Italian multicenter, prospective study to evaluate the negative predictive value of 16- and 64-slice MDCT imaging in patients scheduled for coronary angiography (NIMISCAD-Non Invasive Multicenter Italian Study for Coronary Artery Disease)

This was a prospective, multicenter study designed to evaluate the utility of MDCT in the diagnosis of coronary artery disease (CAD) in patients scheduled for elective coronary angiography (CA) using different MDCT systems from different manufacturers. Twenty national sites prospectively enrolled 367 patients between July 2004 and June 2006. Computed tomography (CT) was performed using a standardized/optimized scan protocol for each type of MDCT system (≥16 slices) and compared with quantitative CA performed within 2 weeks of MDCT. A total of 284 patients (81%) were studied by 16-slice MDCT systems, while 66 patients (19%) by 64-slice MDCT scanners. The primary analysis was on-site/off-site evaluation of the negative predictive value (NPV) on a per-patient basis. Secondary analyses included on-site evaluation on a per-artery and per-segment basis. On-site evaluation included 327 patients (CAD prevalence 58%). NPV, positive predictive value (PPV), sensitivity, specificity, and diagnostic accuracy (DA) were 0.91 (95% CI 0.85–0.95), 0.91 (95% CI 0.86–0.95), 0.94 (95% CI 0.89–0.97), 0.88 (95% CI 0.81–0.93), and 0.91 (95% CI 0.88–0.94), respectively. Off-site analysis included 295 patients (CAD prevalence 56%). NPV, PPV, sensitivity, specificity, and DA were 0.73 (95% CI 0.65–0.79), 0.93 (95% CI 0.87–0.97), 0.73 (95% CI 0.65–0.79), 0.93 (95% CI 0.87–0.97), and 0.82 (95% CI 0.77–0.86), respectively. The results of this study demonstrate the utility of MDCT in excluding significant CAD even when conducted by centers with varying degrees of expertise and using different MDCT machines.     

Chronic total coronary occlusion in patients with intermediate viability: value of low-dose dobutamine and contrast-enhanced 3-T MRI in predicting functional recovery in patients undergoing percutaneous revascularisation with drug-eluting stent

Purpose

Myocardial viability was evaluated by magnetic resonance imaging (MRI) in patients with chronic total coronary occlusion (CTO) treated with a drug-eluting stent. Change in left ventricular ejection fraction (LVEF) was analysed.

Materials and methods

Twenty-three patients with CTO underwent delayed-enhancement (DE) and low-dose dobutamine MRI (LD). Diastolic wall thickness (DWT), dobutamine-induced systolic wall thickening (SWT) and DE transmural extension were quantitatively assessed in vessel-related segments, calculating the contribution of viable tissue to SWT, expressed as viability index (VI)=[SWT×(100 ? DE)]/100. Patients with transmural enhancement were excluded from revascularisation. At 6 months follow-up, patients underwent coronary angiography (CA) and MRI. Functional recovery was defined as a 2-mm increase in SWT.

Results

Transmural enhancement (mean DE 62.88±37.18] was present in three patients. Mean DWT, SWT, VI and DE of recanalised patients were 8.03±2.35, 2.64±1.56, 1.77±1.48 mm and 41.97±30.32. Revascularisation was successful in 14/16. Follow-up CA showed patency of treated vessels. Functional recovery was achieved in 13 patients. Functional recovery showed significant correlation with SWT (β 1,779, p=0.015), and even higher correlation with VI (β 2.032, p=0.011). LVEF improved significantly [Delta 95% confidence interval (CI) ?4.47, p=0.0203).

Conclusions

Invasive CTO treatment has beneficial effects on myocardial contractility that can be predicted by VI, and on LVEF.     

Chromosome aberrations in subject occupationally exposed to radiation. Statistical analysis (author's transl)

The percentage of subjects affected by different chromosomes aberrations, does not differ in subjects occupationally exposed to radiations and in controls. On the other hand the higher percentage of aberrations in the total number of cells in radioexposed subjects is highly significant. Severe limitations employing the cariotipic investigation for insurance finalities are prospected.     

Screening for silent ischemia with coronary artery calcium and nuclear stress testing in nondiabetic patients prior to kidney transplant

Whether coronary artery calcium (CAC) screening in pretransplant patients may help predict silent myocardial ischemia is unknown. Accordingly, we performed CAC imaging on 46 nondiabetic patients awaiting kidneytransplant. All patients underwent multidetector computed tomography imaging for CAC quantification, and a vasodilator myocardial perfusion stress (MPS) test was performed only in patients with a total CAC score>300 or>100 in a single coronary artery. The mean patient's age was 46+/-14 years and the median dialysis vintage was 33 months (interquartile range 19-53). The median CAC score was 82 (interquartile range 0-700) and correlated with patients' age (p=0.006) and dialysis vintage (p=0.02). Nineteen patients qualified for MPS, but 5 refused the test. Of the remaining 14 patients, 7 patients had normal scans and 7 showed a minimal perfusion defect in the inferoposterior segment of the left ventricle. At the time of writing, 12 patients have undergone successful kidney transplantation without untoward complications. CAC screening does not appear to be associated with silent ischemia in pretransplant patients. Though CAC is extensive in dialysis patients, calcium may be associated with nonobstructive atherosclerotic lesions or calcification of the media layer of the vessel wall.     

