Publications by authors named "Carl J Schultz"

47 Publications

The effect of vitamin K1 on arterial calcification activity in subjects with diabetes mellitus: a post hoc analysis of a double-blind, randomized, placebo-controlled trial.

Am J Clin Nutr 2021 Oct 12. Epub 2021 Oct 12.

Division of Internal Medicine, Medical School, University of Western Australia, Perth, Western Australia, Australia.

Background: Coronary and aortic artery calcifications are generally slow to develop, and their burden predicts cardiovascular disease events. In patients with diabetes mellitus, arterial calcification is accelerated and calcification activity can be detected using 18F-sodium fluoride positron emission tomography (18F-NaF PET).

Objectives: We aimed to determine whether vitamin K1 supplementation inhibits arterial calcification activity in individuals with diabetes mellitus.

Methods: This was a post hoc analysis of the ViKCoVaC (effect of Vitamin-K1 and Colchicine on Vascular Calcification activity in subjects with Diabetes Mellitus) double-blind randomized controlled trial conducted in Perth, Western Australia. Individuals with diabetes mellitus and established coronary calcification (coronary calcium score > 10), but without clinical coronary artery disease, underwent baseline 18F-NaF PET imaging, followed by oral vitamin K1 supplementation (10 mg/d) or placebo for 3 mo, after which 18F-NaF PET imaging was repeated. We tested whether individuals randomly assigned to vitamin K1 supplementation had reduced development of new 18F-NaF PET positive lesions within the coronary arteries and aorta.

Results: In total, 149 individuals completed baseline and follow-up imaging studies. Vitamin K1 supplementation independently decreased the odds of developing new 18F-NaF PET positive lesions in the coronary arteries (OR: 0.35; 95% CI: 0.16, 0.78; P = 0.010), aorta (OR: 0.27; 95% CI: 0.08, 0.94; P = 0.040), and in both aortic and coronary arteries (OR: 0.28; 95% CI: 0.13, 0.63; P = 0.002).

Conclusions: In individuals with diabetes mellitus, supplementation with 10 mg vitamin K1/d may prevent the development of newly calcifying lesions within the aorta and the coronary arteries as detected using 18F-NaF PET. Further long-term studies are needed to test this hypothesis.This trial was registered at anzctr.org.au as ACTRN12616000024448.
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http://dx.doi.org/10.1093/ajcn/nqab306DOI Listing
October 2021

Coronary artery segmentation from intravascular optical coherence tomography using deep capsules.

Artif Intell Med 2021 06 15;116:102072. Epub 2021 Apr 15.

Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre, Nedlands and Centre for Medical Research, The University of Western Australia, Perth, Australia; School of Engineering, The University of Western Australia, Perth, Australia; Australian Research Council Centre for Personalised Therapeutics Technologies, Australia; British Heart Foundation Centre for Cardiovascular Science, The University of Edinburgh, UK. Electronic address:

The segmentation and analysis of coronary arteries from intravascular optical coherence tomography (IVOCT) is an important aspect of diagnosing and managing coronary artery disease. Current image processing methods are hindered by the time needed to generate expert-labelled datasets and the potential for bias during the analysis. Therefore, automated, robust, unbiased and timely geometry extraction from IVOCT, using image processing, would be beneficial to clinicians. With clinical application in mind, we aim to develop a model with a small memory footprint that is fast at inference time without sacrificing segmentation quality. Using a large IVOCT dataset of 12,011 expert-labelled images from 22 patients, we construct a new deep learning method based on capsules which automatically produces lumen segmentations. Our dataset contains images with both blood and light artefacts (22.8 %), as well as metallic (23.1 %) and bioresorbable stents (2.5 %). We split the dataset into a training (70 %), validation (20 %) and test (10 %) set and rigorously investigate design variations with respect to upsampling regimes and input selection. We show that our developments lead to a model, DeepCap, that is on par with state-of-the-art machine learning methods in terms of segmentation quality and robustness, while using as little as 12 % of the parameters. This enables DeepCap to have per image inference times up to 70 % faster on GPU and up to 95 % faster on CPU compared to other state-of-the-art models. DeepCap is a robust automated segmentation tool that can aid clinicians to extract unbiased geometrical data from IVOCT.
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http://dx.doi.org/10.1016/j.artmed.2021.102072DOI Listing
June 2021

The effect of Vitamin-K and Colchicine on Vascular Calcification Activity in subjects with Diabetes Mellitus (ViKCoVaC): A double-blind 2x2 factorial randomized controlled trial.

J Nucl Cardiol 2021 Apr 6. Epub 2021 Apr 6.

School of Medicine, Faculty of Health and Biomedical Science, University of Western Australia, Royal Perth Hospital Campus, M570, Po Box X2213, Perth, Western Australia, Australia.

Background: There is currently no treatment for attenuating progression of arterial calcification. F-sodium fluoride positron emission tomography (F-NaF PET) locates regions of calcification activity. We tested whether vitamin-K or colchicine affected arterial calcification activity.

Methods: 154 patients with diabetes mellitus and coronary calcification, as detected using computed tomography (CT), were randomized to one of four treatment groups (placebo/placebo, vitamin-K [10 mg/day]/placebo, colchicine [0.5 mg/day]/placebo, vitamin-K [10 mg/day]/ colchicine [0.5 mg/day]) in a double-blind, placebo-controlled 2x2 factorial trial of three months duration. Change in coronary calcification activity was estimated as a change in coronary maximum tissue-to-background ratio (TBRmax) on F-NaF PET.

Results: 149 subjects completed follow-up (vitamin-K: placebo = 73:76 and colchicine: placebo = 73:76). Neither vitamin-K nor colchicine had a statistically significant effect on the coronary TBRmax compared with placebo (mean difference for treatment groups 0·00 ± 0·16 and 0·01 ± 0·17, respectively, p > 0.05). There were no serious adverse effects reported with colchicine or vitamin-K.

Conclusions: In patients with type 2 diabetes, neither vitamin-K nor colchicine significantly decreases coronary calcification activity, as estimated by F-NaF PET, over a period of 3 months.

Clinical Trial Registration: ACTRN12616000024448.
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http://dx.doi.org/10.1007/s12350-021-02589-8DOI Listing
April 2021

Single high-sensitivity troponin levels to assess patients with potential acute coronary syndromes.

