Prognostic value of coronary computed tomography angiography in patients with prior percutaneous coronary intervention

ObjectiveWe sought to determine the prognostic value of coronary computed tomography angiography (CCTA) in patients with a history of percutaneous coronary intervention (PCI).BackgroundAlthough the prognostic value of CCTA has been well studied, its incremental value in patients with previous PCI has not been robustly investigated.MethodsConsecutive patients with previous PCI were prospectively enrolled and CCTA images were evaluated for coronary artery disease (CAD) severity. Patients were followed for major adverse cardiovascular events (MACE) which was a composite of cardiac death and non-fatal myocardial infarction. All-cause death was assessed as a secondary endpoint.ResultsA total of 501 patients were analyzed with a mean follow-up time of 59.5 ± 32.0 months and 52 patients (10.4%) experienced MACE. Multivariable Cox regression analysis showed that CAD severity was a predictor of MACE with 0, 1, 2, and 3 vessel disease having annual rates of 1.3%, 2.2%, 2.2%, and 5.3%, respectively. All-cause death was similar in all categories of CAD.ConclusionsIn patients with previous PCI, CAD severity as measured with CCTA has independent and incremental prognostic value.     

Right ventricular dysfunction by computed tomography associates with outcomes in severe aortic stenosis patients undergoing transcatheter aortic valve replacement

BackgroundAlthough cardiac computed tomography angiography (CCTA) assessment of right ventricular dysfunction (RVD) is feasible, the incremental prognostic value remains uncertain in patients undergoing transcatheter aortic valve replacement (TAVR) evaluation. This study sought to determine the incremental clinical utility of RVD identification by CCTA while accounting for clinical and echocardiographic parameters.MethodsPatients who underwent multiphasic ECG-gated functional CCTA using dual-source system for routine TAVR planning were evaluated. Biphasic contrast protocol injection allowed for biventricular contrast enhancement. CCTA-based RVD was defined as right ventricular ejection fraction (RVEF) ?< ?50%. The association of CCTA-RVD with all-cause mortality and the composite outcome of death or heart failure hospitalization after TAVR was evaluated and examined for its incremental utility beyond clinical risk assessment and echocardiographic parameters.ResultsA total of 502 patients were included (median [IQR] age, 82 [77 to 87] years; 56% men) with a median follow-up of 22 [16 to 32] months. Importantly, 126 (25%) patients were identified as having RVD by CCTA that was not identified by echocardiography. CCTA-defined RVD predicted death and the composite outcome in both univariate analyses (HR for mortality, 2.15; 95% CI, 1.44–3.22; p ?< ?0.001; HR for composite outcome, 2.11; 95% CI, 1.48–3.01; p ?< ?0.001) and in multivariate models that included clinical risk factors and echocardiographic findings (HR for mortality, 1.74; 95% CI, 1.11–2.74; p ?= ?0.02; HR for composite outcome, 1.63; 95% CI, 1.09–2.44; p ?= ?0.02).ConclusionsFunctional CCTA assessment pre-TAVR correctly identified 25% of patients with RVD that was not evident on 2D echocardiography. The presence of RVD on CCTA independently associates with clinical outcomes post-TAVR.     

Progression of whole-heart Atherosclerosis by coronary CT and major adverse cardiovascular events

BackgroundThe current study aimed to examine the independent prognostic value of whole-heart atherosclerosis progression by serial coronary computed tomography angiography (CCTA) for major adverse cardiovascular events (MACE).MethodsThe multi-center PARADIGM study includes patients undergoing serial CCTA for symptomatic reasons, ≥2 years apart. Whole-heart atherosclerosis was characterized on a segmental level, with co-registration of baseline and follow-up CCTA, and summed to per-patient level. The independent prognostic significance of atherosclerosis progression for MACE (non-fatal myocardial infarction [MI], death, unplanned coronary revascularization) was examined. Patients experiencing interval MACE were not omitted.ResultsThe study population comprised 1166 patients (age 60.5 ?± ?9.5 years, 54.7% male) who experienced 139 MACE events during 8.2 (IQR 6.2, 9.5) years of follow up (15 death, 5 non-fatal MI, 119 unplanned revascularizations). Whole-heart percent atheroma volume (PAV) increased from 2.32% at baseline to 4.04% at follow-up. Adjusted for baseline PAV, the annualized increase in PAV was independently associated with MACE: OR 1.23 (95% CI 1.08, 1.39) per 1 standard deviation increase, which was consistent in multiple subpopulations. When categorized by composition, only non-calcified plaque progression associated independently with MACE, while calcified plaque did not. Restricting to patients without events before follow-up CCTA, those with future MACE showed an annualized increase in PAV of 0.93% (IQR 0.34, 1.96) vs 0.32% (IQR 0.02, 0.90), P ?< ?0.001.ConclusionsWhole-heart atherosclerosis progression examined by serial CCTA is independently associated with MACE, with a prognostic threshold of 1.0% increase in PAV per year.     

