Koen Nieman

All Publications

• Cardiac CT fractal analysis of LV noncompaction and common cardiomyopathies. Journal of cardiovascular computed tomography Manohar, A., Wong, A., Castillo, E., Gunderson, A., Mistelbauer, G., Bagherzadeh, S. P., Haddad, F., Caliskan, K., Budde, R. P., Hirsch, A., Lee, S. P., Lee, W., Owens, A., Litt, H., Wheeler, M., Kwon, D. H., Tang, W. H., Nieman, K. 2025

  Abstract

  Left ventricular noncompaction (LVNC), or hypertrabeculation, is a myocardial condition that remains challenging to diagnose and differentiate from other cardiomyopathies. This study evaluated the ability of cardiac CT to differentiate between LVNC, hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), and controls using fractal analysis of LV trabeculae.Subjects with LVNC, HCM, DCM, as well as controls, who underwent coronary CT angiography were included. LV trabecular structure was quantified using fractal analysis on a stack of 15 short-axis CT images. For each subject, maximum (FDmax) and average (FDglobal) fractal dimensions were reported. A subset of subjects also had clinically acquired cardiac MRI (CMR) exams for comparison. One-way ANOVA, Pearson correlation, and Bland-Altman analysis were used for statistical analysis.The study included 313 subjects (median age: 58.8 [48.1-68.0] years, 153 male) categorized into Control (89), LVNC (46), HCM (106), and DCM (72) cohorts. FDmax was significantly higher in LVNC (1.379 ​± ​0.047) than in Control (1.305 ​± ​0.033), HCM (1.321 ​± ​0.040), and DCM (1.344 ​± ​0.054) cohorts; all p ​< ​0.001. Similarly, FDglobal was significantly higher in LVNC (1.279 ​± ​0.041) than in the other cohorts; all p ​< ​0.05. In a subset of 132 subjects with both CT and CMR exams, fractal dimensions from the two modalities were strongly correlated (r ​= ​0.63, p ​< ​0.0001), with CT-derived values being higher (1.337 ​± ​0.049 vs. 1.262 ​± ​0.045, p ​< ​0.0001).CT-derived fractal dimensions of LV trabecular structure were significantly higher in LVNC compared to control subjects, HCM, and DCM. CT-derived fractal dimensions strongly correlated with, but were higher than, those from cardiac MRI in the same subjects.

  View details for DOI 10.1016/j.jcct.2025.08.004

  View details for PubMedID 40846526

• High-intensity statin therapy is associated with reduced coronary inflammation on CT in patients with type 2 diabetes mellitus. Diabetes, obesity & metabolism Wu, B., Nieman, K., Sandoval, R. 2025

  Abstract

  Pericoronary adipose tissue (PCAT) attenuation, assessed by coronary computed tomography angiography (CCTA), is a biomarker of coronary inflammation. Mean PCAT attenuation ≥ -70.5 Hounsfield Units (HU) corresponds to elevated inflammation and a higher future risk of myocardial infarction. While statins are known to possess anti-inflammatory properties, the impact of statin intensity on vascular inflammation remains underexplored in patients with type 2 diabetes mellitus (T2DM) and coronary atherosclerosis. We aim to evaluate whether high-intensity statins are associated with lower PCAT attenuation in this high-risk cohort.We retrospectively analysed 203 CCTAs performed at our institution between 1/1/2019 and 9/1/2024 in patients with T2DM who met these key criteria: evidence of coronary atherosclerosis on CCTA, treatment with ≥1 oral hypoglycaemic agent, and no history of prior coronary interventions. PCAT attenuation was measured in the proximal right coronary artery.Among the three statin intensity groups, patients receiving high-intensity statins (n = 75) had the lowest PCAT attenuation (high-intensity: -75.0 ± 6.8 HU, moderate-intensity: -71.8 ± 8.2 HU, no statin: -71.6 ± 7.4 HU; adjusted p = 0.027). In addition to high-intensity statins, treatment with glucagon-like peptide-1 receptor agonist was independently associated with a lower likelihood of having elevated PCAT attenuation (≥ -70.5 HU), with an odds ratio of 0.344 (95% CI: 0.132-0.900).In patients with T2DM and coronary atherosclerosis, high-intensity statin therapy was associated with lower coronary inflammation. Our findings emphasize the need for aggressive cardiovascular prevention in this high-risk cohort.

  View details for DOI 10.1111/dom.70032

  View details for PubMedID 40826958

• Coronary CT angiography evaluation with artificial intelligence for individualized medical treatment of atherosclerosis: a Consensus Statement from the QCI Study Group. Nature reviews. Cardiology Schulze, K., Stantien, A., Williams, M. C., Vassiliou, V. S., Giannopoulos, A. A., Nieman, K., Maurovich-Horvat, P., Tarkin, J. M., Vliegenthart, R., Weir-McCall, J., Mohamed, M., Follmer, B., Biavati, F., Stahl, A., Knape, J., Balogh, H., Galea, N., Isgum, I., Arbab-Zadeh, A., Alkadhi, H., Manka, R., Wood, D. A., Nicol, E. D., Nurmohamed, N. S., Martens, F. M., Dey, D., Newby, D. E., Dewey, M. 2025

  Abstract

  Coronary CT angiography is widely implemented, with an estimated 2.2 million procedures in patients with stable chest pain every year in Europe alone. In parallel, artificial intelligence and machine learning are poised to transform coronary atherosclerotic plaque evaluation by improving reliability and speed. However, little is known about how to use coronary atherosclerosis imaging biomarkers to individualize recommendations for medical treatment. This Consensus Statement from the Quantitative Cardiovascular Imaging (QCI) Study Group outlines key recommendations derived from a three-step Delphi process that took place after the third international QCI Study Group meeting in September 2024. Experts from various fields of cardiovascular imaging agreed on the use of age-adjusted and gender-adjusted percentile curves, based on coronary plaque data from the DISCHARGE and SCOT-HEART trials. Two key issues were addressed: the need to harness the reliability and precision of artificial intelligenceandmachine learning tools and to tailor treatment on the basis of individualized plaque analysis. The QCI Study Group recommends that the presence of any atherosclerotic plaque should lead to a recommendation of pharmacological treatment, whereas the 70th percentile of total plaque volume warrants high-intensity treatment. The aim of these recommendations is to lay the groundwork for future trials and to unlock the potential of coronary CT angiography to improve patient outcomes globally.

  View details for DOI 10.1038/s41569-025-01191-6

  View details for PubMedID 40751112

• Personalized and uncertainty-aware coronary hemodynamics simulations: From Bayesian estimation to improved multi-fidelity uncertainty quantification. Computer methods and programs in biomedicine Menon, K., Zanoni, A., Khan, M. O., Geraci, G., Nieman, K., Schiavazzi, D. E., Marsden, A. L. 2025; 271: 108951

  Abstract

  Non-invasive simulations of coronary hemodynamics have improved clinical risk stratification and treatment outcomes for coronary artery disease, compared to relying on anatomical imaging alone. However, simulations typically use empirical approaches to distribute total coronary flow amongst the arteries in the coronary tree, which ignores patient variability, the presence of disease, and other clinical factors. Further, uncertainty in the clinical data often remains unaccounted for in the modeling pipeline.We present an end-to-end uncertainty-aware pipeline to (1) personalize coronary flow simulations by incorporating vessel-specific coronary flows as well as cardiac function; and (2) predict clinical and biomechanical quantities of interest with improved precision, while accounting for uncertainty in the clinical data.We assimilate patient-specific measurements of myocardial blood flow from clinical CT myocardial perfusion imaging to estimate branch-specific coronary artery flows. Simulated noise in the clinical data is used to estimate the joint posterior distributions of the model parameters using adaptive Markov Chain Monte Carlo sampling. Additionally, the posterior predictive distribution for the relevant quantities of interest is determined using a new approach combining multi-fidelity Monte Carlo estimation with non-linear, data-driven dimensionality reduction. This leads to improved correlations between high- and low-fidelity model outputs.Our framework accurately recapitulates clinically measured cardiac function as well as branch-specific coronary flows under measurement noise uncertainty. We observe substantial reductions in confidence intervals for estimated quantities of interest compared to single-fidelity Monte Carlo estimation and state-of-the-art multi-fidelity Monte Carlo methods. This holds especially true for quantities of interest that showed limited correlation between the low- and high-fidelity model predictions. In addition, the proposed multi-fidelity Monte Carlo estimators are significantly cheaper to compute than traditional estimators, under a specified confidence level or variance.The proposed pipeline for personalized and uncertainty-aware predictions of coronary hemodynamics is based on routine clinical measurements and recently developed techniques for CT myocardial perfusion imaging. The proposed pipeline offers significant improvements in precision and reduction in computational cost.

  View details for DOI 10.1016/j.cmpb.2025.108951

  View details for PubMedID 40737995

• Artificial intelligence-based accurate myocardial infarction mapping using 12-lead electrocardiography EUROPEAN HEART JOURNAL - DIGITAL HEALTH Wang, H., Gao, Z., Zhang, H., Zhu, Y., Lian, S., Bo, K., Li, S., Gao, Y., Zhuang, B., Zhou, Z., Zhang, X., Wang, C., Nieman, K., Xu, L. 2025

  View details for DOI 10.1093/ehjdh/ztaf077

  View details for Web of Science ID 001530936800001

• Cardiac Computed Tomography for Prosthetic Heart Valve Assessment: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the European Society of Cardiovascular Radiology (ESCR), the North American Society of Cardiovascular Imaging (NASCI), the Radiological Society of North America (RSNA), the Society for Cardiovascular Angiography & Interventions (SCAI) and Society of Thoracic Surgeons (STS). Journal of the American College of Cardiology Budde, R. P., Faure, M. E., Abbara, S., Alkadhi, H., Cremer, P. C., Feuchtner, G. M., Gonzales, H. M., Kiefer, T. L., Leipsic, J., Nieman, K., Revels, J., Wang, D. D., Williamson, E., Wyler von Ballmoos, M. C., Zwischenberger, B. A., Salgado, R. 2025

  Abstract

  Prosthetic heart valve (PHV) dysfunction is increasingly seen due to the increase in the number of PHV that are being implanted worldwide. Cardiac CT imaging has emerged as a valuable tool to assess PHVs and determine the cause of dysfunction. This consensus document first summarizes the available techniques for PHV assessment. Then the use of CT in PHV (dys)function assessment is discussed in detail including consensus statements for correct indications and patient selection for CT assessment of PHVs, image acquisition, reconstruction and measurement protocols and how to interpret and report the CT findings for specific types of PHV dysfunction.

  View details for DOI 10.1016/j.jacc.2025.05.035

  View details for PubMedID 40526054

• Cardiac Computed Tomography for Prosthetic Heart Valve Assessment. An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the European Society of Cardiovascular Radiology (ESCR), the North American Society of Cardiovascular Imaging (NASCI), the Radiological Society of North America (RSNA), the Society for Cardiovascular Angiography & Interventions (SCAI), and Society of Thoracic Surgeons (STS)1,2. Radiology. Cardiothoracic imaging Budde, R. P., Faure, M. E., Abbara, S., Alkadhi, H., Cremer, P. C., Feuchtner, G. M., Gonzales, H. M., Kiefer, T. L., Leipsic, J., Nieman, K., Revels, J., Wang, D. D., Williamson, E., Wyler von Ballmoos, M. C., Zwischenberger, B. A., Salgado, R. 2025; 7 (3): e250231

  Abstract

  Prosthetic heart valve (PHV) dysfunction is increasingly seen due to the increase in the number of PHV that are being implanted worldwide. Cardiac CT imaging has emerged as a valuable tool to assess PHVs and determine the cause of dysfunction. This consensus document first summarizes the available techniques for PHV assessment. Then the use of CT in PHV (dys)function assessment is discussed in detail including consensus statements for correct indications and patient selection for CT assessment of PHVs, image acquisition, reconstruction and measurement protocols and how to interpret and report the CT findings for specific types of PHV dysfunction. This article was published in Journal of Cardiovascular Computed Tomography, Budde RPJ et al, Cardiac computed tomography for prosthetic heart valve assessment: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the European Society of Cardiovascular Radiology (ESCR), the North American Society for Cardiovascular Imaging (NASCI), the Radiological Society of North America (RSNA), the Society for Cardiovascular Angiography & Interventions (SCAI), and the Society of Thoracic Surgeons (STS). The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation may be used when referencing this document. © 2025 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. on behalf of the Society of Cardiovascular Computed Tomography. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Keywords: Computed Tomography, Valve, Cardiac, Imaging, Dysfunction, Prosthetic.

  View details for DOI 10.1148/ryct.250231

  View details for PubMedID 40526484

• Coronary Computed Tomography Angiography to Guide Percutaneous Coronary Intervention: Expert Opinion from a SCAI/SCCT Roundtable. Journal of the Society for Cardiovascular Angiography & Interventions Sandoval, Y., Leipsic, J. A., Collet, C., Ali, Z. A., Azzalini, L., Barbato, E., Cavalcante, J. L., Costa, R. A., Garcia-Garcia, H. M., Jones, D. A., Khoo, J. K., Maran, A., Nieman, K., Pinilla-Echeverri, N., Seto, A. H., Shlofmitz, E., Brilakis, E. S. 2025; 4 (6): 103664

  Abstract

  Coronary computed tomography angiography (CCTA) has emerged as an important tool for planning percutaneous coronary intervention (PCI). While it has traditionally been employed for diagnostic purposes, increasing evidence and real-world experience suggest that CCTA can be used for the preprocedural planning of PCI and can inform patient triage, shared decision making, case complexity, and resource use. This approach mirrors how computed tomography angiography is routinely used to plan structural interventions. To address these emerging opportunities, the Society for Cardiovascular Angiography & Interventions (SCAI) and the Society of Cardiovascular Computed Tomography (SCCT) organized a multidisciplinary, expert scientific roundtable on the use of CCTA for guiding PCI. The goal of this document is to provide a state-of-the-art overview of CCTA-guided PCI focused on practical applications and key coronary lesion subsets, define unmet needs and barriers, and outline future directions.

  View details for DOI 10.1016/j.jscai.2025.103664

  View details for PubMedID 40630246

  View details for PubMedCentralID PMC12230455

• Cardiac computed tomography for prosthetic heart valve assessment. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the European Society of Cardiovascular Radiology (ESCR), the North American Society of Cardiovascular Imaging (NASCI), the Radiological Society of North America (RSNA), the Society for Cardiovascular Angiography & Interventions (SCAI) and Society of Thoracic Surgeons (STS). Journal of cardiovascular computed tomography Budde, R. P., Faure, M. E., Abbara, S., Alkadhi, H., Cremer, P. C., Feuchtner, G. M., Gonzales, H. M., Kiefer, T. L., Leipsic, J., Nieman, K., Revels, J., Wang, D. D., Williamson, E., Wyler von Ballmoos, M. C., Zwischenberger, B. A., Salgado, R. 2025

  Abstract

  Prosthetic heart valve (PHV) dysfunction is increasingly seen due to the increase in the number of PHV that are being implanted worldwide. Cardiac CT imaging has emerged as a valuable tool to assess PHVs and determine the cause of dysfunction. This consensus document first summarizes the available techniques for PHV assessment. Then the use of CT in PHV (dys)function assessment is discussed in detail including consensus statements for correct indications and patient selection for CT assessment of PHVs, image acquisition, reconstruction and measurement protocols and how to interpret and report the CT findings for specific types of PHV dysfunction.

  View details for DOI 10.1016/j.jcct.2025.04.007

  View details for PubMedID 40527640

• Coronary computed tomography angiography to guide percutaneous coronary intervention: Expert opinion from a SCAI/SCCT roundtable. Journal of cardiovascular computed tomography Sandoval, Y., Leipsic, J., Collet, C., Ali, Z. A., Azzalini, L., Barbato, E., Cavalcante, J. L., Costa, R. A., Garcia-Garcia, H. M., Jones, D. A., Khoo, J. K., Maran, A., Nieman, K., Pinilla-Echeverri, N., Seto, A. H., Shlofmitz, E., Brilakis, E. S. 2025

  Abstract

  Coronary computed tomography angiography (CCTA) has emerged as an important tool for planning percutaneous coronary intervention (PCI). While it has traditionally been employed for diagnostic purposes, increasing evidence and real-world experience suggest that CCTA can be used for the pre-procedural planning of PCI and inform patient triage, shared decision-making, case complexity, and resource use. This approach mirrors how computed tomography angiography is routinely used to plan structural interventions. To address these emerging opportunities, the Society for Cardiovascular Angiography & Interventions (SCAI) and the Society of Cardiovascular Computed Tomography (SCCT) organized a multidisciplinary, expert scientific roundtable on the use of CCTA for guiding PCI. The goal of this document is to provide a state-of-the-art overview of CCTA-guided PCI, focused on practical applications and key coronary lesion subsets, define unmet needs and barriers, and outline future directions.

  View details for DOI 10.1016/j.jcct.2025.04.015

  View details for PubMedID 40360362

• Photon-Counting Detector Coronary CT Angiography A Confidence Booster for Bloomy Vessels JACC-CARDIOVASCULAR IMAGING Nieman, K., Chandrashekhar, Y. 2025; 18 (5): 621-623

  View details for DOI 10.1016/j.jcmg.2025.04.004

  View details for Web of Science ID 001487693300001

  View details for PubMedID 40335217

• Prognostic Value of Compact Myocardial Thinning in Patients with Left Ventricular Non-compaction. The American journal of cardiology Gegenava, T., Tukker, M., Caliskan, K., Hirsch, A., Manohar, A., Lee, S. P., Owens, A., Kwon, D. H., Ramchand, J., Wheeler, M. T., Tang, W. H., Nieman, K. 2025

  Abstract

  Clinical presentations of left ventricular non-compaction (LVNC) range from asymptomatic cases to ventricular tachyarrhythmia (VT), heart failure (HF), and cerebrovascular accidents (CVA). In this multicenter study, we explored the associations between clinical and imaging characteristics and outcomes of LVNC patients and validated the predictive value of myocardial thinning identified on cardiac magnetic resonance imaging (CMR) as previously described.214 adult patients (54% male, mean age 41±16 years) meeting the imaging criteria for LVNC were identified. Myocardial thinning was defined as a 50% or greater diameter reduction of the compacted myocardium compared to a contiguous segment on CMR. The primary endpoint was the occurrence of a major adverse cardiovascular event (MACE), defined as a composite of all-cause mortality, HF hospitalization, left ventricular assist device (LVAD) or heart transplant, cardiac resynchronization therapy (CRT), CVA/transient ischemic attacks (TIA), VT and appropriate implantable cardioverter defibrillator (ICD) therapy.Focal myocardial thinning was observed in 42 patients (20%). Over a median follow-up time of 7 years (IQR, 4-10 years), 54 patients (24%) experienced a primary outcome. Patients with myocardial thinning had more cumulative adverse events than those without myocardial thinning (chi-square = 29.516, log-rank < 0.001), even after matching for medical risk score. In a multivariate Cox regression model, myocardial thinning remained associated with outcomes: HR 3.052 (95% CI: 1.569-5.937, p=0.001).Myocardial thinning is associated with adverse cardiovascular events in LVNC patients. Incorporating myocardial thinning into medical risk assessments can improve the prediction and management of adverse outcomes in these patients.

