Publications by authors named "Gudrun M Feuchtner"

66 Publications

The Clinical Spectrum of Myocardial Infarction and Ischemia With Nonobstructive Coronary Arteries in Women.

JACC Cardiovasc Imaging 2020 Sep 26. Epub 2020 Sep 26.

Dalio Institute of Cardiovascular Imaging, Department of Radiology, NewYork-Presbyterian Hospital and Weill Cornell Medical College, New York, New York. Electronic address:

Women exhibit less burden of anatomic obstructive coronary atherosclerotic disease as compared with men of the same age, but contradictorily show similar or higher cardiovascular mortality rates. The higher prevalence of nonexertional cardiac symptoms and nonobstructive coronary atherosclerotic disease in women may lead to lack of recognition and appropriate management, resulting in undertesting and undertreatment. Leaders in women's health from the American College of Cardiology's Cardiovascular Disease in Women Committee present novel imaging cases that may provoke thought regarding the broad clinical spectrum of myocardial infarction and ischemia with nonobstructive coronary arteries in women. These unique imaging approaches are based on the concept of targeting sex-specific differences in acute and stable ischemic heart disease.
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http://dx.doi.org/10.1016/j.jcmg.2020.06.044DOI Listing
September 2020

Myocardial injury in COVID-19: The role of coronary computed tomography angiography (CTA).

J Cardiovasc Comput Tomogr 2021 Jan-Feb;15(1):e3-e6. Epub 2020 Jul 17.

Department of Internal Medicine III- Cardiology, Innsbruck Medical University, Austria.

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http://dx.doi.org/10.1016/j.jcct.2020.07.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7367010PMC
March 2021

Differences in coronary vasodilatory capacity and atherosclerosis in endurance athletes using coronary CTA and computational fluid dynamics (CFD): Comparison with a sedentary lifestyle.

Eur J Radiol 2020 Sep 11;130:109168. Epub 2020 Jul 11.

Department of Internal Medicine III- Cardiology, Innsbruck Medical University, Austria.

Background: The aim was to assess the effect of endurance exercise on coronary vasodilatory capacity and atherosclerosis by coronary computed tomography angiography (CTA) and computational fluid dynamic (CFD) modelling.

Methods: 100 subjects (age 56.2y±11, 29 females) who underwent coronary CTA were included into this retrospectively matched cohort study. Endurance athletes (≥1 h per unit and ≥3 times per week training) were compared to controls with a sedentary lifestyle, and within subgroups with and without sublingual nitroglycerin preparation. CTA image analysis included coronary stenosis severity (CADRADS), total (segment involvement score = SIS) and mixed plaque burden (G-score), high-risk plaque criteria, the coronary artery calcium score (CACS) and CFD analysis including Fractional Flow Reserve (FFR), myocardial mass (M), total vessel lumen volume (V) and volume-to-mass (V/M) ratio.

Results: The prevalence of atherosclerosis by CTA was 65.4 % and >50 % coronary stenosis was found in 17.3 % of athletes. Coronary stenosis severity (CADRADS), total and mixed non-calcified plaque burden (SIS and G-score) were lower in athletes (p = 0.003 and p < 0.001) but not CACS (p = 0.055) and less high-risk plaques were found (p < 0.001). The G-score was correlated with distal FFR (p = 0.025). V/M-ratio was different between athletes who received nitroglycerin compared with those who did not (V/M: 21.1 vs. 14.8; p < 0.001), but these differences were not observed in the control subjects.

Conclusion: Endurance training improves coronary vasodilatory capacity and reduces high-risk plaque and mixed non-calcifed plaque burden as assessed by coronary CTA angiography. Our study may advocate coronary CTA with FFR for evaluation of coronary artery disease in endurance athletes.
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http://dx.doi.org/10.1016/j.ejrad.2020.109168DOI Listing
September 2020

Society of Cardiovascular Computed Tomography guidance for use of cardiac computed tomography amidst the COVID-19 pandemic Endorsed by the American College of Cardiology.

J Cardiovasc Comput Tomogr 2020 Mar - Apr;14(2):101-104. Epub 2020 Mar 21.

Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, MA, United States. Electronic address:

The world is currently suffering through a pandemic outbreak of severe respiratory syndrome coronavirus 2 (SARS-CoV-2) known as Coronavirus Disease 2019 (COVID-19). The United States (US) Centers for Disease Control and Prevention (CDC) currently advises medical facilities to "reschedule non-urgent outpatient visits as necessary". The European Centre for Disease Prevention and Control, the United Kingdom National Health Service and several other international agencies covering Asia, North America and most regions of the world have recommended similar "social distancing" measures. The Society of Cardiovascular Computed Tomography (SCCT) offers guidance for cardiac CT (CCT) practitioners to help implement these international recommendations in order to decrease the risk of COVID-19 transmission in their facilities while deciding on the timing of outpatient and inpatient CCT exams. This document also emphasizes SCCT's commitment to the health and well-being of CCT technologists, imagers, trainees, and research community, as well as the patients served by CCT.
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http://dx.doi.org/10.1016/j.jcct.2020.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102563PMC
May 2020

Added value of high-risk plaque criteria by coronary CTA for prediction of long-term outcomes.

Atherosclerosis 2020 05 30;300:26-33. Epub 2020 Mar 30.

Department of Radiology, Innsbruck Medical University, Austria.

Background And Aims: Long-term data relating coronary computed tomography angiography (CTA) to coronary artery disease (CAD) prognosis including novel CTA-biomarkers ("high-risk plaque criteria") is scarce. The aim of this study was to define predictors of long-term outcomes.

