Statement from the North American Society for Cardiovascular Imaging on imaging strategies to reduce the scarcity of healthcare resources during the COVID-19 outbreakKicska, Gregory; Litmanovich, Diana E.; Ordovas, Karen G.; Young, Phillip M.; Dennie, Carole; Truong, Quynh A.; Abbara, Suhny; Kirsch, Jacobo
doi: 10.1007/s10554-020-01861-1pmid: 32474676
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an evolving global pandemic that is predicted to strain healthcare resources at multiple locations throughout North America and the World. As of April 6, 2020, the apex of infection rates is predicted to occur within 1 to 5 weeks at various locations. Widespread reports of personal protective equipment (PPE) shortages, and healthcare worker exposure to disease have become commonplace. To mitigate this crisis, we are suggesting imaging strategies that aim to use the least PPE, require the smallest number of potential staff exposures, and streamlines utilization of imaging. They are broadly organized by (1) substituting a noninvasive diagnostic test in place of a semi-invasive or invasive diagnostic tests, and (2) consolidating diagnostic imaging.
Angiography-based quantitative coronary contrast-flow ratio measurements correlate with myocardial ischemia assessed by stress MRILenk, Karsten; Schwarzbach, Valentin; Antoniadis, Marios; Blum, Maximilian; Zeynalova, Samira; Hagendorff, Andreas; Leistner, David; Landmesser, Ulf; Lavall, Daniel; Laufs, Ulrich
doi: 10.1007/s10554-020-01855-zpmid: 32367188
Contrast-flow quantitative flow ratio (cQFR) is a new technology for quantitative evaluation of coronary stenosis using computational fluid dynamics based on angiograms. The aim of this study was to assess the sensitivity and specificity of cQFR to detect myocardial ischemia using stress magnetic resonance imaging (MRI) as a reference standard. Patients who received stress MRI and coronary angiography were selected from the hospital database. Relevant ischemia on stress MRI was defined as a perfusion deficit in ≥ 2 of 16 segments. cQFR was quantitated based on 3-dimensional quantitative coronary angiography using QAngio XA3D1.1 software by two blinded and independent investigators. A cQFR of ≤ 0.80 was considered abnormal. Among 87 patients 230 vessels met the criteria for full analysis by cQFR (88%). In vascular territories with a significant perfusion deficit, cQFR was significantly lower compared to areas with normal perfusion (0.72 (0.62–0.78) vs. 0.96 (0.89–0.99); p < 0.001). The sensitivity of cQFR in detecting significant epicardial stenoses of coronary vessels with documented ischemia in stress MRI was 81% (68–90%), the specificity was 88% (82–92%). Diameter stenoses (DS) and area stenoses (AS) in vessels with positive stress MRI were significantly higher than in vessels without ischemia (DS 59.1% (49.4–68.4%) vs. 34.8% (27.1–46.1%) p < 0.001; AS 75.6% (63.0–85.2%) vs. 45.0% (30.8–63.6%), p < 0.001). The analysis reveals a high correlation between coronary stenosis measured by cQFR and ischemic areas detected by stress MRI. The data set the stage to plan randomized studies assessing cQFR measurements with regard to clinical outcomes.
The impact of the aortic cusps fusion pattern and valve disease severity on the aortic wall mechanics in patients with bicuspid aortic valveKalinowski, Mariusz E.; Szulik, Mariola; Pawlak, Szymon; Rybus-Kalinowska, Barbara; Zembala, Marian; Kalarus, Zbigniew; Kukulski, Tomasz
doi: 10.1007/s10554-020-01838-0pmid: 32303878
The ascending aorta dilatation in the bicuspid aortic valve (BAV) patients is often attributed to congenital abnormalities of the aortic wall, but it may be related to hemodynamic disturbances in the course of BAV disease. At present, ascending aortic diameter is used as almost sole but weak predictor of aortic dissection and rupture in BAV. We examined the association between aortic wall mechanics and severity of aortic valve disease including different cusps fusion patterns using conventional echocardiography and tissue Doppler imaging (TDI). We prospectively studied 106 BAV patients: 72 with right-left (R-L) coronary cusp fusion were matched 1:1 to 34 patients with right-noncoronary (R-N) cusp fusion obtaining 34 pairs of patients. Peak systolic radial velocity and acceleration of the ascending aortic wall, measured by TDI, were used as an index of hemodynamic stress imposed on the aorta. Paired analysis showed higher aortic wall radial velocity (4.71 ± 1.61 cm/s vs. 3.33 ± 1.44 cm/s, p = 0.001) and acceleration (1.08 ± 0.46 m/s2 vs. 0.80 ± 0.34 m/s2, p = 0.015) in-R-L compared to R-N fusion. Pearson correlation showed association of ascending tubular aortic diameter with age (r = 0.258, p = 0.012), weight (r = 0.323, p = 0.001), peak aortic valve gradient (r = 0.386, p = 0.0001), aortic root diameter (r = 0.439, p < 0.0001), and R-N fusion pattern (r = 0.209, p = 0.043). Aortic root diameter was related to male gender (r = 0.296, p = 0.003), weight (r = 0.381, p = 0.0001), ascending aortic diameter (r = 0.439, p < 0.0001), and severity of aortic regurgitation (r = 0.337, p = 0.0009). Regional differences in aortic wall motion between different BAV cusp fusion patterns and association of aortic diameters with the severity of aortic valve disease, both suggest a deleterious hemodynamic impact of cusp fusion patterns and aortic valve dysfunction on ascending aortic wall. Assessment of aortic hemodynamic by TDI is feasible and could be potentially used to improve prediction of acute aortic complications, thus helping to establish optimal timing of aortic surgery in BAV patients.
Atherosclerotic plaque detected by transesophageal echocardiography is an independent predictor for all-cause mortalityHeidari, Houtan; Ran, Hong; Spinka, Georg; Hengstenberg, Christian; Binder, Thomas; Goliasch, Georg; Schneider, Matthias
doi: 10.1007/s10554-020-01840-6pmid: 32301042
Atherosclerotic lesions in the great arteries are frequent findings in the elderly. Numerous studies have shown their strong predictive value for cardiovascular disease, embolic events, and mortality. We sought to determine the risk of all-cause mortality depending on the localization of plaques in the thoracic aorta evaluated by transesophageal echocardiography (TEE). A total of 2,054 patients (median age 65 years, interquartile range 52–73; 58% men) who underwent a TEE examination between 01/2007 and 03/2015 were retrospectively analyzed. For each patient, the presence of atherosclerotic lesions in the ascending aorta, the aortic arch, and in the descending aorta, as well as cardiovascular risk factors and survival were documented. Median follow-up period was 48 months (interquartile range 38–58). Multivariate Cox regression analysis indicated plaque in the ascending aorta (HR of 1.36, 95% CI 1.01–1.83, P = 0.046), the aortic arch (HR of 1.78, 95% CI 1.29–2.45, P < 0.001), the descending aorta (HR of 2.01, 95% CI 1.54–2.77, P < 0.001), and plaque in any part of the thoracic aorta (HR of 1.84, 95% CI 1.42–2.4, P < 0.001), as independent predictors for all-cause mortality after adjusting for age, sex, arterial hypertension, hyperlipidemia, smoking, and diabetes. In this study, we could demonstrate that more than mild plaque at any site of the thoracic aorta predicts all-cause mortality. Assessment of atherosclerotic lesions in all segments of the thoracic aorta should be part of every routine TEE examination.