  View details for DOI 10.1016/j.amjcard.2025.04.018

  View details for PubMedID 40274207

• THE PROGNOSTIC VALUE OF COMPACT MYOCARDIAL THINNING IN PATIENTS WITH LEFT VENTRICULAR NON-COMPACTION Gegenava, T., Tukker, M., Caliskan, K., Hirsch, A., Lee, S., Owens, A., Kwon, D., Ramchand, J., Wheeler, M., Tang, W., Nieman, K. ELSEVIER SCIENCE INC. 2025: 1981

  View details for Web of Science ID 001469727000030

• Left atrial volumetric/mechanical coupling index: best of both worlds? Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography Gegenava, T., Nieman, K. 2024

  View details for DOI 10.1016/j.echo.2024.10.016

  View details for PubMedID 39489402

• Coronary atherosclerotic plaque characterization with silicon-based photon-counting computed tomography (CT): A simulation-based feasibility study. Medical physics Li, M., Wu, M., Pack, J., Wu, P., Yan, P., De Man, B., Wang, A., Nieman, K., Wang, G. 2024

  Abstract

  Recent photon-counting computed tomography (PCCT) development brings great opportunities for plaque characterization with much-improved spatial resolution and spectral imaging capability. While existing coronary plaque PCCT imaging results are based on CZT- or CdTe-materials detectors, deep-silicon photon-counting detectors offer unique performance characteristics and promise distinct imaging capabilities.This study aims to numerically investigate the feasibility of characterizing plaques with a deep-silicon PCCT scanner and to demonstrate its potential performance advantages over traditional CT scanners using energy-integrating detectors (EID).We conducted a systematic simulation study of a deep-silicon PCCT scanner using a newly developed digital plaque phantom with clinically relevant geometrical and chemical properties. Through qualitative and quantitative evaluations, this study investigates the effects of spatial resolution, noise, and motion artifacts on plaque imaging.Noise-free simulations indicated that PCCT imaging could delineate the boundary of necrotic cores with a much finer resolution than EID-CT imaging, achieving a structural similarity index metric (SSIM) score of 0.970 and reducing the root mean squared error (RMSE) by two-thirds. Measuring necrotic core area errors were reduced from 91.5% to 24%, and fibrous cap thickness errors were reduced from 349.8% to 33.3%. In the presence of noise, the optimal reconstruction was achieved using 0.25 mm voxels and a soft reconstruction kernel, yielding the highest contrast-to-noise ratio (CNR) of 3.48 for necrotic core detection and the best image quality metrics among all choices. However, the ultrahigh resolution of PCCT increased sensitivity to motion artifacts, which could be mitigated by keeping residual motion amplitude below 0.4 mm.The findings suggest that deep-silicon PCCT scanner can offer sufficient spatial resolution and tissue contrast for effective plaque characterization, potentially improving diagnostic accuracy in cardiovascular imaging, provided image noise and motion blur can be mitigated using advanced algorithms. This simulation study involves several simplifications, which may result in some idealized outcomes that do not directly translate to clinical practice. Further validation studies with physical scans are necessary and will be considered for future work.

  View details for DOI 10.1002/mp.17422

  View details for PubMedID 39321385

• Personalized and uncertainty-aware coronary hemodynamics simulations: From Bayesian estimation to improved multi-fidelity uncertainty quantification. ArXiv Menon, K., Zanoni, A., Khan, O., Geraci, G., Nieman, K., Schiavazzi, D. E., Marsden, A. L. 2024

  Abstract

  Non-invasive simulations of coronary hemodynamics have improved clinical risk stratification and treatment outcomes for coronary artery disease, compared to relying on anatomical imaging alone. However, simulations typically use empirical approaches to distribute total coronary flow amongst the arteries in the coronary tree, which ignores patient variability, the presence of disease, and other clinical factors. Further, uncertainty in the clinical data often remains unaccounted for in the modeling pipeline.We present an end-to-end uncertainty-aware pipeline to (1) personalize coronary flow simulations by incorporating vessel-specific coronary flows as well as cardiac function; and (2) predict clinical and biomechanical quantities of interest with improved precision, while accounting for uncertainty in the clinical data.We assimilate patient-specific measurements of myocardial blood flow from clinical CT myocardial perfusion imaging to estimate branch-specific coronary artery flows. Simulated noise in the clinical data is used to estimate the joint posterior distributions of the model parameters using adaptive Markov Chain Monte Carlo sampling. Additionally, the posterior predictive distribution for the relevant quantities of interest is determined using a new approach combining multi-fidelity Monte Carlo estimation with non-linear, data-driven dimensionality reduction. This leads to improved correlations between high- and low-fidelity model outputs.Our framework accurately recapitulates clinically measured cardiac function as well as branch-specific coronary flows under measurement noise uncertainty. We observe substantial reductions in confidence intervals for estimated quantities of interest compared to single-fidelity Monte Carlo estimation and state-of-the-art multi-fidelity Monte Carlo methods. This holds especially true for quantities of interest that showed limited correlation between the low- and high-fidelity model predictions. In addition, the proposed multi-fidelity Monte Carlo estimators are significantly cheaper to compute than traditional estimators, under a specified confidence level or variance.The proposed pipeline for personalized and uncertainty-aware predictions of coronary hemodynamics is based on routine clinical measurements and recently developed techniques for CT myocardial perfusion imaging. The proposed pipeline offers significant improvements in precision and reduction in computational cost.

  View details for PubMedID 39279834

  View details for PubMedCentralID PMC11398544

• Artificial intelligence and machine learning for cardiovascular computed tomography (CCT): A white paper of the society of cardiovascular computed tomography (SCCT). Journal of cardiovascular computed tomography Williams, M. C., Weir-McCall, J. R., Baldassarre, L. A., De Cecco, C. N., Choi, A. D., Dey, D., Dweck, M. R., Isgum, I., Kolossvary, M., Leipsic, J., Lin, A., Lu, M. T., Motwani, M., Nieman, K., Shaw, L., van Assen, M., Nicol, E. 2024

  View details for DOI 10.1016/j.jcct.2024.08.003

  View details for PubMedID 39214777

• CT Myocardial Perfusion and CT-FFR versus Invasive FFR for Hemodynamic Relevance of Coronary Artery Disease. Radiology Soschynski, M., Storelli, R., Birkemeyer, C., Hagar, M. T., Faby, S., Schwemmer, C., Nous, F. M., Pugliese, F., Vliegenthart, R., Schlett, C. L., Nikolaou, K., Krumm, P., Nieman, K., Bamberg, F., Artzner, C. P. 2024; 312 (2): e233234

  Abstract

  Background CT-derived fractional flow reserve (CT-FFR) and dynamic CT myocardial perfusion imaging enhance the specificity of coronary CT angiography (CCTA) for ruling out coronary artery disease (CAD). However, evidence on comparative diagnostic value remains scarce. Purpose To compare the diagnostic accuracy of CCTA plus CT-FFR, CCTA plus CT perfusion, and sequential CCTA plus CT-FFR and CT perfusion for detecting hemodynamically relevant CAD with that of invasive angiography. Materials and Methods This secondary analysis of a prospective study included patients with chest pain referred for invasive coronary angiography at nine centers from July 2016 to September 2019. CCTA and CT perfusion were performed with third-generation dual-source CT scanners. CT-FFR was assessed on-site. Independent core laboratories analyzed CCTA alone, CCTA plus CT perfusion, CCTA plus CT-FFR, and a sequential approach involving CCTA plus CT-FFR and CT perfusion for the presence of hemodynamically relevant stenosis. Invasive coronary angiography with invasive fractional flow reserve was the reference standard. Diagnostic accuracy metrics and the area under the receiver operating characteristic curve (AUC) were compared with the Sign test and DeLong test. Results Of the 105 participants (mean age, 64 years ± 8 [SD]; 68 male), 49 (47%) had hemodynamically relevant stenoses at invasive coronary angiography. CCTA plus CT-FFR and CCTA plus CT perfusion showed no evidence of a difference for participant-based sensitivities (90% vs 90%, P > .99), specificities (77% vs 79%, P > .99) and vessel-based AUCs (0.84 [95% CI: 0.77, 0.91] vs 0.83 [95% CI: 0.75, 0.91], P = .90). Both had higher participant-based specificity than CCTA alone (54%, both P < .001) without evidence of a difference in sensitivity between CCTA (94%) and CCTA plus CT perfusion (P = .50) or CCTA plus CT-FFR (P = .63). The sequential approach combining CCTA plus CT-FFR with CT perfusion achieved higher participant-based specificity than CCTA plus CT-FFR (88% vs 77%, P = .03) without evidence of a difference in participant-based sensitivity (88% vs 90%, P > .99) and vessel-based AUC (0.85 [95% CI: 0.77, 0.93], P = .78). Compared with CCTA plus CT perfusion, the sequential approach showed no evidence of a difference in participant-based sensitivity (P > .99), specificity (P = .06), or vessel-based AUC (P = .54). Conclusion There was no evidence of a difference in diagnostic accuracy between CCTA plus CT-FFR and CCTA plus CT perfusion for detecting hemodynamically relevant CAD. A sequential approach combining CCTA plus CT-FFR with CT perfusion led to improved participant-based specificity with no evidence of a difference in sensitivity compared with CCTA plus CT-FFR. ClinicalTrials.gov registration no.: NCT02810795 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Sinitsyn in this issue.

  View details for DOI 10.1148/radiol.233234

  View details for PubMedID 39162632

• Completeness of revascularization by FFRCTin stable angina: Association to adverse cardiovascular outcomes. Journal of cardiovascular computed tomography Madsen, K. T., Norgaard, B. L., Ovrehus, K. A., Jensen, J. M., Parner, E., Grove, E. L., Mortensen, M. B., Iraqi, N., Fairbairn, T. A., Nieman, K., Patel, M. R., Rogers, C., Mullen, S., Mickley, H., Thomsen, K. K., Botker, H. E., Leipsic, J., Ronnow Sand, N. P. 2024

  Abstract

  BACKGROUND: The prognostic impact of complete coronary revascularization relative to non-invasive testing methods is unknown.OBJECTIVES: To assess the association between completeness of revascularization defined by CTA-derived fractional flow reserve (FFRCT) and cardiovascular outcomes in patients with stable angina.METHODS: Multicenter 3-year follow-up study of patients with new onset stable angina and ≥ 30% stenosis by CTA. The lesion-specific FFRCT value (two cm-distal-to-stenosis) was registered in all vessels with stenosis and considered abnormal when ≤ 0.80. Patients with FFRCT ≤ 0.80 were categorized as: Completely revascularized (CR-FFRCT), all vessels with FFRCT ≤ 0.80 revascularized; incompletely revascularized (IR-FFRCT), ≥ 1 vessels with FFRCT ≤ 0.80 non-revascularized. Early revascularization (< 90 days from index CTA) categorized vessels as revascularized. The primary endpoint comprised cardiovascular death and non-fatal myocardial infarction; the secondary endpoint vessel-specific late revascularization and non-fatal myocardial infarction.RESULTS: Amongst 900 patients and 1759 vessels, FFRCT was ≤ 0.80 in 377 (42%) patients, 536 (30%) vessels; revascularization was performed in 244 (27%) patients, 340 (19%) vessels. Risk of the primary endpoint was higher for IR-FFRCT (15/210 [7.1%]) compared to CR-FFRCT (4/167 [2.4%]), RR: 2.98; 95% CI: 1.01-8.8, p​=​0.036, and to normal FFRCT (3/523 [0.6%]), RR: 12.45; 95% CI: 3.6-42.6, p​<​0.001. Incidence of the secondary endpoint was higher in non-revascularized vessels with FFRCT ≤ 0.80 (29/250 [12%]) compared to revascularized vessels with FFRCT ≤ 0.80 (5/286 [1.7%]), p​=​0.001, and to vessels with FFRCT > 0.80 (10/1223 [0.8%]), p​<​0.001.CONCLUSION: Incomplete revascularization of patients with lesion-specific FFRCT ≤ 0.80 is associated to unfavorable cardiovascular outcomes compared to those with complete revascularization or FFRCT > 0.80.

  View details for DOI 10.1016/j.jcct.2024.07.007

  View details for PubMedID 39025756

• Standards for quantitative assessments by coronary computed tomography angiography (CCTA): An expert consensus document of the society of cardiovascular computed tomography (SCCT). Journal of cardiovascular computed tomography Nieman, K., García-García, H. M., Hideo-Kajita, A., Collet, C., Dey, D., Pugliese, F., Weissman, G., Tijssen, J. G., Leipsic, J., Opolski, M. P., Ferencik, M., Lu, M. T., Williams, M. C., Bruining, N., Blanco, P. J., Maurovich-Horvat, P., Achenbach, S. 2024

  Abstract

  In current clinical practice, qualitative or semi-quantitative measures are primarily used to report coronary artery disease on cardiac CT. With advancements in cardiac CT technology and automated post-processing tools, quantitative measures of coronary disease severity have become more broadly available. Quantitative coronary CT angiography has great potential value for clinical management of patients, but also for research. This document aims to provide definitions and standards for the performance and reporting of quantitative measures of coronary artery disease by cardiac CT.

  View details for DOI 10.1016/j.jcct.2024.05.232

  View details for PubMedID 38849237

• Quantification and Visualization of CT Myocardial Perfusion Imaging to Detect Ischemia-Causing Coronary Arteries. IEEE transactions on medical imaging Khan, M. O., Seresti, A. A., Menon, K., Marsden, A. L., Nieman, K. 2024; PP

  Abstract

  Coronary computed tomography angiography (cCTA) has poor specificity to identify coronary stenosis that limit blood flow to the myocardial tissue. Integration of dynamic CT myocardial perfusion imaging (CT-MPI) can potentially improve the diagnostic accuracy. We propose a method that integrates cCTA and CT-MPI to identify culprit coronary lesions that limit blood flow to the myocardium. Coronary arteries and left ventricle surfaces were segmented from cCTA and registered to CT-MPI. Myocardial blood flow (MBF) was derived from CT-MPI. A ray-casting approach was developed to project volumetric MBF onto the left ventricle surface. MBF volume were divided into coronary-specific territories based on proximity to the nearest coronary artery. MBF and normalized MBF were computed for the myocardium and each of the coronary artery. Projection of MBF onto cCTA allowed for direct visualization of perfusion defects. Normalized MBF had higher correlation with ischemic myocardial territory compared to MBF (MBF: R2=0.81 and Index MBF: R2=0.90). There were 18 vessels that showed angiographic disease (stenosis >50%); however, normalized MBF demonstrated only 5 coronary territories to be ischemic. These findings demonstrate that cCTA and CT-MPI can be integrated to visualize myocardial defects and detect culprit coronary arteries responsible for perfusion defects. These methods can allow for non-invasive detection of ischemia-causing coronary lesions and ultimately help guide clinicians to deliver more targeted coronary interventions.

  View details for DOI 10.1109/TMI.2024.3401552

  View details for PubMedID 38748525

• Personalized coronary and myocardial blood flow models incorporating CT perfusion imaging and synthetic vascular trees. Npj imaging Menon, K., Khan, M. O., Sexton, Z. A., Richter, J., Nguyen, P. K., Malik, S. B., Boyd, J., Nieman, K., Marsden, A. L. 2024; 2 (1): 9

  Abstract

  Computational simulations of coronary artery blood flow, using anatomical models based on clinical imaging, are an emerging non-invasive tool for personalized treatment planning. However, current simulations contend with two related challenges - incomplete anatomies in image-based models due to the exclusion of arteries smaller than the imaging resolution, and the lack of personalized flow distributions informed by patient-specific imaging. We introduce a data-enabled, personalized and multi-scale flow simulation framework spanning large coronary arteries to myocardial microvasculature. It includes image-based coronary anatomies combined with synthetic vasculature for arteries below the imaging resolution, myocardial blood flow simulated using Darcy models, and systemic circulation represented as lumped-parameter networks. We propose an optimization-based method to personalize multiscale coronary flow simulations by assimilating clinical CT myocardial perfusion imaging and cardiac function measurements to yield patient-specific flow distributions and model parameters. Using this proof-of-concept study on a cohort of six patients, we reveal substantial differences in flow distributions and clinical diagnosis metrics between the proposed personalized framework and empirical methods based purely on anatomy; these errors cannot be predicted a priori. This suggests virtual treatment planning tools would benefit from increased personalization informed by emerging imaging methods.

