Despite the recommendation of coronary physiology to guide revascularization in angiographically intermediate stenoses without established correlation to ischemia, its uptake in clinical practice is slow. This study aimed to analyze the use of coronary physiology in clinical practice. Based on a multicenter registry (Fractional Flow Reserve Fax Registry, F(FR)2, ClinicalTrials.gov identifier NCT03055910), clinical use, consequences, and complications of coronary physiology were systematically analyzed. F(FR)2 enrolled 2,000 patients with 3,378 intracoronary pressure measurements. Most measurements (96.8

To evaluate diagnostic impact of clinical use of coronary computed tomography angiography (CCTA) in patients with suspected stable coronary artery disease (CAD) and its consequences in daily practice for patient management, depending on stress test results in daily practice. Between 2009 and 2014 of a total population of 1352 patients of the German Cardiac Computed Tomography (CT) Registry who had previously undergone stress tests, CCTA visualizations were carried out on the coronary arteries with suspected stable CAD. Patients were divided into three groups according to stress test results: Group 1 with inconclusive (n = 178, 13.2%), Group 2 with ischemia in stress test (n = 372, 27.5%) and Group 3 without ischemia in stress test (n = 802, 59.3%). The test of preference was the stress electrocardiogram (ECG), which was performed more frequently in patients without ischemia in stress test as compared to those with ischemia (96.3% vs. 93.0%, p = 0.015). The incidence of detected obstructive CAD was lower in patients with suggested ischemia in stress test as compared to patients with inconclusive results (14.1% vs. 21.1%, p = 0.037). There was no difference in the incidence of an obstructive CAD in patients with and without ischemia in stress test (14.1% vs. 15.8%, p = 0.440). CCTA is a reliable, non-invasive option for ruling-out obstructive CAD irrespective of the stress test result.

Cardiac computed tomography permits quantification of coronary calcification as well as detection of coronary artery stenoses after contrast enhancement. Moreover, cardiac CT offers high-resolution morphologic and functional imaging of cardiac structures which is valuable for various structural heart disease interventions and electrophysiology procedures. So far, only limited data exist regarding the spectrum of indications, image acquisition parameters as well as results and clinical consequences of cardiac CT examinations using state-of-the-art CT systems in experienced centers. Twelve cardiology centers with profound expertise in cardiovascular imaging participated in the German Cardiac CT Registry. Criteria for participation included adequate experience in cardiac CT as well of the availability of a 64-slice or newer CT system. Between 2009 and 2014, 7061 patients were prospectively enrolled. For all cardiac CT examinations, patient parameters, procedural data, indication and clinical consequences of the examination were documented. Mean patient age was 61 ± 12 years, 63% were males. The majority (63%) of all cardiac CT examinations were performed in an outpatient setting, 37% were performed during an inpatient stay. 91% were elective and 9% were scheduled in an acute setting. In most examinations (48%), reporting was performed by cardiologists, in 4% by radiologists and in 47% of the cases as a consensus reading. Cardiac CT was limited to native acquisitions for assessment of coronary artery calcification in 9% of patients, only contrast-enhanced coronary CT angiography was performed in 16.6% and combined native and contrast-enhanced coronary CT angiography was performed in 57.7% of patients. Non-coronary cardiac CT examinations constituted 16.6% of all cases. Coronary artery calcification assessment was performed using prospectively ECG-triggered acquisition in 76.9% of all cases. The median dose length product (DLP) was 42 mGy cm (estimated effective radiation dose of 0.6 mSv). Coronary CT angiography was performed using prospectively ECG-triggered acquisition in 77.3% of all cases. Tube voltage was 120 kV in 67.8% of patients and 100 kV in 30.7% of patients, with a resultant median DLP of 256 mGy cm (estimated effective dose of 3.6 mSv). Clinical consequences of cardiac CT were as follows: in 46.8% of the cases, invasive coronary angiography could be avoided; ischemia testing was recommended in 4.7% of the cases, invasive coronary angiography was recommended in 16.4% of the cases and change in medication in 21.6% of the examinations. Cardiac CT is performed in the majority of patients for non-invasive evaluation of the coronary arteries. CT frequently resulted in medication change, and otherwise planned downstream testing including invasive angiography could be avoided in a high percentage of patients. Radiation exposure in experienced centers is relatively low.

