Publications by authors named "Jeffrey M Levsky"

65 Publications

Echocardiography Abnormal Findings and Laboratory Operations during the COVID-19 Pandemic at a High Volume Center in New York City.

Healthcare (Basel) 2020 Dec 3;8(4). Epub 2020 Dec 3.

Department of Medicine, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.

(1) Background: This study sought to explore how the novel coronavirus (COVID-19) pandemic affected the echocardiography (TTE) laboratory operations at a high volume medical center in New York City. Changes in cardiac imaging study volume, turn-around time, and abnormal findings were analyzed and compared to a pre-pandemic period. (2) Methods: Volume of all cardiac imaging studies and TTE reports between 11 March 2020 to 5 May 2020 and the same calendar period in 2019 were retrospectively identified and compared. (3) Results: During the pandemic, our center experienced a 46.72% reduction in TTEs, 82.47% reduction in transesophageal echocardiograms, 83.16% reduction in stress echo, 70.32% reduction in nuclear tests, 46.25% reduction in calcium score, 73.91% reduction in coronary computed tomography angiography, and 87.23% reduction in cardiac magnetic resonance imaging. TTE findings were overall similar between 2020 and 2019 (all ≥ 0.05), except for a significantly higher right ventricular systolic pressure in 2020 (39.8 ± 14.2 vs. 34.6 ± 11.2 mmHg, = 0.012). (4) Conclusions: Despite encountering an influx of critically ill patients, our hospital center experienced a reduction in the number of cardiac imaging studies, which likely represents a change in both patient mindset and physician management approach.
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http://dx.doi.org/10.3390/healthcare8040534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7761727PMC
December 2020

Thoracic aortic dissection classification among radiologists and surgeons and management trends.

Emerg Radiol 2021 Apr 6;28(2):297-301. Epub 2020 Oct 6.

Department of Radiology, Montefiore Medical Center, Bronx, NY, USA.

Objective: To investigate the discrepancy rate in classification of newly diagnosed aortic dissection (AD) between radiologists and surgeons and explore patient management.

Methods: 3255 CTs performed for AD from June 2013 to June 2018 at our institution were retrospectively identified. CT reports and charts were reviewed to identify newly diagnosed AD or intramural hematoma (IMH). Radiology reports and electronic health records were reviewed for Stanford type A or B classification and surgical versus medical management.

Results: Newly diagnosed AD was diagnosed in 1.9% (62/3255) with one false positive, mean age 60 years. Discrepancy rate was 1.6% (1/61). Type A AD/IMH was treated surgically in 85% (23/27), medically in 15% (4/27). Type B AD/IMH was treated surgically in 56% (19/34) (endovascular 95% (18/19)), medically in 44% (15/34).

Conclusions: Discrepancy rate between radiologists and surgeons in Stanford classification of aortic dissection was low. Management of type B AD/IMH was predominantly endovascular, reflecting a shift in practice from the historical binary management strategy of type A dissections being treated surgically and type B dissections medically.
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http://dx.doi.org/10.1007/s10140-020-01861-7DOI Listing
April 2021

Diagnostic Performance of Pulmonary Embolism Imaging in Patients with History of Asthma.

J Nucl Med 2021 Mar 17;62(3):399-404. Epub 2020 Jul 17.

Albert Einstein College of Medicine, Bronx, New York.

Asthma and pulmonary embolism (PE) can present with overlapping symptoms, and distinguishing between these 2 conditions can be challenging. Asthma may limit imaging for PE because of either worsened ventilation defects on ventilation-perfusion scanning (VQ) or increased motion artifacts on CT pulmonary angiography (CTPA). We identified adults evaluated for PE with VQ or CTPA from 2012 to 2016. Patients with chronic lung disease (other than asthma) were excluded. Studies were classified as negative, positive, or nondiagnostic. Follow-up of negative cases was reviewed to determine the rate of repeat exams (within 1 wk) and the false-negative rate (defined as diagnosis of venous thromboembolism within 90 d). We reviewed 19,412 adults (aged 52 ± 18 y, 70% women) evaluated for PE (60% with VQ, 40% with CTPA); 23% had a history of asthma. Nondiagnostic results were comparable for those with and without asthma for both VQ (asthma, 3.3%; nonasthma, 3.8%; = 0.223) and CTPA (asthma, 1.6%; nonasthma, 1.5%; = 0.891). A history of asthma was not associated with a higher rate of repeat exams after negative imaging for VQ (asthma, 1.9%; nonasthma, 2.1%; = 0.547) or CTPA (asthma, 0.6%; nonasthma, 0.6%; = 0.796), nor was a history of asthma associated with a higher false-negative rate for VQ (asthma, 0.4%; nonasthma, 0.9%; = 0.015) or CTPA (asthma, 1.9%; nonasthma 1.5%; = 0.347). A history of asthma in the preceding 10 y was not associated with impaired diagnostic performance of PE imaging for either VQ or CTPA.
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http://dx.doi.org/10.2967/jnumed.120.242776DOI Listing
March 2021

