flow information in a single free-breathing, ten-minute acquisition. However, the data obtained is large and its processing requires dedicated software. We evaluated a cloud-based application package that combines volumetric data correction and visualization of CMR 4D flow data, and assessed its accuracy for the detection and grading of aortic valve regurgitation using transthoracic echocardiography as reference. Between June 2014 and January 2015, patients planned for clinical CMR were consecutively approached to undergo the supplementary CMR 4D flow acquisition. Fifty four patients(median age 39 years, 32 males) were included. Detection and grading of the aortic valve regurgitation using CMR4D flow imaging were evaluated against transthoracic echocardiography. The agreement between 4D flow CMR and transthoracic echocardiography for grading of aortic valve regurgitation was good (j = 0.73). To identify relevant,more than mild aortic valve regurgitation, CMR 4D flow imaging had a sensitivity of 100 % and specificity of 98 %. Aortic regurgitation can be well visualized, in a similar manner as transthoracic echocardiography, when using CMR 4D flow imaging.

    View details for PubMedID 26498478

  • Coronary angiography after cardiac arrest: Rationale and design of the COACT trial. American heart journal Lemkes, J. S., Janssens, G. N., Straaten, H. M., Elbers, P. W., van der Hoeven, N. W., Tijssen, J. G., Otterspoor, L. C., Voskuil, M., van der Heijden, J. J., Meuwissen, M., Rijpstra, T. A., Vlachojannis, G. J., van der Vleugel, R. M., Nieman, K., Jewbali, L. S., Bleeker, G. B., Baak, R., Beishuizen, B., Stoel, M. G., van der Harst, P., Camaro, C., Henriques, J. P., Vink, M. A., Gosselink, M. T., Bosker, H. A., Crijns, H. J., van Royen, N. 2016; 180: 39–45

    Abstract

    Ischemic heart disease is a major cause of out-of-hospital cardiac arrest. The role of immediate coronary angiography (CAG) and percutaneous coronary intervention (PCI) after restoration of spontaneous circulation following cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) remains debated.We hypothesize that immediate CAG and PCI, if indicated, will improve 90-day survival in post-cardiac arrest patients without signs of STEMI.In a prospective, multicenter, randomized controlled clinical trial, 552 post-cardiac arrest patients with restoration of spontaneous circulation and without signs of STEMI will be randomized in a 1:1 fashion to immediate CAG and PCI (within 2 hours) versus initial deferral with CAG and PCI after neurological recovery. The primary end point of the study is 90-day survival. The secondary end points will include 90-day survival with good cerebral performance or minor/moderate disability, myocardial injury, duration of inotropic support, occurrence of acute kidney injury, need for renal replacement therapy, time to targeted temperature control, neurological status at intensive care unit discharge, markers of shock, recurrence of ventricular tachycardia, duration of mechanical ventilation, and reasons for discontinuation of treatment.The COACT trial is a multicenter, randomized, controlled clinical study that will evaluate the effect of an immediate invasive coronary strategy in post-cardiac arrest patients without STEMI on 90-day survival.

    View details for DOI 10.1016/j.ahj.2016.06.025

    View details for PubMedID 27659881

  • Cardiac computed tomography in patients with acute chest pain EUROPEAN HEART JOURNAL Nieman, K., Hoffmann, U. 2015; 36 (15): 906-914

    Abstract

    The efficient and reliable evaluation of patients with acute chest pain is one of the most challenging tasks in the emergency department. Coronary computed tomography (CT) angiography may play a major role, since it permits ruling out coronary artery disease with high accuracy if performed with expertise in properly selected and prepared patients. Several randomized trials have established early cardiac CT as a viable safe and potentially more efficient alternative to functional testing in the evaluation of acute chest pain. Ongoing investigations explore whether advanced anatomic and functional assessments such as high-risk coronary plaque, resting myocardial perfusion, and left ventricular function, or the simulation of the fractional coronary flow reserve will add information to the anatomic assessment for stenosis, which would allow expanding the benefits of cardiac CT from triage to treatment decisions. Especially, the combination of high-sensitive troponins and coronary computed tomography angiography may play a valuable role in future strategies for the management of patients presenting with acute chest pain.