Heart 2021 May 12;107(9):721-727. Epub 2021 Jan 12.

Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia

Objective: We tested the hypothesis that patients with a potential acute coronary syndrome (ACS) and very low levels of high-sensitivity cardiac troponin I can be efficiently and safely discharged from the emergency department after a single troponin measurement.

Methods: This prospective cohort study recruited 2255 consecutive patients aged ≥18 years presenting to the Emergency Department, Royal Perth Hospital, Western Australia, with chest pain without high-risk features but requiring the exclusion of ACS. Patients were managed using a guideline-recommended pathway or our novel Single Troponin Accelerated Triage (STAT) pathway. The primary outcome was the percentage of patients discharged in <3 hours. Secondary outcomes included the duration of observation and death or acute myocardial infarction in the next 30 days.

Results: The study enrolled 1131 patients to the standard cohort and 1124 to the STAT cohort. Thirty-eight per cent of the standard cohort were discharged directly from emergency department compared with 63% of the STAT cohort (p<0.001). The median duration of observation was 4.3 (IQR 3.3-7.1) hours in the standard cohort and 3.6 (2.6-5.4) hours in the STAT cohort (p<0.001), with 21% and 38% discharged in <3 hours, respectively (p<0.001). No patients discharged directly from the emergency department died or suffered an acute myocardial infarction within 30 days in either cohort.

Conclusions: Among low-risk patients with a potential ACS, a pathway which incorporates early discharge based on a single very low level of high-sensitivity cardiac troponin increases the proportion of patients discharged directly from the emergency department, reduces length of stay and is safe.

Trial Registration Number: ACTRN12618000797279.
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http://dx.doi.org/10.1136/heartjnl-2020-317997DOI Listing
May 2021

Use of cardiovascular imaging in risk restratification of the diabetic patient.

Curr Opin Endocrinol Diabetes Obes 2021 04;28(2):122-133

School of Medicine, Faculty of Health and Biomedical Science, University of Western Australia.

Purpose Of Review: Diabetes mellitus is no longer considered a cardiovascular disease (CVD) risk equivalent, but the optimal methods of risk stratification are a matter of debate. The coronary calcium score (CCS) is a measure of the burden of atherosclerosis and is widely used for CVD risk stratification in the general population. We review recently published data to describe the role of the CCS in people with diabetes mellitus.

Recent Findings: People with diabetes mellitus have 10-year event rates for CVD and CVD mortality that are considered high, at a much lower level of CCS than the general population. Different categories of CCS are pertinent to men and women with diabetes mellitus. CCS may be particularly useful in clinical settings when CVD risk is known to be increased but difficult to quantify, for example peri-menopausal women, young persons with diabetes, type 1 diabetic individuals and others. With modern techniques, the radiation dose of a CSS has fallen to levels wherein screening and surveillance could be considered.

Summary: The CCS is able to quantify CVD risk in people with diabetes mellitus when there is clinical uncertainty and identifies those with very high event rates. Future research should aim to identify effective risk reduction strategies in this important group.
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http://dx.doi.org/10.1097/MED.0000000000000611DOI Listing
April 2021

Coronary F-sodium fluoride PET detects high-risk plaque features on optical coherence tomography and CT-angiography in patients with acute coronary syndrome.

Atherosclerosis 2021 02 15;319:142-148. Epub 2020 Dec 15.

Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia; Medical School, University of Western Australia, Perth, Western Australia, Australia. Electronic address:

Background And Aims: F-Sodium Fluoride Positron Emission Tomography (F-NaF PET) non-invasively detects micro-calcification activity, the earliest stage of atherosclerotic arterial calcification. We studied the association between coronary F-NaF uptake and high-risk plaque features on intra-coronary optical coherence tomography (OCT) and CT-angiography (CTCA) and the potential application to patient-level risk stratification.

Methods: Sixty-two prospectively recruited patients with acute coronary syndrome (ACS) underwent multi-vessel OCT, F-NaF PET and CTCA. The maximum tissue to background ratio (TBRmax = standardised uptake value (SUV)max/SUVbloodpool) was measured in each coronary segment on F-NaF PET scans. High-risk plaque features on OCT and CTCA were compared in matched coronary segments. The number of patients testing positive (>2SD above the normal range) for micro-calcification activity was determined.

Results: In 62 patients (age, mean ± standard deviation (SD) = 61 ± 9 years, 85% male) the coronary segments with elevated F-NaF uptake had higher lipid arc (LA) (median [25th-75th centile]: 74° [35°-117°] versus 48° [15°-83°], p=0.021), higher prevalence of macrophages [n(%): 37 (62%) versus 89 (39%), p=0.008] and lower plaque free wall (PFW) (50° [7°-110°] versus 94° [34°-180°], p=0.027) on OCT, and a higher total plaque burden (p=0.011) and higher dense calcified plaque burden (p= 0.001) on CTCA, when compared with F-NaF negative segments. Patients grouped by increasing number of coronary lesions positive for microcalcification activity (0,1, ≥2) showed decreasing plaque free wall, increasing calcification and increasing macrophages on OCT (respectively p=0.008, p < 0.001 and p=0.028).

Conclusions: F-NaF uptake is associated with high-risk plaque features on OCT and CTCA in a per-segment and per-patient analysis in subjects hospitalized for ACS.
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http://dx.doi.org/10.1016/j.atherosclerosis.2020.12.010DOI Listing
February 2021

Invasive Coronary Angiography after Chest Pain Presentations to Emergency Departments.

Int J Environ Res Public Health 2020 12 18;17(24). Epub 2020 Dec 18.

School of Population and Global Health, The University of Western Australia, Perth 6009, Australia.

