A 56-year-old woman was treated for rheumatoid arthritis for 17 years with methotrexate (MTX). Night sweats, fever and weight loss made her visit our hospital. Although levofloxacin failed to resolve ...her fever, she was suspected of having sepsis because of pancytopenia, elevated procalcitonin and a nodular lesion in the lung. After urgent hospitalization, she was diagnosed finally with the methotrexate-related lymphoproliferative disorder (MTX-LPD) associated with macrophage activation syndrome (MAS). Her general condition was improved with MTX withdrawal and 5-day high-dose glucocorticoid administration. Thus, even when the patient was critically ill with MAS, no cytotoxic agents were required to control MTX-LPD.
We have previously demonstrated that cardiac shock wave therapy (CSWT) effectively improves myocardial ischemia through coronary neovascularization both in a porcine model of chronic myocardial ...ischemia and in patients with refractory angina pectoris (AP). In this study, we further addressed the efficacy and safety of CSWT in a single-arm multicenter study approved as a highly advanced medical treatment by the Japanese Ministry of Health, Labour and Welfare. Fifty patients with refractory AP mean age 70.9 ± 12.6 (SD) years, M/F 38/12 without the indications of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) were enrolled in 4 institutes in Japan. Ischemic myocardial regions in the left ventricle (LV) were identified by drug-induced stress myocardial perfusion imaging (MPI). Shock waves (200 shots/spot at 0.09 mJ/mm
2
) were applied to 40–60 spots in the ischemic myocardium 3 times in the first week. The patients were followed up for 3 months thereafter. Forty-one patients underwent CSWT and completed the follow-up at 3 months. CSWT markedly improved weekly nitroglycerin use from 3.5 (IQR 2 to 6) to 0 (IQR 0 to 1) and the symptoms Canadian Cardiovascular Society functional class score, from 2 (IQR 2 to 3) to 1 (IQR 1 to 2) (both
P
< 0.001). CSWT also significantly improved 6-min walking distance (from 384 ± 91 to 435 ± 122 m,
P
< 0.05). There were no significant changes in LV ejection fraction evaluated by echocardiography and LV stroke volume evaluated by cardiac magnetic resonance imaging (from 56.3 ± 14.7 to 58.8 ± 12.8%,
P
= 0.10, and from 52.3 ± 17.4 to 55.6 ± 15.7 mL,
P
= 0.15, respectively). Percent myocardium ischemia assessed by drug-induced stress MPI tended to be improved only in the treated segments (from 16.0 ± 11.1 to 12.1 ± 16.2%,
P
= 0.06), although no change was noted in the whole LV. No procedural complications or adverse effects related to the CSWT were noted. These results of the multicenter trial further indicate that CSWT is a useful and safe non-invasive strategy for patients with refractory AP with no options of PCI or CABG.
Abstract only
Introduction:
Evaluation of the patency of a metallic stent in coronary arteries using CT is difficult because the metallic stent causes a blooming artifact. The CT values of metallic ...stents are influenced by tube kilovoltage (kV). Recent spectral CT with a dual-layer detector can generate CT images at any kiloelectron voltage (keV) (range: 40-200) after ordinary acquisition using virtual monoenergetic settings (VMS).
Hypothesis:
Using a new spectral CT, we can determine the optimal VMS for evaluating the patency of stents in coronary arteries.
Methods:
We performed enhanced 128 slice Spectral CT 7500 scans with a dual-layer detector in 35 patients with CAC who underwent implantation of a metallic stent in coronary arteries (tube voltage: 120 kV). After scanning, VMS images at various keV values were created from the spectral-based images. We measured the mean CT values of the metallic stent, coronary artery calcification (CAC), lumen in the left coronary artery (LCA), and fat tissue around the coronary arteries in the axial images at each keV in the early phase with contrast.
Results:
Lower keV values were associated with markedly increased mean CT values of the metallic stent and CAC. The CT values of the lumen in the LCA were moderately increased. Conversely, the CT values of fat tissue were slightly decreased. The greatest differences in mean CT values between the metallic stent and lumen in the LCA were observed at 40-50 keV, however, those between the metallic stent and CAC were observed at 110-180 keV. The optimal keV for achieving the best contrast between the CT values of the metallic stent, CAC, and the lumen in the LMA at each patient was influenced by age, male sex.