  View details for DOI 10.1038/s44303-024-00014-6

  View details for PubMedID 38706558

  View details for PubMedCentralID PMC11062925

• Atherosclerosis evaluation and cardiovascular risk estimation using coronary computed tomography angiography. European heart journal Nurmohamed, N. S., van Rosendael, A. R., Danad, I., Ngo-Metzger, Q., Taub, P. R., Ray, K. K., Figtree, G., Bonaca, M. P., Hsia, J., Rodriguez, F., Sandhu, A. T., Nieman, K., Earls, J. P., Hoffmann, U., Bax, J. J., Min, J. K., Maron, D. J., Bhatt, D. L. 2024

  Abstract

  Clinical risk scores based on traditional risk factors of atherosclerosis correlate imprecisely to an individual's complex pathophysiological predisposition to atherosclerosis and provide limited accuracy for predicting major adverse cardiovascular events (MACE). Over the past two decades, computed tomography scanners and techniques for coronary computed tomography angiography (CCTA) analysis have substantially improved, enabling more precise atherosclerotic plaque quantification and characterization. The accuracy of CCTA for quantifying stenosis and atherosclerosis has been validated in numerous multicentre studies and has shown consistent incremental prognostic value for MACE over the clinical risk spectrum in different populations. Serial CCTA studies have advanced our understanding of vascular biology and atherosclerotic disease progression. The direct disease visualization of CCTA has the potential to be used synergistically with indirect markers of risk to significantly improve prevention of MACE, pending large-scale randomized evaluation.

  View details for DOI 10.1093/eurheartj/ehae190

  View details for PubMedID 38606889

• Interaction of AI-Enabled Quantitative Coronary Plaque Volumes on Coronary CT Angiography, FFRCT, and Clinical Outcomes: A Retrospective Analysis of the ADVANCE Registry. Circulation. Cardiovascular imaging Dundas, J., Leipsic, J., Fairbairn, T., Ng, N., Sussman, V., Guez, I., Rosenblatt, R., Hurwitz Koweek, L. M., Douglas, P. S., Rabbat, M., Pontone, G., Chinnaiyan, K., de Bruyne, B., Bax, J. J., Amano, T., Nieman, K., Rogers, C., Kitabata, H., Sand, N. P., Kawasaki, T., Mullen, S., Huey, W., Matsuo, H., Patel, M. R., Norgaard, B. L., Ahmadi, A., Tzimas, G. 2024: e016143

  Abstract

  Luminal stenosis, computed tomography-derived fractional-flow reserve (FFRCT), and high-risk plaque features on coronary computed tomography angiography are all known to be associated with adverse clinical outcomes. The interactions between these variables, patient outcomes, and quantitative plaque volumes have not been previously described.Patients with coronary computed tomography angiography (n=4430) and one-year outcome data from the international ADVANCE (Assessing Diagnostic Value of Noninvasive FFRCT in Coronary Care) registry underwent artificial intelligence-enabled quantitative coronary plaque analysis. Optimal cutoffs for coronary total plaque volume and each plaque subtype were derived using receiver-operator characteristic curve analysis. The resulting plaque volumes were adjusted for age, sex, hypertension, smoking status, type 2 diabetes, hyperlipidemia, luminal stenosis, distal FFRCT, and translesional delta-FFRCT. Median plaque volumes and optimal cutoffs for these adjusted variables were compared with major adverse cardiac events, late revascularization, a composite of the two, and cardiovascular death and myocardial infarction.At one year, 55 patients (1.2%) had experienced major adverse cardiac events, and 123 (2.8%) had undergone late revascularization (>90 days). Following adjustment for age, sex, risk factors, stenosis, and FFRCT, total plaque volume above the receiver-operator characteristic curve-derived optimal cutoff (total plaque volume >564 mm3) was associated with the major adverse cardiac event/late revascularization composite (adjusted hazard ratio, 1.515 [95% CI, 1.093-2.099]; P=0.0126), and both components. Total percent atheroma volume greater than the optimal cutoff was associated with both major adverse cardiac event/late revascularization (total percent atheroma volume >24.4%; hazard ratio, 2.046 [95% CI, 1.474-2.839]; P<0.0001) and cardiovascular death/myocardial infarction (total percent atheroma volume >37.17%, hazard ratio, 4.53 [95% CI, 1.943-10.576]; P=0.0005). Calcified, noncalcified, and low-attenuation percentage atheroma volumes above the optimal cutoff were associated with all adverse outcomes, although this relationship was not maintained for cardiovascular death/myocardial infarction in analyses stratified by median plaque volumes.Analysis of the ADVANCE registry using artificial intelligence-enabled quantitative plaque analysis shows that total plaque volume is associated with one-year adverse clinical events, with incremental predictive value over luminal stenosis or abnormal physiology by FFRCT.URL: https://www.clinicaltrials.gov; Unique identifier: NCT02499679.

  View details for DOI 10.1161/CIRCIMAGING.123.016143

  View details for PubMedID 38469689

• Coronary computed tomography angiography derived fractional flow reserve and risk of recurrent angina: A 3-year follow-up study. Journal of cardiovascular computed tomography Madsen, K. T., Norgaard, B. L., Ovrehus, K. A., Jensen, J. M., Parner, E., Grove, E. L., Mortensen, M. B., Fairbairn, T. A., Nieman, K., Patel, M. R., Rogers, C., Mullen, S., Mickley, H., Thomsen, K. K., Botker, H. E., Leipsic, J., Sand, N. P. 2024

  Abstract

  BACKGROUND: The association between coronary computed tomography angiography (CTA) derived fractional flow reserve (FFRCT) and risk of recurrent angina in patients with new onset stable angina pectoris (SAP) and stenosis by CTA is uncertain.METHODS: Multicenter 3-year follow-up study of patients presenting with symptoms suggestive of new onset SAP who underwent first-line CTA evaluation and subsequent standard-of-care treatment. All patients had at least one ≥30​% coronary stenosis. A per-patient lowest FFRCT-value ≤0.80 represented an abnormal test result. Patients with FFRCT ≤0.80 who underwent revascularization were categorized according to completeness of revascularization: 1) Completely revascularized (CR-FFRCT), all vessels with FFRCT ≤0.80 revascularized; or 2) incompletely revascularized (IR-FFRCT) ≥1 vessels with FFRCT ≤0.80 non-revascularized. Recurrent angina was evaluated using the Seattle Angina Questionnaire.RESULTS: Amongst 769 patients (619 [80​%] stenosis ≥50​%, 510 [66​%] FFRCT ≤0.80), 174 (23​%) reported recurrent angina at follow-up. An FFRCT ≤0.80 vs​>​0.80 associated to increased risk of recurrent angina, relative risk (RR): 1.82; 95​% CI: 1.31-2.52, p​<​0.001. Risk of recurrent angina in CR-FFRCT (n​=​135) was similar to patients with FFRCT >0.80, 13​% vs 15​%, RR: 0.93; 95​% CI: 0.62-1.40, p​=​0.72, while IR-FFRCT (n​=​90) and non-revascularized patients with FFRCT ≤0.80 (n​=​285) had increased risk, 37​% vs 15​% RR: 2.50; 95​% CI: 1.68-3.73, p​<​0.001 and 30​% vs 15​%, RR: 2.03; 95​% CI: 1.44-2.87, p​<​0.001, respectively. Use of antianginal medication was similar across study groups.CONCLUSION: In patients with SAP and coronary stenosis by CTA undergoing standard-of-care guided treatment, FFRCT provides information regarding risk of recurrent angina.

  View details for DOI 10.1016/j.jcct.2024.01.010

  View details for PubMedID 38246785

• Quantitative metrics of the LV trabeculated layer by cardiac CT and cardiac MRI in patients with suspected noncompaction cardiomyopathy. European radiology Manohar, A., Vigneault, D. M., Kwon, D. H., Caliskan, K., Budde, R. P., Hirsch, A., Lee, S. P., Lee, W., Owens, A., Litt, H., Haddad, F., Mistelbauer, G., Wheeler, M., Rubin, D., Tang, W. H., Nieman, K. 2023

  Abstract

  To compare cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) for the quantitative assessment of the left ventricular (LV) trabeculated layer in patients with suspected noncompaction cardiomyopathy (NCCM).Subjects with LV excessive trabeculation who underwent both CMR and CCT imaging as part of the prospective international multicenter NONCOMPACT clinical study were included. For each subject, short-axis CCT and CMR slices were matched. Four quantitative metrics were estimated: 1D noncompacted-to-compacted ratio (NCC), trabecular-to-myocardial area ratio (TMA), trabecular-to-endocardial cavity area ratio (TCA), and trabecular-to-myocardial volume ratio (TMV). In 20 subjects, end-diastolic and mid-diastolic CCT images were compared for the quantification of the trabeculated layer. Relationships between the metrics were investigated using linear regression models and Bland-Altman analyses.Forty-eight subjects (49.9 ± 12.8 years; 28 female) were included in this study. NCC was moderately correlated (r = 0.62), TMA and TMV were strongly correlated (r = 0.78 and 0.78), and TCA had excellent correlation (r = 0.92) between CMR and CCT, with an underestimation bias from CCT of 0.3 units, and 5.1, 4.8, and 5.4 percent-points for the 4 metrics, respectively. TMA, TCA, and TMV had excellent correlations (r = 0.93, 0.96, 0.94) and low biases (- 3.8, 0.8,  - 3.8 percent-points) between the end-diastolic and mid-diastolic CCT images.TMA, TCA, and TMV metrics of the LV trabeculated layer in patients with suspected NCCM demonstrated high concordance between CCT and CMR images. TMA and TCA were highly reproducible and demonstrated minimal differences between mid-diastolic and end-diastolic CCT images.The results indicate similarity of CCT to CMR for quantifying the LV trabeculated layer, and the small differences in quantification between end-diastole and mid-diastole demonstrate the potential for quantifying the LV trabeculated layer from clinically performed coronary CT angiograms.• Data on cardiac CT for quantifying the left ventricular trabeculated layer are limited. • Cardiac CT yielded highly reproducible metrics of the left ventricular trabeculated layer that correlated well with metrics defined by cardiac MR. • Cardiac CT appears to be equivalent to cardiac MR for the quantification of the left ventricular trabeculated layer.

  View details for DOI 10.1007/s00330-023-10526-1

  View details for PubMedID 38114847

  View details for PubMedCentralID 10317841

• Deep Learning-based Prediction of Percutaneous Recanalization in Chronic Total Occlusion Using Coronary CT Angiography. Radiology Zhou, Z., Gao, Y., Zhang, W., Zhang, N., Wang, H., Wang, R., Gao, Z., Huang, X., Zhou, S., Dai, X., Yang, G., Zhang, H., Nieman, K., Xu, L. 2023; 309 (2): e231149

  Abstract

  Background CT is helpful in guiding the revascularization of chronic total occlusion (CTO), but manual prediction scores of percutaneous coronary intervention (PCI) success have challenges. Deep learning (DL) is expected to predict success of PCI for CTO lesions more efficiently. Purpose To develop a DL model to predict guidewire crossing and PCI outcomes for CTO using coronary CT angiography (CCTA) and evaluate its performance compared with manual prediction scores.Participants with CTO lesions were prospectively identified from one tertiary hospital between January 2018 and December 2021 as the training set to develop the DL prediction model for PCI of CTO, with fivefold cross validation. The algorithm was tested using an external test set prospectively enrolled from three tertiary hospitals between January 2021 and June 2022 with the same eligibility criteria. All participants underwent preprocedural CCTA within 1 month before PCI. The end points were guidewire crossing within 30 minutes and PCI success of CTO.Results A total of 534 participants (mean age, 57.7 years ± 10.8 [SD]; 417 [78.1%] men) with 565 CTO lesions were included. In the external test set (186 participants with 189 CTOs), the DL model saved 85.0% of the reconstruction and analysis time of manual scores (mean, 73.7 seconds vs 418.2-466.9 seconds) and had higher accuracy than manual scores in predicting guidewire crossing within 30 minutes (DL, 91.0%; CT Registry of Chronic Total Occlusion Revascularization, 61.9%; Korean Multicenter CTO CT Registry [KCCT], 68.3%; CCTA-derived Multicenter CTO Registry of Japan (J-CTO), 68.8%; P < .05) and PCI success (DL, 93.7%; KCCT, 74.6%; J-CTO, 75.1%; P < .05). For DL, the area under the receiver operating characteristic curve was 0.97 (95% CI: 0.89, 0.99) for the training test set and 0.96 (95% CI: 0.90, 0.98) for the external test set. Conclusion The DL prediction model accurately predicted the percutaneous recanalization outcomes of CTO lesions and increased the efficiency of noninvasively grading the difficulty of PCI. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Pundziute-do Prado in this issue.

  View details for DOI 10.1148/radiol.231149

  View details for PubMedID 37962501

• Coronary CT Angiography- Derived Fractional Flow Reserve and Risk of Recurrent Angina in Stable Coronary Artery Disease: A 3-Year Follow-up Study Madsen, K., Norgaard, B., Ovrehus, K., Jensen, J., Parner, E., Grove, E., Mortensen, M., Iraqi, N., Nieman, K., Patel, M., Rogers, C., Mullen, S., Mickley, H., Thomsen, K., Leipsic, J., Sand, N. ELSEVIER SCIENCE INC. 2023: B172

  View details for Web of Science ID 001108754600416

• Prognostic Value of Combined Coronary CT Angiography-Derived Fractional Flow Reserve and Quantitative Plaque Analysis in Patients With Stable Angina Madsen, K., Norgaard, B., Ovrehus, K., Jensen, J., Parner, E., Grove, E., Mortensen, M., Iraqi, N., Nieman, K., Patel, M., Rogers, C., Mullen, S., Mickley, H., Rohold, A., Leipsic, J., Sand, N. ELSEVIER SCIENCE INC. 2023: B173

  View details for Web of Science ID 001108754600417

• Prognostic Value of Coronary CT Angiography-derived Fractional Flow Reserve on 3-year Outcomes in Patients with Stable Angina. Radiology Madsen, K. T., Nørgaard, B. L., Øvrehus, K. A., Jensen, J. M., Parner, E., Grove, E. L., Fairbairn, T. A., Nieman, K., Patel, M. R., Rogers, C., Mullen, S., Mickley, H., Rohold, A., Bøtker, H. E., Leipsic, J., Sand, N. P. 2023; 308 (3): e230524

  Abstract

  Background The prognostic value of coronary CT angiography (CTA)-derived fractional flow reserve (FFR) beyond 1-year outcomes and in patients with high levels of coronary artery calcium (CAC) is uncertain. Purpose To assess the prognostic value of coronary CTA-derived FFR test results on 3-year clinical outcomes in patients with coronary stenosis and among a subgroup of patients with high levels of CAC. Materials and Methods This study represents a 3-year follow-up of patients with new-onset stable angina pectoris who were consecutively enrolled in the Assessing Diagnostic Value of Noninvasive CT-FFR in Coronary Care, known as ADVANCE (ClinicalTrials.gov: NCT02499679) registry, between December 2015 and October 2017 at three Danish sites. A high CAC was defined as an Agatston score of at least 400. A lesion-specific coronary CTA-derived FFR value of 2 cm with distal-to-stenosis value at or below 0.80 represented an abnormal test result. The primary end point was a composite of all-cause death and nonfatal spontaneous myocardial infarction. Event rates were estimated using the one-sample binomial model, and relative risk was compared between participants stratified by results of coronary CTA-derived FFR. Results This study included 900 participants: 523 participants with normal results (mean age, 64 years ± 9.6 [SD]; 318 male participants) and 377 with abnormal results from coronary CTA-derived FFR (mean age, 65 years ± 9.6; 264 male participants). The primary end point occurred in 11 of 523 (2.1%) and 25 of 377 (6.6%) participants with normal and abnormal coronary CTA-derived FFR results, respectively (relative risk, 3.1; 95% CI: 1.6, 6.3; P < .001). In participants with high CAC, the primary end point occurred in four of 182 (2.2%) and 19 of 212 (9.0%) participants with normal and abnormal coronary CTA-derived FFR results, respectively (relative risk, 4.1; 95% CI: 1.4, 11.8; P = .001). Conclusion In individuals with stable angina, a normal coronary CTA-derived FFR test result identified participants with a low 3-year risk of all-cause death or nonfatal spontaneous myocardial infarction, both in the overall cohort and in participants with high CAC scores. Clinical trial registration no. NCT02499679 Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Sinitsyn in this issue.

  View details for DOI 10.1148/radiol.230524

  View details for PubMedID 37698477

• Personalized coronary and myocardial blood flow models incorporating CT perfusion imaging and synthetic vascular trees. medRxiv : the preprint server for health sciences Menon, K., Khan, M. O., Sexton, Z. A., Richter, J., Nieman, K., Marsden, A. L. 2023

  Abstract

  Computational simulations of coronary artery blood flow, using anatomical models based on clinical imaging, are an emerging non-invasive tool for personalized treatment planning. However, current simulations contend with two related challenges - incomplete anatomies in image-based models due to the exclusion of arteries smaller than the imaging resolution, and the lack of personalized flow distributions informed by patient-specific imaging. We introduce a data-enabled, personalized and multi-scale flow simulation framework spanning large coronary arteries to myocardial microvasculature. It includes image-based coronary models combined with synthetic vasculature for arteries below the imaging resolution, myocardial blood flow simulated using Darcy models, and systemic circulation represented as lumped-parameter networks. Personalized flow distributions and model parameters are informed by clinical CT myocardial perfusion imaging and cardiac function using surrogate-based optimization. We reveal substantial differences in flow distributions and clinical diagnosis metrics between the proposed personalized framework and empirical methods based on anatomy; these errors cannot be predicted a priori. This suggests virtual treatment planning tools would benefit from increased personalization informed by emerging imaging methods.