Predictive value of the coronary artery calcium score and advanced plaque characteristics: Post hoc analysis of the PREDICT registry

BackgroundWhether coronary plaque characteristics assessed in coronary computed tomography angiography (CCTA) in association with the coronary artery calcium score (CACS) have predictive value for coronary events is unclear. We aimed to examine the predictive value of the CACS and plaque characteristics for the occurrence of coronary events.MethodsAmong 2802 patients who were analyzed in the PREDICT registry, 2083 with suspected coronary artery disease (CAD) were studied using post hoc analysis. High-risk plaques were defined as having ≥2 adverse characteristics, such as low computed tomographic attenuation, positive remodeling, spotty calcification, and napkin-ring sign. An adjudicative composite of coronary events (cardiac death, nonfatal acute coronary syndrome, and coronary revascularization ≥3 months after indexed CCTA) were analyzed.ResultsSeventy-three (3.5%) patients had coronary events and 313 (15.0%) had high-risk plaques. Multivariate Cox proportional hazard analysis showed that high-risk plaques remained an independent predictor of coronary events (adjusted hazard ratio [HR] 1.95, 95% confidence interval [CI] 1.13–3.34, P ?= ?0.0154), as well as the log-transformed CACS (adjusted HR 1.24, 95% CI 1.11–1.39, P ?= ?0.0002) and the presence of obstructive stenosis (adjusted HR 5.63, 95% CI 3.22–10.12, P 0.0001). In subgroup analyses, high-risk plaques were independently predictive only in the low CACS class (<100).ConclusionThis study shows that assessment of adverse features by coronary plaque imaging independently predicts coronary events in patients with suspected CAD and a low CACS. Our findings suggest that the clinical value of high-risk plaques to CACS and stenosis assessment appears marginal.     

Perivascular fat attenuation for predicting adverse cardiac events in stable patients undergoing invasive coronary angiography

BackgroundInflammation surrounding the coronary arteries can be non-invasively assessed using pericoronary adipose tissue attenuation (PCAT). While PCAT holds promise for further risk stratification of patients with low coronary artery disease (CAD) prevalence, its value in higher risk populations remains unknown.MethodsCORE320 enrolled patients referred for invasive coronary angiography with known or suspected CAD. Coronary computed tomography angiography (CCTA) images were collected for 381 patients for whom clinical outcomes were assessed 5 years after enrollment. Using semi-automated image analysis software, PCAT was obtained and normalized for the right coronary (RCA), left anterior descending (LAD), and left circumflex arteries (LCx). The association between PCAT and major adverse cardiovascular events (MACE) during follow up was assessed using Cox regression models.ResultsThirty-seven patients were excluded due to technical failure. For the remaining 344 patients, median age was 62 (interquartile range, 55–68) with 59% having ≥1 coronary artery stenosis of ≥50% by quantitative coronary angiography. Mean attenuation values for PCAT in RCA, LAD, and LCx were ?74.9, ?74.2, and ?71.2, respectively. Hazard ratios and 95% confidence intervals (CI) for normalized PCAT in the RCA, LAD, and LCx for MACE were 0.96 (CI: 0.75–1.22, p ?= ?0.71), 1.31 (95% CI: 0.96–1.78, p ?= ?0.09), and 0.98 (95% CI: 0.78–1.22, p ?= ?0.84), respectively. For death, stroke, or myocardial infarction only, hazard ratios were 0.68 (0.44–1.07), 0.85 (0.56–1.29), and 0.57 (0.41–0.80), respectively.ConclusionsIn patients referred for invasive coronary angiography with suspected CAD, PCAT did not predict MACE during long term follow up. Further studies are needed to understand the relationship of PCAT with CAD risk.     