Methods: 1430 low-to-intermediate risk patients (57.9 ± 11.1 years; 44.4% females) who underwent CTA and coronary calcium scoring (CCS) were prospectively enrolled. CTAs were evaluated for (1) stenosis severity CADRADS 0-4 (minimal <25%, mild 25-50%, moderate 50-70%, severe >70%), (2) mixed plaque burden weighted for non-calcified plaque (NCP), and (3) high-risk-plaque (HRP) criteria: low-attenuation-plaque (LAP), napkin-ring-sign, spotty calcifications <3 mm or remodeling index >1.1. Endpoints were all-cause and cardiovascular mortality, composite fatal and nonfatal major adverse cardiovascular events (MACE).

Results: Over a mean follow-up of 10.55 years ± 1.98, 106 patients (7.4%) died, 25 from cardiovascular events (1.75%). Composite MACE occurred in 57 (3.9%) patients. In patients with negative CTA, cardiovascular mortality and MACE rates were 0% and 0.2%. Stenosis severity by CTA predicted all 3 endpoints (p < 0.001) while CCS >100 AU predicted only all-cause mortality (p = 0.045) but not MACE. The high risk plaque criteria LAP <60HU (HR: 4.00, 95%CI 95% 1.52-10.52, p = 0.005) and napkin-ring (HR 4.11, CI 95% 1.77-9.52, p = 0.001) predicted MACE but not all-cause-mortality, after adjusting for risk factors, while spotty calcification and remodeling index did not. Similarly, mixed plaque burden predicted MACE (p < 0.0001). HRP criteria, if added to CADRADS + CCS for prediction of MACE, were superior to CCS (c = 0.816 vs 0.716, p < 0.001). In 33.5% of CCS zero patients, non-calcified fibroatheroma were found.

Conclusions: Long-term prognosis is excellent if CTA is negative for CAD. The high-risk plaque criteria LAP<60HU and napkin-ring-sign were independent predictors of MACE while HRP criteria added incremental prognostic value.
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http://dx.doi.org/10.1016/j.atherosclerosis.2020.03.019DOI Listing
May 2020

Accelerating the future of cardiac CT: Social media as sine qua non?

J Cardiovasc Comput Tomogr 2020 Sep - Oct;14(5):382-385. Epub 2020 Jan 31.

Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, VA, USA.

The vision for the Journal of Cardiovascular Computed Tomography's social media efforts is to amplify the impact of the Journal while driving engagement, increasing journal visibility and disseminating content to new audiences globally. Serving as "the front door" to the Journal, this digital evolution represents an important step forward for a field in which advancements in hardware, image processing and clinical evidence have evolved rapidly. However, is social media the panem et circenses of cardiovascular computed tomography (CT), that of superficial appeasement, or of sine qua non; an essential ingredient to the acceleration of the Journal and of the field of cardiovascular CT? This paper aims to present the initial impact of social media within a dedicated cardiovascular CT journal.
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http://dx.doi.org/10.1016/j.jcct.2020.01.011DOI Listing
October 2020

The perivascular fat gradient in HIV-infected patients.

AIDS 2020 03;34(3):490-491

Department of Radiology, Innsbruck Medical University, Austria.

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http://dx.doi.org/10.1097/QAD.0000000000002449DOI Listing
March 2020

Authors reply to Power of zero stronger than "soft" plaque by Budoff et al. The undeniable impact of statins on favorable outcomes.

J Cardiovasc Comput Tomogr 2020 May - Jun;14(3):280. Epub 2019 Dec 4.

Innsbruck Medical University, Dept. Internal Medicine III, Cardiology, Austria.

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http://dx.doi.org/10.1016/j.jcct.2019.11.002DOI Listing
July 2020

Does coronary calcium score zero reliably rule out coronary artery disease in low-to-intermediate risk patients? A coronary CTA study.

J Cardiovasc Comput Tomogr 2020 Mar - Apr;14(2):155-161. Epub 2019 Sep 23.

Department of Radiology, Innsbruck Medical University, Austria. Electronic address:

Background: Objective was to assess if coronary calcium score (CCS) zero (<1.0AU) reliably rules out coronary artery disease (CAD) by coronary CTA; and if a difference between CCS zero and ultralow CCS (0.1-0.9AU) exists.

Methods: 6439 low-to-intermediate ASCVD-risk patients (57.9 ± 11.1 years; 44.4% females) who underwent CTA and CCS were enrolled. Coronary CTAs were evaluated for: (1) stenosis severity (CADRADS: <25%, 25-49%, 50-69%, 70-99%, and 100%), (2) mixed-plaque burden, and (3) high-risk-plaque-(HRP)-criteria. Primary endpoints were all-cause and cardiovascular (CV) mortality, secondary endpoint MACE.

Results: Overall 1451 (22.5%) had CCS<1.0 AU. Among them, 1289 had CCS zero and 162 ultralow CCS (0.1-0.9AU). In CCS zero patients, 25.9% had CAD, 5.1% > 50% and 20.8% less than 50% stenosis, 6.8% had HRP with min 2 criteria, respectively. LAP<30HU, LAP<60HU, Napkin-Ring-Sign, Spotty calcification and PR were found in 1.3%, 3.7%, 2.8%, 2.3% and 8.2%. CAD prevalence was with 87.7% markedly higher in the ultralow CCS (p < 0.001) group, >50% stenosis (16.6%), total plaque burden (p < 0.001) and HRP-criteria rates were higher (up to 19.1%) (p < 0.001, respectively).All-cause mortality was similar (2.7% and 1.9%) in CCS 0 and ultralow patients (mean follow-up 6.6 ± 4.2 years). Composite MACE (n = 7, 0.48%) was higher than CV-mortality (n = 1, 0.06%, p = 0.038, OR 1.08-1.6). More HRP were found on 128-slice-dual-source-CTA compared to 64-slice (p < 0.001). There were no differences in CTA findings between patients with and without chest pain, but more females were symptomatic.

