Introduction We present a case of diffuse distal congenital pulmonary artery hypoplasia with elevated right ventricular systolic pressures, successfully treated with pulmonary artery stenting. Case Report A 35-year-old female presented with increasing exertional dyspnoea, on a background of diffuse distal congenital pulmonary artery hypoplasia due to an elastin gene mutation and morbid obesity.There was evidence of mild right heart failure on examination and oxygen saturations were normal. Her transthoracic echocardiogram showed right ventricular (RV) hypertrophy with moderately impaired systolic function, moderate tricuspid regurgitation and an estimated RV systolic pressure (RVSP) of 120 mmHg. Her right atrial pressure was 8 mmHg on right heart catheterisation, RVSP was 138 mmHg, mean pulmonary artery pressure (mPAP) was 84 mmHg, with a normal cardiac output and pulmonary capillary wedge pressure. A decision was made for an experienced interventional radiologist to proceed initially with balloon pulmonary angioplasty (BPA). Her obesity made her an unsuitable candidate for lung transplantation. BPA to the left and right lower lobe pulmonary artery basal segments was performed, without clinical improvement. One week later, cutting BPA was performed to the left lower lobe pulmonary artery and its A7/8 and A9/10 trunks, without improvement. Finally, PA stenting was undertaken to the left lower lobe main branch and the proximal A7/8 and A9/10 trunks, right lower lobe PA and the right middle lobe A4/5 trunk. Completion angiography showed improved flow to all stented segments, except A4. The mPAP was 36 mmHg and there were no complications.The patient experienced a marked improvement in exercise tolerance at six months follow-up with normal RV contractility. Summary We present a rare case of congenital pulmonary artery hypoplasia treated with BPA and subsequent successful PA stenting. Treatments for this condition not well characterised, highlighting the importance of this case.

This review aims to present contemporary data for SIRT in the treatment of secondary hepatic malignancies including colorectal, neuroendocrine, breast and uveal melanoma.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition occurring in 2%–4% of patients after acute pulmonary embolism. Pulmonary endarterectomy (PEA) is a potential cure for technically operable disease. The epidemiology and long‐term outcomes of CTEPH have not been previously described in Australia and New Zealand.

Purpose This article aims to report Australian experience of percutaneous transhepatic embolization of gastroesophageal and ectopic varices. Method Eight consecutive patients (mean age 61.8 years, 7 men) who had undergone percutaneous transhepatic variceal embolization (PTVE) for variceal bleeding between October 2013 and February 2020 were analyzed. All patients were admitted from the emergency department. The following embolic materials were used—coils, Onyx 18 (Medtronic), and n-butyl cyanoacrylate plus lipiodol. Results Post-PTVE, all eight patients demonstrated clinical and radiological improvement in the immediate postprocedure period (< 24 hours). Patients were followed for a mean of 44 ± 24 days postprocedure. Two patients were lost to follow-up. The postprocedure complications included rebleeding (n = 1), hepatic encephalopathy (n = 1), hemoperitoneum (n = 1), ileus (n = 1), and abdominal pain (n = 3). Conclusion PTVE is an effective treatment option for patients with uncontrolled variceal bleeding (ectopic as well as gastroesophageal) especially when the traditional therapies such as transjugular intrahepatic portosystemic shunts, endoscopic variceal ligation, and balloon-occluded retrograde transvenous obliteration are contraindicated or ineffective.

Purpose Chronic thromboembolic pulmonary hypertension (CTEPH) is defined as pulmonary hypertension resulting from non-resolving fibro-thrombotic obstructions of pulmonary arteries. Pulmonary endarterectomy (PEA) remains the treatment of choice for disease that is technically operable. The epidemiology and long-term outcomes of CTEPH has not been previously described in Australia and New Zealand. Methods Using PHSANZ registry, data was extracted for all CTEPH patients diagnosed between January 2004 and March 2020. We analysed baseline characteristics, treatment strategies, outcome data, and long-term survival. Results A total of 404 patients were included with 146 (36.1%) undergoing PEA and 258 (63.9%) in the non-PEA group. PEA patients were younger (55±16yr vs. 62±16yr) with higher baseline 6MWD (405±122m vs. 323±146m), whilst both groups had similar baseline pulmonary haemodynamics. Pulmonary vasodilator therapy was used in 50% of patients post-PEA, and 76% in the non-PEA group. Actual 1, 5, and 10-yr transplant-free survivals were 93%, 84% and 74% for the PEA group compared to 87%, 63% and 42% for the non-PEA group (log rank test, p < 0.001). Similar survival trends were found in an incident-only cohort. Multivariate survival analysis is shown in Table 1 for a cohort of patients with full data available (total n=342). Conclusion In this first multicentre report of CTEPH in Australia and New Zealand, long-term survival is comparable to other contemporary registries. However, PEA was only offered to a minority of CTEPH patients and significantly less than overseas reports. Greater awareness and improved patient access to experienced CTEPH surgical centres are important priorities. Multivariate survival analysis showed baseline 6MWD was an independent predictor of survival in both operated and medically managed patients.