Influence of operator expertise and coronary luminal segmentation technique on diagnostic performance,precision and reproducibility of reduced-order CT-derived fractional flow reserve technique

BackgroundOnsite workstation-based CT-derived Fractional-Flow-Reserve (CT-FFR) is accurate in assessing hemodynamic-significance of coronary stenoses. We aim to describe the influence of operator expertise and luminal-segmentation technique on the diagnostic performance, precision and reproducibility of CT-FFR in identifying hemodynamically-significant stenosis (FFR≤0.8).MethodsForty-eight consecutive stable-patients (86 vessels) with suspected CAD underwent research indicated invasive-FFR and 320-detector CT-coronary-angiography (CTA). CT-FFR was derived using reduced-order model on standard desktop-computer. Semi-automated coronary luminal segmentation was performed using focused-technique with manual adjustments at regions of stenosis and calcification or comprehensive-technique with manual adjustments along the entire course of the vessel. CT-FFR analysis was performed using 3 blinded operators; core-laboratory engineer using focused-technique and radiographer and cardiologist using the comprehensive-technique. Diagnostic performance was assessed by area under receiver-operating-curve (AUC). Precision with invasive FFR was determined by Bland-Altman analysis, and reproducibility by intraclass-correlation-coefficient (ICC).ResultsDiagnostic performance was comparable among operators (Engineer: AUC = 0.88, Radiographer 0.84; Cardiologist 0.87; P = 0.59). Coronary luminal-segmentation time was shortest using focused technique (engineer 6:17 ± 2.43 min), compared with comprehensive technique (cardiologist 14.83 ± 7.09, radiographer 24.74 ± 12.65; P < 0.001). Use of focused technique was associated with widest limits of agreement (LOA) with FFR and moderate intra-operator reproducibility (engineer LOA -0.20-0.33; ICC 0.66), when compared with the comprehensive technique which demonstrated narrower LOA and excellent reproducibility [radiographer (LOA -0.17-0.20, ICC = 0.91) and cardiologist (LOA-0.15-0.23, ICC = −0.93)]ConclusionA workstation-based CT-FFR technique was reproducible with high and comparable diagnostic performance among operators with different expertise. A comprehensive luminal segmentation technique was the most time-consuming and associated with the highest reproducibility and precision with FFR.     

Are risk factors necessary for pretest probability assessment of coronary artery disease? A patient similarity network analysis of the PROMISE trial

BackgroundPretest probability (PTP) calculators utilize epidemiological-level findings to provide patient-level risk assessment of obstructive coronary artery disease (CAD). However, their limited accuracies question whether dissimilarities in risk factors necessarily result in differences in CAD. Using patient similarity network (PSN) analyses, we wished to assess the accuracy of risk factors and imaging markers to identify ≥50% luminal narrowing on coronary CT angiography (CCTA) in stable chest-pain patients.MethodsWe created four PSNs representing: patient characteristics, risk factors, non-coronary imaging markers and calcium score. We used spectral clustering to group individuals with similar risk profiles. We compared PSNs to a contemporary PTP score incorporating calcium score and risk factors to identify ≥50% luminal narrowing on CCTA in the CT-arm of the PROMISE trial. We also conducted subanalyses in different age and sex groups.ResultsIn 3556 individuals, the calcium score PSN significantly outperformed patient characteristic, risk factor, and non-coronary imaging marker PSNs (AUC: 0.81 vs. 0.57, 0.55, 0.54; respectively, p ?< ?0.001 for all). The calcium score PSN significantly outperformed the contemporary PTP score (AUC: 0.81 vs. 0.78, p ?< ?0.001), and using 0, 1–100 and ?> ?100 cut-offs provided comparable results (AUC: 0.81 vs. 0.81, p ?= ?0.06). Similar results were found in all subanalyses.ConclusionCalcium score on its own provides better individualized obstructive CAD prediction than contemporary PTP scores incorporating calcium score and risk factors. Risk factors may not be able to improve the diagnostic accuracy of calcium score to predict ≥50% luminal narrowing on CCTA.     