Conclusion: Early signs of CAD on CTA are frequent in CCS zero and even present in the majority of ultralow CCS (0.1-0.9AU) patients, who should not be downgraded to CCS zero patients. High-risk plaque and >50% stenosis rate is low but not negligible; and MACE rate very low.
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http://dx.doi.org/10.1016/j.jcct.2019.09.009DOI Listing
September 2020

Quadricuspid aortic valve: 3D-visualization by computed tomography.

J Cardiovasc Comput Tomogr 2020 Nov - Dec;14(6):e109-e110. Epub 2019 Jul 5.

Department of Radiology, Innsbruck Medical University, Austria. Electronic address:

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http://dx.doi.org/10.1016/j.jcct.2019.06.013DOI Listing
February 2021

Coronary atherosclerosis characteristics in HIV-infected patients on long-term antiretroviral therapy: insights from coronary computed tomography-angiography.

AIDS 2019 10;33(12):1853-1862

Department of Radiology, Innsbruck Medical University, Innsbruck, Austria.

Objective: The aim of the study was to assess coronary artery disease (CAD) characteristics by coronary computed tomography-angiography (CCTA) in individuals with HIV infection on long-term antiretroviral therapy (ART) DESIGN:: Retrospective case-controlled matched cohort study.

Methods: Sixty-nine HIV-positive patients who underwent 128-slice dual source CCTA (mean age 54.9 years, 26.1% women) with mean 17.8 ± 9.4 years of HIV infection and a mean duration on ART of 13 ± 7.3 years were propensity score-matched (1 : 1) for age, sex, BMI, and five cardiovascular risk factors with 69 controls. CCTA was evaluated for stenosis severity [according to Coronary Artery Disease - Reporting and Data System (CAD-RADS)], total plaque burden [segment involvement score (SIS) and mixed-noncalcified plaque burden (G-score)]. As inflammatory biomarkers, high-risk plaque (HRP) features (napkin-ring sign, low-attenuation plaque, spotty calcification, positive remodeling), perivascular fat attenuation index (FAI), and ectatic coronary arteries were assessed.

Results: CAD-RADS was higher in HIV-positive participants as compared with controls (2.21 ± 1.4 vs. 1.69 ± 1.5, P = 0.031). A higher prevalence of CAD and G-score (P = 0.043 and P = 0.003) was found. HRP prevalence [23 (34.3%) vs. 8 (12.1%); P = 0.002] and the number of HRP (36 vs. 10, P < 0.001) were higher in HIV-positive individuals. A perivascular FAI greater than -70 Hounsfield units was present in 27.8% of HRP. Ectatic coronary arteries were found in 10 (14.5%) HIV-positive persons vs. 0% in controls (P = 0.003).

Conclusion: Noncalcified and HRP burden in HIV-infected individuals on long-term ART is higher and associated with higher cardiovascular risk. Moreover, HIV-positive individuals displayed a higher stenosis severity (CAD-RADS) and more ectatic coronary arteries compared with the control group.
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http://dx.doi.org/10.1097/QAD.0000000000002297DOI Listing
October 2019

The magic transformation of high-risk plaque to a calcified after 5 years: monitoring by computed tomography angiography: is inflammation the holy grail?

Eur Heart J Cardiovasc Imaging 2019 Nov;20(11):1315

Department of Radiology, Innsbruck Medical University, Anichstr. 35, A Innsbruck, Austria.

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http://dx.doi.org/10.1093/ehjci/jez130DOI Listing
November 2019

Intracavitary right coronary artery - Or just a wrap? A cardiac CT imaging series.

J Cardiovasc Comput Tomogr 2020 Jul - Aug;14(4):370-373. Epub 2019 Apr 24.

Dept. Radiology, Innsbruck Medical University, Austria. Electronic address:

Intracavitary right coronary artery (RCA) is a very rare anomaly occurring in less than 0.1% and up to 0.4% reported by coronary computed tomography angiography (CTA). Literature is scarce, however its recognition is crucial, especially prior to surgical or interventional procedures such as coronary artery bypass graft (CABG) surgery, right heart catheterization or device implantation: Hereby the RCA is at risk of injury with fatal bleeding, or suturing a CABG anastomosis may be difficult or impossible.
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http://dx.doi.org/10.1016/j.jcct.2019.04.001DOI Listing
September 2020

The challenge of imaging congenital heart disease in neonates: How to minimize radiation exposure with advanced CT technology.

J Cardiovasc Comput Tomogr 2019 May - Jun;13(3):i-ii. Epub 2019 Mar 28.

Medical University Innsbruck, Department of Radiology, Innsbruck, Austria. Electronic address:

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http://dx.doi.org/10.1016/j.jcct.2019.03.009DOI Listing
October 2019

Non obstructive high-risk plaque but not calcified by coronary CTA, and the G-score predict ischemia.

J Cardiovasc Comput Tomogr 2019 Nov - Dec;13(6):305-314. Epub 2019 Jan 4.

Dept. Internal Medicine III, Cardiology, Innsbruck Medical University, Austria.

Background: The association of plaque morphology with ischemia in non-obstructive lesions has not been fully eludicated: Calcium density and high-risk plaque features have not been explored.

Objectives: to assess whether high-risk plaque or calcified, and global mixed including non-calcified plaque burden (G-score) by coronary CTA predict ischemia in non-obstructive lesions using non-invasive fractional flow reserve (FFR).