Implementation of an aortic dissection CT protocol with clinical decision support aimed at decreasing radiation exposure by reducing routine abdominopelvic imaging.

Clin Imaging 2020 Nov 8;67:108-112. Epub 2020 Jun 8.

Department of Radiology, Montefiore Medical Center, Bronx, NY 10467, United States; Albert Einstein College of Medicine, Bronx, NY 10467, United States; Department of Medicine, Montefiore Medical Center, Bronx, NY 10467, United States.

Patients suspected of having an acute aortic syndrome in the ED typically undergo CT of the chest/abdomen/pelvis. However, the overwhelming majority of these exams are negative. With the help of clinical decision support, we implemented a new radiologist monitored 'aortic dissection screening protocol' that forgoes routine abdominopelvic imaging in order to reduce radiation dose without compromising diagnostic accuracy. The purpose of the present study is to assess the performance of this protocol. A retrospective analysis was performed to study the effect of the dissection screening protocol on the diagnostic yield, radiation and contrast dose on a total of 835 ED patients who underwent CT scans for suspected aortic dissection over a 48-week study period immediately before and after implementation of the protocol. 3.4% (28/835) of examinations were positive for an acute aortic syndrome over the 48-week study period with no difference in positivity before and after implementation of the 'aortic dissection screening' protocol, 3.0% vs. 3.7%, respectively (p = 0.57). There was a 14.6% reduction in median radiation dose and a 16% decrease in contrast volume utilization for the total ED population who underwent CT for aortic dissection using any protocol in the period after implementation of the 'aortic dissection screening' protocol. Aortic dissection CT in the ED is negative in the overwhelming majority of cases. A monitored 'aortic dissection screening' protocol that initially images the chest only significantly reduced contrast and radiation dose without reducing diagnostic accuracy for ED patients who underwent CT for aortic dissection.
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http://dx.doi.org/10.1016/j.clinimag.2020.06.005DOI Listing
November 2020

Having a Primary Care Provider is the Strongest Predictor of Successful Follow-up of Participants in a Clinical Trial.

J Am Board Fam Med 2020 May-Jun;33(3):431-439

From Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (SHF, LBH, JML); Department of Family and Social Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (COC); Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (COC, LBH, JML); Department of Epidemiology & Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (JL); Current Address: Department of Family Medicine, Overlook Medical Center, Summit, NJ (SHF).

Purpose: Ethnic minorities, women, and those of low socioeconomic status are widely underrepresented in clinical trials. Few studies have explored factors associated with successful follow-up in these historically difficult-to-reach patients. This study's objective was to identify patient characteristics and methods of contact that predict successful contact for follow-up in an urban, predominantly ethnic minority, majority-women, poor population to help devise strategies to improve retention.

Methods: We retrospectively reviewed records from a prospective randomized control trial of 400 hospitalized chest pain patients to determine which characteristics were associated with successful telephone follow-up at 1 year after enrollment. We assessed demographic variables, medical history, and social factors by using bivariate analyses. A multivariate analysis was performed using variables from the bivariate analysis with ≤ .2.

Results: The overall successful 1-year follow-up rate was 95% (381/400). Study participants who completed follow-up were significantly more likely to have a primary care physician (PCP) (88% [337/381] versus 68% [13/19]), speak English natively (52% [199/381] versus 26% [5/19]), have a higher Charlson comorbidity index score, and identify as women (64.0% [244/381] versus 42.1% [8/19]). Having a PCP and native English language remained significant at multivariate analysis. Socioeconomic status score, quantity of contact information recorded at recruitment, and insurance status were not significantly associated with successful follow-up.

