Densitometry for assessment of effect of lung volume reduction surgery for emphysema.

To explore if change in the extent of emphysema correlated with change in lung function, the effect of resection of emphysematous tissue was studied by computed tomography (CT) densitometry. In addition, the current authors studied how surgery-induced change in emphysema related to lung density in control subjects. In total, 30 patients (14 females; mean+/-sd age 59+/-10 yrs) with severe emphysema before and 3 months after lung volume reduction surgery (LVRS), 48 patients with moderate emphysema and 76 control subjects were investigated. Lung density (15th percentile point) of both lungs and heterogeneity of lung density between 12 isovolumetric partitions in each lung were calculated from chest CT images. The 15th percentile point and its heterogeneity could distinguish controls from subjects with moderate emphysema with a sensitivity and specificity of >95%. LVRS significantly increased lung density by 5.0+/-10.9 g.L(-1) (n=30). Improvement in the diffusing capacity of the lung for carbon monoxide and in residual volume significantly correlated with an increase in lung density (n=20 and 28, respectively). Change in forced expiratory volume in one second did not correlate with change in lung density. In conclusion, lung density 15th percentile point is a valuable surrogate marker for detection of both the extent of and reduction in emphysema.     

Values and limitations of transstenotic pressure gradients measured during percutaneous coronary angioplasty

The pressure gradient across coronary stenoses is measured routinely during angioplasty. Due to the finite size of the angioplasty catheter within the stenotic cross section, the remaining luminal area is further reduced and the transstenotic gradient may be overestimating the "true" pressure drop. This "true" pressure gradient can be approximated from the mean coronary blood flow and the stenosis geometry from theoretical models. Goal of this study was to assess the values and limitations of the in vivo measurements of the pressure gradient versus the calculated values. Therefore, flow in the great cardiac vein was measured in 13 patients before and/or after angioplasty of a proximal left anterior descending stenosis, not filled by collaterals. The Poiseuille and turbulent contributions to flow resistance were determined from stenosis geometry assessed by quantitative coronary angiography. A fourfold increase in the luminal area (from 0.7 mm2 pre- to 2.8 mm2 post angioplasty) was associated with a fourfold decrease in the in vivo measured transstenotic gradient (from 59 mm Hg pre- to 13 mm Hg post angioplasty). The occlusion area and the measured gradient were linearly correlated: gradient = 69-17 X occlusion area (r = 0.76). However, as expected, the transstenotic gradient systematically overestimated the theoretical gradient calculated from the laws of fluid dynamics. A nonlinear relation was found between the calculated gradient P and the occlusion area As: P = 15 X As-2 (r = 0.87).     

Relationships between the lung-heart ratio assessed from post-exercise thallium-201 myocardial tomograms,myocardial ischemia and the extent of coronary artery disease

Uptake of thallium (Tl)-201 in the lungs has been proposed as a measure of left ventricular dysfunction. In this study we were interested in pursuing two goals: 1) to assess possible relationships between the post-exercise Tl-201 lung-heart (LH-) ratio determined from the anterior view during SPECT-acquisition, myocardial ischemia and the extent of coronary artery disease; and 2) to explore the effects of coronary revascularisation procedures on the LH-ratio. The study group consisted of 145 patients with early and late postexercise Tl-201 tomograms, including 32 PTCA-patients with pre- and post-PTCA studies and 20 patients who underwent coronary artery bypass surgery (CABG) with corresponding pre- and post-CABG studies. Ischemia was defined as evoked angina during the exercise test in combination with ≥1 mm horizontal or downsloping ST-depression on the ECG. The severity of coronary obstructions was assessed from coronary angiograms with a PC-based digital caliper technique; a stenosis was defined to be significant when its severity exceeded 50% diameter stenosis. The LH-ratio was defined by the ratio of the mean pulmonary counts and the mean myocardial counts assessed from corresponding regions of interest (ROI's) positioned over the left lung and the heart, respectively in the anterior view of a tomographic data acquisition procedure. Our results made clear that the LH-ratio was not significantly different between patients with and without ischemia during exercise, and between patients with single vs. multiple vessel disease. However, the interventions had a significant effect of the LH-ratio:

Automated calibration in vascular X-ray images using the accurate localization of catheter marker bands

RATIONALE AND OBJECTIVES: To develop a new automated calibration method for vessel measurements in vascular x-ray images. METHODS: Radiopaque marker bands mounted equidistantly on a small catheter were acquired in vitro at five image intensifier (II) sizes in x-ray projection images. The positions of the marker centers were detected by using a Hough transform and were computed at subpixel precision by using either a novel, iterative center-of-gravity approach (CGA) or a symmetry filter. Curve-fitting procedures were used to reject false-positive marker detections and to calculate intermarker distances. The calibration factor was calculated from the true marker distance and the average of the measured distances in pixels. Results were compared statistically with a grid calibration method, which was taken as the gold standard. A simulation study was performed to assess the influence of image noise on the CGA method. RESULTS: The iterative CGA method was convergent and faster than the symmetry-based technique. For four II sizes (17, 20, 25, and 31 cm), the results from the CGA method were not significantly different from the results obtained with grid calibration. For the II size of 38 cm, a significant difference (0.3% of the grid calibration factor) was found; however, this was caused by the quantification error in the image data and was not clinically relevant. In general, the performance of the CGA method improved with increasing signal-to-noise ratio. CONCLUSIONS: A practical new calibration method for small catheter sizes was developed and validated for quantitative vascular arteriography.     