We investigated patients presenting to emergency departments (EDs) with chest pain to identify factors that influence the use of invasive coronary angiography (ICA). Using linked ED, hospitalisations, death and cardiac biomarker data, we identified people aged 20 years and over who presented with chest pain to tertiary public hospital EDs in Western Australia from 1 January 2016 to 31 March 2017 (ED chest pain cohort). We report patient characteristics, ED discharge diagnosis, pathways to ICA, ICA within 90 days, troponin test results, and gender differences. Associations were examined with the Pearson Chi-squared test and multivariate logistic regression. There were 16,974 people in the ED chest pain cohort, with a mean age of 55.6 years and 50.7% males, accounting for 20,131 ED presentations. Acute coronary syndrome was the ED discharge diagnosis in 10.4% of presentations. ED pathways were: discharged home (57.5%); hospitalisation (41.7%); interhospital transfer (0.4%); and died in ED (0.03%)/inpatients (0.3%). There were 1546 (9.1%) ICAs performed within 90 days of the first ED chest pain visit, of which 59 visits (3.8%) had no troponin tests and 565 visits (36.6%) had normal troponin. ICAs were performed in more men than women (12.3% vs. 6.1%, < 0.0001; adjusted OR 1.89, 95% CI 1.65, 2.18), and mostly within 7 days. Equal numbers of males and females present with chest pain to tertiary hospital EDs, but men are twice as likely to get ICA. Over one-third of ICAs occur in those with normal troponin levels, indicating that further investigation is required to determine risk profile, outcomes and cost effectiveness.
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http://dx.doi.org/10.3390/ijerph17249502DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7766965PMC
December 2020

F-Sodium Fluoride Positron Emission Tomography Activity Predicts the Development of New Coronary Artery Calcifications.

Arterioscler Thromb Vasc Biol 2021 01 3;41(1):534-541. Epub 2020 Dec 3.

School of Medicine (J.W.B., R.J.F., S.C.L., A.R., J.R.L., G.F.W., C.J.S.), University of Western Australia, Perth.

Objective: The coronary calcium score (CCS) predicts cardiovascular disease risk in individuals with diabetes, and rate of progression of CCS is an additional and incremental marker of risk. F-sodium fluoride positron emission tomography (F-NaF PET) detects early and active calcifications within the vasculature. We aimed to ascertain the relationship between F-NaF PET activity and CCS progression in patients with diabetes. Approach and Results: We identified individuals between 50 and 80 years with diabetes and no history of clinical coronary artery disease. Those with a CCS ≥10 were invited to undergo F-NaF PET scanning and then repeat CCS >2 years later. F-NaF PET and CCS analysis were performed on a per-coronary and a per-patient level. We compared the proportion of CCS progressors in F-NaF PET-positive versus F-NaF PET-negative coronary arteries. Forty-one participants with 163 coronary arteries underwent follow-up CCS 2.8±0.5 years later. F-NaF PET-positive coronary arteries (n=52) were more likely to be CCS progressors, compared with negative coronary arteries (n=111; 86.5% versus 52.3%, <0.001). Adjusting for baseline CCS, F-NaF PET-positive disease was an independent predictor of subsequent CCS progression (odds ratio, 2.92 [95% CI, 1.32-6.45], =0.008). All subjects (100%, 15/15) with ≥2 F-NaF-positive coronary arteries progressed in CCS.

Conclusions: In subjects with diabetes, F-NaF PET positivity at baseline, independently predicted the progression of calcifications within the coronary arteries 2.8 years later. These findings suggest F-NaF PET may be a promising technique for earlier identification of patients at higher risk of cardiovascular events.
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http://dx.doi.org/10.1161/ATVBAHA.120.315364DOI Listing
January 2021

Lipoprotein(a) in Patients With Type 2 Diabetes and Premature Coronary Artery Disease in the Coronary Care Unit.

Heart Lung Circ 2021 May 12;30(5):734-740. Epub 2020 Nov 12.

Medical School, The University of Western Australia, Perth, WA, Australia; Departments of Internal Medicine and Cardiology, Royal Perth Hospital, Perth, WA, Australia; Department of Clinical Biochemistry, PathWest Laboratory Medicine WA, Royal Perth and Fiona Stanley Hospitals, Perth, WA, Australia; Department of Biochemistry, Clinipath Pathology, Perth, WA, Australia.

Introduction: Lipoprotein(a) [Lp(a)] and diabetes are independently associated with premature coronary artery disease (pCAD). However, there is an inverse relationship between Lp(a) concentration and type 2 diabetes (T2D) risk. We examine whether Lp(a) distribution in patients with pCAD differs between those with or without T2D, and whether elevated Lp(a) is associated with pCAD in patients with T2D.

Methods: Lp(a) concentration was measured in consecutive acute coronary syndrome (ACS) patients in two coronary care units (study one: ACS with or without diabetes, study two: ACS and diabetes). Elevated Lp(a) mass concentration was defined as ≥0.5 g/L and pCAD where CAD was diagnosed age <60 years. The association between elevated Lp(a) and pCAD was assessed using logistic regression.

Results: Of 449 patients, 233 (51.9%) had pCAD and 278 (61.9%) had T2D. In patients with pCAD, those with T2D had a significantly lower median Lp(a) concentration (0.13 g/L versus 0.27 g/L, p=0.004). In patients with T2D, elevated Lp(a) was significantly associated with pCAD (OR 2.419, 95% CI 1.513-3.867, p<0.001). After adjusting for gender, smoking, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglycerides, elevated Lp(a) remained significantly associated with pCAD (OR 2.895, 95% CI 1.427-5.876, p=0.003) in patients with T2D.

Conclusions: In coronary care patients with pCAD, patients with T2D had lower Lp(a) concentrations than those without T2D. Despite this, elevated Lp(a) remained predictive of pCAD in patients with T2D. Measurement of Lp(a) should be considered in younger adults with T2D to identify who may benefit from earlier preventative therapies to reduce pCAD burden.
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http://dx.doi.org/10.1016/j.hlc.2020.09.932DOI Listing
May 2021

Case report: Synergetic effect of ischaemia and increased vagal tone inducing ventricular fibrillation in a patient with Brugada syndrome.

Eur Heart J Case Rep 2020 Aug 30;4(4):1-5. Epub 2020 Jul 30.

Department of Cardiology, Erasmus MC, Dr. Molewaterplein 40. 3015 GD, Rotterdam, The Netherlands.

Background: Brugada syndrome (BS) is a hereditary channelopathy associated with syncope, malignant ventricular arrhythmia, and sudden cardiac death. Right ventricular ischaemia and BS have similar underlying substrates precipitating ventricular tachycardia or fibrillation (VF).

Case Summary: A 72-year-old woman with BS and a stenosis on the proximal right coronary artery received several subsequent implantable cardioverter-defibrillator shocks due to VF during an episode of extreme nausea with vomiting.

Discussion: This case report emphasizes on the synergetic effect of mild ischaemia and increased vagal tone on the substrate responsible for BS to create pathophysiological changes precipitating VF.
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http://dx.doi.org/10.1093/ehjcr/ytaa202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7501915PMC
August 2020

A "light based biopsy" for high-risk atherosclerotic plaque.