    View details for DOI 10.1093/eurheartj/ehv034

    View details for Web of Science ID 000353541800010

    View details for PubMedID 25687351

  • The Optimal Imaging Strategy for Patients With Stable Chest Pain A Cost-Effectiveness Analysis ANNALS OF INTERNAL MEDICINE Genders, T. S., Petersen, S. E., Pugliese, F., Dastidar, A. G., Fleischmann, K. E., Nieman, K., Hunink, M. G. 2015; 162 (7): 474-U145

    Abstract

    The optimal imaging strategy for patients with stable chest pain is uncertain.To determine the cost-effectiveness of different imaging strategies for patients with stable chest pain.Microsimulation state-transition model.Published literature.60-year-old patients with a low to intermediate probability of coronary artery disease (CAD).Lifetime.The United States, the United Kingdom, and the Netherlands.Coronary computed tomography (CT) angiography, cardiac stress magnetic resonance imaging, stress single-photon emission CT, and stress echocardiography.Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios.The strategy that maximized QALYs and was cost-effective in the United States and the Netherlands began with coronary CT angiography, continued with cardiac stress imaging if angiography found at least 50% stenosis in at least 1 coronary artery, and ended with catheter-based coronary angiography if stress imaging induced ischemia of any severity. For U.K. men, the preferred strategy was optimal medical therapy without catheter-based coronary angiography if coronary CT angiography found only moderate CAD or stress imaging induced only mild ischemia. In these strategies, stress echocardiography was consistently more effective and less expensive than other stress imaging tests. For U.K. women, the optimal strategy was stress echocardiography followed by catheter-based coronary angiography if echocardiography induced mild or moderate ischemia.Results were sensitive to changes in the probability of CAD and assumptions about false-positive results.All cardiac stress imaging tests were assumed to be available. Exercise electrocardiography was included only in a sensitivity analysis. Differences in QALYs among strategies were small.Coronary CT angiography is a cost-effective triage test for 60-year-old patients who have nonacute chest pain and a low to intermediate probability of CAD.Erasmus University Medical Center.

    View details for DOI 10.7326/M14-0027

    View details for Web of Science ID 000353283400002

    View details for PubMedID 25844996

  • Cardiac computed tomography core syllabus of the European Association of Cardiovascular Imaging (EACVI) EUROPEAN HEART JOURNAL-CARDIOVASCULAR IMAGING Nieman, K., Achenbach, S., Pugliese, F., Cosyns, B., Lancellotti, P., Kitsiou, A. 2015; 16 (4): 351-352

    Abstract

    The European Association of Cardiovascular Imaging (EACVI) Core Syllabus for Cardiac Computed Tomography (CT) is now available online. The syllabus lists key elements of knowledge in Cardiac CT. It represents a framework for the development of training curricula and provides expected knowledge-based learning outcomes to the Cardiac CT trainees.

    View details for DOI 10.1093/ehjci/jeu298

    View details for Web of Science ID 000354716900002

    View details for PubMedID 25680383

  • Fractional Flow Reserve Computed from Noninvasive CT Angiography Data: Diagnostic Performance of an On-Site Clinician-operated Computational Fluid Dynamics Algorithm RADIOLOGY Coenen, A., Lubbers, M. M., Kurata, A., Kono, A., Dedic, A., Chelu, R. G., Dijkshoorn, M. L., Gijsen, F. J., Ouhlous, M., van Geuns, R. M., Nieman, K. 2015; 274 (3): 674-683

    Abstract

    To validate an on-site algorithm for computation of fractional flow reserve (FFR) from coronary computed tomographic (CT) angiography data against invasively measured FFR and to test its diagnostic performance as compared with that of coronary CT angiography.The institutional review board provided a waiver for this retrospective study. From coronary CT angiography data in 106 patients, FFR was computed at a local workstation by using a computational fluid dynamics algorithm. Invasive FFR measurement was performed in 189 vessels (80 of which had an FFR ≤ 0.80); these measurements were regarded as the reference standard. The diagnostic characteristics of coronary CT angiography-derived computational FFR, coronary CT angiography, and quantitative coronary angiography were evaluated against those of invasively measured FFR by using C statistics. Sensitivity and specificity were compared by using a two-sided McNemar test.For computational FFR, sensitivity was 87.5% (95% confidence interval [CI]: 78.2%, 93.8%), specificity was 65.1% (95% CI: 55.4%, 74.0%), and accuracy was 74.6% (95% CI: 68.4%, 80.8%), as compared with the finding of lumen stenosis of 50% or greater at coronary CT angiography, for which sensitivity was 81.3% (95% CI: 71.0%, 89.1%), specificity was 37.6% (95% CI: 28.5%, 47.4%), and accuracy was 56.1% (95% CI: 49.0%, 63.2%). C statistics revealed a larger area under the receiver operating characteristic curve (AUC) for computational FFR (AUC, 0.83) than for coronary CT angiography (AUC, 0.64). For vessels with intermediate (25%-69%) stenosis, the sensitivity of computational FFR was 87.3% (95% CI: 76.5%, 94.3%) and the specificity was 59.3% (95% CI: 47.8%, 70.1%).With use of a reduced-order algorithm, computation of the FFR from coronary CT angiography data can be performed locally, at a regular workstation. The diagnostic accuracy of coronary CT angiography-derived computational FFR for the detection of functionally important coronary artery disease (CAD) was good and was incremental to that of coronary CT angiography within a population with a high prevalence of CAD.