Conclusions:
The metallic stent, CAC, lumen of the LCA, and fat tissue exhibit unique characteristics. When conventional rather than spectral CT is used to evaluate the patency of a metallic stent in coronary arteries, it is necessary to determine the optimal tube voltage based on the age and male sex of the patient.
Abstract only
Introduction:
The risk of subacute thrombosis (SAT) after percutaneous coronary intervention (PCI) or percutaneous peripheral intervention (PPI) is high if patients show high whole ...blood platelet aggregation.
Hypothesis:
For such high-risk patients, even though dual antiplatelet therapy is performed, whole platelet aggregation should be quantitated and if high, the indication for additional antiplatelet therapy determined.
Methods:
This is a retrospective analysis of 12095 stents from 12095 patients (9173 males; mean age 69±11 years; 9470 PCI, 2625 PPI). The whole blood platelet aggregatory threshold index (PATI; WBA-Neo; ISK, Osaka, Japan) was calculated. PATI was used to determine the minimum concentration of adenosine 5'-diphosphate causing a non-reversible aggregation of platelets and indicated platelet aggregation (range 0-8 μM). The higher the PATI, the lower the platelet aggregation. All patients received single or double antiplatelet drug therapy according to physician choice.
Results:
SAT occurred in 18 (0.19%) of 9470 patients after PCI and in 9 patients (0.34%) of 2625 patients after PPI. Of 9470 patients after PCI, total blood PATI was 4.40 in 18 patients with SAT and 7.00 in 9452 patients without SAT (P<0.001). Of 2625 patients after PPI, the total blood PATI was 4.97 in nine patients with SAT and 6.39 in 2616 patients without SAT; the former was significantly lower than the latter (P<0.001). We combined patients with PCI and PPI. PATI was divided into nine grades: 0-0.99, 1-1.99, 2-2.99. 3-3.99, 4-4.99. 5-5.99, 6-6.99, 7-7.99, and >7.99. Of 12095 patients, if PATI was 0-0.99, the incidence of SAT was greatest at 1.89%. If PATI was >7.99, the incidence of SAT was lowest at 0.09%. We divided 12095 patients into two groups: PATI of 0-4.99 (N=2229) and PATI of >4.99(N=9866); the incidence of SAT was greater in the former (0.72%) than latter (0.11%; P<0.001). No significant differences existed in the percentage of each coronary risk factor between patients with and without SAT after PCI, PPI, and PCI or PPI.
Conclusions:
In patients after PCI and/or PPI, despite single or double antiplatelet drug therapy, the whole blood platelet aggregation should be checked, and if PATI is 0-4.99 the indication for additional antiplatelet therapy should be considered.
Abstract only
Introduction:
Fractional flow reserve (FFR) measures percutaneous coronary intervention (PCI) performance. FFR was determined by guide wire (GW)-type FFR. It is now evaluated by ...computed tomography (CT; FFRCT) or invasive coronary angiography (FFRangio; CathWorks, USA), whereby coronary arteries are traced on a conventional angiogram from three different angles to form three-dimensional images; the calculated FFR is FFRangio. In contrast to GW-type FFR, FFRangio does not need a vasodilator drug (e.g. nicorandil) load or GW. Hypothesis: Coronary calcification may influence the effect of vasodilator drugs, causing a difference between FFRangio and GW-type FFR depending on coronary calcium score (CCS).
Methods:
FFRangio and GW-type FFR (SJN, Zeon, ACIST) were simultaneously evaluated at catheter examinations in 11 coronary arteries from 9 patients before PCI (six males, mean age 72±11 years). Nicorandil (2 mg) was directly injected when measuring GW-type FFR. Cardiac CT was performed to measure CCS.