Coronary computed tomography angiography (CTA) is increasingly used as a test to rule out coronary artery disease (CAD) in patients with a low to intermediate pre-test probability of the disease. We used the database of the German CT registry, collected between 2009 and 2014 in a broad patient population, to analyze contemporary radiation dose associated with coronary CTA in clinical practice.

For selected indications, coronary computed tomographic (CT) angiography is an established clinical technology for evaluation in patients suspected of having or known to have coronary artery disease. In coronary CT angiography, image quality is highly dependent on heart rate, with heart rate reduction to less than 60 beats per minute being important for both image quality and radiation dose reduction, especially when single-source CT scanners are used. β-Blockers are the first-line option for short-term reduction of heart rate prior to coronary CT angiography. In recent years, multiple β-blocker administration protocols with oral and/or intravenous application have been proposed. This review article provides an overview of the indications, efficacy, and safety of β-blockade protocols prior to coronary CT angiography with respect to different scanner techniques. Moreover, implications for radiation exposure and left ventricular function analysis are discussed.

In the Bavarian Reperfusion Alternatives Evaluation (BRAVE)-3 study upstream administration of abciximab additional to 600 mg clopidogrel loading did not reduce the infarct size in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary interventions. The aim of this study was to investigate 1-year clinical outcomes in the BRAVE-3 study patients.

Background— The glycoprotein IIb/IIIa receptor inhibitor abciximab has improved the efficacy of primary percutaneous coronary interventions in patients with acute myocardial infarction. However, it is not known whether abciximab remains beneficial after adequate clopidogrel loading in patients with acute ST-segment–elevation myocardial infarction. Methods and Results— A total of 800 patients with acute ST-segment–elevation myocardial infarction within 24 hours from symptom onset, all treated with 600 mg clopidogrel, were randomly assigned in a double-blind fashion to receive either abciximab (n=401) or placebo (n=399) in the intensive care unit before being sent to the catheterization laboratory. The primary end point, infarct size measured by single-photon emission computed tomography with technetium-99m sestamibi before hospital discharge, was 15.7±17.2% (mean±SD) of the left ventricle in the abciximab group and 16.6±18.6% of the left ventricle in the placebo group (P=0.47). At 30 days, the composite of death, recurrent myocardial infarction, stroke, or urgent revascularization of the infarct-related artery was observed in 20 patients in the abciximab group (5.0%) and 15 patients in the placebo group (3.8%) (relative risk, 1.3; 95% CI, 0.7 to 2.6; P=0.40). Major bleeding complications were observed in 7 patients in each group (1.8%). Conclusion— Upstream administration of abciximab is not associated with a reduction in infarct size in patients presenting with acute myocardial infarction within 24 hours of symptom onset and receiving 600 mg clopidogrel.