  View details for DOI 10.1101/2023.08.17.23294242

  View details for PubMedID 37645850

• Exercise electrocardiography for pre-test assessment of the likelihood of coronary artery disease. Heart (British Cardiac Society) Rasmussen, L. D., Schmidt, S. E., Knuuti, J., Newby, D. E., Singh, T., Nieman, K., Galema, T. W., Vrints, C., Bøttcher, M., Winther, S. 2023

  Abstract

  To develop a tool including exercise electrocardiography (ExECG) for patient-specific clinical likelihood estimation of patients with suspected obstructive coronary artery disease (CAD).An ExECG-weighted clinical likelihood (ExECG-CL) model was developed in a training cohort of patients with suspected obstructive CAD undergoing ExECG. Next, the ExECG-CL model was applied in a CAD validation cohort undergoing ExECG and clinically driven invasive coronary angiography and a prognosis validation cohort and compared with the risk factor-weighted clinical likelihood (RF-CL) model for obstructive CAD discrimination and prognostication, respectively.In the CAD validation cohort, obstructive CAD was defined as >50% diameter stenosis on invasive coronary angiography. For prognosis, the endpoint was non-fatal myocardial infarction and death.The training cohort consisted of 1214 patients (mean age 57 years, 57% males). In the CAD (N=408; mean age 55 years, 53% males) and prognosis validation (N=3283; mean age 57 years, 57% males) cohorts, 11.8% patients had obstructive CAD and 4.4% met the endpoint. In the CAD validation cohort, discrimination of obstructive CAD was similar between the ExECG-CL and RF-CL models: area under the receiver-operating characteristic curves 83.1% (95% CIs 77.5% to 88.7%) versus 80.7% (95% CI 74.6% to 86.8%), p=0.14. In the ExECG-CL model, more patients had very low (≤5%) clinical likelihood of obstructive CAD compared with the RF-CL (42.2% vs 36.0%, p<0.01) where obstructive CAD prevalence and event risk remained low.ExECG incorporated into a clinical likelihood model improves reclassification of patients to a very low clinical likelihood group with very low prevalence of obstructive CAD and favourable prognosis.

  View details for DOI 10.1136/heartjnl-2023-322970

  View details for PubMedID 37607813

• Myocardial CT Perfusion Imaging in 2023 JACC-CARDIOVASCULAR IMAGING Nieman, K., Chandrashekhar, Y. 2023; 16 (7): 1000-1002

  View details for DOI 10.1016/j.jcmg.2023.06.001

  View details for Web of Science ID 001040927400001

  View details for PubMedID 37407119

• Coronary Volume to Left Ventricular Mass Ratio in Patients With Hypertension. The American journal of cardiology van Rosendael, S. E., van Rosendael, A. R., Kuneman, J. H., Patel, M. R., Norgaard, B. L., Fairbairn, T. A., Nieman, K., Akasaka, T., Berman, D. S., 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., Rogers, C., Matsuo, H., Leipsic, J. A., Marsan, N. A., Jukema, J. W., Bax, J. J., Saraste, A., Knuuti, J. 2023

  Abstract

  The coronary vascular volume to left ventricular mass (V/M) ratio assessed by coronary computed tomography angiography (CCTA) is a promising new parameter to investigate the relation of coronary vasculature to the myocardium supplied. It is hypothesized that hypertension decreases the ratio between coronary volume and myocardial mass by way of myocardial hypertrophy, which could explain the detected abnormal myocardial perfusion reserve reported in patients with hypertension. Individuals enrolled in the multicenter ADVANCE (Assessing Diagnostic Value of Noninvasive FFRCT in Coronary Care) registry who underwent clinically indicated CCTA for analysis of suspected coronary artery disease with known hypertension status were included in current analysis. The V/M ratio was calculated from CCTA by segmenting the coronary artery luminal volume and left ventricular myocardial mass. In total, 2,378 subjects were included in this study, of whom 1,346 (56%) had hypertension. Left ventricular myocardial mass and coronary volume were higher in subjects with hypertension than normotensive patients (122.7 ± 32.8g vs 120.0 ± 30.5g, p=0.039, and 3,105.0 ± 992.0mm3 vs 2,965.6 ± 943.7mm3, p <0.001, respectively). Subsequently, the V/M ratio was higher in patients with hypertension than those without (26.0 ± 7.6mm3/g vs 25.3 ± 7.3mm3/g, p=0.024). After correcting for potential confounding factors, the coronary volume and ventricular mass remained higher in patients with hypertension (least square) mean difference estimate: 196.3 (95% confidence intervals [CI] 119.9 to 272.7) mm3, p <0.001, and 5.60 (95% CI 3.42 to 7.78) g, p <0.001, respectively), but the V/M ratio was not significantly different (least square mean difference estimate: 0.48 (95% CI -0.12 to 1.08) mm3/g, p=0.116). In conclusion, our findings do not support the hypothesis that the abnormal perfusion reserve would be caused by reduced V/M ratio in patients with hypertension.

  View details for DOI 10.1016/j.amjcard.2023.04.025

  View details for PubMedID 37198076

• Influence of Obesity on Coronary Artery Disease and Clinical Outcomes in the ADVANCE Registry. Circulation. Cardiovascular imaging Lowenstern, A., Ng, N., Takagi, H., Rymer, J. A., Koweek, L. M., Douglas, P. S., Duran, J. M., Rabbat, M., Pontone, G., Fairbairn, T., Chinnaiyan, K., Berman, D. S., De Bruyne, B., Bax, J. J., Akasaka, T., Amano, T., Nieman, K., Rogers, C., Kitabata, H., Sand, N. P., Kawasaki, T., Mullen, S., Matsuo, H., Norgaard, B. L., Patel, M. R., Leipsic, J., Daubert, M. A. 2023; 16 (5): e014850

  Abstract

  The relationship between body size and cardiovascular events is complex. This study utilized the ADVANCE (Assessing Diagnostic Value of Noninvasive FFRCT in Coronary Care) Registry to investigate the association between body mass index (BMI), coronary artery disease (CAD), and clinical outcomes.The ADVANCE registry enrolled patients undergoing evaluation for clinically suspected CAD who had >30% stenosis on cardiac computed tomography angiography. Patients were stratified by BMI: normal <25 kg/m2, overweight 25-29.9 kg/m2, and obese ≥30 kg/m2. Baseline characteristics, cardiac computed tomography angiography and computed tomography fractional flow reserve (FFRCT), were compared across BMI groups. Adjusted Cox proportional hazards models assessed the association between BMI and outcomes.Among 5014 patients, 2166 (43.2%) had a normal BMI, 1883 (37.6%) were overweight, and 965 (19.2%) were obese. Patients with obesity were younger and more likely to have comorbidities, including diabetes and hypertension (all P<0.001), but were less likely to have obstructive coronary stenosis (65.2% obese, 72.2% overweight, and 73.2% normal BMI; P<0.001). However, the rate of hemodynamic significance, as indicated by a positive FFRCT, was similar across BMI categories (63.4% obese, 66.1% overweight, and 67.8% normal BMI; P=0.07). Additionally, patients with obesity had a lower coronary volume-to-myocardial mass ratio compared with patients who were overweight or had normal BMI (obese BMI, 23.7; overweight BMI, 24.8; and normal BMI, 26.3; P<0.001). After adjustment, the risk of major adverse cardiovascular events was similar regardless of BMI (all P>0.05).Patients with obesity in the ADVANCE registry were less likely to have anatomically obstructive CAD by cardiac computed tomography angiography but had a similar degree of physiologically significant CAD by FFRCT and similar rates of adverse events. An exclusively anatomic assessment of CAD in patients with obesity may underestimate the burden of physiologically significant disease that is potentially due to a significantly lower volume-to-myocardial mass ratio.

  View details for DOI 10.1161/CIRCIMAGING.122.014850

  View details for PubMedID 37192296

• Computed tomographic angiography in coronary artery disease. EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology Serruys, P. W., Kotoku, N., Nørgaard, B. L., Garg, S., Nieman, K., Dweck, M. R., Bax, J. J., Knuuti, J., Narula, J., Perera, D., Taylor, C. A., Leipsic, J. A., Nicol, E. D., Piazza, N., Schultz, C. J., Kitagawa, K., Bruyne, B. D., Collet, C., Tanaka, K., Mushtaq, S., Belmonte, M., Dudek, D., Zlahoda-Huzior, A., Tu, S., Wijns, W., Sharif, F., Budoff, M. J., Mey, J. d., Andreini, D., Onuma, Y. 2023; 18 (16): e1307-e1327

  Abstract

  Coronary computed tomographic angiography (CCTA) is becoming the first-line investigation for establishing the presence of coronary artery disease and, with fractional flow reserve (FFRCT), its haemodynamic significance. In patients without significant epicardial obstruction, its role is either to rule out atherosclerosis or to detect subclinical plaque that should be monitored for plaque progression/regression following prevention therapy and provide risk classification. Ischaemic non-obstructive coronary arteries are also expected to be assessed by non-invasive imaging, including CCTA. In patients with significant epicardial obstruction, CCTA can assist in planning revascularisation by determining the disease complexity, vessel size, lesion length and tissue composition of the atherosclerotic plaque, as well as the best fluoroscopic viewing angle; it may also help in selecting adjunctive percutaneous devices (e.g., rotational atherectomy) and in determining the best landing zone for stents or bypass grafts.

  View details for DOI 10.4244/EIJ-D-22-00776

  View details for PubMedID 37025086

  View details for PubMedCentralID PMC10071125

• Prediction of Coronary Artery Calcium Using Deep Learning of Echocardiograms. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography Yuan, N., Kwan, A. C., Duffy, G., Theurer, J., Chen, J. H., Nieman, K., Botting, P., Dey, D., Berman, D. S., Cheng, S., Ouyang, D. 2022

  Abstract

  BACKGROUND: Coronary artery calcification (CAC), often assessed by computed tomography (CT), is a powerful marker of coronary artery disease (CAD) that can guide preventive therapies. CTs, however, are not always accessible or serially obtainable. It remains unclear if other widespread tests such as transthoracic echocardiograms (TTEs) can be used to predict CAC.METHODS: Using a dataset of 2881 TTE videos paired with coronary calcium CTs, we trained a video-based artificial intelligence (AI) convolutional neural network to predict CAC scores from parasternal long axis (PLAX) views. We evaluated the model's ability to classify patients from a held-out sample as well as an external site sample into zero CAC and high CAC (CAC ≥400 Agatston units) groups by receiver operating characteristic (ROC) and precision-recall curves. We also investigated whether such classifications prognosticated significant differences in 1-year mortality rates by log-rank test of Kaplan-Meier curves.RESULTS: TTE AI models had high discriminatory abilities in predicting zero CAC (ROC AUC 0.81 (95% CI 0.74-0.88), F1 0.95) and high CAC (AUC 0.74 (0.68-0.8), F1 0.74). This performance was confirmed in an external test dataset of 92 TTEs ((AUC 0.75 (0.65-0.85), F1 0.77), (AUC 0.85 (0.76-0.93), F1 0.59), respectively). Risk stratification by TTE-predicted CAC performed similarly to CT CAC scores in prognosticating significant differences in 1-year survival in high CAC patients (CT CAC≥400 vs. CT CAC<400 p=0.03, TTE-predicted CAC≥400 vs. TTE-predicted CAC<400 p=0.02).CONCLUSIONS: A video-based deep learning model successfully used TTE videos to predict zero CAC and high CAC with high accuracy. TTE-predicted CAC prognosticated differences in 1-year survival similar to CT CAC. Deep learning of TTEs holds promise for future adjunctive CAD risk stratification to guide preventive therapies.

  View details for DOI 10.1016/j.echo.2022.12.014

  View details for PubMedID 36566995

• Role of cardiac imaging in acute chest pain. The British journal of radiology Koh, N., Nieman, K. 2022: 20220307

  Abstract

  RESULTS: Real-world considerations such as accessibility and affordability are also discussed in the paper because while guidelines offer clinicians the flexibility of evidence-based choice, physician decision must necessarily be made in consideration of real-world constraints.

  View details for DOI 10.1259/bjr.20220307

  View details for PubMedID 36533544

• 2022 ASNC/AAPM/SCCT/SNMMI guideline for the use of CT in hybrid nuclear/CT cardiac imaging. Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology Al-Mallah, M. H., Bateman, T. M., Branch, K. R., Crean, A., Gingold, E. L., Thompson, R. C., McKenney, S. E., Miller, E. J., Murthy, V. L., Nieman, K., Villines, T. C., Yester, M. V., Einstein, A. J., Mahmarian, J. J. 2022

  View details for DOI 10.1007/s12350-022-03089-z

  View details for PubMedID 36056224

• Pre-procedural planning of coronary revascularization by cardiac computed tomography. Journal of cardiovascular computed tomography Andreini, D., Collet, C., Leipsic, J., Nieman, K., Bittencurt, M., De Mey, J., Buls, N., Onuma, Y., Mushtaq, S., Conte, E., Bartorelli, A. L., Stefanini, G., Sonck, J., Knaapen, P., Ghoshhajra, B., Serruys, P. 2022

  Abstract

  Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; c) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; d) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

  View details for DOI 10.1016/j.jcct.2022.08.003

  View details for PubMedID 36008263

• Pre-procedural Planning of Coronary Revascularization by Cardiac Computed Tomography : An Expert Consensus Document of the Society of Cardiovascular Computed Tomography. EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology Andreini, D., Collet, C., Leipsic, J., Nieman, K., Bittencurt, M., De Mey, J., Buls, N., Onuma, Y., Mushtaq, S., Conte, E., Bartorelli, A. L., Stefanini, G., Sonck, J., Knaapen, P., Ghoshhajra, B., Serruys, P. W. 2022

  Abstract

  Coronary CT angiography (CCTA) demonstrated high diagnostic accuracy for detecting coronary artery disease (CAD) and a key role in the management of patients with low-to-intermediate pretest likelihood of CAD. However, the clinical information provided by this noninvasive method is still regarded insufficient in patients with diffuse and complex CAD and for planning percutaneous coronary intervention (PCI) and surgical revascularization procedures. On the other hand, technology advancements have recently shown to improve CCTA diagnostic accuracy in patients with diffuse and calcific stenoses. Moreover, stress CT myocardial perfusion imaging (CT-MPI) and fractional flow reserve derived from CCTA (CT-FFR) have been introduced in clinical practice as new tools for evaluating the functional relevance of coronary stenoses, with the possibility to overcome the main CCTA drawback, i.e. anatomical assessment only. The potential value of CCTA to plan and guide interventional procedures lies in the wide range of information it can provide: a) detailed evaluation of plaque extension, volume and composition; b) prediction of procedural success of CTO PCI using scores derived from CCTA; 3) identification of coronary lesions requiring additional techniques (e.g., atherectomy and lithotripsy) to improve stent implantation success by assessing calcium score and calcific plaque distribution; 4) assessment of CCTA-derived Syntax Score and Syntax Score II, which allows to select the mode of revascularization (PCI or CABG) in patients with complex and multivessel CAD. The aim of this Consensus Document is to review and discuss the available data supporting the role of CCTA, CT-FFR and stress CT-MPI in the preprocedural and possibly intraprocedural planning and guidance of myocardial revascularization interventions.

  View details for DOI 10.4244/EIJ-E-22-00036

  View details for PubMedID 35994043

• Blood flow modeling reveals improved collateral artery performance during the regenerative period in mammalian hearts. Nature cardiovascular research Anbazhakan, S., Rios Coronado, P. E., Sy-Quia, A. N., Seow, L. W., Hands, A. M., Zhao, M., Dong, M. L., Pfaller, M. R., Amir, Z. A., Raftrey, B. C., Cook, C. K., D'Amato, G., Fan, X., Williams, I. M., Jha, S. K., Bernstein, D., Nieman, K., Pașca, A. M., Marsden, A. L., Horse, K. R. 2022; 1 (8): 775-790

  Abstract

  Collateral arteries bridge opposing artery branches, forming a natural bypass that can deliver blood flow downstream of an occlusion. Inducing coronary collateral arteries could treat cardiac ischemia, but more knowledge on their developmental mechanisms and functional capabilities is required. Here we used whole-organ imaging and three-dimensional computational fluid dynamics modeling to define spatial architecture and predict blood flow through collaterals in neonate and adult mouse hearts. Neonate collaterals were more numerous, larger in diameter and more effective at restoring blood flow. Decreased blood flow restoration in adults arose because during postnatal growth coronary arteries expanded by adding branches rather than increasing diameters, altering pressure distributions. In humans, adult hearts with total coronary occlusions averaged 2 large collaterals, with predicted moderate function, while normal fetal hearts showed over 40 collaterals, likely too small to be functionally relevant. Thus, we quantify the functional impact of collateral arteries during heart regeneration and repair-a critical step toward realizing their therapeutic potential.

  View details for DOI 10.1038/s44161-022-00114-9

  View details for PubMedID 37305211

  View details for PubMedCentralID PMC10256232

• Great debates in cardiac computed tomography: OPINION: "Artificial intelligence is key to the future of CCTA - The great hope". Journal of cardiovascular computed tomography Motwani, M., Williams, M. C., Nieman, K., Choi, A. D. 2022

  View details for DOI 10.1016/j.jcct.2022.07.004

  View details for PubMedID 35945132

• Recommendations for Multimodality Cardiovascular Imaging of Patients with Hypertrophic Cardiomyopathy: An Update from the American Society of Echocardiography, in Collaboration with the American Society of Nuclear Cardiology, the Society for Cardiovascular Magnetic Resonance, and the Society of Cardiovascular Computed Tomography. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography Nagueh, S. F., Phelan, D., Abraham, T., Armour, A., Desai, M. Y., Dragulescu, A., Gilliland, Y., Lester, S. J., Maldonado, Y., Mohiddin, S., Nieman, K., Sperry, B. W., Woo, A. 2022; 35 (6): 533-569

  Abstract

  Hypertrophic cardiomyopathy (HCM) is defined by the presence of left ventricular hypertrophy in the absence of other potentially causative cardiac, systemic, syndromic, or metabolic diseases. Symptoms can be related to a range of pathophysiologic mechanisms including left ventricular outflow tract obstruction with or without significant mitral regurgitation, diastolic dysfunction with heart failure with preserved and heart failure with reduced ejection fraction, autonomic dysfunction, ischemia, and arrhythmias. Appropriate understanding and utilization of multimodality imaging is fundamental to accurate diagnosis as well as longitudinal care of patients with HCM. Resting and stress imaging provide comprehensive and complementary information to help clarify mechanism(s) responsible for symptoms such that appropriate and timely treatment strategies may be implemented. Advanced imaging is relied upon to guide certain treatment options including septal reduction therapy and mitral valve repair. Using both clinical and imaging parameters, enhanced algorithms for sudden cardiac death risk stratification facilitate selection of HCM patients most likely to benefit from implantable cardioverter-defibrillators.