Pattern of recurrence and survival of c-Ia NSCLC diagnosed by transpleural methods

AIM: The aim of this study was to evaluate if transpleural diagnostic methods as percutaneous fine-needle aspiration biopsy (FNAB) or tumour wedge resection by video-assisted thoracoscopic surgery (VATS) impact on local recurrence and long term survival of patients affected by non-small cell lung cancer (NSCLC). METHODS: Records concerning 179 patients with peripheral c-Ia NSCLC who underwent complete resection from 1994 to 2000 have been reviewed. Patients were randomized into two groups according to the diagnostic method employed, as follows: in group I (N.=63) diagnosis was obtained by bronchoscopy; in group II (N.=116) diagnosis was obtained by FNAB (N.=59) or tumour wedge resection by VATS (N.=57) after a negative bronchoscopy. Survival curves were compared using log-rank test. Distribution of frequencies was analyzed with Chi-square and Fisher's exact test. RESULTS: The two groups of patients did not significantly differ in terms of age, gender, forced expiratory volume in 1 second, comorbidities, histological type and tumour size; pathologic stage IIb was more frequent in group I. At a median follow-up of 48 months, (range 2-108 months), local recurrence was found in 9.5% (N.=6) of the patients in group I and in 12.5% (N.=15) of patients in group II (P=NS); distant metastasis were found in 28.6% (N.=18) of patients in group I and in 13.8% (N.=16) in group II (P=0.03). Patients in group II had a statistically better five-year survival rate than patients in group I (70% and 55% respectively P=0.016). CONCLUSION: FNAB and tumour wedge resection by VATS represent valuable diagnostic methods for lung cancers, since they do not seem to increase the risk of local recurrence. On the other hand, tumours diagnosed by bronchoscopy have a worse prognosis, that may be related to their higher metastatic potential rather than to diagnostic procedure itself.     

How to quantify infarct size on delayed-enhancement MR images: a comparison between visual and quantitative approach

PURPOSE: Our aim was to evaluate the reliability of visual quantification of infarct extent on delayed enhanced magnetic resonance images. MATERIALS AND METHODS: Eighty patients with previous myocardial infarction underwent cine and contrast-enhanced cardiac magnetic resonance imaging. The gadolinium-enhanced images were evaluated using a segmental model with two different methods: a visual score on a 5-point scale (0 no hyperenhancement, 4 hyperenhancement>76% of myocardial wall) and a quantitative analysis based on the manual tracing of infarct contours with automatic threshold analysis. Each segment was also assigned a wall-motion score ranging from 0 (normokinesia) to 4 (dyskinesia). Statistical evaluation was performed. RESULTS: Out of 1,280 segments, 322 (25.1%) showed wall-motion abnormalities with enhancement in 327 (25.5%) evaluated with visual score and in 414 (32.3%) quantitatively. Among segments with normal or mild hypokinesia, 89.2% had a delayed-enhancement scoreor=3. Mean time required for the visual and quantitative approach was 7+/-3 and 18+/-9 min, respectively. There was strong agreement between the visual and quantitative method (k=0.92; p<0.01). CONCLUSIONS: Visual analysis of delayed enhancement is a timesaving approach that is sufficient to assess the transmural extent of infarction. Moreover, it has high correlation with wall-motion abnormalities.     

Echocardiographic diastolic dysfunction and magnetic resonance infarct size in healed myocardial infarction treated with primary angioplasty

Background: After acute myocardial infarction (MI) the severity of diastolic dysfunction by echocardiography represents an independent prognostic marker. However, the mechanisms whereby diastolic dysfunction portends an increased risk after MI are not fully understood. We investigated the relationship between echocardiographic diastolic dysfunction severity and infarct size quantitatively measured by contrast‐enhanced magnetic resonance (ce‐MR). Methods: Cross‐sectional prospective study. We quantified “healed” infarct size by ce‐MR measuring the percentage of delayed enhancement with respect to left ventricular mass and diastolic function by Doppler echocardiography. Both exams were scheduled at least 1 month after a first acute ST segment elevation MI (STEMI) successfully treated with primary angioplasty and stenting. To increase the specificity, individual echocardiographic parameters were integrated to grade global diastolic function in 4 grades: normal diastolic function, impaired relaxation with normal, or near‐normal filling pressures; impaired relaxation with moderate elevation of filling pressures, and impaired relaxation with marked elevation of filling pressures, “restrictive filling.” Results: We prospectively enrolled 52 patients (mean age 62 ± 13 years, 77% men). ce‐MR and echocardiography were performed 48 ± 15 days after the MI. There was a significant but modest correlation between diastolic function grade and infarct size (r = 0.423, P = 0.002), which was independent of global and regional systolic function and persisted after further adjustment for age, sex, body surface area, left ventricular mass, end‐diastolic volumes, and sphericity index (all P < 0.05). Among single echocardiographic variables, infarct size correlated best with tissue Doppler velocities Em (r =?0.307, P = 0.03), Am (r =?0.39, P = 0.005), and flow propagation velocity (r =?0.34, P = 0.015). Conclusions: In healed STEMI successfully treated with primary angioplasty and stenting, diastolic function grade was independently albeit weakly correlated with infarct size. Therefore, the increased risk of diastolic dysfunction after MI is not fully explained by infarct size