calculation of the electroand magnetocardiogram is used for generation of the MCG data [ 5 ] [ 6 J . The anatomy of the heart is represented in a data file using a 2.5mm grid. The Simulation of the activation sequence is performed by a point-to-point propagation procedure similar to Huygen's construction of wavefronts. The anisotropy of propagation in the ventricular myocardium, the different conduction velocities in different cardiac tissues and different action potential shapes in the various regions of the heart are taken into account. The isochrones of excitation are in good agreement with measurements by Durrer et al[7). The electro(ECG)-anci magnetocardiogram(MCG) are calculated by numerically evaluating a simplified version of the formulas of the bidomain model [8]. The infinite half space is used to model the torso for the MCG calculations in which the component of the magnetic field perpendicular to the ehest plane is evaluated. The magnetocardiogram of the entire excitation process is calculated at 37 positions of a hexagonal arrangement of magnetometers, spacing between calculation points is 2.7cm. An ischemic region in the heart is characterized by a slowed conduction and by abnormal action potentials. For simulating an ischemic area in the process of calculating the activation of the heart, the conduction velocity in this region is reduced by approximately 60% resulting in a delayed excitation of this region. For calculation of the MCG the action potential of the ischemic region is altered according to Fig. 1. In this study, a left anterolateral ischemia is simulated comprising 3.5% of the total cardiac volume. The injury current can be explained äs follows: In myocardial ischemia, the action potential is altered compared to normal action potentials (Fig. 1). The resting potential is closer to zero in the ischemic area than in the normal area, thus a current flow from ischemic to normal tissue results during the T-Q segment of the electroand magnetocardiogram(ECG/MCG). This current is called the secondary injury current. During the ST-segment a so-called primary injury current flows in the opposite direction due to the gradient of the action potential from normal to ischemic tissue. Since magnetocardiographic Signals are usually baseline-corrected using the T-P segment äs zero-line, only the primary injury current can be The reconstruction of the primary injury current in myocardial ischemia from magnetocardiographic data using lead field theory is investigated. Computer Simulation of the excitation process and the aasociated magnetocardiogram in myocardial ischemia is perfonned using a model of the entire human heart. Current density reconstruction based on lead field theory is applied to simulated magnetocardiographic maps during the ST-segment. The results show a current flowing from intact to ischemic myocardium, the primary injury current in myocardial ischemia. This indicates the possibility of reconstruction of important electrophysiologic phenomena in the case of myocardial ischemia frora magnetocardiographic data.

Article Klinische Anwendung einfacher geometrischer Volumenleitermodelle in der Magnetokardiographie was published on January 1, 1992 in the journal Biomedical Engineering / Biomedizinische Technik (volume 37, issue s2).

Background— Recent clinical trials have suggested that intensive versus standard lipid-lowering therapy provides for additional benefit. Electron-beam computed tomography provides the opportunity to quantify the progression of coronary artery calcification (CAC) in serial measurements. Methods and Results— In a multicenter, randomized, double-blind trial, 471 patients (age 61±8 years) who had no history of coronary artery disease and no evidence of high-grade coronary stenoses (>50% diameter reduction) were randomized if they had ≥2 cardiovascular risk factors and moderate calcified coronary atherosclerosis as evidenced by a CAC score ≥30. Patients were assigned to receive 80 mg or 10 mg of atorvastatin per day over 12 months. Progression of CAC volume scores could be analyzed in 366 patients. After pretreatment with 10 mg of atorvastatin for 4 weeks, 12 months of study medication reduced LDL cholesterol from 106±22 to 87±33 mg/dL in the group randomized to receive 80 mg of atorvastatin ( P <0.001), whereas levels remained stable in the group randomized to receive 10 mg (108±23 at baseline, 109±28 mg/dL at the end of the study, P =NS). The mean progression of CAC volume scores, corrected for the baseline CAC volume score, was 27% (95% CI 20.8% to 33.1%) in the 80-mg atorvastatin group and 25% (95% CI 19.1% to 30.8%) in the 10-mg atorvastatin group ( P =0.65). CAC progression showed no relationship with on-treatment LDL cholesterol levels. Conclusions— We did not observe a relationship between on-treatment LDL cholesterol levels and the progression of calcified coronary atherosclerosis. Over a period of 12 months, intensive atorvastatin therapy was unable to attenuate CAC progression compared with standard atorvastatin therapy. The possibility remains that the time window was too short to demonstrate an effect.