We conclude, that with careful patient selection and experienced proceduralists, there is significant improvement in haemodynamic outcomes with both surgery and intervention, and an acceptable complication profile.

Purpose: Despite advances in medical treatment, pulmonary endarterectomy (PEA) remains the most curative option for patients with chronic thromboembolic pulmonary hypertension (CTEPH). The majority of centres initiating a PEA service report a significant surgical learning curve. This study examines the outcomes of patients undergoing PEA for CTEPH in a single institution with initial surgical mentoring and double evaluation of patient suitability with an established high-volume centre.

Introduction: To facilitate coaxial device deployment in transcatheter mitral valve replacement (TMVR), a coaxial approach to the mitral annular plane is needed. We sought to establish a method to determine an 'orthogonal' left ventricular (LV) access point for transapical TMVR and to quantitatively characterize its location in patients with severe mitral regurgitation using cardiac computed tomography.Methods: Cardiac CT data sets of 54 patients with moderate-severe mitral regurgitation evaluated for potential TMVR were analyzed. The D-shaped mitral annular contour was segmented and a 2 dimensional annular plane was derived, allowing for subsequent definition of the perpendicularly oriented mitral annular trajectory. The 'orthogonal' LV access point was defined as the transection point of mitral trajectory with the LV epicardial surface. The location of the access point was quantified by its epicardial distance from the true apex and by the rotational offset from a 3-chamber view.Results: LV access points orthogonal to the mitral annular plane were most frequently located in the anterolateral (n = 22, 40.7%) and anterior (n = 16, 29.6%), less frequently anteroseptal (n = 6, 11.1%) and inferolateral (n = 5, 9.3%) ventricular segment; none inferior or inferoseptal. The mean distance to the LV apex was 17.6 +/- 7.7 mm. The mean forward rotational offset from the 3-chamber view was 96.4 +/- 43.4 degrees, relating to a mean forward rotational offset of 6.4 +/- 43.4 degrees in regard to a hypothetical, secondary 90 degrees x-plane view. No significant difference between patients with degenerative mitral valve disease or functional mitral regurgitation was observed.Conclusion: The location of the LV access point that provides an orthogonal trajectory to the mitral annular plane exhibits relevant inter-individual variability. It is commonly not identical with the true apex, and frequently localized in the anterolateral or anterior ventricular segments. (C) 2017 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.

Background: Coronary computed tomographic angiography (CCTA) has been demonstrated to improve efficiency in the evaluation of patients with acute chest pain. However, these studies were conducted in controlled environments and real world impact of such strategy has not been confirmed. Method: In this single centre observational study, we used a novel CCTA orientated chest pain pathway for intermediate risk chest. The pathway is executed by exclusively by routine hospital staff. Comparisons were made with historical records 12 months prior. Primary endpoint was the length of stay and rate of same-day discharge. Secondary endpoint included rate of invasive angiography, proportion of significant angiographic findings and chest pain representations within 3 months for those whom coronary disease has been ruled out. Safety end points included coronary events and cardiovascular death. Results: From 1/10/2012 to 30/9/2014, 385 patients (60% of eligible patients) were assessed using the pathway. Length of stay was 2.3days (historical data 1.7 days) for overall and1.0 days (1.6 days) with coronary ischaemia ruled out. Same-day discharge rate was 33.9% (14.6%) and 40.4% (17.2%). Chest pain presentation within 3 months after ruling out was 3% (9%) and no coronary events (2 coronary events in the historical arm) occurred within 3 months. Rate of significant findings on coronary angiography is 64% (46%). Conclusion: The CCTA focussed pathway has demonstrated improvement in all primary and secondary endpoints in a real world setting. The main drawback was the lower than expected rate of compliance in using the pathway.