Methods: In 106 patients with low-to-intermediate pre-test probability referred to coronary 128-slice dual source CTA, lesion-based and distal FFR were computated. The 4 high-risk-plaque criteria: Low-attenuation-plaque, Napkin Ring Sign, positive remodelling and spotty calcification were recorded. Plaque density (HU) and stenosis (MLA,MLD,%area,%diameter stenosis) were quantified. Plaque composition was classified as type 1-4:1 = calcified, 2 = mixed (calcified > non-calcified), 3 = mixed (non-calcified > calcified), 4 = non-calcified, and expressed by the G-score: Z = Sum of type 1-4 per segment. The total plaque segment involvement score (SIS) and the Coronary Calcium Score (Agatston) were calculated.

Results: 89 non-obstructive lesions were included. Both lesion-based and distal FFR were lower in high-risk-plaque as compared to calcified (0.85 vs 0.93, p < 0.001 and 0.79 vs 0.86, p = 0.002). The prevalence of lesion-based ischemia (FFR<0.8) was higher in high-risk-plaque as compared to calcified (25% vs. 2.5%, p = 0.007). Similarly, the rate of distal ischemia (40% vs 17.5%) was higher, respectively. Lower plaque density (HU) indicating higher lipid plaque component (p = 0.024) predicted lesion based FFR in low attenuation plaque. For all lesions (n = 89) including calcified (p = 0.003), the correlation enhanced. Positive remodelling and an increasing non-calcified plaque burden (G-score) in relation to calcified were associated with lower FFR distal (p = 0.042), but not the SIS and calcium score.

Conclusion: High-risk-plaque but not calcified, an increasing lipid-necrotic-core component and non-calcified mixed plaque burden (G-score) predict ischemia in non-obstructive lesions (INOCA), while an increasing calcium compactness acts contrary.
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http://dx.doi.org/10.1016/j.jcct.2019.01.010DOI Listing
February 2020

Long-term clinical outcome and graft patency of radial artery and saphenous vein grafts in multiple arterial revascularization.

J Thorac Cardiovasc Surg 2019 08 14;158(2):442-450. Epub 2018 Nov 14.

Department of Medical Statistics, Informatics and Health Economics, Innsbruck Medical University, Innsbruck, Austria.

Objective: The long-term benefits of multiple arterial revascularization (MAR) in coronary artery bypass grafting remain uncertain. The aim of this study was to investigate the clinical outcome, graft patency, and need for subsequent target revascularization of radial artery (RA) versus saphenous vein graft in patients undergoing MAR in both patient- and graft-specific analyses.

Methods: Between 2001 and 2016, we followed 1654 patients over a median of 7.4 years in a prospective, longitudinal study. Major adverse cardiac and cerebrovascular events, graft patency, and need for revascularization were assessed through clinical manifestation, coronary angiography, or coronary computed tomography and analyzed with propensity score-adjusted Cox regression, general estimating equation, and competing risk models.

Results: Bilateral internal thoracic artery (BITA) grafting was performed in 910 patients (55.0%), and 744 patients (45.0%) received a left internal thoracic artery graft together with at least 1 RA graft. Patients receiving BITA, of whom 187 received an additional RA, showed improved survival (hazard ratio, 0.57; 95% confidence interval [CI], 0.38-0.86; P = .009), major adverse cardiac and cerebrovascular event-free survival (hazard ratio, 0.33; 95% CI, 0.23-0.46; P < .001), and lower need for repeat revascularization (subhzhard ratio, 0.59; 95% CI, 0.39-0.90; P = .015). In a subgroup of 512 patients, comparing 419 RA with 487 saphenous vein grafts, RA grafting showed a lower risk for graft occlusion (odds ratio, 0.59; 95% CI, 0.47-0.73; P < .001) and target revascularization (subhazard ratio, 0.58; 95% CI, 0.43-0.78; P < .001).

Conclusions: MAR with BITA and RA grafting revealed to be the recommended strategy in coronary artery bypass grafting to achieve long-term beneficial results. The use of saphenous vein graft showed less favorable outcomes regarding patency and the need for target-vessel revascularization.
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http://dx.doi.org/10.1016/j.jtcvs.2018.10.135DOI Listing
August 2019

Prognostic value of chronic total occlusions detected on coronary computed tomographic angiography.

Heart 2019 02 30;105(3):196-203. Epub 2018 Jul 30.

Dalio Institute of Cardiovacular Imaging, New York-Presbyterian Hospital and Weill Cornell Medicine, New York, USA.

Objective: Data describing clinical relevance of chronic total occlusion (CTO) identified by coronary CT angiography (CCTA) have not been reported to date. We investigated the prognosis of CTO on CCTA.

Methods: We identified 22 828 patients without prior known coronary artery disease (CAD), who were followed for a median of 26 months. Based on CCTA, coronary lesions were graded as normal (no atherosclerosis), non-obstructive (1%-49%), moderate-to-severe (50%-99%) or totally occluded (100%). All-cause mortality, and major adverse cardiac events defined as mortality, non-fatal myocardial infarction and late coronary revascularisation (≥90 days after CCTA) were assessed.

Results: The distribution of patients with normal coronaries, non-obstructive CAD, moderate-to-severe CAD and CTO was 10 034 (44%), 7965 (34.9%), 4598 (20.1%) and 231 (1%), respectively. The mortality rate per 1000 person-years of CTO patients was non-significantly different from patients with moderate-to-severe CAD (22.95; 95% CI 12.71 to 41.45 vs 14.46; 95% CI 12.34 to 16.94; p=0.163), and significantly higher than of those with normal coronaries and non-obstructive CAD (p<0.001 for both). Among 14 382 individuals with follow-up for the composite end point, patients with CTO had a higher rate of events than those with moderate-to-severe CAD (106.56; 95% CI 76.51 to 148.42 vs 65.45; 95% CI 58.01 to 73.84, p=0.009). This difference was primarily driven by an increase in late revascularisations in CTO patients (27 of 35 events). After multivariable adjustment, compared with individuals with normal coronaries, the presence of CTO conferred the highest risk for adverse cardiac events (14.54; 95% CI 9.11 to 23.20, p<0.001).