Conclusions: Patients engaged with the health care system by having a PCP are significantly more likely to achieve follow-up. Successful follow-up is also associated with native English speaking. The potential of improving follow-up by facilitating connections with health care providers requires further study.
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http://dx.doi.org/10.3122/jabfm.2020.03.190018DOI Listing
January 2019

Meeting ACR Dose Guidelines for CT Lung Cancer Screening in an Overweight and Obese Population.

Acad Radiol 2021 03 10;28(3):381-386. Epub 2020 Apr 10.

Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210 Street, Bronx, New York 10467.

Rationale And Objectives: Lung cancer screening adoption coincides with a growing obesity epidemic. Maintaining high-quality imaging at low radiation dose is challenging in obesity. We investigate the feasibility of meeting American College of Radiology (ACR) dose guidelines for lung cancer screening in a predominantly overweight and obese population.

Materials And Methods: Radiation dose (Volumetric CT dose index [CTDIvol], dose-length product), and body mass index (BMI) were collected for baseline screening CTs December, 2012-December, 2017. Dose metrics were analyzed according to BMI classification (normal <25, overweight 25-29, obese ≥30 kg/m), using k = 0.014 mSv/mGy*cm. Results were compared to ACR dose guidelines and mean national 2017 Lung Cancer Screening Registry dose metrics. Analysis used Kruskal-Wallis (SPSS, version 24.0.0, IBM corp, Armonk, NY).

Results: Study population comprised 1478 patients (49.2% [727] women: mean BMI 28.1 ± 6.5 kg/m, 26.9% [397] normal weight, 35.9% [530] overweight, 37.2% [551] obese). ACR dose requirements were met for both genders in all BMI classifications. Dose metrics were higher in men than in women; median effective dose and CTDIvol were 1.39 (0.8-1.58) mSv and 2.78 (1.41-2.80) mGy in men versus 1.16 (0.71-1.43) mSv and 2.70 (1.4-2.78) mGy in women. There were significant differences in dose metrics between men and women in the same BMI classification and between BMI classifications (p < 0.001). Mean dose metrics in our program were considerably lower than 2017 national average- mean CTDIvol and effective dose 2.45 ± 1.14 mGy and 1.26 ± 0.59 mSv versus 3.24 mGy and 1.35 mSv, respectively for our program and nationally. Mean dose metrics were also lower in our obese patients versus obese patients nationally.

Conclusion: ACR dose metrics for lung cancer screening were met and can be appropriately tailored in a predominantly overweight and obese population clinical program.
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http://dx.doi.org/10.1016/j.acra.2020.02.009DOI Listing
March 2021

Clinical significance of incidental findings on coronary CT angiography: Insights from a randomized controlled trial.

J Nucl Cardiol 2020 12 20;27(6):2306-2315. Epub 2019 Feb 20.

Department of Radiology, Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA.

Background: The effect of incidental findings from coronary computed tomography angiography (CCTA) on management has not been rigorously investigated. This study uses a control group to explore this relationship.

Methods: Analysis of data from a randomized controlled trial of acute chest pain patients admitted to telemetry was performed. Patients were randomized to undergo either CCTA (n = 200) or radionuclide myocardial perfusion imaging (MPI) (n = 200). Incidental findings were determined from imaging reports. Records were reviewed to determine subsequent management and imaging during and after hospitalization. Comparisons were performed using Fischer's exact tests.

Results: 386 incidental findings were found among 187 CCTA studies. No extra-cardiac incidental findings were noted in the MPI arm, which served as an effective control group. There were significantly more non-coronary medical workups during admission in the CCTA group compared to the MPI group [20% (39) vs. 12% (23), P = 0.038]. CCTA patients underwent significantly more resting echocardiography during the inpatient workup compared to the MPI group [38% (75) vs. 18% (55), P = 0.042]. CCTA patients underwent significantly more non-contrast chest CT exams in the year following admission compared to MPI patients [14% (27) vs. 7% (13) P = 0.029].

Conclusions: Incidental findings on inpatient CCTAs performed for chest pain have a significant impact on treatment and imaging during and following hospital admission.
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http://dx.doi.org/10.1007/s12350-019-01647-6DOI Listing
December 2020

Effectiveness of Lung-RADS in Reducing False-Positive Results in a Diverse, Underserved, Urban Lung Cancer Screening Cohort.

J Am Coll Radiol 2019 Apr 23;16(4 Pt A):419-426. Epub 2018 Aug 23.

Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York; Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.