Atherosclerosis 2020 09 28;309:65-66. Epub 2020 Aug 28.

Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia; Medical School, University of Western Australia, Perth, Western Australia, Australia. Electronic address:

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http://dx.doi.org/10.1016/j.atherosclerosis.2020.08.023DOI Listing
September 2020

The effects of vitamin K-rich green leafy vegetables on bone metabolism: A 4-week randomised controlled trial in middle-aged and older individuals.

Bone Rep 2020 Jun 26;12:100274. Epub 2020 Apr 26.

School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia.

Background: High vegetable intake is associated with beneficial effects on bone. However, the mechanisms remain uncertain. Green leafy vegetables are a rich source of vitamin K1, which is known to have large effects on osteoblasts and osteocalcin (OC) metabolism.

Objective: To examine the effects of consumption of two to three extra serves of green leafy vegetables daily on bone metabolism.

Methods: Thirty individuals (mean age 61.8 ± 9.9 years, 67% male) completed three experimental phases in a randomised controlled crossover design, each lasting four weeks, with a washout period of four weeks between phases (clinical trial registration: ACTRN12615000194561). The three experimental phases were: (i) increased dietary vitamin K1 by consuming green leafy vegetables (H-K; ~200 g/d containing 164.3 [99.5-384.7] μg/d of vitamin K1); (ii) low vitamin K1 by consuming vitamin K1-poor vegetables (L-K; ~200 g/d containing 9.4 [7.7-11.6] μg/d of vitamin K1); and (iii) control (CON) where participants consumed an energy-matched non-vegetable control. OC forms, total OC (tOC), carboxylated OC (cOC) and undercarboxylated OC (ucOC), were measured in serum pre- and post-intervention for each experimental phase using a sandwich-electrochemiluminescence immunoassay.

Results: Pre-intervention tOC, ucOC and ucOC:tOC levels were similar between phases ( > .05). Following H-K, but not L-K, tOC, ucOC and ucOC:tOC levels were significantly lower compared to pre-intervention levels ( ≤ .001) and compared to CON (~14%, 31% and 19%, respectively, all  < .05), while cOC remained unchanged.

Conclusions: In middle-aged healthy men and women, an easily achieved increase in dietary intake of vitamin K1-rich green leafy vegetables substantially reduces serum tOC and ucOC suggesting increased entry of OC into bone matrix, where it may improve the material property of bone. In conjunction with previous epidemiological and randomised controlled trial data, these findings suggest that interventions to increase vegetable intake over extended periods should include bone end points including fracture risk.
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http://dx.doi.org/10.1016/j.bonr.2020.100274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7235933PMC
June 2020

A randomised controlled crossover trial investigating the short-term effects of different types of vegetables on vascular and metabolic function in middle-aged and older adults with mildly elevated blood pressure: the VEgetableS for vaScular hEaLth (VESSEL) study protocol.

Nutr J 2020 05 12;19(1):41. Epub 2020 May 12.

School of Medical and Health Sciences, Edith Cowan University, Royal Perth Hospital Research Foundation, Rear 50, Murray Street, Joondalup, Perth, WA, 6000, Australia.

Background: A diet rich in fruits and vegetables is recommended for cardiovascular health. However, the majority of Australians do not consume the recommended number of vegetable servings each day. Furthermore, intakes of vegetables considered to have the greatest cardiovascular benefit are often very low. Results from prospective observational studies indicate that a higher consumption of cruciferous vegetables (e.g. broccoli, cabbage, cauliflower) is associated with lower cardiovascular disease risk. This may be due to the presence of specific nutrients and bioactive compounds found almost exclusively, or at relatively high levels, in cruciferous vegetables. Therefore, the aim of this randomised controlled crossover trial is to determine whether regular consumption of cruciferous vegetables results in short-term improvement in measures related to cardiovascular disease risk, including ambulatory blood pressure, arterial stiffness, glycaemic control, and circulating biomarkers of oxidative stress and inflammation.

Methods: Twenty-five participants (50-75 years) with mildly elevated blood pressure (systolic blood pressure 120-160 mmHg) will complete two 2-week intervention periods in random order, separated by a 2-week washout period. During the intervention period, participants will consume 4 servings (~ 300 g) of cruciferous vegetables per day as a soup (~ 500-600 mL/day). The 'control' soup will consist of other commonly consumed vegetables (potato, sweet potato, carrot, pumpkin). Both soups will be approximately matched for energy, protein, fat, and carbohydrate content. All measurements will be performed at the beginning and end of each intervention period.

Discussion: The findings of this study will provide evidence regarding the potential cardiometabolic health benefits of cruciferous vegetables, which may contribute to the revision of dietary and clinical guidelines.

Trial Registration: The trial was registered with the Australian New Zealand Clinical Trial Registry on 19th September 2019 (ACTRN12619001294145).
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http://dx.doi.org/10.1186/s12937-020-00559-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7218618PMC
May 2020

Quantifying dietary vitamin K and its link to cardiovascular health: a narrative review.

Food Funct 2020 Apr;11(4):2826-2837

School of Health and Medical Sciences, Edith Cowan University, Perth, Western Australia, Australia. and School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Western Australia, Australia.

Cardiovascular disease is the leading cause of death and disability worldwide. Recent work suggests a link between vitamin K insufficiency and deficiency with vascular calcification, a marker of advanced atherosclerosis. Vitamin K refers to a group of fat-soluble vitamins important for blood coagulation, reducing inflammation, regulating blood calcium metabolism, as well as bone metabolism, all of which may play a role in promoting cardiovascular health. Presently, there is a lack of a comprehensive vitamin K database on individual foods, which are required to accurately calculate vitamin K1 and K2 intake for examination in epidemiological studies. This has likely contributed to ambiguity regarding the recommended daily intake of vitamin K, including whether vitamin K1 and K2 may have separate, partly overlapping functions. This review will discuss the presence of: (i) vitamin K1 and K2 in the diet; (ii) the methods of quantitating vitamin K compounds in foods; and (iii) provide an overview of the evidence for the cardiovascular health benefits of vitamin K in observational and clinical trials.
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http://dx.doi.org/10.1039/c9fo02321fDOI Listing
April 2020

An age-matched computed tomography angiographic study of coronary atherosclerotic plaques in patients with familial hypercholesterolaemia.

