968 Chronic total occlusion: the last frontier / Imaging, other

968
Chronic total occlusion: the last frontier / Imaging, other
everolimus-eluting stents. The only independent predictor of stent thrombosis in
these patients was minimum lumen diameter after stenting. Clinical presentation
was relatively benign in all cases.
P5323 | BEDSIDE
Long-term survival benefit of revascularization for chronic total
occlusions in patients with reduced left ventricular ejection
fraction in comparison with medical treatment
A. Fujino, H. Sakamoto, M. Fujino, T. Yamane, T. Nagai, Y. Asaumi, T. Miyagi,
M. Ishihara, S. Yasuda, H. Ogawa. National Cardiovascular Center, Department
of Internal Medicine, Division of Cardiology, Suita, Osaka, Japan
Conclusions: Although routine performance of revascularization for CTO was
not necessarily associated with improved survival, revascularization for CTO in
patients with reduced LVEF may contribute to improve their prognosis.
P5331 | BEDSIDE
Computed tomography myocardial perfusion and myocardial blood
flow by oxygen 15 positron emission tomography
M.C. Williams 1 , N. Weir 2 , M. Dweck 1 , S. Mirsadraee 2 , E.J.R. Van Beek 2 ,
J.H. Reid 2 , N. Uren 3 , G. Mckillop 3 , D.E. Newby 1 . 1 University of Edinburgh,
Centre for Cardiovascular Science, Edinburgh, United Kingdom; 2 University
of Edinburgh, Clinical Research Imaging Centre, Edinburgh, United Kingdom;
3 Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
Introduction: Non-invasive computed tomography imaging has the potential to
achieve comprehensive cardiac assessment in a rapid and low radiation dose assessment. We assessed computed tomography coronary angiography (CTCA)
and computed tomography myocardial perfusion (CTP) compared to invasive
coronary angiography (ICA) and fractional flow reserve (FFR). In addition we assessed myocardial blood flow using oxygen-15 labelled water positron emission
tomography (PET).
Methods: Contrast enhanced, electrocardiogram gated CTCA and adenosine
stress CTP was performed in 31 patients (69% male) using a 320 multidetector
scanner. Significant coronary disease was assessed on a per vessel basis as a
stenosis greater than 50% with corresponding hypoperfusion on CTP. All patients
underwent ICA and significant coronary artery disease was assessed as a stenosis greater than 70% and/or an FFR less than 0.8. Five patients underwent rest
and adenosine stress oxygen-15 PET. The total coronary resistance (TCR) at rest
and stress was calculated as the mean arterial pressured divided by myocardial
blood flow.
Results: The mean age was 63 years (95% CI 61, 66), body mass index 28 kg/m2
(27, 30) and radiation dose 564 mGy.cm (437, 692). The sensitivity, specificity,
negative predictive value and positive predictive value of CTCA/CTP for detecting
significant coronary artery disease as compared to ICA/FFR were 85%, 84%,
30% and 92% respectively. TCR at rest and stress were 80 (72, 87) and 31 (28,
33) for normal regions compared to 97 (43, 151) and 33 (32, 34) for regions with
hypoperfusion on CTP.
POSTER SESSION 7
IMAGING, OTHER
P5330 | BEDSIDE
Epicardial adipose tissue and left atrial size as CT-derived
predictors of atrial fibrillation: the heinz nixdorf recall study
A.A. Mahabadi 1 , N. Lehmann 2 , H. Kalsch 1 , M. Bauer 1 , I. Dykun 1 , S. Moebus 2 ,
K.-H. Jockel 2 , R. Erbel 1 , S. Mohlenkamp 3 on behalf of Heinz Nixdorf Recall
Investigative Group. 1 University Hospital of Essen, Department of Cardiology,
Essen, Germany; 2 University of Duisburg-Essen, Institute for Medical
Informatics, Biometry and Epidemiology, Essen, Germany; 3 Krankenhaus
Bethanien, Department of Cardiology, Moers, Germany
Purpose: Left atrial size (LA) is an established predictor of atrial fibrillation (AF).
Also, epicardial adipose tissue (EAT) is suggested to influence AF due to its inflammatory modulating effect. We aimed to determine, whether these CT-derived
measures predict AF.
Figure 1. CTCA/CTP compared to ICA/FFR
Abstract P5330 – Table 1. Association of epicardial adipose tissue (EAT) and left atrial size (LA) with overall and incident atrial fibrillation (AF).
