Evaluation of coronary allograft vasculopathy using multi-detector row computed tomography: a systematic review.
01 Feb 2012-European Journal of Cardio-Thoracic Surgery (Oxford University Press)-Vol. 41, Iss: 2, pp 415-422
TL;DR: The high sensitivity and NPV of MDCT suggest that it may be a useful, noninvasive screening tool to rule out CAV.
Abstract: Summary Coronary allograft vasculopathy (CAV) is a significant cause of morbidity and mortality after cardiac transplantation and requires frequent surveillance with catheter-based coronary angiography (CCA). Multi-detector row computed tomography (MDCT) has been shown to be effective in assessing atherosclerosis in native coronary arteries. This article systematically reviews the literature to determine the accuracy of MDCT in CAVassessment. An English-language literature search was performed using EMBASE, OVID, PubMed, and Cochrane Library databases. Studies that directly compared MDCTwith CCA and/or IVUS for the detection of coronary artery stenosis or significant intimal thickening in cardiac transplant patients were analyzed. Data were pooled to obtain weighted sensitivities, specificities, and diagnostic accuracies. Negative and positive predictive values (NPV/PPV) were calculated. A total of seven studies with a sum of 272 patients were included in this review. There were three studies examining 16-slice MDCTand four studies looking at 64-slice MDCT in CAV. Using per-segment analysis, MDCTassessed between 91% and 96% of all coronary segments when evaluating for stenosis. Pooled estimates for sensitivity and specificity for MDCTranged from 82% to 89% and 89% to 99%, respectively, while NPV was 99%. Per-patient analysis revealed a sensitivity of 87—100% and NPV of 96—100%. PPV was less than 50% for 64slice MDCT in both per-segment and per-patient analysis. When compared with IVUS, MDCT had a sensitivity of 74—96% and specificity of 88—92% in assessment of intimal thickening. NPVand PPV were 80—81% and 84—98%, respectively. The high sensitivity and NPV of MDCTsuggest that it may be a useful, noninvasive screening tool to rule out CAV. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
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TL;DR: CCTA using currently available technology is a reliable noninvasive imaging alternative to coronary angiography with an excellent sensitivity, specificity, and NPV for the detection of CAV.
Abstract: Objectives This study aimed to evaluate the diagnostic accuracy of coronary computed tomography angiography (CCTA) for detecting cardiac allograft vasculopathy (CAV) in comparison with conventional coronary angiography (CCAG) alone or with intravascular ultrasound (IVUS). Background CAV limits long-term survival after heart transplantation, and screening for CAV is performed on annual basis. CCTA is currently not recommended for CAV screening due to the limited accuracy reported by early studies. Technological advances, however, might have resulted in improved test performance and might justify re-evaluation of this recommendation. Methods A systematic review of Medline, Cochrane, and Embase for all prospective trials assessing CAV using CCTA was performed using a standard approach for meta-analysis for diagnostic test and a bivariate analysis. Results Thirteen studies evaluating 615 patients (mean age 52 years, 83% male) and 9,481 segments fulfilled inclusion criteria. Patient-based analyses comparing CCTA versus CCAG for the detection of any CAV (> luminal irregularities) and significant CAV (stenosis ≥50%), showed mean weighted sensitivities of 97% and 94%, specificities of 81% and 92%, a negative predictive value (NPV) of 97% and 99%, a positive predictive value (PPV) of 78% and 67%, and diagnostic accuracies of 88% and 94%, respectively. There was a strong trend toward improved sensitivity (97% vs. 91%, p = 0.06) and NPV (99% vs. 97%, p = 0.06) to detect significant CAV with 64-slice compared with 16-slice CCTA. A patient-based analysis of 64-slice CCTA versus IVUS showed a mean weighted sensitivity and specificity of 81% and 75% to detect CAV (intimal thickening >0.5 mm), whereas the PPV and NPV were 93% and 50%, respectively. Conclusions CCTA using currently available technology is a reliable noninvasive imaging alternative to coronary angiography with an excellent sensitivity, specificity, and NPV for the detection of CAV.
112 citations
TL;DR: The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.