  View details for DOI 10.1016/j.echo.2022.03.012

  View details for PubMedID 35659037

• Implications of the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Chest Pain Guideline for Cardiovascular Imaging: A Multisociety Viewpoint. JACC. Cardiovascular imaging Blankstein, R., Shaw, L. J., Gulati, M., Atalay, M. K., Bax, J., Calnon, D. A., Dyke, C. K., Ferencik, M., Heitner, J. F., Henry, T. D., Hung, J., Knuuti, J., Lindner, J. R., Phillips, L. M., Raman, S. V., Rao, S. V., Rybicki, F. J., Saraste, A., Stainback, R. F., Thompson, R. C., Williamson, E., Nieman, K., Tremmel, J. A., Woodard, P. K., Di Carli, M. F., Chandrashekhar, Y. S. 2022; 15 (5): 912-926

  View details for DOI 10.1016/j.jcmg.2022.02.021

  View details for PubMedID 35512960

• Colocalization of Coronary Plaque with Wall Shear Stress in Myocardial Bridge Patients. Cardiovascular engineering and technology Khan, M. O., Nishi, T., Imura, S., Seo, J., Wang, H., Honda, Y., Nieman, K., Rogers, I. S., Tremmel, J. A., Boyd, J., Schnittger, I., Marsden, A. 2022

  Abstract

  PURPOSE: Patients with myocardial bridges (MBs) have a higher prevalence of atherosclerosis. Wall shear stress (WSS) has previously been correlated with plaque in coronary artery disease patients, but such correlations have not been investigated in symptomatic MB patients. The aim of this paper was to use a multi-scale computational fluid dynamics (CFD) framework to simulate hemodynamics in MB patient, and investigate the co-localization of WSS and plaque.METHODS: We identified N = 10 patients from a previously reported cohort of 50 symptomatic MB patients, all of whom had plaque in the proximal vessel. Dynamic 3D models were reconstructed from coronary computed tomography angiography (CCTA), intravascular ultrasound (IVUS) and catheter angiograms. CFD simulations were performed to compute WSS proximal to, within and distal to the MB. Plaque was quantified from IVUS images in 2 mm segments and registered to CFD model. Plaque area was compared to absolute and patient-normalized WSS.RESULTS: WSS was lower in the proximal segment compared to the bridge segment (6.1 ± 2.9 vs. 16.0 ± 7.1 dynes/cm2, p value < 0.01). Plaque area and plaque burden measured from IVUS peaked at 1-3 cm proximal to the MB entrance, coinciding with the first diagonal branch. Normalized WSS showed a statistically significant moderate correlation with plaque area (r = 0.41, p < 0.01).CONCLUSION: WSS may be obtained non-invasively in MB patients and provides a surrogate marker of plaque area. Using CFD, it may be possible to non-invasively assess the extent of plaque area, and identify patients who could benefit from frequent monitoring or medical management.

  View details for DOI 10.1007/s13239-022-00616-4

  View details for PubMedID 35296987

• Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part II. European heart journal. Cardiovascular Imaging Pontone, G., Rossi, A., Guglielmo, M., Dweck, M. R., Gaemperli, O., Nieman, K., Pugliese, F., Maurovich-Horvat, P., Gimelli, A., Cosyns, B., Achenbach, S. 2022

  Abstract

  Cardiac computed tomography (CT) was initially developed as a non-invasive diagnostic tool to detect and quantify coronary stenosis. Thanks to the rapid technological development, cardiac CT has become a comprehensive imaging modality which offers anatomical and functional information to guide patient management. This is the second of two complementary documents endorsed by the European Association of Cardiovascular Imaging aiming to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. In this article, emerging CT technologies and biomarkers, such as CT-derived fractional flow reserve, perfusion imaging, and pericoronary adipose tissue attenuation, are described. In addition, the role of cardiac CT in the evaluation of atherosclerotic plaque, cardiomyopathies, structural heart disease, and congenital heart disease is revised.

  View details for DOI 10.1093/ehjci/jeab292

  View details for PubMedID 35175348

• Coronary volume to left ventricular mass ratio in patients with diabetes mellitus. Journal of cardiovascular computed tomography Kuneman, J. H., El Mahdiui, M., van Rosendael, A. R., van den Hoogen, I. J., Patel, M. R., Norgaard, B. L., Fairbairn, T. A., Nieman, K., Akasaka, T., Berman, D. S., Hurwitz Koweek, L. M., Pontone, G., Kawasaki, T., Ronnow Sand, N. P., Jensen, J. M., Amano, T., Poon, M., Ovrehus, K. A., Sonck, J., Rabbat, M. G., De Bruyne, B., Rogers, C., Matsuo, H., Bax, J. J., Leipsic, J. A., Knuuti, J. 2022

  Abstract

  BACKGROUND: Diabetes mellitus is a major risk factor for coronary artery disease (CAD) and may provoke structural and functional changes in coronary vasculature. The coronary volume to left ventricular mass (V/M) ratio is a new anatomical parameter capable of revealing a potential physiological imbalance between coronary vasculature and myocardial mass. The aim of this study was to examine the V/M derived from coronary computed tomography angiography (CCTA) in patients with diabetes.METHODS: Patients with clinically suspected CAD enrolled in the ADVANCE (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) registry and known diabetic status were included. Coronary artery volume and left ventricular myocardial mass were analyzed from CCTA and the V/M ratio was calculated and compared between patients with and without diabetes.RESULTS: Of the 3053 patients (age 66​±​10 years; 66% male) with known diabetic status, diabetes was present in 21.9%. Coronary volume was lower in patients with diabetes compared to those without diabetes (2850​±​940​mm3 vs. 3040​±​970​mm3, p​<​0.0001), whereas the myocardial mass was comparable between the 2 groups (122​±​33​g vs. 122​±​32​g, p​=​0.70). The V/M ratio was significantly lower in patients with diabetes (23.9​±​6.8​mm3/g vs. 25.7​±​7.5​mm3/g, p​<​0.0001). Among subjects with obstructive CAD (n​=​2191, 24.0% diabetics) and non-obstructive CAD (16.7% diabetics), the V/M ratio was significantly lower in patients with diabetes compared to those without (23.4​±​6.7​mm3/g vs. 25.0​±​7.3​mm3/g, p​<​0.0001 and 25.6​±​6.9​mm3/g vs. 27.3​±​7.6​mm3/g, respectively, p​=​0.006).CONCLUSION: The V/M ratio was significantly lower in patients with diabetes compared to non-diabetics, even after correcting for obstructive coronary stenosis. The clinical value of the reduced V/M ratio in diabetic patients needs further investigation.

  View details for DOI 10.1016/j.jcct.2022.01.004

  View details for PubMedID 35190274

• Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part I. European heart journal. Cardiovascular Imaging Pontone, G., Rossi, A., Guglielmo, M., Dweck, M. R., Gaemperli, O., Nieman, K., Pugliese, F., Maurovich-Horvat, P., Gimelli, A., Cosyns, B., Achenbach, S. 1800

  Abstract

  Cardiac computed tomography (CT) was introduced in the late 1990's. Since then, an increasing body of evidence on its clinical applications has rapidly emerged. From an initial emphasis on its technical efficiency and diagnostic accuracy, research around cardiac CT has now evolved towards outcomes-based studies that provide information on prognosis, safety, and cost. Thanks to the strong and compelling data generated by large, randomized control trials, the scientific societies have endorsed cardiac CT as pivotal diagnostic test for the management of appropriately selected patients with acute and chronic coronary syndrome. This consensus document endorsed by the European Association of Cardiovascular Imaging is divided into two parts and aims to provide a summary of the current evidence and to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. This first part focuses on the most established applications of cardiac CT from primary prevention in asymptomatic patients, to the evaluation of patients with chronic coronary syndrome, acute chest pain, and previous coronary revascularization.

  View details for DOI 10.1093/ehjci/jeab293

  View details for PubMedID 35076061

• Incremental value of volumetric quantification for myocardial perfusion imaging by computed tomography. Kardiologia polska Oleksiak, A., Kepka, C., Nieman, K., Debski, M., Demkow, M., Kruk, M. 1800

  Abstract

  BACKGROUND: The extent of myocardial ischemia is the crucial prognostic dimension for interventional treatment decisions for coronary artery disease. Computed tomography perfusion (CTP) ability to provide the missing volumetric information and its clinical value remains unknown.AIMS: The study aimed to compare a novel ischemic volume quantification method based on dynamic computed tomography perfusion (VOL CTP) with other CT-based imaging modalities for revascularization prediction.METHODS: In this prospective study, 53 (25 females, 63.5 [8.5] years old) consecutive symptomatic patients with ≥1 50%-90% coronary artery stenosis on coronary computed tomography angiography underwent computed-tomography-derived fractional flow reserve (CT-FFR) analysis and dynamic CTP. We calculated the percentage of myocardial ischemia on the CTP-derived images. A 10% was used to define functionally significant ischemia. The outcomes include coronary revascularization during the follow-up of 2.5 (1.4-2.8) years. Physicians blinded to the CTP and CT-FFR.RESULTS: Of the 53 patients in the study (68 arteries with 50%-90% stenosis), 16 underwent revascularization (12 elective, 4 event-driven). In the CTP quantitative analysis, 26 patients had ischemia. Overall, 18 patients had ischemia ≥ 10% on volumetric ischemia quantification based on dynamic computed tomography perfusion (VOL CTP), and 28 patients had CT-FFR <0.8. VOL CTP, standard CTP, CT-FFR, and computed tomography coronary angiography (CTA) ≥70% performed well for the prediction of total revascularization (area under the curve [AUC], 0.973 vs. AUC, 0.865, vs. AUC, 0.793, vs. AUC, 0.668, respectively). The VOL CTP with ≥10% cut-off was superior to the CT-FFR, standard CTP, and CTA ≥70% (P <0.001; P = 0.002 and P <0.001 respectively).CONCLUSIONS: VOL CTP quantification is feasible and adds important, actionable information to that provided by standard CTP or CT-FFR in patients with 50%-90% coronary artery stenosis.

  View details for DOI 10.33963/KP.a2022.0015

  View details for PubMedID 35040484

• Low-dose coronary calcium scoring CT using a dedicated reconstruction filter for kV-independent calcium measurements. European radiology Jubran, A., Mastrodicasa, D., van Praagh, G. D., Willemink, M. J., Kino, A., Wang, J., Fleischmann, D., Nieman, K. 1800

  Abstract

  In this prospective, pilot study, we tested a kV-independent coronary artery calcium scoring CT protocol, using a novel reconstruction kernel (Sa36f). From December 2018 to November 2019, we performed an additional research scan in 61 patients undergoing clinical calcium scanning. For the standard protocol (120 kVp), images were reconstructed with a standard, medium-sharp kernel (Qr36d). For the research protocol (automated kVp selection), images were reconstructed with a novel kernel (Sa36f). Research scans were sequentially performed using a higher (cohort A, n=31) and a lower (cohort B, n=30) dose optimizer setting within the automatic system with customizable kV selection. Agatston scores, coronary calcium volumes, and radiation exposure of the standard and research protocol were compared. A phantom study was conducted to determine inter-scan variability. There was excellent correlation for the Agatston score between the two protocols (r=0.99); however, the standard protocol resulted in slightly higher Agatston scores (29.4 [0-139.0] vs 17.4 [0-158.2], p=0.028). The median calcium volumes were similar (11.5 [0-109.2] vs 11.2 [0-118.0] mm3; p=0.176), and the number of calcified lesions was not significantly different (p=0.092). One patient was reclassified to another risk category. The research protocol could be performed at a lower kV and resulted in a substantially lower radiation exposure, with a median volumetric CT dose index of 4.1 vs 5.2mGy, respectively (p<0.001). Our results showed that a consistent coronary calcium scoring can be achieved using a kV-independent protocol that lowers radiation doses compared to the standard protocol. KEY POINTS: The Sa36f kernel enables kV-independent Agatston scoring without changing the original Agatston weighting threshold. Agatston scores and calcium volumes of the standard and research protocols showed an excellent correlation. The research protocol resulted in a significant reduction in radiation exposure with a mean reduction of 22% in DLP and 25% in CTDIvol.

  View details for DOI 10.1007/s00330-021-08451-2

  View details for PubMedID 34989838

• The Influence of Obesity on Coronary Artery Disease and Clinical Outcomes in the ADVANCE Registry Lowenstern, A., Takagi, H., Ng, N., Rymer, J., Koweek, L., Douglas, P., Duran, J., Rabbat, M., Chinnaiyan, K., Berman, D., De Bruyne, B., Bax, J., Akasaka, T., Amano, T., Nieman, K., Rogers, C., Kitabata, H., Sand, N., Kawasaki, T., Mullen, S., Matsuo, H., Norgaard, B., Patel, M., Leipsic, J., Daubert, M. ELSEVIER SCIENCE INC. 2021: B124-B125

  View details for Web of Science ID 000715526900284

• Relationship Between Coronary CT Angiography-Derived Fractional Flow Reserve and Clinical Outcomes in Patients With and Without Diabetes Gulsin, G., Tzimas, G., Takagi, H., Eddy, R., Blanke, P., Park, P., Koweek, L., Norgaard, B., Rabbat, M., Fairbairn, T., Chinnaiyan, K., Douglas, P., Huey, W., Matsuo, H., Sand, N., Nieman, K., Bax, J., Amano, T., Kawasaki, T., Akasaka, T., Rogers, C., Berman, D., Patel, M., De Bruyne, B., Mullen, S., Leipsic, J. ELSEVIER SCIENCE INC. 2021: B164

  View details for Web of Science ID 000715526900375

• Anatomic and Functional Discordance Among Patients With Nonobstructive Coronary Disease Rymer, J., Takagi, H., Lowenstern, A., Rabbat, M., Fairbairn, T., Chinnaiyan, K., Douglas, P., Koweek, L., Berman, D., De Bruyne, B., Bax, J., Akasaka, T., Amano, T., Nieman, K., Rogers, C., Kitabata, H., Sand, N., Kawasaki, T., Mullen, S., Matsuo, H., Norgaard, B., Leipsic, J., Patel, M., Daubert, M. ELSEVIER SCIENCE INC. 2021: B36-B37

  View details for Web of Science ID 000715526900080

• Relationship Between Coronary Atheroma, Epicardial Adipose Tissue Inflammation, and Adipocyte Differentiation Across the Human Myocardial Bridge. Journal of the American Heart Association McLaughlin, T., Schnittger, I., Nagy, A., Zanley, E., Xu, Y., Song, Y., Nieman, K., Tremmel, J. A., Dey, D., Boyd, J., Sacks, H. 2021: e021003

  Abstract

  Background Inflammation in epicardial adipose tissue (EAT) may contribute to coronary atherosclerosis. Myocardial bridge is a congenital anomaly in which the left anterior descending coronary artery takes a "tunneled" course under a bridge of myocardium: while atherosclerosis develops in the proximal left anterior descending coronary artery, the bridged portion is spared, highlighting the possibility that geographic separation from inflamed EAT is protective. We tested the hypothesis that inflammation in EAT was related to atherosclerosis by comparing EAT from proximal and bridge depots in individuals with myocardial bridge and varying degrees of atherosclerotic plaque. Methods and Results Maximal plaque burden was quantified by intravascular ultrasound, and inflammation was quantified by pericoronary EAT signal attenuation (pericoronary adipose tissue attenuation) from cardiac computed tomography scans. EAT overlying the proximal left anterior descending coronary artery and myocardial bridge was harvested for measurement of mRNA and microRNA (miRNA) using custom chips by Nanostring; inflammatory cytokines were measured in tissue culture supernatants. Pericoronary adipose tissue attenuation was increased, indicating inflammation, in proximal versus bridge EAT, in proportion to atherosclerotic plaque. Individuals with moderate-high versus low plaque burden exhibited greater expression of inflammation and hypoxia genes, and lower expression of adipogenesis genes. Comparison of gene expression in proximal versus bridge depots revealed differences only in participants with moderate-high plaque: inflammation was higher in proximal and adipogenesis lower in bridge EAT. Secreted inflammatory cytokines tended to be higher in proximal EAT. Hypoxia-inducible factor 1a was highly associated with inflammatory gene expression. Seven miRNAs were differentially expressed by depot: 3192-5P, 518D-3P, and 532-5P were upregulated in proximal EAT, whereas miR 630, 575, 16-5P, and 320E were upregulated in bridge EAT. miR 630 correlated directly with plaque burden and inversely with adipogenesis genes. miR 3192-5P, 518D-3P, and 532-5P correlated inversely with hypoxia/oxidative stress, peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PCG1a), adipogenesis, and angiogenesis genes. Conclusions Inflammation is specifically elevated in EAT overlying atherosclerotic plaque, suggesting that EAT inflammation is caused by atherogenic molecular signals, including hypoxia-inducible factor 1a and/or miRNAs in an "inside-to-out" relationship. Adipogenesis was suppressed in the bridge EAT, but only in the presence of atherosclerotic plaque, supporting cross talk between the vasculature and EAT. miR 630 in EAT, expressed differentially according to burden of atherosclerotic plaque, and 3 other miRNAs appear to inhibit key genes related to adipogenesis, angiogenesis, hypoxia/oxidative stress, and thermogenesis in EAT, highlighting a role for miRNA in mediating cross talk between the coronary vasculature and EAT.