Atherosclerosis 2020 04 6;298:52-57. Epub 2020 Mar 6.

School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia; Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia. Electronic address:

Background And Aims: Familial hypercholesterolaemia (FH) is characterised by a high, but variable risk of premature coronary artery disease (CAD). Cardiac computed tomography angiography (CCTA) can be employed to assess subclinical coronary atherosclerosis. We investigated the features and distribution of coronary artery plaques in asymptomatic patients with and without genetically confirmed heterozygous FH.

Methods: We undertook an aged-matched case-control study of asymptomatic phenotypic FH patients with (cases, M+) and without (controls, M-) an FH-causing mutation. Coronary atherosclerosis was assessed by CCTA and calcium scoring. Coronary segments were evaluated for global and vessel-level coronary plaques and degree of stenosis.

Results: We studied 104 cases and 104 controls (mean age 49.9 ± 10.4 years), who had a similar spectrum of non-cardiovascular risk factors. Pre-treatment plasma LDL-cholesterol was higher in the M+ than M- group (7.8 ± 2.1 vs 6.2 ± 1.2 mmol/L, p<0.001). There was a greater proportion of patients with mixed and calcified plaque, as well as a higher coronary artery calcium score and segment stenosis score (all p<0.05), in the M+ compared with the M- group. M+ patients also had a significantly higher frequency of coronary artery calcium in the left main and anterior descending and right coronary arteries (all p<0.05), but not in the left circumflex.

Conclusions: Among patients with phenotypic FH, those with a genetically confirmed diagnosis had a higher frequency and severity of coronary atherosclerotic plaques, and specifically more advanced calcified plaques.
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http://dx.doi.org/10.1016/j.atherosclerosis.2020.03.001DOI Listing
April 2020

Optimizing arterial F-sodium fluoride positron emission tomography analysis.

J Nucl Cardiol 2019 Dec 23. Epub 2019 Dec 23.

School of Medicine, University of Western Australia, Perth, WA, Australia.

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http://dx.doi.org/10.1007/s12350-019-01992-6DOI Listing
December 2019

A genetic risk score predicts coronary artery disease in familial hypercholesterolaemia: enhancing the precision of risk assessment.

Clin Genet 2020 02 9;97(2):257-263. Epub 2019 Oct 9.

School of Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia.

Familial hypercholesterolaemia (FH) is associated with increased risk of coronary artery disease (CAD); however, risk prediction and stratification remain a challenge. Genetic risk scores (GRS) may have utility in identifying FH patients at high CAD risk. The study included 811 patients attending the lipid disorders clinic at Royal Perth Hospital with mutation-positive (n = 251) and mutation-negative (n = 560) FH. Patients were genotyped for a GRS previously associated with CAD. Associations between the GRS, clinical characteristics, and CAD were assessed using regression analyses. The average age of patients was 49.6 years, and 44.1% were male. The GRS was associated with increased odds of a CAD event in mutation-positive [odds ratio (OR) = 3.3; 95% confidence interval (CI) = 1.3-8.2; P = .009] and mutation-negative FH patients (OR = 1.8; 95% CI = 1.0-3.3; P = .039) after adjusting for established predictors of CAD risk. The GRS was associated with greater subclinical atherosclerosis as assessed by coronary artery calcium score (P = .039). A high GRS was associated with CAD defined clinically and angiographically in FH patients. High GRS patients may benefit from more intensive management including lifestyle modification and aggressive lipid-lowering therapy. Further assessment of the utility of the GRS requires investigation in prospective cohorts, including its role in influencing the management of FH patients in the clinic.
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http://dx.doi.org/10.1111/cge.13648DOI Listing
February 2020

What's new on therapies for elevated lipoprotein(a).

Expert Rev Clin Pharmacol 2019 Jun 30;12(6):495-499. Epub 2019 Apr 30.

b School of Medicine, Faculty of Health and Medical Sciences , University of Western Australia , Perth , Australia.

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http://dx.doi.org/10.1080/17512433.2019.1610391DOI Listing
June 2019

Coronary artery 18F-NaF PET analysis with the use of an elastic motion correction software.

J Nucl Cardiol 2020 06 25;27(3):952-961. Epub 2019 Jan 25.

Cardiology Department, Royal Perth Hospital, 197 Wellington St, Perth, WA, 6000, Australia.

Introduction: 18F-Sodium Fluoride Positron Emission Tomography (18F-NaF PET) is a novel molecular imaging modality with promise for use as a risk stratification tool in cardiovascular disease. There are limitations in the analysis of small and rapidly moving coronary arteries using traditional PET technology. We aimed to validate the use of a motion correction algorithm (eMoco) on coronary 18F-NaF PET outcome parameters.

Methods: Patients admitted with an acute coronary syndrome underwent 18F-NaF PET and computed tomography coronary angiography. 18F-NaF PET data were analyzed using a diastolic reconstruction, an ungated reconstruction and the eMoco reconstruction.

Results: Twenty patients underwent 18F-NaF PET imaging and 17 patients had at least one positive lesion that could be used to compare PET reconstruction datasets. eMoco improved noise (the coefficient of variation of the blood pool radiotracer activity) compared to the diastolic dataset (0.09 [0.07 to 0.12] vs 0.14[0.11 to 0.17], p < .001) and marginally improved coronary lesion maximum tissue-to-background ratios compared to the ungated dataset (1.33 [1.05 to 1.48]vs 1.29 [1.04 to 1.40], p = .011).

Conclusion: In this pilot dataset, the eMoco reconstruction algorithm for motion correction appears to have potential in improving coronary analysis of 18F-NaF PET by reducing noise and increasing maximum counts. Further testing in a larger patient dataset is warranted.
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http://dx.doi.org/10.1007/s12350-018-01587-7DOI Listing
June 2020

In search of the vulnerable patient or the vulnerable plaque: F-sodium fluoride positron emission tomography for cardiovascular risk stratification.

J Nucl Cardiol 2018 10 10;25(5):1774-1783. Epub 2018 Jul 10.

Department of Cardiology, Royal Perth Hospital, 197 Wellington St, Perth, WA, 6000, Australia.