Abstract: The development of cardiac CT has provided a non-invasive alternative to echocardiography, exercise electrocardiogram, and invasive angiography and cardiac CT continues to develop at an exponential speed even now. The appropriate use of cardiac CT may lead to improvements in the medical performances of physicians and can reduce medical costs which eventually contribute to better public health. However, until now, there has been no guideline regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.
61 citations
TL;DR: It is therefore of utmost importance that interventional cardiologists become familiar with image interpretation and up-to-date regarding several CCTA features, taking advantage of this information in planning the procedure, ultimately leading to improvement in patient outcomes.
Abstract: In recent years, coronary CT angiography (CCTA) has become a widely adopted technique, not only due to its high diagnostic accuracy, but also to the fact that CCTA provides a comprehensive evaluation of the total (obstructive and non-obstructive) coronary atherosclerotic burden. More recently, this technique has become mature, with a large body of evidence addressing its prognostic validation. In addition, CT angiography has moved from the field of ‘imagers’ and clinicians and entered the interventional cardiology arena, aiding in the planning of both coronary and structural heart interventions, being transcatheter aortic valve implantation one of its most successful examples. It is therefore of utmost importance that interventional cardiologists become familiar with image interpretation and up-to-date regarding several CTA features, taking advantage of this information in planning the procedure, ultimately leading to improvement in patient outcomes. On the other hand, the increasing use of CCTA as a gatekeeper for invasive coronary angiography is expected to lead to an increase in the ratio of interventional to diagnostic procedures and significant changes in the daily cath-lab routine. In a foreseeable future, cath-labs will probably offer an invasive procedure only to patients expected to undergo an intervention, perhaps becoming in this change true interventional-labs.
15 citations
TL;DR: MCP-1, RANTES, and fractalkine probably promote instability of coronary atherosclerotic plaque.
Abstract: Our aim was to investigate the role of chemokines in promoting instability of coronary atherosclerotic plaques and the underlying molecular mechanism. Coronary angiography and intravascular ultrasound (IVUS) were performed in 60 stable angina pectoris (SAP) patients and 60 unstable angina pectoris (UAP) patients. The chemotactic activity of monocytes in the 2 groups of patients was examined in Transwell chambers. High-sensitivity C-reactive protein (hs-CRP), monocyte chemoattractant protein-1 (MCP-1), regulated on activation in normal T-cell expressed and secreted (RANTES), and fractalkine in serum were examined with ELISA kits, and expression of MCP-1, RANTES, and fractalkine mRNA was examined with real-time PCR. In the SAP group, 92 plaques were detected with IVUS. In the UAP group, 96 plaques were detected with IVUS. The plaques in the UAP group were mainly lipid 51.04% (49/96) and the plaques in the SAP group were mainly fibrous 52.17% (48/92). Compared with the SAP group, the plaque burden and vascular remodeling index in the UAP group were significantly greater than in the SAP group (P<0.01). Chemotactic activity and the number of mobile monocytes in the UAP group were significantly greater than in the SAP group (P<0.01). Concentrations of hs-CRP, MCP-1, RANTES, and fractalkine in the serum of the UAP group were significantly higher than in the serum of the SAP group (P<0.05 or P<0.01), and expression of MCP-1, RANTES, and fractalkine mRNA was significantly higher than in the SAP group (P<0.05). MCP-1, RANTES, and fractalkine probably promote instability of coronary atherosclerotic plaque.
10 citations
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...Complications include occlusion, rupture, and hemorrhage (2,3)....
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TL;DR: This work intends to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data to assist the clinicians and other health professionals when using cardiac CT for diagnosis and treatments of heart diseases in Korea.
Abstract: This work is supported by a Grant from National Strategic Coordiating Center for Clinical Research, Republic of Korea (A102065). Heart disease is one of the leading causes of deaths in Korea, along with malignant neoplasms and cerebrovascular diseases. The proper diagnosis and management for patients with suspected heart diseases should be warranted for the public health care. Advances in CT technology have allowed detailed images of the heart to be obtained, which enable evaluations not only of the coronary arteries but also of other cardiac structures. Currently, the latest multi-detector CT machines are widespread around Korea. The appropriate use of cardiac CT may lead to improvements of the physicians’ medical performances and to reduce medical costs which eventually contribute to promotions of public health. However, until now, there has been no guidelines regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist the clinicians and other health professionals when using cardiac CT for diagnosis and treatments of heart diseases.