Unadjusted
OR (95% CI)
Overall AF (n=96)
Incident AF (n=50)
EAT
LA
EAT
LA
1.85 (1.60–2.14)
3.08 (2.62–3.63)
1.78 (1.44–2.18)
2.29 (1.88–2.79)
p-value
<0.0001
<0.0001
<0.0001
<0.0001
Risk factor adjusted
OR (95% CI)
p-value
1.30 (1.05–1.59)
2.62 (2.18–3.15)
1.19 (0.88–1.61)
1.78 (1.42–2.25)
0.014
<0.0001
0.26
<0.0001
+ LA-adjusted/EAT-adjusted
OR (95% CI)
p-value
1.20 (0.95–1.51)
2.60 (2.16–3.13)
1.10 (0.81–1.50)
1.77 (1.40–2.23)
0.13
<0.0001
0.52
<0.0001
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Background: It remains unknown whether revascularization for chronic total occlusions (CTO) may have survival benefit in comparison with medical treatment.
Methods: Between 1998 and 2008, 1231 consecutive patients (M/F 1078/153,
age 67±11 years) with CTO were examined and divided into the following 2
groups; revascularization (REV) and medical treatment (MED) groups. We compared all-cause mortality between the 2 groups and performed a subgroup analysis according to the baseline left ventricular ejection fraction (LVEF; ≤40% or
>40%). To minimize differences in baseline characteristics, multivariate Cox regression analysis was performed.
Results: Percutaneous (n=439; 36%) or surgical (n=411; 33%) revascularization
were performed in 850 (69%) patients. The rate of successful revascularization
for CTO was 82%. The remaining 381 patients (31%) underwent medical treatment. During a median follow-up of 7.5 years (4.5-10.2), all-cause mortality rate
was significantly lower in REV group than MED group (23% vs. 31%, P=0.005).
However, multivariate analysis demonstrated that revascularization for CTO was
not significantly associated with the overall survival improvement (hazard ratio
[HR], 0.77; 95% confidence interval [CI], 0.55 to 1.07; P=0.12). In the subgroup
analysis for patients with LVEF ≤40%, revascularization for CTO was associated
with a survival advantage (HR, 0.45; 95% CI, 0.26 to 0.78; P=0.004), whereas
there was no significant difference in survival between the 2 groups for patients
with LVEF >40% (HR, 1.20; 95% CI, 0.83 to 1.73; P=0.34) (figure).
Methods: Participants from the Heinz Nixdorf Recall Study free of cardiovascular
disease were included. EAT was defined as fat inside the pericardium. LA was
defined as area at the level of the mitral valve. AF was determined from ECG
at baseline and 5-year follow-up examination. Logistic regression analysis determined the association of EAT and LA with AF in unadjusted, AF risk factors
adjusted (age, gender, BMI, systolic blood pressure, and antihypertensive medication), and ancillary LA/EAT adjusted models. Results are given as odds ratio
per standard deviation of LA/EAT.
Results: Of 3905 subjects included (mean age 59±7.7 years, 47.2% male), 96
subjects had AF (46 with AF at baseline examination, 50 with sinus rhythm at
baseline and AF at follow up). Subjects with AF had higher EAT volume and LA
area then those in sinus rhythm (EAT: 139±65 vs. 95±48 ml, p<0.0001, LA:
25.8±0.9 cm2 vs. 17.6±0.4 cm2 , p<0.0001). EAT and LA were associated with
AF in univariate and risk factors adjusted analysis (table). When adding both LA
and EAT in the model, association for LA remained stable, while the link of EAT
was attenuated. For incident AF, both parameters were strongly associated in
univariate analysis, while in multivariable analysis, EAT showed no independent
link. CT-derived measures improved the area under the receiver operating characteristic curve over risk factors (0.810 to 0.852, p=0.0045). Again, this effect was
predominantly explained by LA (0.810 to 0.848, p=0.0076).
Conclusion: LA size as a morphological correlate of LA remodeling is a stronger
predictor of AF than the inflammatory modulating EAT.
Imaging, other
Conclusion: The diagnostic accuracy of CTCA/CTP imaging compares well with
ICA/FFR. CTP may detect additional areas of hypoperfusion and oxygen-15 PET
imaging will assist the assessment of these technologies.