    View details for DOI 10.1148/radiol.14140992

    View details for Web of Science ID 000349990500006

    View details for PubMedID 25322342

  • Multislice computed tomography angiography for noninvasive assessment of the 18-month performance of a novel radiolucent bioresorbable vascular scaffolding device: the ABSORB trial (a clinical evaluation of the bioabsorbable everolimus eluting coronary stent system in the treatment of patients with de novo native coronary artery lesions). Journal of the American College of Cardiology Nieman, K., Serruys, P. W., Onuma, Y., van Geuns, R., Garcia-Garcia, H. M., De Bruyne, B., Thuesen, L., Smits, P. C., Koolen, J. J., McClean, D., Chevalier, B., Meredith, I., Ormiston, J. 2013; 62 (19): 1813-1814

    View details for DOI 10.1016/j.jacc.2013.07.030

    View details for PubMedID 23933536

  • Expert Consensus for Multi-Modality Imaging Evaluation of Cardiovascular Complications of Radiotherapy in Adults: A Report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography JOURNAL OF THE AMERICAN SOCIETY OF ECHOCARDIOGRAPHY Lancellotti, P., Nkomo, V. T., Badano, L. P., Bergler, J., Bogaert, J., Davin, L., Cosyns, B., Coucke, P., Dulgheru, R., Edvardsen, T., Gaemperli, O., Galderisi, M., Griffin, B., Heidenreich, P. A., Nieman, K., Plana, J. C., Port, S. C., Scherrer-Crosbie, M., Schwartz, R. G., Sebag, I. A., Voigt, J., Wann, S., Yang, P. C. 2013; 26 (9): 1013-1032

    Abstract

    Cardiac toxicity is one of the most concerning side effects of anti-cancer therapy. The gain in life expectancy obtained with anti-cancer therapy can be compromised by increased morbidity and mortality associated with its cardiac complications. While radiosensitivity of the heart was initially recognized only in the early 1970s, the heart is regarded in the current era as one of the most critical dose-limiting organs in radiotherapy. Several clinical studies have identified adverse clinical consequences of radiation-induced heart disease (RIHD) on the outcome of long-term cancer survivors. A comprehensive review of potential cardiac complications related to radiotherapy is warranted. An evidence-based review of several imaging approaches used to detect, evaluate, and monitor RIHD is discussed. Recommendations for the early identification and monitoring of cardiovascular complications of radiotherapy by cardiac imaging are also proposed.

    View details for DOI 10.1016/j.echo.2013.07.005

    View details for Web of Science ID 000324028300003

    View details for PubMedID 23998694

  • Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography EUROPEAN HEART JOURNAL-CARDIOVASCULAR IMAGING Lancellotti, P., Nkomo, V. T., Badano, L. P., Bergler, J., Bogaert, J., Davin, L., Cosyns, B., Coucke, P., Dulgheru, R., Edvardsen, T., Gaemperli, O., Galderisi, M., Griffin, B., Heidenreich, P. A., Nieman, K., Plana, J. C., Port, S. C., Scherrer-Crosbie, M., Schwartz, R. G., Sebag, I. A., Voigt, J., Wann, S., Yang, P. C. 2013; 14 (8): 721-740

    Abstract

    Cardiac toxicity is one of the most concerning side effects of anti-cancer therapy. The gain in life expectancy obtained with anti-cancer therapy can be compromised by increased morbidity and mortality associated with its cardiac complications. While radiosensitivity of the heart was initially recognized only in the early 1970s, the heart is regarded in the current era as one of the most critical dose-limiting organs in radiotherapy. Several clinical studies have identified adverse clinical consequences of radiation-induced heart disease (RIHD) on the outcome of long-term cancer survivors. A comprehensive review of potential cardiac complications related to radiotherapy is warranted. An evidence-based review of several imaging approaches used to detect, evaluate, and monitor RIHD is discussed. Recommendations for the early identification and monitoring of cardiovascular complications of radiotherapy by cardiac imaging are also proposed.