Sex- and age-specific differences in the long-term prognostic value of morphological plaque features detected by coronary computed tomography angiography

BackgroundAlthough sex- and age-specific differences in coronary plaque features detected by coronary computed tomography angiography (CCTA) are known, insufficient information regarding the long-term prognostic value of these findings exists.MethodsA total of 1615 patients with suspected but not previously diagnosed coronary artery disease (CAD) were examined by CCTA and coronary plaque features were assessed. The median follow-up period was 10.5 (IQR 9.2–11.4) years. Cox proportional-hazards analysis was used for the combined endpoint of cardiac death or nonfatal myocardial infarction.ResultsThe endpoint occurred more often in patients older than 65 years (5.66% vs. 2.05%; p = 0.00029) but similarly between female (3.34%) and male (3.07%) patients (p = 0.76). Both sexes displayed a similar prevalence for noncalcified (female vs. male: 0.77 ± 1.38 vs. 0.89 ± 1.41; p = 0.098) and low-attenuation (female vs. male: 2.6% vs. 4.37%; p = 0.096) plaques. As assessed by p for interaction CADRADS (p for interaction = 0.013), noncalcified plaques (p for interaction = 0.022) and low-attenuation plaques (p for interaction = 0.045) had a better primary endpoint association in women than in men. Concerning age, no difference in outcome association was apparent as evaluated by p for interaction.ConclusionCCTA demonstrates excellent long-term prognostic value irrespective of sex and age and independent from the higher prevalence of atherosclerotic plaques in men and patients older than 65 years. Although similarly prevalent in both sexes, noncalcified and low-attenuation plaques exhibit a better prognostic value in women.     

CT assessment of the left atrial appendage post-transcatheter occlusion – A systematic review and meta analysis

BackgroundTransesophageal echocardiography (TEE) is the standard imaging modality used to assess the left atrial appendage (LAA) after transcatheter device occlusion. Cardiac computed tomography angiography (CCTA) offers an alternative non-invasive modality in these patients. We aimed to conduct a comparison of the two modalities.MethodsWe performed a comprehensive systematic review of the current literature pertaining to CCTA to establish its usefulness during follow-up for patients undergoing LAA device closure. Studies that reported the prevalence of inadequate LAA closure on both CCTA and TEE were further evaluated in a meta-analysis. 19 studies were used in the systematic review, and six studies were used in the meta-analysis.ResultsThe use of CCTA was associated with a higher likelihood of detecting LAA patency than the use of TEE (OR, 2.79, 95% CI 1.34–5.80, p ?= ?0.006, I² ?= ?70.4%). There was no significant difference in the prevalence of peridevice gap ≥5 ?mm (OR, 3.04, 95% CI 0.70–13.17, p ?= ?0.13, I² ?= ?0%) between the two modalities. Studies that reported LAA assessment in early and delayed phase techniques detected a 25%–50% higher prevalence of LAA patency on the delayed imaging.ConclusionCCTA can be used as an alternative to TEE for LAA assessment post occlusion. Standardized CCTA acquisition and interpretation protocols should be developed for clinical practice.     

CT multivessel aggregate stenosis score: A novel point-of-care tool for predicting major adverse cardiac events

BackgroundWe evaluated the utility of a novel 15-point multivessel aggregate stenosis (MVAS) score for predicting major adverse cardiac events (MACE) in low-risk patients with suspected ischaemic symptoms undergoing CTCA. Prognostic performance was compared with the Coronary Artery Disease Reporting and Data System (CAD-RADS) classification and the 16-point Segment Involvement Score (SIS).Methods772 consecutive patients underwent CTCA and coronary artery calcification scoring (CACS) from 2010 to 2015. Coronary artery disease severity was calculated according to CAD-RADS class (0–5 ?± ?vulnerability modifier), the SIS (0–16), and an MVAS score (0–15) based on the aggregate stenosis severity in all 4 coronary vessels (maximum 12 points) plus the presence of any high-risk plaque features (additional 3 points). 52 patients were referred directly for coronary angiography based on CTCA findings and were excluded; the remainder were followed-up for 64.6 ?± ?19.1 months.Results54 ?MACE were observed in 720 patients (7.5%); MACE patients had higher CAD-RADS class (3.92 ?± ?0.7 vs 0.91 ?± ?1.2, p ?< ?0.0001), SIS (4.59 ?± ?2.7 vs 0.79 ?± ?1.2, p ?< ?0.0001), and MVAS scores (10.1 ?± ?1.7 vs 1.7 ?± ?2.1, p ?< ?0.0001). Adjusted Cox proportional hazards analysis identified CAD-RADS class (HR 2.96 (2.2–4), p ?< ?0.0001), SIS (HR 1.29 (1.2–1.4, p ?< ?0.0001), and MVAS score (HR 1.82 (1.6–2.1), p ?< ?0.0001) as predictors of MACE. Adjusted receiver operating characteristic (ROC) analysis found MVAS a more powerful predictor of MACE than CAD-RADS and SIS (AUC: 0.92 vs 0.84 vs 0.83, p ?= ?0.018).ConclusionsCAD-RADS and SIS are reliable predictors of MACE, and the MVAS score provided incremental prognostic data. MVAS may potentiate risk stratification, particularly in institutions without advanced plaque analysis software.     