P5332 | BEDSIDE
Diagnostic value of cardiac multi-detector computed tomography
for detection of subclinical atherosclerosis in asymptomatic
diabetic patients
H.C. Jeong, I.N.N.A. Kim, Y. Ahn, K.H. Park, D.S. Sim, Y.H. Hong, J.H. Kim,
M.H. Jeong. Chonnam National University Hospital, Gwangju, Korea, Republic of
P5333 | BEDSIDE
320-row area detector computed tomography with novel protocol
might be useful in evaluating aortic comorbidity in ischemic heart
disease patients
S. Ide, K. Yokoi, K. Okayama, P. Siegrist, I. Mizote, M. Kumada, T. Kuroda,
K. Tachibana, S. Sumitsuji, S. Nanto. Osaka University, Graduate School of
Medicine, Department of Advanced Cardiovascular Therapeutics, Osaka, Japan
Purpose: Despite frequent aortic comorbidity in ischemic heart disease (IHD) patients, concomitant coronary (CA) and aortic (Ao) evaluation with using conventional helical Ao scan before intervention is controversial. Novel 320-row-area-
detector CT (ADCT) incorporates Wide-5-Volume protocol (W5Vp) and AdaptiveInteractive-Dose-Reduction-3-Dimensional-Reconstruction (AIDR), reducing contrast medium dosage (CMD) and radiation exposure. We hypothesized that ADCT
might be useful in evaluating Ao comorbidity in patients suspected of IHD.
Method: Patients with suspected IHD underwent Ao and CA evaluation with
ADCT under W5Vp and AIDR. Retrospective ECG gating was performed for CA
phase. Tube voltage was 100kV for patients with body mass index (BMI) of less
than 25kg/m2 , and 120kV for BMI of 25kg/m2 or more.CMD was calculated as
0.6×body weight. The mean attenuation was measured at Ao arch, ascending,
descending, and abdominal Ao and femoral arteries (FA). We compared CMD
and radiation exposure among the protocols of W5Vp, cardiac CT with helical Ao
scan (CCTWAo) and Cardiac-CT (CCT).
Result: 80 examinations were performed. 27 CA, 9 subclavian and 8 iliac arterial stenotic lesions were revealed. Shaggy Ao was noticed in 5 patients. The
mean radiation dose was not significantly smaller than that of CCT (13.8±4.6
mSv versus 14.9±5.8mSv). The mean CMD was significantly smaller than that
of CCTWAo (38±7ml versus 79.9±11.6 ml; p<0.0001). Regarding the image
quality, mean attenuation was 423±99 Hounsfield units (HU) at ascending Ao,
456±89HU at descending Ao, 366±99HU at abdominal Ao, and 362±108HU at
common FA.
Conclusion: With ADCT incorporating novel W5Vp and AIDR, evaluation of Ao
comorbidity in patients with suspected IHD might be possible with less CMD and
lower radiation with good image quality.
P5334 | SPOTLIGHT 2013
Carotid plaque inflammation in patients with acute coronary
syndrome assessed by 18f-fluorodeoxyglucose positron emission
tomography
S. Kim 1 , H.S. Seo 2 , E.J. Kim 2 , J.W. Kim 2 , D.J. Oh 2 . 1 Department of Nuclear
Medicine, Korea University Guro Hospital, seoul, Korea, Republic of; 2 Korea
University Guro Hospital, Cardiovascular Center, seoul, Korea, Republic of
Background: A systematic plaque instability is suggested in patients with
acute coronary syndrome. Plaque inflammation could be assessed by 18Ffluorodeoxyglucose Positron Emission Tomography (18F-FDG PET). We investigated whether carotid plaque inflammation could be related to coronary plaque
instability using 18F-FDG PET.
Methods: In 50 (male 14, 48.1±7.7 yrs) patients who were newly diagnosed as
acute coronary syndrome (28 patients, male 6, 46.8±7.9 yrs) or stable angina (22
patients, male 13, 49.5±9.8), the co-registration of PET and contrast enhanced
computed tomography (CT) images was performed within 1 week after percutaneous coronary intervention. Regional (neck) PET/CT imaging at 1 hour (early
scan) and additional scan at 2 hours (delayed scan) after 555 MBq of 18F-FDG
injection and the multislice CT angiogram were acquired at 180 min on the Philips
GEMINI TF scanner with 16 slice CT. The maximum standardized uptake values
(SUVs) were measured in individual plaques.