    View details for DOI 10.1093/ehjci/jet123

    View details for Web of Science ID 000321833100001

    View details for PubMedID 23847385

  • Comparison of postprocessing techniques for the detection of perfusion defects by cardiac computed tomography in patients presenting with acute ST-segment elevation myocardial infarction JOURNAL OF CARDIOVASCULAR COMPUTED TOMOGRAPHY Rogers, I. S., Cury, R. C., Blankstein, R., Shapiro, M. D., Nieman, K., Hoffmann, U., Brady, T. J., Abbara, S. 2010; 4 (4): 258-266

    Abstract

    Despite rapid advances in cardiac computed tomography (CT), a strategy for optimal visualization of perfusion abnormalities on CT has yet to be validated.We evaluated the performance of several postprocessing techniques of source data sets to detect and characterize perfusion defects in acute myocardial infarctions with cardiac CT.Twenty-one subjects (18 men; 60 +/- 13 years) that were successfully treated with percutaneous coronary intervention for ST-segment myocardial infarction underwent 64-slice cardiac CT and 1.5 Tesla cardiac magnetic resonance imaging (MRI) scans after revascularization. Delayed enhancement MR images were analyzed to identify the location of infarcted myocardium. Contiguous short-axis images of the left ventricular myocardium were created from the CT source images with 0.75-mm multiplanar reconstruction (MPR), 5-mm MPR, 5-mm maximal intensity projection (MIP), and 5-mm minimum intensity projection (MinIP) techniques. Segments already confirmed to contain infarction by MRI were then evaluated qualitatively and quantitatively with CT.Overall, 143 myocardial segments were analyzed. On qualitative analysis, the MinIP and thick MPR techniques had greater visibility and definition than the thin MPR and MIP techniques (P < 0.001). On quantitative analysis, the absolute difference in Hounsfield unit attenuation between normal and infarcted segments was significantly greater for the MinIP (65.4 Hounsfield unit [HU]) and thin MPR (61.2 HU) techniques. However, the relative difference in Hounsfield unit attenuation was significantly greatest for the MinIP technique alone (95%; P < 0.001). Contrast to noise was greatest for the MinIP (4.2) and thick MPR (4.1) techniques (P < 0.001).The results of our current investigation found that MinIP and thick MPR detected infarcted myocardium with greater visibility and definition than MIP and thin MPR.

    View details for DOI 10.1016/j.jcct.2010.04.003

    View details for Web of Science ID 000208521500005

    View details for PubMedCentralID PMC2898897

  • A bioabsorbable everolimus-eluting coronary stent system (ABSORB): 2-year outcomes and results from multiple imaging methods LANCET Serruys, P. W., Ormiston, J. A., Onuma, Y., Regar, E., Gonzalo, N., Garcia-Garcia, H. M., Nieman, K., Bruining, N., Dorange, C., Miquel-Hebert, K., Veldhof, S., Webster, M., Thuesen, L., Dudek, D. 2009; 373 (9667): 897-910

    Abstract

    Drug-eluting metallic coronary stents predispose to late stent thrombosis, prevent late lumen vessel enlargement, hinder surgical revascularisation, and impair imaging with multislice CT. We assessed the safety of the bioabsorbable everolimus-eluting stent (BVS).30 patients with a single de-novo coronary artery lesion were followed up for 2 years clinically and with multiple imaging methods: multislice CT, angiography, intravascular ultrasound, derived morphology parameters (virtual histology, palpography, and echogenicity), and optical coherence tomography (OCT).Clinical data were obtained from 29 of 30 patients. At 2 years, the device was safe with no cardiac deaths, ischaemia-driven target lesion revascularisations, or stent thromboses recorded, and only one myocardial infarction (non-Q wave). 18-month multislice CT (assessed in 25 patients) showed a mean diameter stenosis of 19% (SD 9). At 2-year angiography, the in-stent late loss of 0.48 mm (SD 0.28) and the diameter stenosis of 27% (11) did not differ from the findings at 6 months. The luminal area enlargement on OCT and intravascular ultrasound between 6 months and 2 years was due to a decrease in plaque size without change in vessel size. At 2 years, 34.5% of strut locations presented no discernible features by OCT, confirming decreases in echogenicity and in radiofrequency backscattering; the remaining apparent struts were fully apposed. Additionally, vasomotion occurred at the stented site and adjacent coronary artery in response to vasoactive agents.At 2 years after implantation the stent was bioabsorbed, had vasomotion restored and restenosis prevented, and was clinically safe, suggesting freedom from late thrombosis. Late luminal enlargement due to plaque reduction without vessel remodelling needs confirmation.