Deep learning with convolutional neural network for estimation of the characterisation of coronary plaques: Validation using IB-IVUS

IntroductionDeep learning approaches have shown high diagnostic performance in image classifications, such as differentiation of malignant tumors and calcified coronary plaque. However, it is unknown whether deep learning is useful for characterizing coronary plaques without the presence of calcification using coronary computed tomography angiography (CCTA). The purpose of this study was to compare the diagnostic performance of deep learning with a convolutional neural network (CNN) with that of radiologists in the estimation of coronary plaques.MethodsWe retrospectively enrolled 178 patients (191 coronary plaques) who had undergone CCTA and integrated backscatter intravascular ultrasonography (IB-IVUS) studies. IB-IVUS diagnosed 81 fibrous and 110 fatty or fibro-fatty plaques. We manually captured vascular short-axis images of the coronary plaques as Portable Network Graphics (PNG) images (150 × 150 pixels). The display window level and width were 100 and 700 Hounsfield units (HU), respectively. The deep-learning system (CNN; GoogleNet Inception v3) was trained on 153 plaques; its performance was tested on 38 plaques. The area under the curve (AUC) obtained by receiver operating characteristic analysis of the deep learning system and by two board-certified radiologists was compared.ResultsWith the CNN, the AUC and the 95% confidence interval were 0.83 and 0.69–0.96, respectively; for radiologist 1 they were 0.61 and 0.42–0.80; for radiologist 2 they were 0.68 and 0.51–0.86, respectively. The AUC for CNN was significantly higher than for radiologists 1 (p = 0.04); for radiologist 2 it was not significantly different (p = 0.22).ConclusionDL-CNN performed comparably to radiologists for discrimination between fatty and fibro-fatty plaque on CCTA images.Implications for practiceThe diagnostic performance of the CNN and of two radiologists in the assessment of 191 ROIs on CT images of coronary plaques whose type corresponded with their IB-IVUS characterization was comparable.     

Proton Pump Inhibitors Increase the Risk of Early Biliary Infection After Placement of Percutaneous Transhepatic Biliary Stents

PurposeTo investigate the association between the use of proton pump inhibitors (PPIs) and the risk of early biliary infection (EBI) after the placement of percutaneous transhepatic biliary stents (PTBS) in patients with unresectable malignant biliary obstruction (MBO).Materials and MethodsA total of 136 patients with unresectable MBO (82 males and 54 females) treated with PTBS were included in this multicenter retrospective study. PPIs were prescribed to MBO patients with dyspepsia. The risk factors for EBI were identified by univariate and multivariate analyses. The association between the use of PPIs and EBI was assessed by logistic analyses.ResultsA total of 72 (53%) patients were regular users of PPIs, and 33 (24%) patients developed EBI after PTBS. Univariate and multivariate analyses revealed that diabetes (hazard ratio [HR], 20.3; 95% confidence interval [CI], 5.6–72.9; P <.001), biliary stones (HR, 20.3; 95% CI, 5.6–72.9; P <.001) and PPIs (HR, 4.0; 95% CI, 1.2–12.8; P =.020) were risk factors for EBI. Further analyses of the correlation between the duration of PPIs use and EBI demonstrated that a prolonged use of PPIs significantly increased the risk of EBI (PPIs for <15 days vs 15–30 days: HR, 10.2; 95% CI, 3.1–33.3; P <.001; and PPIs <15 days vs ≥30 days; HR, 20.4; 95% CI, 2.2–192.3; P <.001).ConclusionThe use of PPIs increased the risk of EBI after PTBS in patients with unresectable MBO. Furthermore, the risk of EBI increased with a prolonged duration of PPIs use.     