  View details for DOI 10.1161/JAHA.121.021003

  View details for PubMedID 34726081

• Prognostic value of coronary computed tomography angiographic derived fractional flow reserve: a systematic review and meta-analysis. Heart (British Cardiac Society) Norgaard, B. L., Gaur, S., Fairbairn, T. A., Douglas, P. S., Jensen, J. M., Patel, M. R., Ihdayhid, A. R., Ko, B. S., Sellers, S. L., Weir-McCall, J., Matsuo, H., Sand, N. P., Ovrehus, K. A., Rogers, C., Mullen, S., Nieman, K., Parner, E., Leipsic, J., Abdulla, J. 2021

  Abstract

  OBJECTIVES: To obtain more powerful assessment of the prognostic value of fractional flow reserveCT testing we performed a systematic literature review and collaborative meta-analysis of studies that assessed clinical outcomes of CT-derived calculation of FFR (FFRCT) (HeartFlow) analysis in patients with stable coronary artery disease (CAD).METHODS: We searched PubMed and Web of Science electronic databases for published studies that evaluated clinical outcomes following fractional flow reserveCT testing between 1 January 2010 and 31 December 2020. The primary endpoint was defined as 'all-cause mortality (ACM) or myocardial infarction (MI)' at 12-month follow-up. Exploratory analyses were performed using major adverse cardiovascular events (MACEs, ACM+MI+unplanned revascularisation), ACM, MI, spontaneous MI or unplanned (>3 months) revascularisation as the endpoint.RESULTS: Five studies were identified including a total of 5460 patients eligible for meta-analyses. The primary endpoint occurred in 60 (1.1%) patients, 0.6% (13/2126) with FFRCT>0.80%and 1.4% (47/3334) with FFRCT ≤0.80 (relative risk (RR) 2.31 (95% CI 1.29 to 4.13), p=0.005). Likewise, MACE, MI, spontaneous MI or unplanned revascularisation occurred more frequently in patients with FFRCT ≤0.80versus patients with FFRCT >0.80. Each 0.10-unit FFRCT reduction was associated with a greater risk of the primary endpoint (RR 1.67 (95% CI 1.47 to 1.87), p<0.001).CONCLUSIONS: The 12-month outcomes in patients with stable CAD show low rates of events in those with a negative FFRCT result, and lower risk of an unfavourable outcome in patients with a negative test result compared with patients with a positive test result. Moreover, the FFRCT numerical value was inversely associated with outcomes.

  View details for DOI 10.1136/heartjnl-2021-319773

  View details for PubMedID 34686567

• Deep learning evaluation of biomarkers from echocardiogram videos. EBioMedicine Hughes, J. W., Yuan, N., He, B., Ouyang, J., Ebinger, J., Botting, P., Lee, J., Theurer, J., Tooley, J. E., Nieman, K., Lungren, M. P., Liang, D. H., Schnittger, I., Chen, J. H., Ashley, E. A., Cheng, S., Ouyang, D., Zou, J. Y. 2021; 73: 103613

  Abstract

  BACKGROUND: Laboratory testing is routinely used to assay blood biomarkers to provide information on physiologic state beyond what clinicians can evaluate from interpreting medical imaging. We hypothesized that deep learning interpretation of echocardiogram videos can provide additional value in understanding disease states and can evaluate common biomarkers results.METHODS: We developed EchoNet-Labs, a video-based deep learning algorithm to detect evidence of anemia, elevated B-type natriuretic peptide (BNP), troponin I, and blood urea nitrogen (BUN), as well as values of ten additional lab tests directly from echocardiograms. We included patients (n=39,460) aged 18 years or older with one or more apical-4-chamber echocardiogram videos (n=70,066) from Stanford Healthcare for training and internal testing of EchoNet-Lab's performance in estimating the most proximal biomarker result. Without fine-tuning, the performance of EchoNet-Labs was further evaluated on an additional external test dataset (n=1,301) from Cedars-Sinai Medical Center. We calculated the area under the curve (AUC) of the receiver operating characteristic curve for the internal and external test datasets.FINDINGS: On the held-out test set of Stanford patients not previously seen during model training, EchoNet-Labs achieved an AUC of 0.80 (0.79-0.81) in detecting anemia (low hemoglobin), 0.86 (0.85-0.88) in detecting elevated BNP, 0.75 (0.73-0.78) in detecting elevated troponin I, and 0.74 (0.72-0.76) in detecting elevated BUN. On the external test dataset from Cedars-Sinai, EchoNet-Labs achieved an AUC of 0.80 (0.77-0.82) in detecting anemia, of 0.82 (0.79-0.84) in detecting elevated BNP, of 0.75 (0.72-0.78) in detecting elevated troponin I, and of 0.69 (0.66-0.71) in detecting elevated BUN. We further demonstrate the utility of the model in detecting abnormalities in 10 additional lab tests. We investigate the features necessary for EchoNet-Labs to make successful detection and identify potential mechanisms for each biomarker using well-known and novel explainability techniques.INTERPRETATION: These results show that deep learning applied to diagnostic imaging can provide additional clinical value and identify phenotypic information beyond current imaging interpretation methods.FUNDING: J.W.H. and B.H. are supported by the NSF Graduate Research Fellowship. D.O. is supported by NIH K99 HL157421-01. J.Y.Z. is supported by NSF CAREER 1942926, NIH R21 MD012867-01, NIH P30AG059307 and by a Chan-Zuckerberg Biohub Fellowship.

  View details for DOI 10.1016/j.ebiom.2021.103613

  View details for PubMedID 34656880

• Highlights of the 16th annual scientific meeting of the society of cardiovascular computed tomography. Journal of cardiovascular computed tomography Williams, M. C., Ferencik, M., Branch, K. R., Nieman, K., Ghoshhajra, B. B., Choi, A. D., Nicol, E. D., Williamson, E. 2021

  Abstract

  The 16th Society of Cardiovascular Computed Tomography (SCCT) annual scientific meeting welcomed 781 digital attendees from 55 countries. The program included 27 sessions across three simultaneously streaming channels, 11 exhibitors, 153 poster presentations, and 32​hours of on demand videos. The main themes of the meeting included coronary artery disease, valvular heart disease, structural heart disease, and advanced analytics including machine learning. This article summaries the main themes of the meeting and some of the key presentations, which will shape the future of cardiovascular computed tomography in clinical practice.

  View details for DOI 10.1016/j.jcct.2021.10.002

  View details for PubMedID 34688579

• Dual-energy CT plaque characteristics of post mortem thin-cap fibroatheroma in comparison to infarct-related culprit lesions. Heart and vessels Sheta, H. M., Precht, H., Busk, C. A., Heinsen, L. J., Nieman, K., Egstrup, K., Lambrechtsen, J. 2021

  Abstract

  Improvement of non-invasive identification of high-risk plaque may increase the preventive options of acute coronary syndrome. To describe the characteristics of thin-cap fibroatheroma (TCFA) in a post mortem model in comparison to characteristics of culprit lesions in patients with non-ST-elevation-myocardial-infarction (NSTEMI) using the dual energy computed tomography (DECT). Three post mortem hearts were prepared with iodine-contrast, inserted in a Kyoto phantom and scanned by DECT. Six TCFA were identified using histopathological analysis (cap thickness<65mum and necrotic core>10% of the plaque area). In the NSTEMI group, 29 patients were scheduled to DECT prior to coronary angiography and invasive treatment. Culprit lesions were identified blinded for the patient history by two independent invasive cardiologists using the coronary angiography. The DECT analysis of TCFA and culprit lesions was performed retrospectively with determination of effective atomic number (Effective-Z), Hounsfield Unit (HU), plaque type (non-calcified, predominantly non-calcified, predominantly calcified or calcified), spotty calcification,, plaque length, plaque volume and plaque burden and the remodeling index. The Effective-Z, HU and plaqueburden were significantly different between TCFA and culprit lesions (P<0.05).The TCFA plaques were more calcified in comparison to culprit lesions (P<0.05). No significant difference in the other plaque characteristics was observed. The use of DECT demonstrated different Effective-Z values and different characteristics of post mortem TCFA in comparison to in vivo culprit lesions. This finding may highlight, that not all TCFA should be considered as vulnerable.

  View details for DOI 10.1007/s00380-021-01942-8

  View details for PubMedID 34608510

• Impact of Diastolic Vessel Restriction on Quality of Life in Symptomatic Myocardial Bridging Patients Treated With Surgical Unroofing: Preoperative Assessments With Intravascular Ultrasound and Coronary Computed Tomography Angiography. Circulation. Cardiovascular interventions Hashikata, T., Honda, Y., Wang, H., Pargaonkar, V. S., Nishi, T., Hollak, M. B., Rogers, I. S., Nieman, K., Yock, P. G., Fitzgerald, P. J., Schnittger, I., Boyd, J. H., Tremmel, J. A. 2021; 14 (10): e011062

  Abstract

  [Figure: see text].

  View details for DOI 10.1161/CIRCINTERVENTIONS.121.011062

  View details for PubMedID 34665656

• Dynamic Myocardial Perfusion CT for the Detection of Hemodynamically Significant Coronary Artery Disease. JACC. Cardiovascular imaging Nous, F. M., Geisler, T., Kruk, M. B., Alkadhi, H., Kitagawa, K., Vliegenthart, R., Hell, M. M., Hausleiter, J., Nguyen, P. K., Budde, R. P., Nikolaou, K., Kepka, C., Manka, R., Sakuma, H., Malik, S. B., Coenen, A., Zijlstra, F., Klotz, E., van der Harst, P., Artzner, C., Dedic, A., Pugliese, F., Bamberg, F., Nieman, K. 2021

  Abstract

  OBJECTIVES: In this international, multicenter study, using third-generation dual-source computed tomography (CT), we investigated the diagnostic performance of dynamic stress CT myocardial perfusion imaging (CT-MPI) in addition to coronary CT angiography (CTA) compared to invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR).BACKGROUND: CT-MPI combined with coronary CTA integrates coronary artery anatomy with inducible myocardial ischemia, showing promising results for the diagnosis of hemodynamically significant coronary artery disease in single-center studies.METHODS: At 9 centers in Europe, Japan, and the United States, 132 patients scheduled for ICA were enrolled; 114 patients successfully completed coronary CTA, adenosine-stress dynamic CT-MPI, and ICA. Invasive FFR was performed in vessels with 25% to 90% stenosis. Data were analyzed by independent core laboratories. For the primary analysis, for each coronary artery the presence of hemodynamically significant obstruction was interpreted by coronary CTA with CT-MPI compared to coronary CTA alone, using an FFR of≤0.80 and angiographic severity as reference. Territorial absolute myocardial blood flow (MBF) and relative MBF were compared using C-statistics.RESULTS: ICA and FFR identified hemodynamically significant stenoses in 74 of 289 coronary vessels (26%). Coronary CTA with≥50% stenosis demonstrated a per-vessel sensitivity, specificity, and accuracy for the detection of hemodynamically significant stenosis of 96% (95%CI: 91-100), 72% (95%CI: 66-78), and 78% (95%CI: 73-83), respectively. Coronary CTA with CT-MPI showed a lower sensitivity (84%; 95%CI: 75-92) but higher specificity (89%; 95%CI: 85-93) and accuracy (88%; 95%CI: 84-92). The areas under the receiver-operating characteristic curve of absolute MBF and relative MBF were 0.79 (95%CI: 0.71-0.86) and 0.82 (95%CI: 0.74-0.88), respectively. The median dose-length product of CT-MPI and coronary CTA were 313 mGy·cm and 138 mGy·cm, respectively.CONCLUSIONS: Dynamic CT-MPI offers incremental diagnostic value over coronary CTA alone for the identification of hemodynamically significant coronary artery disease. Generalized results from this multicenter study encourage broader consideration of dynamic CT-MPI in clinical practice. (Dynamic Stress Perfusion CT for Detection of Inducible Myocardial Ischemia [SPECIFIC]; NCT02810795).

  View details for DOI 10.1016/j.jcmg.2021.07.021

  View details for PubMedID 34538630

• Trans-lesional fractional flow reserve gradient as derived from coronary CT improves patient management: ADVANCE registry. Journal of cardiovascular computed tomography Takagi, H., Leipsic, J. A., McNamara, N., Martin, I., Fairbairn, T. A., Akasaka, T., Norgaard, B. L., Berman, D. S., Chinnaiyan, K., Hurwitz-Koweek, L. M., Pontone, G., Kawasaki, T., Ronnow 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., Douglas, P. S., Patel, M. R., Nieman, K., Ihdayhid, A. R. 2021

  Abstract

  BACKGROUND: The role of change in fractional flow reserve derived from CT (FFRCT) across coronary stenoses (DeltaFFRCT) in guiding downstream testing in patients with stable coronary artery disease (CAD) is unknown.OBJECTIVES: To investigate the incremental value of DeltaFFRCT in predicting early revascularization and improving efficiency of catheter laboratory utilization.MATERIALS: Patients with CAD on coronary CT angiography (CCTA) were enrolled in an international multicenter registry. Stenosis severity was assessed as per CAD-Reporting and Data System (CAD-RADS), and lesion-specific FFRCT was measured 2​cm distal to stenosis. DeltaFFRCT was manually measured as the difference of FFRCT across visible stenosis.RESULTS: Of 4730 patients (66​±​10 years; 34% female), 42.7% underwent ICA and 24.7% underwent early revascularization. DeltaFFRCT remained an independent predictor for early revascularization (odds ratio per 0.05 increase [95% confidence interval], 1.31 [1.26-1.35]; p​<​0.001) after adjusting for risk factors, stenosis features, and lesion-specific FFRCT. Among the 3 models (model 1: risk factors​+​stenosis type and location​+​CAD-RADS; model 2: model 1​+​FFRCT; model 3: model 2​+​DeltaFFRCT), model 3 improved discrimination compared to model 2 (area under the curve, 0.87 [0.86-0.88] vs 0.85 [0.84-0.86]; p​<​0.001), with the greatest incremental value for FFRCT 0.71-0.80. DeltaFFRCT of 0.13 was the optimal cut-off as determined by the Youden index. In patients with CAD-RADS ≥3 and lesion-specific FFRCT ≤0.8, a diagnostic strategy incorporating DeltaFFRCT >0.13, would potentially reduce ICA by 32.2% (1638-1110, p​<​0.001) and improve the revascularization to ICA ratio from 65.2% to 73.1%.CONCLUSIONS: DeltaFFRCT improves the discrimination of patients who underwent early revascularization compared to a standard diagnostic strategy of CCTA with FFRCT, particularly for those with FFRCT 0.71-0.80. DeltaFFRCT has the potential to aid decision-making for ICA referral and improve efficiency of catheter laboratory utilization.

  View details for DOI 10.1016/j.jcct.2021.08.003

  View details for PubMedID 34518113

• CARDIAC COMPUTED TOMOGRAPHY ANGIOGRAPHY FOR THE SCREENING OF CARDIAC ALLOGRAFT VASCULOPATHY, TWO YEARS OF EXPERIENCE Roest, S., Nous, F. M. A., Brugts, J. J., Attrach, M., Nieman, K., Caliskan, K., Hirsch, A., Constantinescu, A. A., Budde, R. P. J., Manintveld, O. WILEY. 2021: 79

  View details for Web of Science ID 000689725500196

• Clinical implementation of coronary computed tomography angiography for routine detection of cardiac allograft vasculopathy in heart transplant patients. Transplant international : official journal of the European Society for Organ Transplantation Nous, F. M., Roest, S., van Dijkman, E. D., Attrach, M., Caliskan, K., Brugts, J. J., Nieman, K., Hirsch, A., Constantinescu, A. A., Manintveld, O. C., Budde, R. P. 2021

  Abstract

  Cardiac allograft vasculopathy (CAV) is an accelerated form of coronary artery disease that affects long-term outcomes in heart transplant (HTx) patients. We prospectively evaluated the feasibility of coronary computed tomography angiography (CCTA) for the detection of CAV during clinical implementation at our center. All consecutive HTx patients >4 years post-transplant were actively converted from myocardial perfusion imaging to CCTA for the annual assessment of CAV. Between February 2018 and May 2019, 129/172 (75%) HTx patients underwent a CCTA. Renal impairment (n=21/43) was the most frequent reason patients could not undergo CCTA. CCTA image quality was good-excellent in 118/129 (92%) patients and the radiation dose was 2.1 (1.6-2.8) mSv. CCTA showed obstructive CAV in 19/129 (15%) patients. Thirteen (10%) patients underwent additional tests, of which 8 patients underwent coronary revascularization within 90 days of CCTA. After 1 year, 3 additional coronary angiograms were performed, resulting in one revascularization in a patient with known severe CAV who developed ventricular tachycardia. One myocardial infarction after coronary stenting and 2 non-cardiac deaths were observed. CCTA can be successfully implemented for routine detection of CAV with good image quality and low radiation dose. CCTA allows CAV evaluation with limited need for additional invasive testing.

  View details for DOI 10.1111/tri.13973

  View details for PubMedID 34268796

• Coronary Artery Calcium Scoring: Toward a New Standard. Investigative radiology van Praagh, G. D., Wang, J., van der Werf, N. R., Greuter, M. J., Mastrodicasa, D., Nieman, K., van Hamersvelt, R. W., Oostveen, L. J., Lange, F. d., Slart, R. H., Leiner, T., Fleischmann, D., Willemink, M. J. 2021

  Abstract

  OBJECTIVES: Although the Agatston score is a commonly used quantification method, rescan reproducibility is suboptimal, and different CT scanners result in different scores. In 2007, McCollough et al (Radiology 2007;243:527-538) proposed a standard for coronary artery calcium quantification. Advancements in CT technology over the last decade, however, allow for improved acquisition and reconstruction methods. This study aims to investigate the feasibility of a reproducible reduced dose alternative of the standardized approach for coronary artery calcium quantification on state-of-the-art CT systems from 4 major vendors.MATERIALS AND METHODS: An anthropomorphic phantom containing 9 calcifications and 2 extension rings were used. Images were acquired with 4 state-of-the-art CT systems using routine protocols and a variety of tube voltages (80-120 kV), tube currents (100% to 25% dose levels), slice thicknesses (3/2.5 and 1/1.25 mm), and reconstruction techniques (filtered back projection and iterative reconstruction). Every protocol was scanned 5 times after repositioning the phantom to assess reproducibility. Calcifications were quantified as Agatston scores.RESULTS: Reducing tube voltage to 100 kV, dose to 75%, and slice thickness to 1 or 1.25 mm combined with higher iterative reconstruction levels resulted in an on average 36% lower intrascanner variability (interquartile range) compared with the standard 120 kV protocol. Interscanner variability per phantom size decreased by 34% on average. With the standard protocol, on average, 6.2 ± 0.4 calcifications were detected, whereas 7.0 ± 0.4 were detected with the proposed protocol. Pairwise comparisons of Agatston scores between scanners within the same phantom size demonstrated 3 significantly different comparisons at the standard protocol (P < 0.05), whereas no significantly different comparisons arose at the proposed protocol (P > 0.05).CONCLUSIONS: On state-of-the-art CT systems of 4 different vendors, a 25% reduced dose, thin-slice calcium scoring protocol led to improved intrascanner and interscanner reproducibility and increased detectability of small and low-density calcifications in this phantom. The protocol should be extensively validated before clinical use, but it could potentially improve clinical interscanner/interinstitutional reproducibility and enable more consistent risk assessment and treatment strategies.