Conclusions: The detection of CTO on non-invasive CCTA is associated with increased rate of late revascularisation but similar 2-year mortality as compared with moderate-to-severe CAD.

Trial Registration Number: NCT01443637.
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http://dx.doi.org/10.1136/heartjnl-2017-312907DOI Listing
February 2019

Cardiovascular computed tomographic angiography: Entering into the 5th stage.

J Cardiovasc Comput Tomogr 2018 May - Jun;12(3):181-183. Epub 2018 May 5.

Uniformed Services University School of Medicine and the Walter Reed Medical Center, Bethesda, MD, United States.

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http://dx.doi.org/10.1016/j.jcct.2018.05.006DOI Listing
November 2018

Sonographic cross-sectional area measurement in carpal tunnel syndrome patients: can delta and ratio calculations predict severity compared to nerve conduction studies?

Eur Radiol 2015 Aug 10;25(8):2419-27. Epub 2015 Apr 10.

Department of Diagnostic Radiology, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.

Objective: To evaluate the accuracy of two different sonographic median nerve measurement calculations in predicting carpal tunnel syndrome (CTS) severity in a study population with clinically and electrophysiologically confirmed CTS.

Methods: 643 wrists of 427 patients (325 females and 102 males, age range: 17-90 years, mean ± SD: 57.9 ± 14.7) were included with CTS diagnosis based on clinical and nerve conduction studies (NCS). Cross-sectional area (CSA) measurement of the median nerve was performed at the carpal tunnel level (CSAc) and at the pronator quadratus muscle level (CSAp). Two parameters were calculated: delta (∆-CSA), which is the difference between proximal and distal measurements, and ratio (R-CSA), calculated by dividing distal over proximal measurements.

Results: Patients were classified into mild, moderate and severe CTS based upon NCS. The mean ∆-CSA (4.2 ± 2.6, 6.95 ± 2.2 and 10.7 ± 4.9 mm(2)) and mean R-CSA (1.5 ± 0.4, 1.95 ± 0.4 and 2.4 ± 0.7) values were significantly different between all groups (p < 0.001). Optimal cut-off values for ∆-CSA and R-CSA were 6 mm(2) and 1.7, respectively, to distinguish mild from moderate disease, and 9 mm(2) and 2.2, respectively, to distinguish moderate from severe disease.

Conclusion: Threshold values for the calculated sonographic parameters ∆-CSA and R-CSA are useful in predicting CTS severity compared to NCS.

Key Points: • Two proposed parameters were calculated (∆-CSA, R-CSA) and compared to NCS. • A defined sonoanatomical proximal landmark was used for the calculation. • Both parameters showed ability to detect CTS severity comparable to NCS. • Cut-off values could be determined for both parameters.
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http://dx.doi.org/10.1007/s00330-015-3649-8DOI Listing
August 2015

Sonoelastography: musculoskeletal applications.

Radiology 2014 Sep;272(3):622-33

From the Department of Diagnostic Radiology (A.S.K., G.M.F., M.C.W., W.R.J.) and Department of Internal Medicine I, Division of Clinical Immunology and Infectious Diseases (R.B.W.), Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria; and Department of Orthopaedic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (H.M.).

All participants for image samplings provided written informed consent. Conventional B-mode ultrasonography (US) has been widely utilized for musculoskeletal problems as a first-line approach because of the advantages of real-time access and the relatively low cost. The biomechanical properties of soft tissues reflect to some degree the pathophysiology of the musculoskeletal disorder. Sonoelastography is an in situ method that can be used to assess the mechanical properties of soft tissue qualitatively and quantitatively through US imaging techniques. Sonoelastography has demonstrated feasibility in the diagnosis of cancers of the breast and liver, and in some preliminary work, in several musculoskeletal disorders. The main types of sonoelastography are compression elastography, shear-wave elastography, and transient elastography. In this article, the current knowledge of sonoelastographic techniques and their use in musculoskeletal imaging will be reviewed.
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http://dx.doi.org/10.1148/radiol.14121765DOI Listing
September 2014

Sex-based prognostic implications of nonobstructive coronary artery disease: results from the international multicenter CONFIRM study.

Radiology 2014 Nov 15;273(2):393-400. Epub 2014 Jul 15.

From the Department of Radiology and Medicine, St Paul's Hospital, University of British Columbia, 1081 Burrard St, Vancouver, BC, Canada V6S 1Y6 (J.L.); Department of Radiology and Medicine, St Paul's Hospital, University of British Columbia, 1081 Burrard St, Vancouver, BC, Canada V6S 1Y6 (J.L., C.M.T., A.A., A.T., K.H.); Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, Calif (H.G., D.S.B.); Department of Medicine, Emory University School of Medicine, Atlanta, Ga (L.J.S.); Division of Cardiology, Technische Universität München, Munichs, Germany (J.H.); Department of Medicine, University of Erlangen, Erlangen, Germany (S.A.); Department of Medicine, King Abdulaziz Cardiac Center, Riyadh, Saudi Arabia (M.A.M.); Department of Medicine, Harbor UCLA Medical Center, Los Angeles, Calif (M.J.B.); Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier di Treviso, Italy (F.C.); Tennessee Heart and Vascular Institute, Hendersonville, Tenn (T.Q.C.); Division of Cardiology, Severance Cardiovascular Hospital, Seoul, South Korea (H.J.C.); Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ont, Canada (B.J.W.C.); Baptist Hospital of Miami and Baptist Cardiac and Vascular Institute, Miami, Fla (R.C.C.); Capital Cardiology Associates, Albany, NY (A.J.D.); Department of Public Health and Medicine, Weill Cornell Medical College and the New York Presbyterian Hospital, New York, NY (A.L.D., F.Y.L.); Department of Radiology II, Innsbruck Medical University, Innsbruck, Austria (G.M.F.); Department of Radiology and Nuclear Medicine, German Heart Center, Munich, Germany (M.H.); Department of Cardiac Imaging, University Hospital, Zurich, Switzerland (P.A.K.); Department of Radiology, William Beaumont Hospital, Royal Oak, Mich (K.M.C., G.L.R.); Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy (E.M.); Department of Medicine, Walter Reed Medical Center, Washington, DC (T.C.V.); and Weill Cornell Medical Coll