    View details for Web of Science ID 000264158700031

    View details for PubMedID 19286089

  • Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography CIRCULATION Nieman, K., Cademartiri, F., Lemos, P. A., Raaijmakers, R., Pattynama, P. M., de Feyter, P. J. 2002; 106 (16): 2051-2054

    Abstract

    Multislice spiral computed tomography (MSCT) is a promising technique for noninvasive coronary angiography, although clinical application has remained limited because of frequently incomplete interpretability, caused by motion artifacts and calcifications.In 59 patients (53 male, aged 58+/-12 years) with suspected obstructive coronary artery disease, ECG-gated MSCT angiography was performed with a 16-slice MSCT scanner (0.42-s rotation time, 12x0.75-mm detector collimation). Thirty-four patients were given additional beta-blockers (average heart rate: 56+/-6 min(-1)). After contrast injection, all data were acquired during an approximately 20-s breath hold. The left main (LM), left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA), including > or =2.0-mm side branches, were independently evaluated by two blinded observers and screened for > or =50% stenoses. The consensus reading was compared with quantitative coronary angiography. MSCT was successful in 58 patients. Eighty-six of the 231 evaluated branches were significantly diseased. Without exclusion of branches, the sensitivity, specificity and positive and negative predictive value to identify > or =50% obstructed branches was 95% (82/86), 86% (125/145), 80% (82/102), and 97% (125/129), respectively. The overall accuracy for the LM, LAD, RCA, and LCX was 100%, 91%, 86%, and 81%, respectively. No obstructed LM, LAD, or RCA branches remained undetected. Classification of patients as having no, single, or multivessel disease was accurate in 78% (45/58) of patients and no patients with significant obstructions were incorrectly excluded.Improvements in MSCT technology, combined with heart rate control, allow reliable noninvasive detection of obstructive coronary artery disease.

    View details for DOI 10.1161/01.CIR.0000037222.58317.3D

    View details for Web of Science ID 000178683600007

    View details for PubMedID 12379572

  • Coronary angiography with multi-slice computed tomography LANCET Nieman, K., Oudkerk, M., Rensing, B. J., van Ooijen, P., Munne, A., van Geuns, R. J., de Feyter, P. J. 2001; 357 (9256): 599-603

    Abstract

    A new generation of subsecond multi-slice computed tomography (MSCT) scanners, which allow complete coronary coverage, are becoming widely available. We investigated the potential value of MSCT angiography in a range of coronary disorders.We studied 35 patients, including 11 who had undergone percutaneous transluminal coronary angioplasty and four who had had coronary-artery bypass grafts, by both MSCT and conventional coronary angiography. After intravenous injection of a non-ionic contrast medium with high iodine content, the entire heart was scanned within a single breath-hold. The total examination time was no more than 20 min. The retrospective electrocardiographically gated reconstruction source images and three-dimensional reconstructed volumes were analysed by two investigators, unaware of the results of conventional angiography.In the 31 patients without previous coronary surgery, 173 (73%) of the 237 proximal and middle coronary segments were assessable. In the assessable segments, 17 of 21 significant stenoses (>50% reduction of vessel diameter) were correctly diagnosed. The non-assessable segments included four lesions. Misinterpretations were mainly the result of severe calcification of the vessel wall. Segments with implanted stents were poorly visualised, but stent patency could be assessed in all cases. Of the 17 segments of bypass grafts, 15 were assessable and four of five graft lesions were detected. Two cases of anomalous coronary anatomy could be visualised well.These preliminary data suggest that MSCT allows non-invasive imaging of coronary-artery stenoses and has potential to develop into a reliable clinical technique.

    View details for Web of Science ID 000167119100013

    View details for PubMedID 11558487