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.
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
References
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TL;DR: ICUS is associated with (but not necessarily the direct cause of) a minor acute clinical risk, and vessel spasm is the most frequent event occurring during ICUS.
Abstract: Background Intracoronary ultrasound (ICUS) is increasingly used in clinical practice to study the natural history of coronary artery disease and to assess the effects of intracoronary, catheter-based interventions. However, the risk associated with the procedure is not well documented.
Methods and Results ICUS studies performed in 28 centers were retrospectively included; these centers agreed to contribute to the study among a total of 60 centers initially invited. Among the 2207 ICUS studies, 505 (23%) were performed in heart transplant recipients and 1702 (77%) in nontransplant patients. Indication for ICUS was diagnostic imaging in 915 (41%), drug testing in 244 (11%), and guidance for intracoronary interventions in 1048 patients (47%). There were no complications in 2034 patients (92.2%). In 87 patients (3.9%), complications occurred but were judged to be “not related” to ICUS by the operator. In 63 patients (2.9%), spasm occurred during ICUS imaging. In 9 patients (0.4%), complications other than spasm were judged to have a “certain relation” to ICUS, including acute procedural events in 6 (3 acute occlusion, 1 embolism, 1 dissection, and 1 thrombus) and major events in 3 patients (2 occlusion and 1 dissection; all resulting in myocardial infarction). In 14 patients (0.6%), complications with “uncertain relation” to ICUS were recorded, including acute procedural events in 9 (5 acute occlusion, 3 dissection, and 1 arrhythmia) and major events in 5 patients (2 myocardial infarction and 3 emergency coronary artery bypass surgery). The incidence of acute procedural or major complications judged to be associated with ICUS (uncertain relation or certain relation to ICUS) was compared in different patient groups. The complication rate was higher in patients with unstable angina or acute myocardial infarction (2.1% events) as compared with patients with stable angina pectoris and asymptomatic patients (0.8% and 0.4%, respectively; χ2=10.9, P <.01). These complications were also more frequent in patients undergoing interventions (1.9%) as compared with transplant and nontransplant patients undergoing diagnostic ICUS imaging (0% and 0.6%, respectively; χ2=13.5, P <.001). Adverse events were few, and no association was detected between these events and the size or type of ICUS catheter used.
Conclusions ICUS is associated with (but not necessarily the direct cause of) a minor acute clinical risk. Vessel spasm is the most frequent event occurring during ICUS. Other complications predominantly occur in patients with acute coronary syndromes and during guidance for intervention.
238 citations
"Evaluation of coronary allograft va..." refers background in this paper
...The risk of serious complications associated with IVUS has been estimated at between 1% and 3% [28]....
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TL;DR: The Editor-in-Chief of the European Journal of Cardiothoracic Surgery (EJCTS) and EJCTSyICVTS is chosen to provide an overview of existing guidelines, accepted treatment strategies and overall to improve the quality of care for patients w8–10x.
Abstract: The Editor-in-Chief of the European Journal of Cardiothoracic SurgeryyInteractive CardioVascular Thoracic Surgery (EJCTSyICVTS) can be appointed for a maximum of two terms of five years each. The former Editor-in-Chief, Ludwig von Segesser, has served these two terms and I am proud to be chosen as the new Editor-in-Chief of these prestigious journals (Fig. 1). This change in the incumbent of the post of Editor-in-Chief every five or 10 years allows new ideas to be implemented and the further development of the already very successful story of EJCTS and ICVTS. In addition to a new Editor-in-Chief, it was also necessary to appoint a new Managing Editor when Ian Beecroft retired after serving for 15 years as Managing Editor of EJCTSy ICVTS. We are very happy to have Birgit Knapp on board, a very experienced, educated and innovative person who is perfect for this demanding position. In addition, Rita Brightwell retired and was replaced by Tanja Gunser, a very reliable and knowledgeable person in the Editorial Office. Judy Gaillard, who has already worked for EJCTSyICVTS for more than eight years, is now the valuable person with the longest experience within the Editorial Office. In addition, the location of the Office changed from Martigny in Switzerland to Freiburg in Germany in order to allow close collaboration in a timely manner between all members of the Editorial Office during the busy surgical day. I am happy to be supported in this task by my entire team in Freiburg (Fig. 2). The goal of scientific journals is to spread new knowledge w1–4x, push forward the frontiers of current knowledge in every aspect w5–7x, allow publication of creative ideas and form the basis for ongoing innovations. Furthermore, our aims are to present and discuss the results of new or standard forms of treatment and to provide an overview of existing guidelines, accepted treatment strategies and overall to improve the quality of care for patients w8–10x. There is a saying that ‘cardiothoracic surgery is 70% com-
231 citations
TL;DR: The presumption that the donor heart remains denervated in humans is based primarily on the lack of appropriate neural reflex—mediated changes in the heart rate, so it is surprising that reinnervation would not occur, because there is extensive evidence of sympathetic reinnoration after cardiac transplantation in nearly all animal models.
Abstract: ALTHOUGH coronary artery disease develops within three years of heart transplantation in up to 40 percent of transplant recipients,1 , 2 chest pain late after cardiac transplantation is usually dismissed as being "noncardiac" because it has been assumed that the transplanted heart is permanently denervated. The presumption that the donor heart remains denervated in humans is based primarily on the lack of appropriate neural reflex—mediated changes in the heart rate.3 , 4 That reinnervation would not occur is surprising, because there is extensive evidence of sympathetic reinnervation after cardiac transplantation in nearly all animal models.5 6 7 8 In the transplanted heart, sympathetic nerves are severed from . . .
214 citations
Additional excerpts
...graft failure or malignant cardiac arrhythmias [17]....
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TL;DR: Negative 64-slice CT reliably excluded significant coronary disease, however, the data suggest that stenoses shown on 64- slice CT require confirmation, and scan protocols should be optimized to minimize risk.
193 citations
"Evaluation of coronary allograft va..." refers result in this paper
...Although not obviously explained, this has been a finding described in previous meta-analysis examining the efficacy of both scanners [24]....
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TL;DR: Coronary revascularization may be an effective palliative therapy in suitable cardiac transplant recipients and angioplasty has an acceptable survival in patients without angiographic distal arteriopathy.
189 citations
"Evaluation of coronary allograft va..." refers background in this paper
...Although detection of distal disease may not result in revascularization, it still offers important diagnostic and prognostic value [34]....
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