Consistency of quantitative analysis of coronary computed tomography angiography

BackgroundThe present study aimed to assess the reliability and reproducibility of coronary computed tomography angiography (CCTA) for the serial quantitative assessment of plaque volume.MethodsPatients who underwent repeated CCTA scans within 90 days were retrospectively screened and enrolled. Clinical data and CCTA imaging data were collected. Paired CCTA scans were analyzed using the quantitative method by separate observers blinded to the other paired CCTA scans. Results were compared between the index CCTA and follow-up CCTA.ResultsPaired CT scans of 95 patients (61 ± 13 years; 56.8% men) with same tube voltages (kVp) at both CCTAs and 24 patients (57 ± 19 years; 48.3% men) with different kVp at two CCTAs were analyzed. In patients with same kVp at both CCTAs, there were no difference in PV and PVs of each components in per-segment analysis and per-lesion analysis (all p > 0.05). In per-lesion analysis of CCTAs from patients who used different kVp between two CCTAs, lesion length, area and diameter stenosis, and PVs were not different between index and follow-up CCTAs (all p > 0.05). Segment length and PV were also showed no difference between two serial CCTAs in per-segment analysis.ConclusionWe showed the reproducibility and reliability of quantitative analysis of CCTA for assessment of coronary plaques. CCTA can be applied for the serial quantitative assessment of coronary artery disease progression, regardless of differences in the image acquisition protocol.     

Influence of coronary stenosis location on diagnostic performance of machine learning-based fractional flow reserve from CT angiography

BackgroundCompared with invasive fractional flow reserve (FFR), coronary CT angiography (cCTA) is limited in detecting hemodynamically relevant lesions. cCTA-based FFR (CT-FFR) is an approach to overcome this insufficiency by use of computational fluid dynamics. Applying recent innovations in computer science, a machine learning (ML) method for CT-FFR derivation was introduced and showed improved diagnostic performance compared to cCTA alone. We sought to investigate the influence of stenosis location in the coronary artery system on the performance of ML-CT-FFR in a large, multicenter cohort.MethodsThree hundred and thirty patients (75.2% male, median age 63 years) with 502 coronary artery stenoses were included in this substudy of the MACHINE (Machine Learning Based CT Angiography Derived FFR: A Multi-Center Registry) registry. Correlation of ML-CT-FFR with the invasive reference standard FFR was assessed and pooled diagnostic performance of ML-CT-FFR and cCTA was determined separately for the following stenosis locations: RCA, LAD, LCX, proximal, middle, and distal vessel segments.ResultsML-CT-FFR correlated well with invasive FFR across the different stenosis locations. Per-lesion analysis revealed improved diagnostic accuracy of ML-CT-FFR compared with conventional cCTA for stenoses in the RCA (71.8% [95% confidence interval, 63.0%–79.5%] vs. 54.8% [45.7%–63.8%]), LAD (79.3 [73.9–84.0] vs. 59.6 [53.5–65.6]), LCX (84.1 [76.0–90.3] vs. 63.7 [54.1–72.6]), proximal (81.5 [74.6–87.1] vs. 63.8 [55.9–71.2]), middle (81.2 [75.7–85.9] vs. 59.4 [53.0–65.6]) and distal stenosis location (67.4 [57.0–76.6] vs. 51.6 [41.1–62.0]).ConclusionIn a multicenter cohort with high disease prevalence, ML-CT-FFR offered improved diagnostic performance over cCTA for detecting hemodynamically relevant stenoses regardless of their location.     