Purpose: To determine the clinical outcomes of women and men with nonobstructive coronary artery disease ( CAD coronary artery disease ) with coronary computed tomographic (CT) angiography data in patients who were similar in terms of CAD coronary artery disease risk factors, angina typicality, and CAD coronary artery disease extent and distribution.

Materials And Methods: Institutional review board approval was obtained for all participating sites, with either informed consent or waiver of informed consent. In a prospective international multicenter cohort study of 27 125 patients undergoing coronary CT angiography at 12 centers, 18 158 patients with no CAD coronary artery disease or nonobstructive (<50% stenosis) CAD coronary artery disease were examined. Men and women were propensity matched for age, CAD coronary artery disease risk factors, angina typicality, and CAD coronary artery disease extent and distribution, which resulted in a final cohort of 11 462 subjects. Nonobstructive CAD coronary artery disease presence and extent were related to incident major adverse cardiovascular events ( MACE major adverse cardiovascular events ), which were inclusive of death and myocardial infarction and were estimated by using multivariable Cox proportional hazards models.

Results: At a mean follow-up ± standard deviation of 2.3 years ± 1.1, MACE major adverse cardiovascular events occurred in 164 patients (0.6% annual event rate). After matching, women and men experienced identical annualized rates of myocardial infarction (0.2% vs 0.2%, P = .72), death (0.5% vs 0.5%, P = .98), and MACE major adverse cardiovascular events (0.6% vs 0.6%, P = .94). In multivariable analysis, nonobstructive CAD coronary artery disease was associated with similarly increased MACE major adverse cardiovascular events for both women (hazard ratio: 1.96 [95% confidence interval { CI confidence interval }: 1.17, 3.28], P = .01) and men (hazard ratio: 1.77 [95% CI confidence interval : 1.07, 2.93], P = .03).

Conclusion: When matched for age, CAD coronary artery disease risk factors, angina typicality, and nonobstructive CAD coronary artery disease extent, women and men experience comparable rates of incident mortality and myocardial infarction.
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http://dx.doi.org/10.1148/radiol.14140269DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334228PMC
November 2014

Prognostic significance of calcified plaque among symptomatic patients with nonobstructive coronary artery disease.

J Nucl Cardiol 2014 Jun 29;21(3):453-66. Epub 2014 Mar 29.

Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Room 529, Atlanta, GA, USA.

Background: Coronary artery calcium (CAC) is a well-established predictor of clinical outcomes for population screening. Limited evidence is available as to its predictive value in symptomatic patients without obstructive coronary artery disease (CAD). The aim of the current study was to assess the prognostic value of CAC scores among symptomatic patients with nonobstructive CAD.

Methods: From the COronary Computed Tomographic Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter (CONFIRM) registry, 7,200 symptomatic patients with nonobstructive CAD (<50% coronary stenosis) on coronary-computed tomographic angiography were prospectively enrolled and followed for a median of 2.1 years. Patients were categorized as without (0% stenosis) or with (>0% but <50% coronary stenosis) a luminal stenosis. CAC scores were calculated using the Agatston method. Univariable and multivariable Cox proportional hazard models were employed to estimate all-cause mortality and/or myocardial infarction (MI). Four-year death and death or MI rates were 1.9% and 3.3%.

Results: Of the 4,380 patients with no luminal stenosis, 86% had CAC scores of <10 while those with a luminal stenosis had more prevalent and extensive CAC with 31.9% having a CAC score of ≥100. Among patients with no luminal stenosis, CAC was not predictive of all-cause mortality (P = .44). However, among patients with a luminal stenosis, 4-year mortality rates ranged from 0.8% to 9.8% for CAC scores of 0 to ≥400 (P < .0001). The mortality hazard was 6.0 (P = .004) and 13.3 (P < .0001) for patients with a CAC score of 100-399 and ≥400. In patients with a luminal stenosis, CAC remained independently predictive in all-cause mortality (P < .0001) and death or MI (P < .0001) in multivariable models containing CAD risk factors and presenting symptoms.

Conclusions: CAC allows for the identification of those at an increased hazard for death or MI in symptomatic patients with nonobstructive disease. From the CONFIRM registry, the extent of CAC was an independent estimator of long-term prognosis among symptomatic patients with luminal stenosis and may further define risk and guide preventive strategies in patients with nonobstructive CAD.
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http://dx.doi.org/10.1007/s12350-014-9865-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4374635PMC
June 2014

Carpal tunnel syndrome: diagnosis by means of median nerve elasticity--improved diagnostic accuracy of US with sonoelastography.

Radiology 2014 Feb 6;270(2):481-6. Epub 2013 Nov 6.

From the Department of Diagnostic Radiology (H.M., M.K., G.M.F., W.R.J., A.S.K.), Department of Trauma Surgery and Sports Medicine (M.G., R.A.), and Department of Internal Medicine I, Clinical Immunology and Infectious Diseases (R.B.), Medical University Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria; Department of Orthopaedic Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (H.M.); and Department of Radiology, Thomas Jefferson University, Philadelphia, Pa (E.J.H.).