  View details for DOI 10.1097/RLI.0000000000000808

  View details for PubMedID 34261083

• Emerging methods for the characterization of ischemic heart disease: ultrafast Doppler angiography, micro-CT, photon-counting CT, novel MRI and PET techniques, and artificial intelligence. European radiology experimental Willemink, M. J., Varga-Szemes, A., Schoepf, U. J., Codari, M., Nieman, K., Fleischmann, D., Mastrodicasa, D. 2021; 5 (1): 12

  Abstract

  After an ischemic event, disruptive changes in the healthy myocardium may gradually develop and may ultimately turn into fibrotic scar. While these structural changes have been described by conventional imaging modalities mostly on a macroscopic scale-i.e., late gadolinium enhancement at magnetic resonance imaging (MRI)-in recent years, novel imaging methods have shown the potential to unveil an even more detailed picture of the postischemic myocardial phenomena. These new methods may bring advances in the understanding of ischemic heart disease with potential major changes in the current clinical practice. In this review article, we provide an overview of the emerging methods for the non-invasive characterization of ischemic heart disease, including coronary ultrafast Doppler angiography, photon-counting computed tomography (CT), micro-CT (for preclinical studies), low-field and ultrahigh-field MRI, and 11C-methionine positron emission tomography. In addition, we discuss new opportunities brought by artificial intelligence, while addressing promising future scenarios and the challenges for the application of artificial intelligence in the field of cardiac imaging.

  View details for DOI 10.1186/s41747-021-00207-3

  View details for PubMedID 33763754

• Accreditation in cardiovascular CT. Journal of cardiovascular computed tomography Nieman, K. 2021

  View details for DOI 10.1016/j.jcct.2021.03.001

  View details for PubMedID 33744174

• Characteristics of culprit lesion in patients with non-ST-elevation myocardial infarction and improvement of diagnostic utility using dual energy cardiac CT. The international journal of cardiovascular imaging Sheta, H. M., Moller, S., Heinsen, L. J., Nieman, K., Thomsen, T., Egstrup, K., Lambrechtsen, J. 2021

  Abstract

  AIMS: The aim of the study was to identify the characteristics of the culprit lesions compared to non-culprit lesions in patients with non-ST-elevation-myocardial infarction using dual energy computed tomography (DECT).METHODS AND RESULTS: In 29 patients, we identified 29 culprit lesions and 227 non-culprit lesions. Quantitative values such as the effective atomic number (effective-Z) and Hounsfield Units (HU) values were measured. Furthermore, all the lesions were characterised using characteristics such as composition (non-calcified, predominantly-non-calcified, predominantly-calcified, or calcified), presence of spotty calcification, remodelling index, and napkin ring sign. The mean effective-Z and HU values were significantly lower in culprit lesions than in non-culprit lesions (8.99±1.21 vs 9.79±1.52; p=0.0066 and 87.41±84.97 vs. 154.45±176.13; p=0.0447). The culprit lesions had a higher frequency of non-calcified plaques and predominantly non-calcified plaques, and were with a greater presence of napkin ring signs in comparison with non-culprit lesions. There were no differences in the presence of spotty calcification or remodelling index. By adding effective-Z to plaque characteristics such as non-calcified, positive remodelling, spotty calcification, and napkin rings we observed a significant increased sensitivity of detecting culprit lesions (65.5% vs.44.8%), but no significant changes in area under curve (AUC).CONCLUSION: The use of DECT adds new information of the plaque composition expressed by the effective-Z, which differs significantly in culprit lesions in comparison with non-culprit lesions. The use of the effective-Z improves the diagnostic sensitivity in detection of culprit lesions.

  View details for DOI 10.1007/s10554-020-02141-8

  View details for PubMedID 33502653

• From Inception to 2020: a Review of Dynamic Myocardial CT Perfusion Imaging CURRENT CARDIOVASCULAR IMAGING REPORTS Balla, S., Nieman, K. 2021; 14 (1)

  View details for DOI 10.1007/s12410-020-09551-1

  View details for Web of Science ID 000605209300001

• Coronary Computed Tomographic Angiography for Complete Assessment of Coronary Artery Disease: JACC State-of-the-Art Review. Journal of the American College of Cardiology Serruys, P. W., Hara, H., Garg, S., Kawashima, H., Nørgaard, B. L., Dweck, M. R., Bax, J. J., Knuuti, J., Nieman, K., Leipsic, J. A., Mushtaq, S., Andreini, D., Onuma, Y. 2021; 78 (7): 713-736

  Abstract

  Coronary computed tomography angiography (CTA) has shown great technological improvements over the last 2 decades. High accuracy of CTA in detecting significant coronary stenosis has promoted CTA as a substitute for conventional invasive coronary angiography in patients with suspected coronary artery disease. In patients with coronary stenosis, CTA-derived physiological assessment is surrogate for intracoronary pressure and velocity wires, and renders possible decision-making about revascularization solely based on computed tomography. Computed tomography coronary anatomy with functionality assessment could potentially become a first line in diagnosis. Noninvasive imaging assessment of plaque burden and morphology is becoming a valuable substitute for intravascular imaging. Recently, wall shear stress and perivascular inflammation have been introduced. These assessments could support risk management for both primary and secondary cardiovascular prevention. Anatomy, functionality, and plaque composition by CTA tend to replace invasive assessment. Complete CTA assessment could provide a 1-stop-shop for diagnosis, risk management, and decision-making on treatment.

  View details for DOI 10.1016/j.jacc.2021.06.019

  View details for PubMedID 34384554

• Best Practices for Imaging Cardiac Device-Related Infections and Endocarditis: A JACC: Cardiovascular Imaging Expert Panel Statement. JACC. Cardiovascular imaging Dilsizian, V., Budde, R. P., Chen, W., Mankad, S. V., Lindner, J. R., Nieman, K. 2021

  Abstract

  The diagnosis of cardiac device infection and, more importantly, accurate localization of the infection site, such as defibrillator pocket, pacemaker lead, along the peripheral driveline or central portion of the left ventricular assist device, prosthetic valve ring abscesses, and perivalvular extensions, remain clinically challenging. Although transthoracic and transesophageal echocardiography are the first-line imaging tests in suspected endocarditis and for assessing hemodynamic complications, recent studies suggest that cardiac computed tomography (CT) or CT angiography and functional imaging with 18F-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) with CT (FDG PET/CT) may have an incremental role in technically limited or inconclusive cases on echocardiography. One of the key benefits of FDG PET/CT is in its detection of inflammatory cells early in the infection process, before morphological damages ensue. However, there are many unanswered questions in the literature. In this document, we provide consensus on best practices among the various imaging studies, which includes the detection of cardiac device infection, differentiation of infection from inflammation, image-guided patient management, and detailed recommendations on patient preparation, image acquisition, processing, interpretation, and standardized reporting.

  View details for DOI 10.1016/j.jcmg.2021.09.029

  View details for PubMedID 34922877

• A Policy Statement on Cardiovascular Test Substitution and Authorization: Principles of Patient-Centered Noninvasive Testing. Journal of the American College of Cardiology Thompson, R. C., Bateman, T. M., Blankstein, R., Di Carli, M. F., Heydari, B., Hung, J., Kwong, R. Y., Lindner, J. R., Nieman, K., Dorbala, S. 2021; 78 (13): 1385-1389

  View details for DOI 10.1016/j.jacc.2021.07.043

  View details for PubMedID 34556324

• Association Among Local Hemodynamic Parameters Derived From CT Angiography and Their Comparable Implications in Development of Acute Coronary Syndrome. Frontiers in cardiovascular medicine Yang, S., Choi, G., Zhang, J., Lee, J. M., Hwang, D., Doh, J., Nam, C., Shin, E., Cho, Y., Choi, S., Chun, E. J., Norgaard, B. L., Nieman, K., Otake, H., Penicka, M., Bruyne, B. D., Kubo, T., Akasaka, T., Taylor, C. A., Koo, B. 2021; 8: 713835

  Abstract

  Background: Association among local hemodynamic parameters and their implications in development of acute coronary syndrome (ACS) have not been fully investigated. Methods: A total of 216 lesions in ACS patients undergoing coronary CT angiography (CCTA) before 1-24 months from ACS event were analyzed. High-risk plaque on CCTA was defined as a plaque with ≥2 of low-attenuation plaque, positive remodeling, spotty calcification, and napkin-ring sign. With the use of computational fluid dynamics analysis, fractional flow reserve (FFR) derived from CCTA (FFRCT) and local hemodynamic parameters including wall shear stress (WSS), axial plaque stress (APS), pressure gradient (PG) across the lesion, and delta FFRCT across the lesion (DeltaFFRCT) were obtained. The association among local hemodynamics and their discrimination ability for culprit lesions from non-culprit lesions were compared. Results: A total of 66 culprit lesions for later ACS and 150 non-culprit lesions were identified. WSS, APS, PG, and DeltaFFRCT were strongly correlated with each other (all p < 0.001). This association was persistent in all lesion subtypes according to a vessel, lesion location, anatomical severity, high-risk plaque, or FFRCT ≤ 0.80. In discrimination of culprit lesions causing ACS from non-culprit lesions, WSS, PG, APS, and DeltaFFRCT were independent predictors after adjustment for lesion characteristics, high-risk plaque, and FFRCT ≤ 0.80; and all local hemodynamic parameters significantly improved the predictive value for culprit lesions of high-risk plaque and FFRCT ≤ 0.80 (all p < 0.05). The risk prediction model for culprit lesions with FFRCT ≤ 0.80, high-risk plaque, and DeltaFFRCT had a similar or superior discrimination ability to that with FFRCT ≤ 0.80, high-risk plaque, and WSS, APS, or PG; and the addition of WSS, APS, or PG into DeltaFFRCT did not improve the model performance. Conclusions: Local hemodynamic indices were significantly intercorrelated, and all indices similarly provided additive and independent predictive values for ACS risk over high-risk plaque and impaired FFRCT.

  View details for DOI 10.3389/fcvm.2021.713835

  View details for PubMedID 34589527

• Relationship of Stress Test Findings to Anatomic or Functional Extent of Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve. BioMed research international Doukas, D. n., Allen, S. n., Wozniak, A. n., Kunchakarra, S. n., Verma, R. n., Marot, J. n., Lopez, J. J., Nieman, K. n., Pontone, G. n., Leipsic, J. n., Bax, J. n., Rabbat, M. G. 2021; 2021: 6674144

  Abstract

  In the United States, functional stress testing is the primary imaging modality for patients with stable symptoms suspected to represent coronary artery disease (CAD). Coronary computed tomography angiography (CTA) is excellent at identifying anatomic coronary artery disease (CAD). The application of computational fluid dynamics to coronary CTA allows fractional flow reserve (FFR) to be calculated noninvasively (FFRCT). The relationship of noninvasive stress testing to coronary CTA and FFRCT in real-world clinical practice has not been studied.We evaluated 206 consecutive patients at Loyola University Chicago with suspected CAD who underwent noninvasive stress testing followed by coronary CTA and FFRCT when indicated. Patients were categorized by stress test results (positive, negative, indeterminate, and equivocal). Duke treadmill score (DTS), METS, exercise duration, and chest pain with exercise were analyzed. Lesions ≥ 50%stenosis were considered positive by coronary CTA. FFRCT < 0.80 was considered diagnostic of ischemia.Two hundred and six patients had paired noninvasive stress test and coronary CTA/FFRCT results. The median time from stress test to coronary CTA was 49 days. Average patient age was 60.3 years, and 42% were male. Of the 206 stress tests, 75% were exercise (70% echocardiographic, 26% nuclear, and 4% EKG). There were no associations of stress test results with CAD > 50% or FFRCT < 0.80 (p = 0.927 and p = 0.910, respectively). Of those with a positive stress test, only 30% (3/10) had CAD > 50% and only 50% (5/10) had FFRCT < 0.80. Chest pain with exercise did not correlate with CAD > 50% or FFRCT < 0.80 (p = 0.66 and p = 0.12, respectively). There were no significant correlations between METS, DTS, or exercise duration and FFRCT (r = 0.093, p = 0.274; r = 0.012, p = 0.883; and r = 0.034, p = 0.680; respectively).Noninvasive stress testing, functional capacity, chest pain with exercise, and DTS are not associated with anatomic or functional CAD using a diagnostic strategy of coronary CTA and FFRCT.

  View details for DOI 10.1155/2021/6674144

  View details for PubMedID 33681370

  View details for PubMedCentralID PMC7929671

• SCCT: A growing community. Journal of cardiovascular computed tomography Nieman, K. 2020

  View details for DOI 10.1016/j.jcct.2020.12.004

  View details for PubMedID 33349563

• Cardiovascular CT in a world adrift. Journal of cardiovascular computed tomography Nieman, K. 2020

  View details for DOI 10.1016/j.jcct.2020.08.002

  View details for PubMedID 32800769

• 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)

  View details for DOI 10.1007/s12170-020-0639-4

  View details for Web of Science ID 000527933200001

• 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

• The clinical utility of FFRCT stratified by age. Journal of cardiovascular computed tomography Anastasius, M. n., Maggiore, P. n., Huang, A. n., Blanke, P. n., Patel, M. R., Nørgaard, B. L., Fairbairn, T. A., Nieman, K. n., Akasaka, T. n., Berman, D. S., Raff, G. L., Hurwitz Koweek, L. M., Pontone, G. n., Kawasaki, T. n., Rønnow Sand, N. P., Jensen, J. M., Amano, T. n., Poon, M. n., Øvrehus, K. A., Sonck, J. n., Rabbat, M. G., Mullen, S. n., De Bruyne, B. n., Rogers, C. n., Matsuo, H. n., Bax, J. J., Leipsic, J. n. 2020

  Abstract

  CT coronary angiography (CTA) with Fractional Flow Reserve as determined by CT (FFRCT) is a safe alternative to invasive coronary angiography. A negative FFRCT has been shown to have low cardiac event rates compared to those with a positive FFRCT. However, the clinical utility of FFRCT according to age is not known.Patients' in the ADVANCE (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) registry, were stratified into those ≥65 or <65 years of age. The impact of FFRCT on clinical decision-making, as assessed by patient age, was determined by evaluating patient management using CTA results alone, followed by site investigators submitting a report on the treatment plan based upon the newly provided FFRCT data. Outcomes at 1-year post CTA were assessed, including major adverse cardiovascular events (myocardial infarction, all-cause mortality or unplanned hospitalization for ACS leading to revascularisation) and total revascularisation. Positive FFRCT was deemed to be ≤ 0.8.FFRCT was calculated in 1849 (40.6%) subjects aged <65 and 2704 (59.4%) ≥ 65 years of age. Subjects ≥65 years were more likely to have anatomic obstructive disease on CTA (≥50% stenosis), compared to those aged <65 (69.7% and 73.2% respectively, p = 0.008). There was a similar graded increase in recommended and actual revascularisation with either CABG or PCI, with declining FFRCT strata for subjects above and below the age of 65. MACE and revascularisation rates were not significantly different for those ≥ or <65, regardless of FFRCT positivity or stenosis severity <50% or ≥50%. With a negative FFRCT result, and anatomical stenosis ≥50%, those ≥ and <65 years of age, had similar rates of MACE (0.2% for both, p = 0.1) and revascularisation (8.7% and 10.4% respectively p = 0.4). Logistic regression analysis, with age as a continuous variable, and adjustment for Diamond Forrester Risk, baseline FFRCT and treatment (CABG, PCI, medical therapy), indicated a statistically significant, but small increase in the odds of a MACE event with increasing age (OR 1.04, 95% CI 1.006-1.08, p = 0.02). Amongst patients with a FFRCT > 0.80, there was no effect of age on the odds of revascularisation.The findings of this study point to a low risk of MACE events or need for revascularisation in those aged ≥ or <65 with a FFRCT>0.80, despite the higher incidence of anatomic obstructive CAD in those ≥65 years. The findings show the clinical usefulness and outcomes of FFRCT are largely constant regardless of age.