Cardiovascular disease (CVD) remains a leading cause of death. Preventative therapies that reduce CVD are most effective when targeted to individuals at high risk. Current risk stratification tools have only modest prognostic capabilities, resulting in over-treatment of low-risk individuals and under-treatment of high-risk individuals. Improved methods of CVD risk stratification are required. Molecular imaging offers a novel approach to CVD risk stratification. In particular, F-sodium fluoride (F-NaF) positron emission tomography (PET) has shown promise in the detection of both high-risk atherosclerotic plaque features and vascular calcification activity, which predicts future development of new vascular calcium deposits. The rate of change of coronary calcium scores, measured by serial computed tomography scans over a 2-year period, is a strong predictor of CVD risk. Vascular calcification activity, as measured with F-NaF PET, has the potential to provide prognostic information similar to consecutive coronary calcium scoring, with a single-time-point convenience. However, owing to the rapid motion and small size of the coronary arteries, new solutions are required to address the traditional limitations of PET imaging. Two different methods of coronary PET analysis have been independently proposed and here we compare their respective strengths, weaknesses, and the potential for clinical translation.
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http://dx.doi.org/10.1007/s12350-018-1360-2DOI Listing
October 2018

Elevated lipoprotein(a) and low-density lipoprotein cholesterol as predictors of the severity and complexity of angiographic lesions in patients with premature coronary artery disease.

J Clin Lipidol 2018 Jul - Aug;12(4):1019-1026. Epub 2018 Apr 3.

Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia; School of Medicine, Faculty of Health and Medical Science, University of Western Australia, Perth, Western Australia, Australia. Electronic address:

Background: Elevated lipoprotein(a) (Lp[a]) and low-density lipoprotein (LDL) cholesterol are important inheritable risk factors for premature coronary artery disease (CAD). Lp(a) mediates cardiovascular risk through prothrombotic, proinflammatory, and proatherogenic properties. The association of Lp(a) and LDL cholesterol with angiographic disease severity and complexity in patients with premature CAD has yet to be established.

Objective: To investigate the relationship of Lp(a) and LDL cholesterol with the severity and complexity of coronary artery lesions using the SYNergy between percutaneous coronary intervention with TAXUS and Cardiac Surgery (SYNTAX) and Gensini scores, in patients with premature CAD.

Methods: Plasma Lp(a) levels were consecutively measured by an automated latex-enhanced immunoassay in 147 patients with premature coronary events (aged <60 years). Elevated Lp(a) was defined as >0.5 g/L, and elevated LDL cholesterol as an untreated LDL cholesterol of >5.0 mmol/L (>193 mg/dL). Demographical, biochemical, and clinical data were retrospectively collected from medical records. SYNTAX and Gensini scores were independently assessed by 2 investigators.

Results: Patients were subdivided into tertiles using SYNTAX scores. The proportion of patients with elevated Lp(a) and elevated LDL cholesterol were significantly higher in patients with higher SYNTAX and Gensini scores (P < .05). In multivariate analysis (adjusting for age, diabetes, hypertension, and previous coronary event), elevated Lp(a) and elevated LDL cholesterol remained significant, independent predictors of higher SYNTAX and Gensini scores (P < .05). Patients with both elevated Lp(a) and elevated LDL cholesterol constituted most of the patients in the highest SYNTAX tertile, while patients with nonelevated Lp(a) and nonelevated LDL cholesterol were predominantly in the lowest SYNTAX tertile (P < .05).

Conclusion: In patients with premature CAD, elevated Lp(a) and LDL cholesterol (in a range consistent with familial hypercholesterolemia) were significant, independent predictors of the severity of CAD. Both lipid disorders should be routinely screened for in younger patients presenting to the coronary care unit.
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http://dx.doi.org/10.1016/j.jacl.2018.03.090DOI Listing
October 2019

Elevated lipoprotein(a) and familial hypercholesterolemia in the coronary care unit: Between Scylla and Charybdis.

Clin Cardiol 2018 Mar 26;41(3):378-384. Epub 2018 Feb 26.

School of Medicine, University of Western Australia, Perth, Australia.

Background: Elevated lipoprotein(a) (Lp[a]) and familial hypercholesterolemia (FH) are inherited lipid disorders. Their frequencies, coexistence, and associations with premature coronary artery disease (CAD) in patients admitted to the coronary care unit (CCU) remain to be defined.

Hypothesis: Elevated Lp(a) and FH are commonly encountered among CCU patients and independently associated with increased premature CAD risk.

Methods: Plasma Lp(a) concentrations were measured in consecutive patients admitted to the CCU with an acute coronary syndrome (ACS) or prior history of CAD for 6.5 months. Elevated Lp(a) was defined as concentrations ≥0.5 g/L. Patients with LDL-C ≥ 5 mmol/L exhibited phenotypic FH. Premature CAD was diagnosed in those age < 60 years, and the relationship between this and elevated Lp(a) and FH was determined by logistic regression.

Results: 316 patients were screened; 163 (51.6%) had premature CAD. Overall, elevated Lp(a) and FH were identified in 27.0% and 11.6% of patients, respectively. Both disorders were detected in 4.4% of individuals. Elevated Lp(a) (32.0% vs 22.2%; P = 0.019) and FH phenotype (15.5% vs 8.0%; P = 0.052) were more common with premature vs nonpremature CAD. Elevated Lp(a) alone conferred a 1.9-fold, FH alone a 3.2-fold, and the combination a 5.3-fold increased risk of premature CAD (P = 0.005).

Conclusions: Elevated Lp(a) and phenotypic FH were commonly encountered and more frequent with premature CAD. The combination of both disorders is especially associated with increased CAD risk. Patients admitted to the CCU with ACS or previously documented CAD should be routinely screened for elevated Lp(a) and FH.
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http://dx.doi.org/10.1002/clc.22880DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6489753PMC
March 2018

Round-the-clock performance of coronary CT angiography for suspected acute coronary syndrome: Results from the BEACON trial.

Eur Radiol 2018 May 15;28(5):2169-2175. Epub 2017 Dec 15.

Department of Cardiology, Erasmus University Medical Center, Room: Ca-207a, 's-Gravendijkwal 230, Rotterdam, 3015 CE, The Netherlands.

Objective: To assess the image quality of coronary CT angiography (CCTA) for suspected acute coronary syndrome (ACS) outside office hours.