Purpose: To compare the elasticity of the median nerve (MN) between healthy volunteers and patients with carpal tunnel syndrome (CTS) and to evaluate the diagnostic utility of sonoelastographic measurements of the elasticity of the MN.

Materials And Methods: This study was performed with institutional review board approval and written informed consent from all participants. Hands in 22 healthy volunteers and in 31 patients with symptomatic CTS were studied. The cross-sectional area (CSA) and the elasticity of the MN, which was measured as the acoustic coupler (AC)/MN strain ratio, were evaluated.

Results: Both hands in 22 healthy volunteers (three men [mean age, 52.7 years; age range, 41-65 years]; 19 women [mean age, 62.2 years; age range, 40-88 years]) and 43 hands in 31 patients with symptomatic CTS (three men [mean age, 69.0 years; age range, 46-88 years]; 28 women [mean age, 61.2 years; age range, 39-92 years]) were studied. Both the AC/MN strain ratio and the CSA in the patients with CTS were significantly higher than those in the healthy volunteers (P < .001). The presence of CTS was predicted by means of AC/MN strain ratio and CSA cutoff values, respectively, of 4.3 and 11 mm(2), with areas under the receiver operating characteristic curves (AUCs) of 0.78 (95% confidence interval [CI]: 0.69, 0.88) and 0.85 (95% CI: 0.78, 0.93). A logistic model that combined the AC/MN strain ratio and the CSA improved diagnostic accuracy for CTS, with an AUC of 0.91 (95% CI: 0.85, 0.97; P < .001).

Conclusion: Sonoelastography provides significant improvement in the diagnostic accuracy of the ultrasonographic assessment of CTS.
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http://dx.doi.org/10.1148/radiol.13122901DOI Listing
February 2014

Greater trochanteric pain syndrome.

Semin Musculoskelet Radiol 2013 Feb 13;17(1):43-8. Epub 2013 Mar 13.

Department of Diagnostic Radiology, Innsbruck Medical University, Innsbruck, Austria.

Pain around the greater trochanter is still a common clinical problem that may be secondary to a variety of either intra-articular or periarticular pathologies. Gluteal tendon pathologies are one of the primary causes of greater trochanteric pain, with attrition of the fasciae latae against the gluteus medius and minimus tendons, and the trochanteric bursa being possible causes. Key sonographic findings of gluteal tendinopathy, bursitis, and differential diagnosis are described in this overview. Clinical diagnosis and treatment of greater trochanteric pain syndrome is still challenging; therefore ultrasound is helpful to localize the origin of pain, determine underlying pathology, and, based on these findings, to guide local aspiration and/or injection in cases of tendinopathy and/or bursitis.
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http://dx.doi.org/10.1055/s-0033-1333913DOI Listing
February 2013

Achilles tendon assessed with sonoelastography: histologic agreement.

Radiology 2013 Jun 28;267(3):837-42. Epub 2013 Feb 28.

Department of Diagnostic Radiology, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.

Purpose: To compare and determine the level of agreement of findings at conventional B-mode ultrasonography (US) and sonoelastography of the Achilles tendon with findings at histologic assessment.

Materials And Methods: This study was conducted with the approval of the institutional review boards, and all cadavers were in legal custody of the study institution. Thirteen Achilles tendons in 10 cadavers (four male, six female; age range, 70-90 years) were examined with B-mode US and sonoelastography. B-mode US grading was as follows: Grade 1 indicated a normal-appearing tendon with homogeneous fibrillar echotexture; grade 2, a focal fusiform or diffuse enlarged tendon; and grade 3, a hypoechoic area with or without tendon enlargement. Sonoelastography grading was as follows: Grade 1 indicated blue (hardest) to green (hard); grade 2, yellow (soft); and grade 3, red (softest). Twenty-five biopsy specimens from representative lesions of the middle and distal thirds of the Achilles tendons were evaluated histologically. The concordance of B-mode US grading compared with sonoelastographic grading was assessed by using κ analysis.

Results: With B-mode US and sonoelastography, all 11 tendon thirds of histologically normal tendons were verified as normal (grade 1). Sonoelastography depicted 14 of 14 (100%) tendon thirds with histologic degeneration (grade 2 or 3), whereas B-mode US could depict only 12 of 14 (86%) lesions (grade 2 or 3). Only moderate agreement between B-mode US and sonoelastography was seen (κ = 0.52, P < .001).

Conclusion: Sonoelastography might help predict signs of histopathologic degeneration of Achilles tendinosis, potentially more sensitively than B-mode US.
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http://dx.doi.org/10.1148/radiol.13121936DOI Listing
June 2013

Triage of patients presenting with chest pain to the emergency department: implementation of coronary CT angiography in a large urban health care system.

AJR Am J Roentgenol 2013 Jan;200(1):57-65

Baptist Health of South Florida and Baptist Cardiac and Vascular Institute, 8900 N Kendall Dr, Miami, FL 33176, USA.

Objective: There is growing evidence supporting the use of coronary CT angiography (CTA) to triage patients in the emergency department (ED) with acute chest pain and low risk of acute coronary syndrome (ACS). We hypothesized that coronary CTA can guide early management and safely discharge patients by introducing a dedicated patient management protocol.

Subjects And Methods: We conducted a prospective cohort study in three EDs of a large health care system (> 1300 beds). Five hundred twenty-nine patients (mean age, 52.1 years; 56% women) with chest pain, negative cardiac enzyme results, normal or nondiagnostic ECG findings, and a thrombolysis in myocardial infarction (TIMI) risk score of 2 or less were admitted and underwent CTA. A new dedicated chest pain triage protocol (levels 1-5) was implemented. On the basis of CTA findings, patients were stratified into one of the following four groups: 0, low (negative CTA findings); 1, mild (1-49% stenosis); 2, moderate (50-69% stenosis); or 3, severe (≥ 70% stenosis) risk of ACS. Outcome measures included major adverse cardiac events (MACEs) during the first 30 days after CTA, downstream testing results, and length of stay (LOS). LOS was compared before and after implementation of our chest pain triage protocol.