Baseline global longitudinal strain by computed tomography is associated with post transcatheter aortic valve replacement outcomes

BackgroundsSubclinical myocardial dysfunction detected by global longitudinal strain (GLS) using echocardiography is associated with poor outcomes in patients with severe aortic stenosis (AS) despite normal left ventricular ejection fraction (LVEF). Computed tomography angiography derived GLS (CTA-GLS) has recently shown to be feasible, however the prognostic value remains unclear in severe AS patients treated with transcatheter aortic valve replacement (TAVR).MethodsWe analyzed consecutive patients who underwent TAVR with pre-TAVR retrospective gated acquisition CTA study with adequate image quality covering the entire left ventricle. CTA-GLS analysis was performed using 2D CT-Cardiac Performance Analysis prototype software (TomTec GmbH). Kaplan-Meier and Cox regression analyses were performed to evaluate the association of baseline CTA-GLS with all-cause mortality and a composite outcome of all-cause death and hospitalization for heart failure after TAVR.ResultsA total of 223 patients were included (mean age 83.5 ± 6.8 years, 45.7% female, mean CTA-LVEF 50.7 ± 14.5%). During a median follow-up of 32 months, 81 all-cause deaths and 134 composite outcomes occurred. When compared to patients with normal LVEF (≥50%) and preserved CTA-GLS (≤-20.5%), patients with normal LVEF but reduced CTA-GLS (>-20.5%) had higher all-cause mortality (Chi-square 6.89, p = 0.032) and the risk of composite outcome (Chi-square 7.80, p = 0.020) which was no different than those with impaired LVEF. Reduced CTA-GLS was independently associated with all-cause mortality (HR 1.71, 95% CI 1.01–2.90, p = 0.049) and the risk of composite outcome (HR 1.51, 95% CI 1.01–2.25, p = 0.044) on multivariable Cox regression analysis.ConclusionsReduced CTA-GLS provides independent prognostic value above multiple clinical and echocardiographic characteristics.     

Risk Factors for Early Port Infections in Adult Oncologic Patients

PurposeThe purpose of this study was to retrospectively investigate risk factors for chest port (port) infections within 30 days of placement (early port infections) in adult oncologic patients.Materials and MethodsThis single-institution, three-center retrospective study identified 1,714 patients (868 males, 846 females; median age 60.0 years old) who underwent port placement between January 2013 and August 2017. All patients received an intravenous antibiotic prior to port placement. The median absolute neutrophil count was 5,260 cells/μL, the median white blood cell (WBC) count was 7,700 cells/μL, and the median serum albumin was 4.00 g/dL at the time of port placement. Double-lumen ports were most commonly implanted (74.85%) more frequently in an outpatient setting (72.69%). Risk factors for early port infections were elucidated using univariate and multivariate proportional subdistribution hazard regression analyses.ResultsA total of 20 patients (1.2%) had early port infections; 15 patients (0.9%) had positive blood cultures. The mean time to infection was 20 days (range, 9–30 days). The port-related 30-day mortality rate was 0.2% (4 of 1,714 patients). Most bloodstream infections were attributed to Staphylococcus spp. (n = 11). In multivariate analysis, hematologic malignancy (hazard ratio [HR], 2.61; 95% confidence interval (CI), 1.15–5.92.; P = .02), hypoalbuminemia (albumin <3.5 g/dL; HR, 3.52; 95% CI: 1.48–8.36; P = .004), leukopenia (WBC <3,500 cells/μL; HR, 3.00; 95% CI: 1.11–8.09; P = .03), and diabetes mellitus (HR, 3.71; 95% CI: 1.57–8.83) remained statistically significant risk factors for early port infection.ConclusionsHematologic malignancy, hypoalbuminemia, leukopenia, and diabetes mellitus at the time of port placement were independent risk factors for early port infections.     

γ-Glutamyltranspeptidase as a Prognostic Biomarker in Advanced Hepatocellular Carcinoma Treated with Transarterial Chemoembolization