  View details for DOI 10.1016/j.jcct.2020.08.006

  View details for PubMedID 33032976

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

• Cardiac Imaging in the Post-ISCHEMIA Trial Era: A Multisociety Viewpoint. JACC. Cardiovascular imaging Shaw, L. n., Kwong, R. Y., Nagel, E. n., Salerno, M. n., Jaffer, F. n., Blankstein, R. n., Dilsizian, V. n., Flachskampf, F. n., Grayburn, P. n., Leipsic, J. n., Marwick, T. n., Nieman, K. n., Raman, S. n., Sengupta, P. n., Zoghbi, W. n., Pellikka, P. A., Swaminathan, M. n., Dorbala, S. n., Thompson, R. n., Al-Mallah, M. n., Calnon, D. n., Polk, D. n., Soman, P. n., Beanlands, R. n., Garrett, K. N., Henry, T. D., Rao, S. V., Duffy, P. L., Cox, D. n., Grines, C. n., Mahmud, E. n., Bucciarelli-Ducci, C. n., Plein, S. n., Greenwood, J. P., Berry, C. n., Carr, J. n., Arai, A. E., Murthy, V. L., Ruddy, T. D., Chandrashekhar, Y. n. 2020; 13 (8): 1815–33

  View details for DOI 10.1016/j.jcmg.2020.05.001

  View details for PubMedID 32762886

• 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

  View details for DOI 10.1016/j.jcmg.2019.03.003

  View details for Web of Science ID 000505784200015

• Sex Differences in Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve: Lessons From ADVANCE. JACC. Cardiovascular imaging Fairbairn, T. A., Dobson, R. n., Hurwitz-Koweek, L. n., Matsuo, H. n., Norgaard, B. L., Rønnow Sand, N. P., Nieman, K. n., Bax, J. J., Pontone, G. n., Raff, G. n., Chinnaiyan, K. M., Rabbat, M. n., Amano, T. n., Kawasaki, T. n., Akasaka, T. n., Kitabata, H. n., Binukrishnan, S. n., Rogers, C. n., Berman, D. n., Patel, M. R., Douglas, P. S., Leipsic, J. n. 2020

  Abstract

  This study is to determine the management and clinical outcomes of patients investigated with coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) according to sex.Women are underdiagnosed with conventional ischemia testing, have lower rates of obstructive coronary artery disease (CAD) at invasive coronary angiography (ICA), yet higher mortality compared to men. Whether FFRCT improves sex-based patient management decisions compared to CCTA alone is unknown.Subjects with symptoms and CAD on CCTA were enrolled (2015 to 2017). Demographics, symptom status, CCTA anatomy, coronary volume to myocardial mass ratio (V/M), lowest FFRCT values, and management plans were captured. Endpoints included reclassification rate between CCTA and FFRCT management plans, incidence of ICA demonstrating obstructive CAD (≥50% stenosis) and revascularization rates.A total of 4,737 patients (n = 1,603 females, 33.8%) underwent CCTA and FFRCT. Women were older (age 68 ± 10 years vs. 65 ± 10 years; p < 0.0001) with more atypical symptoms (41.5% vs. 33.9%; p < 0.0001). Women had less obstructive CAD (65.4% vs. 74.7%; p < 0.0001) at CCTA, higher FFRCT (0.76 ± 0.10 vs. 0.73 ± 0.10; p < 0.0001), and lower likelihood of positive FFRCT ≤ 0.80 for the same degree stenosis (p < 0.0001). A positive FFRCT less than or equal to 0.80 resulted in equal referral to ICA (n = 510 [54.5%] vs. n = 1,249 [56.5%]; p = 0.31), but more nonobstructive CAD (n = 208 [32.1%] vs. n = 354 [24.5%]; p = 0.0003) and less revascularization (n = 294 [31.4%] vs. n = 800 [36.2%]; p < 0.0001) in women, unless the FFRCT was ≤0.75 where revascularization rates were similar (n = 253 [41.9%] vs. n = 715 [46.4%]; p = 0.06). Women have a higher V/M ratio (26.17 ± 7.58 mm3/g vs. 24.76 ± 7.22 mm3/g; p < 0.0001) that is associated with higher FFRCT independent of degree stenosis (p < 0.001). Predictors of revascularization included stenosis severity, FFRCT, symptoms, and V/M ratio (p < 0.001) but not female sex (p = 0.284).FFRCT differs between the sexes, as women have a higher FFRCT for the same degree of stenosis. In FFRCT-positive CAD, women have less obstructive CAD at ICA and less revascularization, which is associated with higher V/M ratio. The findings suggest that CAD and FFRCT variations by sex need specific interpretation as these differences may affect therapeutic decision making and clinical outcomes. (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care [ADVANCE]; NCT02499679).

  View details for DOI 10.1016/j.jcmg.2020.07.008

  View details for PubMedID 32861656

• Current Evidence and Recommendations for Coronary CTA First in Evaluation of Stable Coronary Artery Disease. Journal of the American College of Cardiology Poon, M. n., Lesser, J. R., Biga, C. n., Blankstein, R. n., Kramer, C. M., Min, J. K., Noack, P. S., Farrow, C. n., Hoffman, U. n., Murillo, J. n., Nieman, K. n., Shaw, L. J. 2020; 76 (11): 1358–62

  View details for DOI 10.1016/j.jacc.2020.06.078

  View details for PubMedID 32912449

• Pace of guidance publishing accelerates in cardiovascular CT. Journal of cardiovascular computed tomography Nieman, K. n. 2020

  View details for DOI 10.1016/j.jcct.2020.09.010

  View details for PubMedID 33032974

  View details for PubMedCentralID PMC7527878

• Lipid-rich Plaques Detected by Near-infrared Spectroscopy Are More Frequently Exposed to High Shear Stress. Journal of cardiovascular translational research Hartman, E. M., De Nisco, G. n., Kok, A. M., Hoogendoorn, A. n., Coenen, A. n., Mastik, F. n., Korteland, S. A., Nieman, K. n., Gijsen, F. J., van der Steen, A. F., Daemen, J. n., Wentzel, J. J. 2020

  Abstract

  High wall shear stress (WSS) and near-infrared spectroscopy (NIRS) detected lipid-rich plaque (LRP) are both known to be associated with plaque destabilization and future adverse cardiovascular events. However, knowledge of spatial co-localization of LRP and high WSS is lacking. This study investigated the co-localization of LRP based on NIRS and high WSS. Fifty-three patients presenting acute coronary syndrome underwent NIRS-intravascular-ultrasound (NIRS-IVUS) imaging of a non-culprit coronary artery. WSS was obtained using WSS profiling in 3D-reconstructions of the coronary arteries based on fusion of IVUS-segmented lumen and CT-derived 3D-centerline. Thirty-eight vessels were available for final analysis and divided into 0.5 mm/45° sectors. LRP sectors, as identified by NIRS, were more often colocalized with high WSS than sectors without LRP. Moreover, there was a dose-dependent relationship between lipid content and high WSS exposure. This study is a first step in understanding the evolution of LRPs to vulnerable plaques. Graphical Abstract.

  View details for DOI 10.1007/s12265-020-10072-x

  View details for PubMedID 33034862

• Highlights of the 15th annual scientific meeting of the Society of Cardiovascular Computed Tomography. Journal of cardiovascular computed tomography Weir-McCall, J. R., Branch, K. n., Ferencik, M. n., Blankstein, R. n., Choi, A. D., Ghoshhajra, B. B., Chinnaiyan, K. n., Parwani, P. n., Nicol, E. n., Nieman, K. n. 2020

  Abstract

  The 15th Society of Cardiovascular Computed Tomography (SCCT) annual scientific meeting (ASM) welcomed 770 digital attendees from 44 countries, over 2 days, with a program that included 30 sessions across three simultaneously streaming channels, 10 exhibitors and a diverse range of scientific abstracts. In addition, #SCCT2020 generated >5900 tweets from nearly 700 engaged social media participants resulting in an estimated 38 million digital impressions and becoming #1 trending medical meeting in social media in the world during the meeting time period. 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 cardiovascular computed tomography.

  View details for DOI 10.1016/j.jcct.2020.09.008

  View details for PubMedID 33028509

• Stress myocardial perfusion with qualitative magnetic resonance and quantitative dynamic computed tomography: comparison of diagnostic performance and incremental value over coronary computed tomography angiography. European heart journal cardiovascular Imaging de Knegt, M. C., Rossi, A. n., Petersen, S. E., Wragg, A. n., Khurram, R. n., Westwood, M. n., Saberwal, B. n., Mathur, A. n., Nieman, K. n., Bamberg, F. n., Jensen, M. T., Pugliese, F. n. 2020

  Abstract

  Assessment of haemodynamically significant coronary artery disease (CAD) using cardiovascular magnetic resonance (CMR) imaging perfusion or dynamic stress myocardial perfusion imaging by computed tomography (CT perfusion) may aid patient selection for invasive coronary angiography (ICA). We evaluated the diagnostic performance and incremental value of qualitative CMR perfusion and quantitative CT perfusion complementary to cardiac computed tomography angiography (CCTA) for the diagnosis of haemodynamically significant CAD using fractional flow reserve (FFR) and quantitative coronary angiography (QCA) as reference standard.CCTA, qualitative visual CMR perfusion, visual CT perfusion, and quantitative relative myocardial blood flow (CT-MBF) were performed in patients with stable angina pectoris. FFR was measured in coronary vessels with stenosis visually estimated between 30% and 90% diameter reduction on ICA. Haemodynamically significant CAD was defined as FFR <0.80, or QCA ≥80% in those cases where FFR could not be performed. A total of 218 vessels from 93 patients were assessed. An optimal cut-off of 0.72 for relative CT-MBF was determined. The diagnostic performances (area under the receiver-operating characteristics curves, 95% CI) of visual CMR perfusion (0.84, 0.77-0.90) and relative CT-MBF (0.86, 0.81-0.92) were comparable and outperformed visual CT perfusion (0.64, 0.57-0.71). In combination with CCTA ≥50%, CCTA + visual CMR perfusion (0.91, 0.86-0.96), CCTA + relative CT-MBF (0.92, 0.88-0.96), and CCTA + visual CT perfusion (0.82, 0.75-0.90) improved discrimination compared with CCTA alone (all P < 0.05).Visual CMR perfusion and relative CT-MBF outperformed visual CT perfusion and provided incremental discrimination compared with CCTA alone for the diagnosis of haemodynamically significant CAD.

  View details for DOI 10.1093/ehjci/jeaa270

  View details for PubMedID 33029616

• 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. n., Nieman, K. n., Channon, K. n., 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

• SCCT 2021 expert consensus document on coronary computed tomographic angiography: A report of the society of Cardiovascular Computed Tomography. Journal of cardiovascular computed tomography Narula, J. n., Chandrashekhar, Y. n., Ahmadi, A. n., Abbara, S. n., Berman, D. S., Blankstein, R. n., Leipsic, J. n., Newby, D. n., Nicol, E. D., Nieman, K. n., Shaw, L. n., Villines, T. C., Williams, M. n., Hecht, H. S. 2020

  View details for DOI 10.1016/j.jcct.2020.11.001

  View details for PubMedID 33303384

• Multimodality Cardiovascular Imaging in the Midst of the COVID-19 Pandemic: Ramping Up Safely to a New Normal. JACC. Cardiovascular imaging Zoghbi, W. A., DiCarli, M. F., Blankstein, R. n., Choi, A. D., Dilsizian, V. n., Flachskampf, F. A., Geske, J. B., Grayburn, P. A., Jaffer, F. A., Kwong, R. Y., Leipsic, J. A., Marwick, T. H., Nagel, E. n., Nieman, K. n., Raman, S. V., Salerno, M. n., Sengupta, P. P., Shaw, L. J., Chandrashekhar, Y. S. 2020; 13 (7): 1615–26

  View details for DOI 10.1016/j.jcmg.2020.06.001

  View details for PubMedID 32646721

  View details for PubMedCentralID PMC7290215

• 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. n., Schnittger, I. n., Tremmel, J. n., Pargaonkar, V. n., Rogers, I. n., Becker, H. C., Yang, S. n., Mastrodicasa, D. n., Willemink, M. n., Fleischmann, D. n., Nieman, K. n. 2020; 13 (2): e009576

  View details for DOI 10.1161/CIRCIMAGING.119.009576

  View details for PubMedID 32069114

• 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. J. W., Koweek, L. M., Fleischmann, D. 2019; 13 (6): 347–52

  View details for DOI 10.1016/j.jcct.2018.10.014

  View details for Web of Science ID 000502828000012

• 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

  View details for DOI 10.1007/s00330-019-06196-7

  View details for Web of Science ID 000490625400039

• 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

• 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

• 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

  View details for DOI 10.2214/AJR.18.20774

  View details for Web of Science ID 000477908100022

• 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-+

  View details for DOI 10.1093/eurheartj/ehy404

  View details for Web of Science ID 000474259100018

• 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)

  View details for DOI 10.1007/s12410-019-9496-2

  View details for Web of Science ID 000467015800001

• 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

• 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) AMERICAN JOURNAL OF CARDIOLOGY Nous, F. M. A., Coenen, A., Boersma, E., Kim, Y., Kruk, M. B. P., Tesche, C., de Geer, J., Yang, D., Kepka, C., Schoepf, U., Persson, A., Kurata, A., Budde, R. P. J., Nieman, K. 2019; 123 (4): 537-543

  View details for DOI 10.1016/j.amjcard.2018.11.024

  View details for Web of Science ID 000459226300001

• 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. J., Roos-Hesselink, J. W. 2019; 276: 230–35

  View details for DOI 10.1016/j.ijcard.2018.08.067

  View details for Web of Science ID 000454877900051

• Incremental Value of Aortomitral Continuity Calcification for Risk Assessment after Transcatheter Aortic Valve Replacement. Radiology. Cardiothoracic imaging Willemink, M. J., Maret, E. n., Moneghetti, K. J., Kim, J. B., Haddad, F. n., Kobayashi, Y. n., Nishi, T. n., Nieman, K. n., Cauwenberghs, N. n., Kuznetsova, T. n., Higashigaito, K. n., Sailer, A. M., Yeung, A. C., Lee, A. M., Miller, D. C., Fischbein, M. n., Fearon, W. F., Fleischmann, D. n. 2019; 1 (5): e190067

  Abstract

  To investigate the association of aortomitral continuity calcification (AMCC) with all-cause mortality, postprocedural paravalvular leak (PVL), and prolonged hospital stay in patients undergoing transcatheter aortic valve replacement (TAVR).The authors retrospectively evaluated 329 patients who underwent TAVR between March 2013 and March 2016. AMCC, aortic valve calcification (AVC), and coronary artery calcification (CAC) were quantified by using preprocedural CT. Pre-procedural Society of Thoracic Surgeons (STS) score was recorded. Associations between baseline AMCC, AVC, and CAC and 1-year mortality, PVL, and hospital stay longer than 7 days were analyzed.The median follow-up was 415 days (interquartiles, 344-727 days). After 1 year, 46 of the 329 patients (14%) died and 52 (16%) were hospitalized for more than 7 days. Of the 326 patients who underwent postprocedural echocardiography, 147 (45%) had postprocedural PVL. The CAC score (hazard ratio: 1.11 per 500 points) and AMCC mass (hazard ratio: 1.13 per 500 mg) were associated with 1-year mortality. AVC mass (odds ratio: 1.93 per 100 mg) was associated with postprocedural PVL. Only the STS score was associated with prolonged hospital stay (odds ratio: 1.19 per point).AMCC is associated with mortality within 1 year after TAVR and substantially improves individual risk classification when added to a model consisting of STS score and AVC mass only.Supplemental material is available for this article.© RSNA, 2019See also the commentary by Brown and Leipsic in this issue.

  View details for DOI 10.1148/ryct.2019190067

  View details for PubMedID 33778530

  View details for PubMedCentralID PMC7977784

• Coronary CT Angiography-derived Fractional Flow Reserve Testing in Patients with Stable Coronary Artery Disease: Recommendations on Interpretation and Reporting. Radiology. Cardiothoracic imaging Nørgaard, B. L., Fairbairn, T. A., Safian, R. D., Rabbat, M. G., Ko, B. n., Jensen, J. M., Nieman, K. n., Chinnaiyan, K. M., Sand, N. P., Matsuo, H. n., Leipsic, J. n., Raff, G. n. 2019; 1 (5): e190050

  Abstract

  Noninvasive fractional flow reserve derived from coronary CT angiography (FFRCT) is increasingly used in patients with coronary artery disease as a gatekeeper to the catheterization laboratory. While there is emerging evidence of the clinical benefit of FFRCT in patients with moderate coronary disease as determined with coronary CT angiography, there has been less focus on interpretation, reporting, and integration of FFRCT results into routine clinical practice. Because FFRCT analysis provides a plethora of information regarding pressure and flow across the entire coronary tree, standardized criteria on interpretation and reporting of the FFRCT analysis result are of crucial importance both in context of the clinical adoption and in future research. This report represents expert opinion and recommendation on a standardized FFRCT interpretation and reporting approach. Published under a CC BY 4.0 license.

  View details for DOI 10.1148/ryct.2019190050

  View details for PubMedID 33778528

  View details for PubMedCentralID PMC7977999

• 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. n., Renker, M. n., Schoepf, U. J., De Cecco, C. N., Coenen, A. n., De Geer, J. n., Kruk, M. n., Kim, Y. H., Albrecht, M. H., Duguay, T. M., Jacobs, B. E., Bayer, R. R., Litwin, S. E., Weiss, C. n., Akin, I. n., Borggrefe, M. n., Yang, D. H., Kepka, C. n., Persson, A. n., Nieman, K. n., Tesche, C. n. 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. n., Nieman, K. n., Town, K. n., 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. n., Coenen, A. n., Kim, Y. H., Kruk, M. n., Tesche, C. n., Schoepf, U. J., Kepka, C. n., Yang, D. H., Nieman, K. n., Persson, A. n. 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. n., Weir-McCall, J. R., Baggiano, A. n., Del Torto, A. n., Fusini, L. n., Guglielmo, M. n., Muscogiuri, G. n., Guaricci, A. I., Andreini, D. n., Patel, M. n., Nieman, K. n., Akasaka, T. n., Rogers, C. n., Nørgaard, B. L., Bax, J. n., Raff, G. L., Chinnaiyan, K. n., Berman, D. n., Fairbairn, T. n., Koweek, L. H., Leipsic, J. n. 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

• 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. n., Dharampal, A. n., Lubbers, M. n., Kock, M. n., Wildberger, J. E., Das, M. n., Niezen, A. n., van Tilborg, F. n., Kofflard, M. n., Laghi, A. n., Krestin, G. n., Nieman, K. n. 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

• 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

• Computed tomography myocardial perfusion imaging vs. computed tomography-derived fractional flow reserve, which way forward? EUROPEAN HEART JOURNAL-CARDIOVASCULAR IMAGING Nieman, K. 2018; 19 (11): 1230-1231

  View details for DOI 10.1093/ehjci/jey125

  View details for Web of Science ID 000455358100003

• 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; 12 (6): 523-528

  View details for DOI 10.1016/j.jcct.2018.09.005

  View details for Web of Science ID 000451378700013

• Cardiac Computed Tomography 2.0 Adding Physiology to Anatomy JACC-CARDIOVASCULAR IMAGING Nieman, K., Shaw, L. J., Chandrashekhar, Y. 2018; 11 (11): 1733-1735

  View details for DOI 10.1016/j.jcmg.2018.10.002

  View details for Web of Science ID 000449294100032

• Comprehensive Cardiac CT With Myocardial Perfusion Imaging Versus Functional Testing in Suspected Coronary Artery 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): 1625-1636

  View details for DOI 10.1016/j.jcmg.2017.10.010

  View details for Web of Science ID 000449294100011

• 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

• 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. n., Greuter, M. J., Koweek, L. M., Fleischmann, D. n. 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

• 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. P. 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

• 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)

  View details for DOI 10.1161/CIRCIMAGING.117.006535

  View details for Web of Science ID 000401548500018

  View details for PubMedID 28487324

• 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

• 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

• 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

• 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

• 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

• 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 DOI 10.1007/s10554-015-0779-7

  View details for PubMedID 26498478

  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

• 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