7 citations
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3,259 citations
"Evaluation of coronary allograft va..." refers methods in this paper
...Coronary segments were described most often using the system proposed by the American Heart Association [8], or modified versions of this system....
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...Coronary segments were described most often using the system proposed by the American Heart Association [8], or modified versions of this...
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TL;DR: In this prospective multicenter trial of chest pain patients without known CAD, 64-multidetector row CCTA possesses high diagnostic accuracy for detection of obstructive coronary stenosis at both thresholds of 50% and 70% stenosis.
Abstract: Objectives The purpose of this study was to evaluate the diagnostic accuracy of electrocardiographically gated 64-multidetector row coronary computed tomographic angiography (CCTA) in individuals without known coronary artery disease (CAD) Background CCTA is a promising method for detection and exclusion of obstructive coronary artery stenosis To date, no prospective multicenter trial has evaluated the diagnostic accuracy of 64-multidetector row CCTA in populations with intermediate prevalence of CAD Methods We prospectively evaluated subjects with chest pain at 16 sites who were clinically referred for invasive coronary angiography (ICA) CCTAs were scored by consensus of 3 independent blinded readers The ICAs were evaluated for coronary stenosis based on quantitative coronary angiography (QCA) No subjects were excluded for baseline coronary artery calcium score or body mass index Results A total of 230 subjects underwent both CCTA and ICA (591% male; mean age: 57 ± 10 years) On a patient-based model, the sensitivity, specificity, and positive and negative predictive values to detect ≥50% or ≥70% stenosis were 95%, 83%, 64%, and 99%, respectively, and 94%, 83%, 48%, 99%, respectively No differences in sensitivity and specificity were noted for nonobese compared with obese subjects or for heart rates ≤65 beats/min compared with >65 beats/min, whereas calcium scores >400 reduced specificity significantly Conclusions In this prospective multicenter trial of chest pain patients without known CAD, 64-multidetector row CCTA possesses high diagnostic accuracy for detection of obstructive coronary stenosis at both thresholds of 50% and 70% stenosis Importantly, the 99% negative predictive value at the patient and vessel level establishes CCTA as an effective noninvasive alternative to ICA to rule out obstructive coronary artery stenosis (A Study of Computed Tomography [CT] for Evaluation of Coronary Artery Blockages in Typical or Atypical Chest Pain; NCT00348569)
1,941 citations
"Evaluation of coronary allograft va..." refers methods in this paper
...In the ACCURACY trial [23], MDCT had a similarly low PPV (51% with vessel-based analysis) in assessing significant native CAD where disease prevalence was also low (25%)....
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TL;DR: The increase in spatial and temporal resolution with 64-slice CTA is associated with an increased radiation dose for coronary CTA and dose-saving algorithms are very effective in reducing radiation exposure.
Abstract: Background— Multislice computed tomography angiography (CTA) is a promising technology for imaging patients with suspected coronary artery disease Compared with 16-slice CTA, the improved spatial
718 citations
TL;DR: This study demonstrates that coronary atherosclerosis begins at a young age and that lesions are present in 1 of 6 teenagers, and suggest the need for intensive efforts at coronary disease prevention in young adults.
Abstract: Background—Most of our knowledge about atherosclerosis at young ages is derived from necropsy studies, which have inherent limitations. Detailed, in vivo data on atherosclerosis in young individuals are limited. Intravascular ultrasonography provides a unique opportunity for in vivo characterization of early atherosclerosis in a clinically relevant context. Methods and Results—Intravascular ultrasound was performed in 262 heart transplant recipients 30.9±13.2 days after transplantation to investigate coronary arteries in young asymptomatic subjects. The donor population consisted of 146 men and 116 women (mean age of 33.4±13.2 years). Extensive imaging of all possible (including distal) coronary segments was performed. Sites with the greatest and least intimal thickness in each CASS segment were measured in multiple coronary arteries. Sites with intimal thickness ≥0.5 mm were defined as atherosclerotic. A total of 2014 sites within 1477 segments in 574 coronary arteries (2.2 arteries per person) were anal...
671 citations