Clinical application of quantitative coronary angiography using the CAAS system: Preliminary results of the INTACT study (international nifedipine trial on antiatherosclerotic therapy)

Summary It is the objective of the INTACT-study to test in man, whether a significant retardation of the progression of coronary artery disease is attainable with the Ca-antagonist nifedipine; this may be possible on the basis of numerous animal experiments. INTACT is a prospective, randomized, double blind, placebo controlled investigation in 423 patients with preferably early stages of coronary sclerosis in whom a progression of the disease seems likely. A proper coronary angiogram led to inclusion of the patients in the study (October 1983–June 1985). Over the following 3-years-period patients received either nifedipine 80 mg/day or placebo. The study is concluded by a control coronary angiogram with angiographic projections which are identical to those of the first coronary angiography. The extent of coronary sclerosis is objectivated by computer-assisted quantitative measurement of the entire coronary arterial system with the CAAS-system (Rotterdam). For definition purposes the coronary artery system subdivided into 25 segments. Parameters for progression assessment will be mean segment diameter, minimal obstruction diameter, percentage severity of obstruction, length of obstruction and plaque area.So far 4826 coronary segments have been analyzed from the first angiograms of 383 patients. Per patient an average of 12.6 different segments could be evaluated in at least one angiographic projection. The major coronary segments could be measured in 72–93% of the patients in one or more angiographic projections (at the average about 2 different projections). Five hundred and forty-six coronary obstructions were analyzed; 131 of these were total occlusions. Only 9% of the length of the vessel contours detected by the computer algorithm required manual correction by the operators, suggesting a high reliability of the system. It can be concluded that quantitative measurement of the complete coronary artery system can indeed be obtained in a large angiographical multicenter study such as INTACT.     

In-stent fractional flow reserve variations and related optical coherence tomography findings: the FFR–OCT co-registration study

We sought to assess in-stent variations in fractional flow reserve (FFR) in patients with previous percutaneous coronary intervention (PCI) and to associate any drop in FFR with findings by optical coherence tomography (OCT) imaging. Suboptimal post-PCI FFR values were previously associated with poor outcomes. It is not known to which extent in-stent pressure loss contributes to reduced FFR. In this single-arm observational study, 26 patients who previously underwent PCI with drug-eluting stent or scaffold implantation were enrolled. Motorized FFR pullback during continuous intravenous adenosine infusion and OCT assessments was performed. Post-PCI FFR?<?0.94 was defined as suboptimal. At a median of 63 days after PCI (interquartile range: 59–64 days), 18 out of 26 patients (72%) had suboptimal FFR. The in-stent drop in FFR was significantly higher in patients with suboptimal FFR vs. patients with optimal FFR (0.08?±?0.07 vs. 0.01?±?0.02, p?<?0.001). Receiver operating characteristic curve analysis showed that an in-stent FFR variation of >?0.03 was associated with suboptimal FFR. In patients with suboptimal FFR, the OCT analyses revealed higher mean neointimal area (respectively: 1.06?±?0.80 vs. 0.51?±?0.23 mm²; p?=?0.018) and higher neointimal thickness of covered struts (respectively 0.11?±?0.07 vs. 0.06?±?0.01 mm; p?=?0.021). Suboptimal FFR values following stent-implantation are mainly caused by significant in-stent pressure loss during hyperemia. This finding is associated to a larger neointimal proliferation.     

Advantages and limitations of two software calipers in quantitative coronary arteriography

Summary Software calipers allowing the measurement of the distances between pairs of manually defined picture elements in digitized images may be useful tools for a rapid assessment of the morphology of coronary vessels, e.g. for choosing the appropriate balloon or stent sizes before or during cardiac intervention procedures. In this paper we have studied extensively the advantages and limitations of two manual software calipers — one developed for a PC-based cinefilm analysis workstation, the other for the Philips DCI system.Based on analyses of a perspex vessel phantom with 17 sectors of known size filled with different concentrations (50 and 100%) of the contrast agent and acquired at two kV-levels (68 and 92 kV), it was found that the cinefilm approach is characterized by a very small overall (averaged over te data from three observers) systematic overestimation of 0.03 mm, and the DCI system by a systematic underestimation of 0.07 mm; the worst case accuracy value for an individual observer on frames with 100% contrast dye concentration was 0.20 mm for cinefilm, and –0.34 mm for the DCI, respectively. The overall variabilities in the measurements (precision) were almost identical for the two approaches (overall 0.07 and 0.08 mm for the cinefilm and digital approaches, respectively, and worst case for individual observers on the 100% contrast frames, 0.16 and 0.13 mm, respectively. Inverting the images (bright or dark contrast containing structures) of the phantom at 100% contrast concentration and acquired at 62 kV had no significant effect on the results obtained with the cinefilm analysis system (overall accuracy –0.12 mm for both situations), whereas it had on the results from the DCI system (overall accuracies –0.29 (dark vessels on bright background) and –0.08 mm (bright vessels on dark background), respectively). Enhancing the digital images on the DCI with unsharp masking techniques did not significantly influence the measurement accuracy and precision. Finally, it was found that woven dacron, polyurethane and polyvinylchloride catheters filled with 100% contrast dye can be measured with an overall accuracy of better than 0.13 mm on the DCI system. On the PC-based system the woven dacron and polyvinylchloride catheters would result in an overall accuracy better than 0.17 mm, and the polyurethane catheter better than 0.30 mm. The evaluation study has made clear that the nylon catheter should not be applied in QCA-studies. Thus based on the data presented and extrapolating these to the routine clinical situations, it can be concluded that the software caliper technique may be a useful tool for the rapid measurement of the size of a contrast filled structure in coronary angiograms, either from digitized cinefilm or from the digital images acquired with the Philips DCI system. However, it is to be expected that the measurements will be less accurate and precise when applied to coronary arteriograms due to additional variabilities caused by the non-uniform and rough size of coronary arterial segments. The accuracy and precision of the measurements can be improved significantly by using more sophisticated techniques with automated edge detection.