Background: Intermediate (50-70%) stenoses on CTCA frequently prompt further investigation. Noting that contrast intensity tends to decrease more markedly across more severe lesions, we aimed to develop a simple technique to quantify this intensity reduction, and evaluate its efficacy in assessing the severity of coronary stenoses. Methods and Results: Data from 33 consecutive patients with an intermediate stenosis on CTCA and subsequent invasive coronary angiography (ICA) in St Vincent's Hospital, Sydney were analysed. Exclusion criteria included significant motion artefacts, excessive calcification or coronary stents involving the target lesion. The investigators were blinded to the ICA results. The difference of the minimum Hounsfield unit (HU) count measured across each stenosis and a reference segment immediately proximal to the lesion were used to determine the absolute and percentage reductions in HU. 39 intermediate stenoses among 33 CTCAs were assessed and compared to ICA: 18 stenoses were graded >70% by ICA. Using an absolute cut-off of 123 HU reduction, the sensitivity, specificity, positive predictive value and negative predictive value for > 70% ICA stenosis were 100%, 76.2%, 78.3% and 100%, respectively; and for a percentage HU reduction cut-off of 30%, the corresponding results were 100%, 71.4%, 75.0% and 100%, respectively. Conclusion: Measurement of the HU reduction across intermediate coronary lesions on CTCA provides useful discrimination of the less severe stenoses at subsequent ICA. Our results suggest that the strong negative predictive value of an absolute reduction <123 HU or a relative reduction <30% would obviate the need for further investigation.

Multislice computed tomography coronary angiography (CTCA) demonstrates good agreement with invasive coronary angiography (ICA). The prognostic value of CTCA in cardiac transplant recipients, however, is not known. This study aims to explore prognostic value of CTCA in cardiac transplant recipients. Screening electrocardiogram-gated contrast-enhanced CTCA scans (320-DR; Aquilion One, Toshiba, Japan) were performed on cardiac transplant recipients from September 2009 to July 2014. Scans were analyzed using a 15 coronary-segment model. The primary end point was the composite of ischaemia-related death and non-fatal coronary event. Secondary end points included non-ischaemia-related death and image quality. Outcome was assessed by reviewing the patient record within the Heart & Lung Transplant Unit of St Vincent’s Hospital, Sydney. 2103 coronary segments were analysed. Mean age 53.7 ± 15.1 years; mean time from transplantation 9.3 ± 8.6 years; median follow up 384 days. Of 145 scans, 86 (59%) had grade 0 cardiac allograft vasculopathy (CAV); 44 (30%) grade 1; 3 (2%) grade 2 and 2 (1%) grade 3 CAV. A further seven scans revealed eight patent coronary stents. Three (2%) scans were non-diagnostic. By segment-analysis, 2043 segments (97%) were of diagnostic quality and 81 (3.9%) of these were considered diseased. One major coronary event occurred (suspected coronary dissection from a non-obstructive plaque). No ischaemia-related deaths were reported. One non-ischaemic death occurred (cardiac failure due to restrictive cardiomyopathy). Four patients underwent subsequent ICA for further evaluation of CTCA findings; two of these patients underwent coronary stenting. The majority of cardiac transplant CTCA studies are of diagnostic quality. The prevalence of significant CAV detected on routine surveillance CTCA is low but appreciable. Early detection led to appropriate therapy and was associated with no ischaemic events. The only coronary event occurred in a patient with minor CAV. The majority of patients had no visible coronary disease (59%) and had no subsequent ischaemic events. CTCA is an effective and predictive imaging strategy in cardiac transplant recipients.

Liver-directed therapies are continuing to evolve in the field of interventional oncology and are gaining increasing use in the treatment of unresectable primary and secondary liver cancers. In this article, we review two liver-directed therapies that are currently used for the palliative treatment of primary and secondary hepatic tumours: transcatheter arterial chemoembolisation (TACE), including a new type of TACE with drug-eluting beads (DEB-TACE), and radioembolisation. The concept of these transcatheter intraarterial therapies is to selectively deliver high doses of anticancer treatment to the tumour. While TACE delivers one or more chemotherapeutic drugs into the hepatic arteries supplying the tumour, radioembolisation uses non-embolic microspheres incorporating the radioactive isotope 90Y. In this article, we discuss some technical aspects, patient selection, current clinical evidence, and future directions of TACE, TACE with drug-eluting beads (DEB-TACE) and radioembolisation for primary and secondary liver cancer.

In this article, we review two liver-directed therapies that are currently used for the palliative treatment of primary and secondary hepatic malignancies, transcatheter arterial chemoembolization (TACE), including a new type of TACE with drug-eluting beads, and radioembolization. Important developments and administration techniques for all therapies are discussed, as well as their integration into the current routine clinical care for management of metastatic colorectal cancer. According to published data from clinical trials, as presented in this review, both radioembolization and TACE/TACE with drug-eluting beads have been proven to be safe and effective in selected patients with chemorefractory liver metastases from colorectal cancer. For patients with unresectable liver-only or liver-dominant disease who have failed standard chemotherapy options or for whom chemotherapy is contraindicated, new modalities, such as those discussed, are particularly valid and promising if clinical guidelines for patient selection and treatment administration are followed.