Methods: Patients with symptoms suggestive of an ACS underwent CCTA at the emergency department 24 hours, 7 days a week. A total of 118 patients, of whom 89 (75 %) presented during office hours (weekdays between 07:00 and 17:00) and 29 (25 %) outside office hours (weekdays between 17:00 and 07:00, weekends and holidays) underwent CCTA. Image quality was evaluated per coronary segment by two experienced readers and graded on an ordinal scale ranging from 1 to 3.

Results: There were no significant differences in acquisition parameters, beta-blocker administration or heart rate between patients presenting during office hours and outside office hours. The median quality score per patient was 30.5 [interquartile range 26.0-33.5] for patients presenting during office hours in comparison to 27.5 [19.75-32.0] for patients presenting outside office hours (p=0.043). The number of non-evaluable segments was lower for patients presenting during office hours (0 [0-1.0] vs. 1.0 [0-4.0], p=0.009).

Conclusion: Image quality of CCTA outside office hours in the diagnosis of suspected ACS is diminished.

Key Points: • Quality scores were higher for coronary-CTA during office hours. • There were no differences in acquisition parameters. • There was a non-significant trend towards higher heart rates outside office hours. • Coronary-CTA on the ED requires state-of-the-art scanner technology and sufficiently trained staff. • Coronary-CTA on the ED needs preparation time and optimisation of the procedure.
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http://dx.doi.org/10.1007/s00330-017-5082-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5882623PMC
May 2018

New data on familial hypercholesterolaemia and acute coronary syndromes: The promise of PCSK9 monoclonal antibodies in the light of recent clinical trials.

Eur J Prev Cardiol 2017 07 9;24(11):1200-1205. Epub 2017 May 9.

1 School of Medicine, University of Western Australia, Australia.

Background Familial hypercholesterolaemia (FH) is an autosomal dominant disorder characterised by substantially elevated low-density lipoprotein (LDL) cholesterol. Although affecting approximately one in 250 individuals worldwide, FH is currently underreported and a greater awareness of this condition is required. Opportunistic screening for FH in acute coronary syndrome patients offers utility for identifying previously undiagnosed individuals and for initiating treatment. Methods The purpose of this commentary is to provide a brief update on recent data investigating several key aspects of FH in patients with acute coronary syndromes, including prevalence, risk of coronary artery disease, molecular diagnosis, cardiac imaging, as well as the efficacy of PCSK9 inhibition. Results FH is relatively common among patients with coronary artery disease and is associated with a considerably increased risk of premature and recurrent cardiovascular events. Computed tomographic coronary angiography may be useful for identifying high-risk FH individuals. FH patients with a pathogenic mutation have a greater risk of the same LDL cholesterol than individuals without a mutation. PCSK9 monoclonal antibodies significantly lower LDL cholesterol in heterozygous and homozygous FH patients, with a greater attainment of LDL cholesterol targets, and can reduce the need for lipoprotein apheresis. Conclusions These data support the opportunistic screening for FH at the time of angiography or an acute coronary syndrome, followed by cascade testing of relatives of index cases. PCSK9 monoclonal antibodies are an important therapeutic advance for safely inhibiting the progression of atherosclerotic burden in FH, as supported by the most recent clinical endpoint trials.
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http://dx.doi.org/10.1177/2047487317708890DOI Listing
July 2017

Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins: Randomized Multicenter Study.

J Am Coll Cardiol 2016 Jan;67(1):16-26

Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.

Background: It is uncertain whether a diagnostic strategy supplemented by early coronary computed tomography angiography (CCTA) is superior to contemporary standard optimal care (SOC) encompassing high-sensitivity troponin assays (hs-troponins) for patients suspected of acute coronary syndrome (ACS) in the emergency department (ED).

Objectives: This study assessed whether a diagnostic strategy supplemented by early CCTA improves clinical effectiveness compared with contemporary SOC.

Methods: In a prospective, open-label, multicenter, randomized trial, we enrolled patients presenting with symptoms suggestive of an ACS at the ED of 5 community and 2 university hospitals in the Netherlands. Exclusion criteria included the need for urgent cardiac catheterization and history of ACS or coronary revascularization. The primary endpoint was the number of patients identified with significant coronary artery disease requiring revascularization within 30 days.

Results: The study population consisted of 500 patients, of whom 236 (47%) were women (mean age 54 ± 10 years). There was no difference in the primary endpoint (22 [9%] patients underwent coronary revascularization within 30 days in the CCTA group and 17 [7%] in the SOC group [p = 0.40]). Discharge from the ED was not more frequent after CCTA (65% vs. 59%, p = 0.16), and length of stay was similar (6.3 h in both groups; p = 0.80). The CCTA group had lower direct medical costs (€337 vs. €511, p < 0.01) and less outpatient testing after the index ED visit (10 [4%] vs. 26 [10%], p < 0.01). There was no difference in incidence of undetected ACS.

Conclusions: CCTA, applied early in the work-up of suspected ACS, is safe and associated with less outpatient testing and lower costs. However, in the era of hs-troponins, CCTA does not identify more patients with significant CAD requiring coronary revascularization, shorten hospital stay, or allow for more direct discharge from the ED. (Better Evaluation of Acute Chest Pain with Computed Tomography Angiography [BEACON]; NCT01413282).
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http://dx.doi.org/10.1016/j.jacc.2015.10.045DOI Listing
January 2016

Frequency of familial hypercholesterolemia in patients with early-onset coronary artery disease admitted to a coronary care unit.

J Clin Lipidol 2015 Sep-Oct;9(5):703-8. Epub 2015 Jul 18.

School of Medicine and Pharmacology, University of Western Australia, Western Australia, Australia; Lipid Disorders Clinic, Cardiovascular Medicine, Royal Perth Hospital, Western Australia, Australia. Electronic address:

Background: Familial hypercholesterolemia (FH) is the most common dominantly inherited cause of premature coronary artery disease (CAD). However, the diagnosis of FH in patients who have premature CAD in hospital settings is under-recognized, this also represents a missed opportunity for screening their close family members and implementing primary prevention.

Objective: To investigate the point prevalence of FH in a coronary care unit (CCU) among patients with early-onset CAD.

Methods: The prevalence of FH, based on modified phenotypic Dutch Lipid Clinic Network Criteria, and the spectrum of associated CAD risk factors, were investigated in a CCU setting. Data were collected on 175 coronary care patients with onset of CAD at age <60 years.