In unserer Ambulanz stellte sich ein 48-jähriger Patient mit einem linksthorakalen Druckgefühl vor, welches seit ca. 2 h mit undulierender Intensität bestand. Der Schmerz war nicht auf Druck auslösbar und nicht bewegungsabhängig. Anamnestisch hatte der Patient seit 3 Wochen rezidivierend ähnliche linksthorakale Beschwerden. Der Schmerz trat jeweils unabhängig von körperlicher Aktivität auf und war innerhalb von 1–2 h spontan reversibel.

Due to its high temporal resolution, EB-CT is well suited for cardiac imaging. Although the major cardiac application of EB-CT to date has been detection and quantification of coronary calcifications, studies have demonstrated that cardiac EB-CT in combination with intravenous injection of contrast agent permits imaging of the coronary vessel lumen and detection of coronary artery stenoses and occlusions. Results obtained for the left main and LAD coronary artery, as well as for venous bypass grafts, correlate well with conventional angiography, whereas motion artifacts and anatomic difficulties currently reduce the diagnostic value for the right and especially left circumflex coronary arteries. Even though improvements in scanner design and in the investigation protocol are warranted, clinical applications of the method (e.g., in the followup after coronary revascularization) seem possible. In the year 2000, cardiac-gated multislice CT has emerged as a very serious competitor for both EB-CT and MRI/MRA. The jury is still out as to which imaging modality will ultimately prevail. This topic continues to be hotly debated at many cardiac imaging meetings.