PurposeTo evaluate the prognostic value of pretreatment serum γ-glutamyltransferase (GGT) level in patients with advanced hepatocellular carcinoma (HCC) receiving transarterial chemoembolization.Materials and MethodsThis retrospective study included 140 patients (123 male, 17 female; mean age, 56.9 y ± 12.0; range, 22.0–82.0 y) with Barcelona Clinic Liver Cancer class C HCC who received first-line conventional chemoembolization between December 2013 and March 2018. Patients were divided into low and high GGT groups based on a cutoff value calculated with a receiver operating characteristic curve. Overall survival (OS) was compared between groups by log-rank test. Univariate and multivariate survival analyses were performed.ResultsThe optimal cutoff values of GGT were 119.5 U/L in men and 175.0 U/L in women. The 6-, 9-, and 12-mo OS rates were 81.7%, 72.4%, and 62.9%, respectively, for patients in the low GGT group (n = 44) and 58.8%, 35.7%, and 28.8%, respectively, for patients in the high GGT group (n = 96; P < .001). Multivariable Cox regression analysis identified high pretreatment serum GGT level (hazard ratio [HR], 2.71; 95% confidence interval [CI], 1.67–4.40; P < .001), multiple tumors (HR, 3.05; 95% CI, 1.23–7.53; P = .02), and performance of target treatment (ie, sorafenib; HR, 0.41; 95% CI, 0.24–0.72; P = .002) or ablation (HR, 0.35; 95% CI, 0.18–0.66; P = .001) as independent prognostic factors for OS.ConclusionsPretreatment serum GGT level was an independent prognostic factor for OS in patients with advanced HCC treated with chemoembolization, suggesting that GGT is a useful prognostic biomarker for advanced HCC.     

4D Flow MR Imaging to Improve Microwave Ablation Prediction Models: A Feasibility Study in an In Vivo Porcine Liver

PurposeTo characterize the effect of hepatic vessel flow using 4-dimensional (4D) flow magnetic resonance (MR) imaging and correlate their effect on microwave ablation volumes in an in vivo non-cirrhotic porcine liver model.Materials and MethodsMicrowave ablation antennas were placed under ultrasound guidance in each liver lobe of swine (n = 3 in each animal) for a total of 9 ablations. Pre- and post-ablation 4D flow MR imaging was acquired to quantify flow changes in the hepatic vasculature. Flow measurements, along with encompassed vessel size and vessel-antenna spacing, were then correlated with final ablation volume from segmented MR images.ResultsThe linear regression model demonstrated that the preablation measurement of encompassed hepatic vein size (β = –0.80 ± 0.25, 95% confidence interval [CI] –1.15 to –0.22; P = .02) was significantly correlated to final ablation zone volume. The addition of hepatic vein flow rate found via 4D flow MRI (β = –0.83 ± 0.65, 95% CI –2.50 to 0.84; P = .26), and distance from antenna to hepatic vein (β = 0.26 ± 0.26, 95% CI –0.40 to 0.92; P = .36) improved the model accuracy but not significantly so (multivariate adjusted R² = 0.70 vs univariate (vessel size) adjusted R² = 0.63, P = .24).ConclusionsHepatic vein size in an encompassed ablation zone was found to be significantly correlated with final ablation zone volume. Although the univariate 4D flow MR imaging-acquired measurements alone were not found to be statistically significant, its addition to hepatic vein size improved the accuracy of the ablation volume regression model. Pre-ablation 4D flow MR imaging of the liver may assist in prospectively optimizing thermal ablation treatment.     

Risk Factors Associated with Clinical Failure of Uterine Artery Embolization for Postpartum Hemorrhage

PurposeTo identify risk factors for clinical failure of uterine artery embolization (UAE) for postpartum hemorrhage (PPH), with particular attention to the uterine artery diameter.Materials and MethodsThis retrospective study included 47 patients who underwent UAE for PPH between January 1, 2010, and January 31, 2021. Technical success was defined as the completion of embolization of the arteries thought to be the cause of the bleeding. Clinical success was defined as no recurrent bleeding or need for additional therapeutic interventions. Univariate and multivariate analyses were performed to examine the risk factors associated with clinical failure of UAE.ResultsOf the 47 patients, 6 had recurrent bleeding. Of the 6 patients, 4 underwent hysterectomy, and 2 underwent repeat embolization. The clinical success rate was 87.2% (41/47), with no major adverse events such as uterine infarction or death. In univariate analysis, there were slight differences in multiparity (P = .115) and placental abruption (P = .128) and a significant difference in the findings of a narrow uterine artery on digital subtraction angiography (DSA) (P = .005). In multivariate analysis, only a narrow uterine artery on DSA was a significant factor (odds ratio, 18.5; 95% confidence interval, 2.5–134.8; P = .004).ConclusionsA narrow uterine artery on DSA was a risk factor for clinically unsuccessful UAE for PPH. It may be prudent to conclude the procedure only after it is ensured that vasospasm has been relieved.