Results:
The correlation coefficients between FFR magnitude (=mean of FFRangio and GW-type FFR) and CCS in all vessels, and a vessel with FFR measurement, were -0.845 and -0.843, respectively. The correlation coefficients between difference in FFRangio minus GW-type FFR and CCS in all vessels, and a vessel with FFR measurement, were 0.627 and 0.752, respectively. The greater the CCS of both all vessels and a vessel in FFR measurements, the smaller the FFR. The greater the CCS of both all vessels and a vessel with FFR measurement, the greater the difference in FFRangio minus GW-type FFR (Figures). This may indicate the greater the CCS, the smaller the vasodilation effect of a direct nicorandil injection.
Conclusions:
Of GW-type FFR, FFRangio, and FFR CT, only GW-type FFR requires a vasodilator injection. Coronary arteries, known to cause blooming artifacts and impair the accuracy of FFRCT, also influence vasodilator effects, especially with borderline FFR (0.75-0.80).
Abstract only
Introduction:
Spectral CT with a dual-layer detector generates CT images at any keV (range: 40-200) after ordinary acquisition using virtual monoenergetic settings (VMS). An appropriate ...keV improves the contrast of a pulmonary artery (PA) thrombus (PAT). On iodine no water (INW) display, areas with decreased PA blood flow are visualized. With effective atomic number display (Z effective), infarcted and normal lung tissues are distinguished.
Hypothesis:
Spectral CT improves the detection of PAT, areas with decreased PA blood flow, and infarcted lung tissue, increasing diagnostic accuracy.
Methods:
We performed enhanced 128 slice Spectral CT 7500 (Philips) scans with a dual-layer detector in 23 patients (11 males, 61±13 years) with clinically suspected PAT. VMS images at various keV values were created from spectral-based images. We developed an INW display to detect decrements in PA blood flow and also made Z effective displays to distinguish infarcted from normal lung tissue. We measured patent PA lumens, PAT, lung areas with decrements in PA flow and infarcted lung tissue.
Results:
19 patients had PAT. Of the remaining 4 patients, two revealed decrements in PA flow on INW display and lung tissue changes on Z effective display. On a spectral profile analysis using images in the early phases using contrast, lower keV values were associated with markedly and slightly increased mean CT values for the patent PA lumen and PAT, respectively. Lower keV values were associated with markedly increased mean CT values for normal lung tissue, however, mean CT values were constant at various keV values for an area related to decrements in PA blood flow by INW display and also infarcted lung tissue by Z profile, simultaneously, respectively (Figure).
Conclusions:
A small PAT may be missed in enhanced CT. However, spectral CT can detect PAT, an area corresponding to decrements in PA blood flow on INW display, and also distinguish infarcted from normal lung tissue on a Z profile, simultaneously.
Abstract only
Introduction:
Differentiating intramural hematoma (IH) from a thrombosed false lumen (FL) in aortic dissection (AD) is difficult by CT since both are regarded as AD without a tear. IH ...may be caused by vasa vasorum rupture, and therefore differentiation should be by histology. Spectral CT with a dual layer detector can generate CT images at any keV after ordinary acquisition using virtual monoenergetic settings (VMS).
Hypothesis:
Using spectral CT (range 40-200 keV), and a spectral distribution of CT values for aortic true lumen (TL) and FL, we can differentiate IH from thrombosed FL in AD in early and late-phase enhanced CT values.
Methods:
We performed enhanced 128-slice spectral CT 7500 (Philips) scans with a dual-layer detector in 8 patients (5 males, 71±14 years), with suspected IH or thrombosed FL in AD in the ascending aorta (Group 1), and 6 patients (4 males, 67±12 years) with thrombosed FL in AD in the descending aorta (Group 2). VMS images at various keV values were created from spectral-based images. We measured TL, FL or IH lumens in axial images at each keV in early and late phases using contrast.
Results:
On spectral profile analysis, in Group 1, lower keV values were associated with almost no and slightly increased mean CT values for FL or IH, in early and late phases using contrast. In Group 2, lower keV values were associated with slightly and moderately increased mean CT values for FL, in early and late phases using contrast. The degree of increments in CT values in lower keV images in late phase with contrast was significantly smaller for FL or IH in ascending aortas (n=8) than for FL in descending aortas (n=6) (P<0.05).