HomeCirculationVol. 105, No. 6Anomalous Course of the Left Main or Left Anterior Descending Coronary Artery Originating From the Right Sinus of Valsalva Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherPDF/EPUBAnomalous Course of the Left Main or Left Anterior Descending Coronary Artery Originating From the Right Sinus of ValsalvaIdentification of Four Common Variations by Electron Beam Tomography Dieter Ropers, MD, Gisbert Gehling, MD, Karsten Pohle, MD, Ralph Maeffert, MD, Matthias Regenfus, MD, Werner Moshage, MD, Peter Schuster, MD, Werner G. Daniel, MD and Stephan Achenbach, MD Dieter RopersDieter Ropers From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Gisbert GehlingGisbert Gehling From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Karsten PohleKarsten Pohle From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Ralph MaeffertRalph Maeffert From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Matthias RegenfusMatthias Regenfus From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Werner MoshageWerner Moshage From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Peter SchusterPeter Schuster From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Werner G. DanielWerner G. Daniel From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author and Stephan AchenbachStephan Achenbach From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author Originally published12 Feb 2002https://doi.org/10.1161/hc0602.102020Circulation. 2002;105:e42–e43An aberrant origin of the left main coronary artery (LM) or left anterior descending coronary artery (LAD) from the right sinus of Valsalva is a rare anomaly that has been associated with myocardial ischemia and sudden cardiac death. Depending on the anatomic relationship of the anomalous vessel to the aorta and the pulmonary trunk, the anomaly can be classified into 4 common courses: posterior, interarterial, anterior, and septal course. Contrast-enhanced electron beam tomography (EBT) has been shown to permit classification of anomalous coronary arteries. We present 4 cases that illustrate the common variations of this anomaly. In all cases, EBT was performed using a C-150 XP EBT scanner (Imatron Inc). During inspiratory breathhold, 40 to 50 axial cross-sections of the heart were acquired triggered to the ECG at 40% of the R-R interval (100 ms acquisition time, slice thickness 3 mm, table feed 2 mm, intravenous injection of 160 mL contrast agent at 4 mL/second). In addition to the original axial images, 2-dimensional multiplanar reconstructions and 3-dimensional reconstructions were rendered on an image processing workstation (NetraMD, ScImage) to display the anatomic course of the anomalous LM or LAD. In all cases, the results were confirmed by invasive coronary angiography.Posterior or Retroaortic CourseIn the nonprocessed axial image (Figure 1A) and the 3-dimensional reconstruction (Figure 1B), EBT shows the retroaortic course of the LM that originates from the right sinus of Valsalva and passes posterior and inferior to the aortic root. Download figureDownload PowerPointFigure 1. Posterior or retroaortic course of the left main coronary artery. A, Axial cross-sectional image. The arrow points at the artery posterior and inferior to aortic root. LA indicates left atrium; RA, right atrium; LV, left ventricle; MV, mitral valve. B, 3-Dimensional reconstruction (lateral view). The arrows point at the left main coronary artery. The arrowhead indicates the right coronary artery. Ao indicates ascending aorta; PA, pulmonary artery.Interarterial or Preaortic CourseThe course of the LM between the aorta and the pulmonary trunk is clearly delineated both in the original cross-section (Figure 2A) and in the 3-dimensional reconstruction (Figure 2B). Download figureDownload PowerPointFigure 2. Interarterial or preaortic course of the left main coronary artery. A, Original axial cross-section. Arrows indicate the left main taking a path between the ascending aorta and pulmonary trunk. The arrowhead points at the right coronary artery. Ao indicates ascending aorta; PA, pulmonary artery. B, 3-Dimensional reconstruction. The arrows point at the left main coronary artery. LA indicates left atrium; RA, right atrium.Anterior or Prepulmonic CourseIn a patient with a right-sided single coronary artery, the LAD originates from the proximal right coronary artery and takes a course anterior to the right ventricular outflow tract to the left anterior interventricular groove (Figures 3A and 3B). The left circumflex coronary artery (LCX) follows a retroaortic course (not displayed). Download figureDownload PowerPointFigure 3. Anterior or prepulmonic course of the left anterior descending coronary artery. A, Original axial cross-section. The arrows point at the LAD. Ao indicates ascending aorta; PA, pulmonary artery; Vcs, superior vena cava. B, 3-Dimensional reconstruction (anterior view). The arrows point at the LAD, which takes a course anterior to the right ventricular outflow tract. The arrowhead points at the orthotopic right coronary artery. The left circumflex coronary artery (which follows a retroaortic course) is not displayed.Septal or Subpulmonic CourseIn this case, the LM ostium is located adjacent to the right coronary ostium. The LCX takes a prepulmonic path, whereas the LAD follows an intramyocardial course through the interventricular septum beneath the right ventricular infundibulum (Figure 4A). The artery surfaces in the midsection of the interventricular groove, which is clearly shown in the 3-dimensional reconstruction (Figure 4B). Download figureDownload PowerPointFigure 4. Septal or subpulmonic course of the left anterior descending coronary artery. A, Curved multiplanar reconstruction. The arrows point at the LAD, which takes an intramyocardial course through the interventricular septum beneath the right ventricular infundibulum. Ao indicates ascending aorta; PA, pulmonary artery. B, 3-Dimensional reconstruction that shows the LAD surfacing in the midsection of the anterior interventricular groove (white arrow). The black arrow indicates the left circumflex coronary artery, which follows a course anterior to the pulmonary artery. Arrowhead indicate right coronary artery.These examples illustrate the potential of contrast-enhanced EBT to visualize the exact 3-dimensional course of anomalous coronary arteries.The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St.Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.Circulation encourages readers to submit cardiovascular images to the Circulation Editoral Office, St.Luke's Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MCI-267, Houston, TX 77030.FootnotesCorrespondence to Dr D. 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Gać P, Żórawik A and Poręba R (2022) A Single Coronary Artery Originating from the Right Coronary Sinus with a Typical Course of the Right Coronary Artery and the Interarterial Course of the Left Main, Left Anterior Descending, and Left Circumflex as an Example of a Rare Case of High-Risk Coronary Anomaly, Diagnostics, 10.3390/diagnostics12010167, 12:1, (167) February 12, 2002Vol 105, Issue 6 Advertisement Article InformationMetrics https://doi.org/10.1161/hc0602.102020 Originally publishedFebruary 12, 2002 PDF download Advertisement