Results: In all patients, carotid plaque with increased 18F-FDG uptake was observed in the fused PET/CT images. Age and gender-adjusted SUV of FDG on
delayed scan was significantly higher in the carotid plaques of patients with acute
coronary syndrome than those of patients with stable angina (mean 4.13±1.24
(3.19 to 5.27) vs. 2.87±0.98 (2.47 to 3.62), p=0.003). There were no differences
of risk factors between two groups.
Conclusions: The patients presenting with acute coronary syndrome demonstrate simultaneous increase of inflammatory activity of the carotid plaque, supporting a potential causal role of inflammation regarding widespread plaque
destabilization associated with acute coronary syndrome. This study was supported by a grant of the Korean Health Technology R&D Project, Ministry of
Health, Welfare & Family Affairs, Republic of Korea (A070001)
P5335 | BEDSIDE
Improvement of left ventricular function after successful chronic
total occlusion recanalization in patients with evidence of ischemia
by stress myocardial perfusion imaging
M. Iwama, F. Tokoro, S. Tanaka, R. Matsuoka, T. Kojima, H. Yagasaki, M. Iida,
M. Arai, T. Noda, S. Watanabe. gifu prefectural general medical center, gifu,
Japan
Comparison of Effective Dose and CMD
Backgroud: Several observational studies have suggested survival advantages
after successful chronic total occlusion (CTO) recanalization by percutaneous
coronary intervention (PCI). However, controversy persists and it is unclear
whether CTO recanalization ameliorates left ventricular ejection fraction (LVEF),
generally considered to be a predictor of mortality in patients with ischemic heart
disease.
Method: Enrolled were 88patients (67.5±8.6years old, 67males) having CTO lesions on their coronary arteries. In each patients, stress myocardial perfusion
imaging (MPI) using Thallium-201 were performed before PCI. LVEF was assessed echocardiographically before and 6 months after PCI procedure. According to the results of PCI and preexisting ischemia, patients were divided into 4
groups as the followings; 1) recanalization(+) ischemia(+) group (n=55), 2) recanalization(+) ischemia(-) group (n=12), 3) recanalization(-) ischemia(+) group
(n=7), 4) recanalization(-) ischemia(-) group (n=14) groups.
Result: In the recanalization(+) ischemia(+) group, LVEF increased significantly
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Purpose: Silent myocardial ischemia in asymptomatic subjects with no history
of ischemic heart disease is a frequent condition in diabetic patients. Therefore
the detection of subclinical atherosclerosis in asymptomatic diabetic patients is
important. The aim of the present study was to investigate the prevalence, characteristics, and prognostic value of coronary 64-slice multi-detector computed tomography (MDCT) in asymptomatic diabetic patients.
Methods: We retrospectively enrolled self-referred 444 diabetic patients (age =
58.2±8.3 years, 326 males) who underwent both coronary MDCT angiography
and coronary calcium scoring from January 2008 to June 2011. For all subjects, we evaluated clinical risk factors and investigated cardiac events. Subclinical atherosclerosis was defined as the any detectable plaques on MDCT and
significant stenosis was defined as more than 75% narrowing of coronary artery
diameter in this study.
Results: Subclinical atherosclerosis was found in 214 subjects (48.2%). The subclinical atherosclerosis group was older, more patients with male, smokers, high
level of fasting serum glucose. Independent predictors of subclinical atherosclerosis were old age (≥ 65years) [odds ratio (OR): 1.099, 95% confidence interval (CI): 1.01-1.19, p=0.022], and high level of HbA1C (≥ 7.0%) (HR: 1.64, 95%
CI: 1.02-2.66, p=0.042) in multivariate logistic regression analysis. And significant coronary stenosis in MDCT was found in 83 patients (18.7%). The significant stenosis group was older, more patients with hypertension, smokers, high
level of high sensitivity C-reactive protein (hs-CRP). High level of hs-CRP high
(≥ 2mg/L) was an independent predictor of significant stenosis (OR: 2.66, 95%
CI: 1.67-4.02, p=0.012). 71 patients who showed significant stenosis underwent
stress test, such as treadmill exercise test or myocardial SPECT. Among them,
48 patients underwent conventional coronary angiogram and 20 patients underwent percutaneous coronary intervention. During clinical follow-up (mean followup period=21.5±11.3 months), of all subjects myocardial infarction was developed in 3, unstable angina in 17, target lesion revascularization in 4 patients.
Conclusions: In this study, the prevalence of subclinical coronary atherosclerosis
in asymptomatic diabetic patients was nearly fifty percent. Cardiac MDCT will be
an useful method for detection of subclinical atherosclerosis in diabetic patients.
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