Results: The prevalence of probable/definite FH was 14.3% (95% confidence interval, 9.0%-19.5%); 46.3% of the patients gave a family history of premature CAD and 20.6% had an untreated low-density lipoprotein cholesterol >5.0 mmol/L. Diabetes, hypertension, obesity, and smoking were common and equally prevalent in patients with and without FH.

Conclusions: FH is relatively frequent among patients with a history of early-onset CAD in the CCU. Every effort should be made to detect FH in these patients and to initiate cascade testing of available family members to prevent the development of CAD in those who may be unaware that they also have the condition.
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http://dx.doi.org/10.1016/j.jacl.2015.07.005DOI Listing
June 2016

Rotational angiography with motion compensation: first-in-man use for the 3D evaluation of transcatheter valve prostheses.

EuroIntervention 2015 Aug;11(4):442-9

Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands.

Aims: We evaluated a novel motion-compensating 3D reconstruction technique applied to rotational angiography (R-angio) which produces MSCT-like images for evaluation of implanted TAVI prostheses without requiring rapid pacing.

Methods And Results: Fifty-one consecutive patients were retrospectively identified who were evaluated with rotational angiography (R-angio) using the Siemens Artis zee angiographic C-arm system after TAVI with a Medtronic CoreValve prosthesis. A novel 3D image reconstruction technique was applied which corrects for cardiac motion. CoreValve frame geometry was evaluated according to the same protocol for MSCT and R-angio at the level of: 1) the inflow, 2) the nadirs, 3) central coaptation, and 4) the commissures. The native aortic annulus dimensions were measured at the nadirs of the three leaflets. Sizing ratio, prosthesis expansion and frame ellipticity were assessed. Good quality 3D reconstructions were obtained in 43 patients (84%) and failure was predictable prior to reconstruction in six of the other seven patients (superposition of radiographically dense object n=4, obesity n=2). Prosthesis inflow ellipticity and expansion were correlated with implantation depth (respectively r=-0.46, p<0.01, and r=0.61, p<0.001). Aortic regurgitation grade ≥2 was associated with greater prosthesis ellipticity at the level of central coaptation (median [25th-75th percentile]: 1.15 [1.10-1.20] vs. 1.08 [1.06-1.12], p=0.009). The inter-observer, inter-modality (MSCT, R-angio) variability in measurement at the level of coaptation for minimum diameter, maximum diameter and area were all low (respectively, mean ±SD:1.2% ±1.2; 1.7% ±1.8 and 2.0% ±1.3).

Conclusions: R-angio with motion-compensated reconstruction offers new possibilities for evaluation of the post-implantation geometry of percutaneous structural heart prostheses and the potential clinical effects.
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http://dx.doi.org/10.4244/EIJY14M06_08DOI Listing
August 2015

An objective and reproducible method for quantification of aortic regurgitation after TAVI.

EuroIntervention 2014 Jul;10(3):355-63

Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands.

Aims: We describe a new semi-automated method that measures aortic regurgitation (AR) on contrast aortography with the objectives of reducing the inter-observer variability and standardising image acquisition.

Methods And Results: Aortograms from three participating centres were reviewed to generate the following quality criteria: entire left ventricle and aortic root in view, descending aorta or TOE probe not over-projected, breath hold, no table motion, and adequate contrast opacification of the aortic root. AR was visually graded (Sellers) and was quantified by measuring the area under time-contrast density curves in the aortic root (reference) and the left ventricle. Quality criteria were met in 44 retrospectively identified aortograms and in 22 (69%) of 32 prospectively collected aortograms. The visual AR grade (Sellers) was highly correlated with time-density measurements including relative area under the curve (RAUC) and qRA index (r=0.81 and 0.83, respectively, p<0.001). Inter-observer reproducibility of visual grading was moderate (kappa 0.47-0.60, p<0.001). Inter-observer measurement of RAUC and qRA index were highly correlated (r=0.98, p<0.001) and showed a high level of agreement.

Conclusions: Quantification of aortic regurgitation by measurement of time-density changes on contrast aortography may improve the reproducibility of AR assessment in the catheter laboratory. Steps for standardised aortography acquisition are proposed.
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http://dx.doi.org/10.4244/EIJY14M05_06DOI Listing
July 2014

Effect of body mass index on the image quality of rotational angiography without rapid pacing for planning of transcatheter aortic valve implantation: a comparison with multislice computed tomography.

Eur Heart J Cardiovasc Imaging 2014 Feb 25;15(2):133-41. Epub 2013 Mar 25.

Department of Cardiology, Erasmus MC, PB 412, Rotterdam 3000 CA, the Netherlands.

Aims: To evaluate the feasibility of procedural planning for transcatheter aortic valve implantation (TAVI) using rotational angiography (R-angio) by comparison with multislice computed tomography (MSCT) and to investigate determinants of the image quality of R-angio.

Methods And Results: Patients who underwent R-angio of the left ventricle and cardiac MSCT were eligible. R-angio acquisition was performed during contrast injection through a 6F pigtail catheter positioned in the left ventricle. On 3D R-angio and MSCT data sets, diameter measurements were made on short-axis images at the level of the aortic annulus (D(perimeter), D(area)), ascending aorta, sino-tubular junction (ST-junction), and the sinus of Valsalva. At the level of the aortic annulus, diagnostic image quality was obtained in 49 of 56 patients. In all patients with a body mass index (BMI) < 29 kg/m(2), image quality was acceptable whether or not rapid pacing was used. In patients with BMI ≥ 29 kg/m(2), the image quality was poor in 1 of 9 (11%) who were rapidly paced compared with 6 of 12 (50%) who were not. The correlation between R-angio and MSCT measurements was high for aortic annulus D(perimeter), D(area), ST-junction, Valsalva sinus, and ascending aorta (respectively, R = 0.90, 0.90, 0.91, 0.92, and 0.89). The correlations improved further when the analysis was limited to patients with a BMI < 29 kg/m(2) (respectively, 0.92, 0.92, 0.92, 0.92, and 0.93).

Conclusion: R-angio of the left ventricle allows precise measurement of the aortic root and annulus and was feasible for sizing at the time of TAVI. Diagnostic image quality was obtained without rapid pacing in all patients with a BMI < 29 kg/m(2).
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http://dx.doi.org/10.1093/ehjci/jet037DOI Listing
February 2014
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