Conclusions:
On CT, TL, FL, and IH lumens, in early and late phases using contrast are unique. IH may be caused by vasa vasorum rupture and thrombosed FL in AD spreading contrast in late phase. This may cause a difference in the degree of increments in CT values in lower keV images in late phase using contrast for FL or IH in the ascending aorta and for FL in the descending aorta.
Abstract only
Introduction:
Non calcified plaque (NCP) in coronary arteries on CT is correlated with occurrence of acute coronary syndromes and coronary artery calcification (CAC) may occasionally be ...co-existed. CAC induces a blooming artifact, which magnifies the calcification versus its actual size. The CT values of NCP and CAC are influenced by tube kilovoltage (kV). Recent spectral CT with a dual-layer detector can generate CT images at any kiloelectron voltage (keV) (range: 40-200) after ordinary acquisition using virtual monoenergetic settings (VMS).
Hypothesis:
Using a new spectral CT, we can determine the optimal VMS settings for achieving best contrast between NCP, CAC and the lumen in coronary arteries.
Methods:
We performed enhanced 128 slice Spectral CT 7500 scans using a dual-layer detector in 42 patients with NCP and CAC on CT (tube voltage: 120 kV). After scanning, VMS images at various keV values were created from the spectral-based images. We measured the mean CT values of NCP and CAC, lumen in left main artery (LMA), and fat tissue around coronary arteries within a 1.0 mm2 circle in the axial images at each keV in early phase with a contrast.
Results:
Lower keV values were linked to only slightly increased mean CT values of NCP, but markedly increased mean CT values of CAC. The CT values of the lumen in the LMA were markedly increased. Conversely, the CT values of fat tissue were slightly decreased. The greatest differences in mean CT values between NCP and the LMA were observed at 40 keV. However, considering blooming artifact of CAC at 40 keV, the optimal keV for achieving the best contrast between the CT values of NCP and the lumen in the LMA was influenced by age, male sex.
Conclusions:
The NCP in coronary arteries, CAC, lumen of the LMA, and fat tissue exhibit unique characteristics. When conventional CT rather than spectral CT is used to evaluate the occurrence of NCP, it is necessary to determine the optimal tube voltage based on the age and male sex of the patient, CAC, and lumen of the LMA.
This study investigated the factors associated with coronary artery stenosis in outpatients. Furthermore, the usefulness of maximum carotid intima-media thickness (maximum-IMT) as a surrogate marker ...of coronary artery stenosis was evaluated.
We conducted a single-center retrospective study. A total of 601 outpatients (338 males; 263 females; mean age, 69.8±10.0 years) who underwent coronary computed tomography angiography between April 2006 and March 2012 were analyzed. The associations between coronary artery stenosis (≥75%) as determined by coronary computed tomography angiography and clinical and laboratory parameters were evaluated by multivariate logistic regression. Validation of maximum-IMT as measured by ultrasonography as a surrogate marker of coronary artery stenosis was analyzed by receiver operating characteristic (ROC) curve analysis.
The estimated glomerular filtration rate (eGFR: mL/min/1.73 m
) (odds ratio OR 0.985,
<0.01), diabetes mellitus (OR 1.98,
<0.05), and maximum-IMT (mm) (OR 1.76,
<0.01) were significantly associated with coronary artery stenosis (≥75%). In analysis of each group categorized by identified factors, such as renal impairment (eGFR <60 mL/min/1.73 m
) and diabetes mellitus, the ROC curve of maximum-IMT was significant in the group of patients with diabetes mellitus without renal impairment (
<0.01) (cutoff value of maximum-IMT, 2.0 mm; sensitivity, 0.74; and specificity, 0.54) but not in other groups.
Renal impairment, diabetes mellitus, and increased maximum-IMT may be significant risk factors of coronary artery stenosis. Maximum-IMT as measured by ultrasonography may be a useful surrogate marker for coronary artery stenosis in patients with diabetes mellitus without renal impairment but not in other patients.
PDF