Background: High calcium score may limit interpretation of computed tomography coronary angiograms (CTCA) due to excessive blooming artifacts and it has been suggested that CTCA may not reliably exclude significant disease in this setting. With recent improvements in CT technology and interpretation techniques, high calcium score appears to be less of a limiting factor. Method: We retrospectively analysed all CTCAs from September 2009 to February 2012 in our centre using a 320-row detector (Toshiba AquilianOne). A threshold of 600 (Agaston) was used to define a high calcium score. The studies were classified into non-diagnostic, mild, intermediate and severe disease. Patients were followed up for up to 24 months and further investigations were performed at the discretion of treating physician. Results: Sixty-five studies with calcium score of 600 or greater were identified. The average calcium score was 1439.7 (range 605–4458). Seven (11%) studies were non diagnostic, 23 (35%) had mild or no significant disease, 16 (25%) had moderate disease and 19 (29%) has severe disease. In the moderate disease group, 10 (63%) further investigations available however in only one case (10%) were the findings suggestive of ischaemia indicating a tendency to over rather than under-call lesion severity. Conclusions: In the setting of high coronary calcium, CTCA by 320 detector row CT is seldom non-diagnostic and clinically significant lesions may be excluded.

Improved multi-detector computed tomography (MDCT) temporal and spatial resolution allows for the assessment of coronary artery disease, left ventricular systolic function and resting myocardial perfusion defects with high sensitivity and specificity. Here we present a case using a novel combination technique of cardiac computed tomography scanning with dipyridamole stress for the detection of functionally significant coronary disease, and demonstrate that dipyridamole-induced myocardial ischaemia is both detectable and quantifiable by cardiac MDCT.

Introduction: Coronary artery calcium score (CACS) measurement is a well validated and commonly used prognostic tool that currently requires a second non-contrast scan in additional to contrast enhanced CT coronary angiography. We present the final results of a prospectively registered validation study of a new technique to measure the coronary calcium score from a single contrast-enhanced cardiac CT. Methods: Paired contrast enhanced and calcium score scans from 120 sequential patients were prospectively analysed. All scans were performed using a wide-volume 320-detector row CT scanner. Eleven contrast scans were excluded due to pre-specified exclusion criteria of complete coronary occlusion or excessive image noise. The volume of intramural coronary calcium above 320 Hounsfield units was quantified using a semi-automated technique and standard clinical software tools. Using an empiric conversion coefficient the Agatston score was then calculated from the high resolution calcium volume measurement. Results: There was excellent correlation between the contrast enhanced CT derived CACS and the traditional CACS measurement (R2 = 0.99). Assignment of patients to traditional calcium score risk bands was near perfect (quadratic weighted kappa = 0.96) as was the inter and intra-observer reliability (intra-class correlation 0.99 for both). Using the new technique in the studied population an average radiation dose reduction of 40% can be achieved as well as combined coronary CT and calcium score evaluation at less than 1 mSv in selected patients. Conclusion: The coronary calcium score may be accurately measured from contrast enhanced CT allowing substantial radiation dose reductions (ACTRN12610000354088).

BACKGROUND: Limitations to the coronary calcium score include its requirement for noncontrast imaging and radiation exposure that approaches current methods for contrast-enhanced CT angiography.OBJECTIVES: We sought to derive and validate a method of measuring the coronary artery calcium score (CACS) from standard contrast-enhanced CT, obviating the need for a second non-contrast calcium scan.METHODS: The volume of intramural calcium of >320 HU in major coronary vessels was measured in 90 contrast-enhanced and traditional non-contrast calcium scan pairs. An empiric conversion factor was derived to convert the small voxel contrast-enhanced calcium volume to an Agatston calcium score. The accuracy of this technique was then prospectively validated in 120 consecutive patients undergoing clinical calcium scans and contrasted-enhanced coronary CT. Eleven patients were excluded from analysis because of the prespecified criteria of excessive noise in the contrast-enhanced CT or total coronary artery occlusion.RESULTS: The Pearson correlation of the contrast scan-derived calcium score with the measured CACS was r(2) = 0.99. With standard CACS risk bands, agreement of the contrast-enhanced calcium score estimate with the measured CAC by quadratic weighted kappa was 0.96. The 95% limits of agreement (Agatston units) were given by +/-(3.2+0.14 x CACS +4.44 root CACS). Inter-observer and intra-observer reliability with the intraclass correlation was 0.99.CONCLUSION: The calcium score can be accurately measured from contrast-enhanced cardiac CT scans with the use of a Hounsfield unit threshold of 320. (C) 2012 Published by Elsevier Inc. on behalf of Society of Cardiovascular Computed Tomography.