Results: Three hundred seventeen patients (59.9%) with negative CTA findings and 151 (28.5%) with mild stenosis were discharged from the ED with a very low downstream testing rate and a very low MACE rate (negative predictive value = 99.8%). Twenty-five patients (4.7%) had moderate stenosis (n = 17 undergoing further testing). Thirty-six patients (6.8%) had stenosis of 70% or greater by CTA (n = 34 positive by invasive angiography or SPECT-myocardial perfusion imaging). The sensitivity of CTA was 94%. The rate of MACEs in patients with stenosis of 70% or greater (8.3%) was significantly higher (p < 0.001) than in patients with negative CTA findings (0%) or those with mild stenosis (0.2%). A 51% decrease in LOS-from 28.8 to 14.0 hours--was noted after implementation of the dedicated chest pain protocol (p < 0.001).

Conclusion: Chest pain patients with negative or mild nonobstructive CTA findings can be safely discharged from the ED without further testing. Implementation of a dedicated chest pain triage protocol is critical for the success of a coronary CTA program.
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http://dx.doi.org/10.2214/AJR.12.8808DOI Listing
January 2013

Coronary computed tomographic angiography as a gatekeeper to invasive diagnostic and surgical procedures: results from the multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: an International Multicenter) registry.

J Am Coll Cardiol 2012 Nov 17;60(20):2103-14. Epub 2012 Oct 17.

Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.

Objectives: This study sought to examine patterns of follow-up invasive coronary angiography (ICA) and revascularization (REV) after coronary computed tomography angiography (CCTA).

Background: CCTA is a noninvasive test that permits direct visualization of the extent and severity of coronary artery disease (CAD). Post-CCTA patterns of follow-up ICA and REV are incompletely defined.

Methods: We examined 15,207 intermediate likelihood patients from 8 sites in 6 countries; these patients were without known CAD, underwent CCTA, and were followed up for 2.3 ± 1.2 years for all-cause mortality. Coronary artery stenosis was judged as obstructive when ≥50% stenosis was present. A multivariable logistic regression was used to estimate ICA use. A Cox proportional hazards model was used to estimate all-cause mortality.

Results: During follow-up, ICA rates for patients with no CAD to mild CAD according to CCTA were low (2.5% and 8.3%), with similarly low rates of REV (0.3% and 2.5%). Most ICA procedures (79%) occurred ≤3 months of CCTA. Obstructive CAD was associated with higher rates of ICA and REV for 1-vessel (44.3% and 28.0%), 2-vessel (53.3% and 43.6%), and 3-vessel (69.4% and 66.8%) CAD, respectively. For patients with <50% stenosis, early ICA rates were elevated; over the entirety of follow-up, predictors of ICA were mild left main, mild proximal CAD, respectively, or higher coronary calcium scores. In patients with <50% stenosis, the relative hazard for death was 2.2 (p = 0.011) for ICA versus no ICA. Conversely, for patients with CAD, the relative hazard for death was 0.61 for ICA versus no ICA (p = 0.047).

Conclusions: These findings support the concept that CCTA may be used effectively as a gatekeeper to ICA.
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http://dx.doi.org/10.1016/j.jacc.2012.05.062DOI Listing
November 2012

Comparison of image quality and radiation dose of different pulmonary CTA protocols on a 128-slice CT: high-pitch dual source CT, dual energy CT and conventional spiral CT.

Eur Radiol 2012 Feb 28;22(2):279-86. Epub 2011 Aug 28.

Department of Radiology, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria.

Objectives: To compare image quality and radiation dose of high-pitch dual-source computed tomography (DSCT), dual energy CT (DECT) and conventional single-source spiral CT (SCT) for pulmonary CT angiography (CTA) on a 128-slice CT system.

Methods: Pulmonary CTA was performed with five protocols: high-pitch DSCT (100 kV), high-pitch DSCT (120 kV), DECT (100/140 kV), SCT (100 kV), and SCT (120 kV). For each protocol, 30 sex, age, and body-mass-index (mean 25.3 kg/m(2)) matched patients were identified. Retrospectively, two observers subjectively assessed image quality, measured CT attenuation (HU±SD) at seven central and peripheral levels, and calculated signal-to-noise-ratio (SNR) and contrast-to-noise-ratio (CNR). Radiation exposure parameters (CTDIvol and DLP) were compared.

Results: Subjective image quality was rated good to excellent in >92% (>138/150) with an interobserver agreement of 91.4%. The five protocols did not significantly differ in image quality, neither by subjective, nor by objective measures (SNR, CNR). By contrast, radiation exposure differed between protocols: significant lower radiation was achieved by using high-pitch DSCT at 100 kV (p < 0.01 in all). Radiation exposure of DECT was in between SCT at 100 kV and 120 kV.

Conclusions: SCT, high-pitch DSCT, and DECT protocols techniques result in similar subjective and objective image quality, but radiation exposure was significantly lower with high-pitch DSCT at 100 kV.

Key Points: New CT protocols show promising results in pulmonary embolism assessment. High-pitch dual-source CT (DSCT) at 100 kV provides radiation dose savings for pulmonary CTA. High-pitch DSCT at 100 kV maintains diagnostic image quality for pulmonary CTA. Dual energy CT uses more radiation but also provides lung perfusion evaluation. Whether the additional perfusion data is worth the extra radiation remains undetermined.
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http://dx.doi.org/10.1007/s00330-011-2251-yDOI Listing
February 2012