Purpose: The Lung CT Screening Reporting and Data System (Lung-RADS) was created to standardize lung cancer screening CT reporting and recommendations but has not been well validated prospectively in clinical practice. The aim of this study was to determine the effectiveness of lung cancer screening using Lung-RADS in a diverse, underserved, academic clinical screening program, focusing on whether Lung-RADS would successfully reduce the 23.3% false-positive rate found in the National Lung Screening Trial.

Methods: Institutional review board approval was obtained to study the clinical lung cancer screening cohort. Low-dose CT results were prospectively assigned a Lung-RADS or equivalent score. The proportion of examinations in each Lung-RADS category and the corresponding lung cancer rate, subsequent imaging, interventions, mortality, and compliance were tracked. The National Death Index was queried for follow-up losses.

Results: The cohort comprised 1,181 patients with 2,270 person-years of follow-up from December 2012 to December 2016. The mean age was 64 ± 16.2 years, with 51% women, 63% nonwhite, 71% current smokers, 69% overweight and obese, and multiple comorbidities. The Lung-RADS false-positive rate was 10.4% (95% confidence interval, 8.8%-12.3%). Baseline CT results were negative in 87% (n = 1,031): for Lung-RADS 1, the lung cancer rate was 0.2%, and for Lung-RADS 2, the cancer rate was 0.5%. Positive baseline examinations were Lung-RADS 3 in 10% (n = 119), 4a in 1.2% (n = 14), and 4b in 1.5% (n = 18). Corresponding cancer rates were 3.4%, 43%, and 83%, respectively. Lung cancer prevalence was 2.1%. Mortality was 40% in patients with lung cancer versus 2.5% in the remaining cohort (P < .001). Fifty-four percent of patients were overdue for first annual examinations. Eighty-four percent of patients (n = 989) had follow-up verified via electronic records or personal contact, and the remainder had vital status ascertained via the National Death Index.

Conclusions: Lung cancer screening using Lung-RADS was effective in reducing the false-positive rate compared with the National Lung Screening Trial in a diverse and underserved urban population.
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http://dx.doi.org/10.1016/j.jacr.2018.07.011DOI Listing
April 2019

Ventricular Myocardial Fat: An Unexpected Biomarker for Long-term Survival?

Eur Radiol 2019 Jan 14;29(1):241-250. Epub 2018 Jun 14.

Department of Radiology, Montefiore Medical Center, 111 East 210th St, Bronx, NY, 10467, USA.

Purpose: To examine the association between myocardial fat, a poorly understood finding frequently observed on non-contrast CT, and all-cause mortality in patients with and without a history of prior MI.

Materials And Methods: A retrospective cohort from a diverse urban academic center was derived from chronic myocardial infarction (MI) patients (n = 265) and three age-matched patients without MI (n = 690) who underwent non-contrast chest CT between 1 January 2005-31 December 2008. CT images were reviewed for left and right ventricular fat. Electronic records identified clinical variables. Kaplan-Meier and Cox proportional hazard analyses assessed the association between myocardial fat and all-cause mortality. The net reclassification improvement assessed the utility of adding myocardial fat to traditional risk prediction models.

Results: Mortality was 40.1% for the no MI and 71.7% for the MI groups (median follow-up, 6.8 years; mean age, 73.7 ± 10.6 years). In the no MI group, 25.7% had LV and 49.9% RV fat. In the MI group, 32.8% had LV and 42.3% RV fat. LV and RV fat was highly associated (OR 5.3, p < 0.001). Ventricular fat was not associated with cardiovascular risk factors. Myocardial fat was associated with a reduction in the adjusted hazard of death for both the no MI (25%, p = 0.04) and the MI group (31%, p = 0.018). Myocardial fat resulted in the correct reclassification of 22% for the no MI group versus the Charlson score or calcium score (p = 0.004) and 47% for the MI group versus the Charlson score (p = 0.0006).

Conclusions: Patients with myocardial fat have better survival, regardless of MI status, suggesting that myocardial fat is a beneficial biomarker and may improve risk stratification.

Key Points: • Myocardial fat is commonly found on chest CT, yet is poorly understood • Myocardial fat is associated with better survival in patients with and without prior MI and is not associated with traditional cardiovascular risk factors • This finding may provide clinically meaningful prognostic value in the risk stratification of patients.
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http://dx.doi.org/10.1007/s00330-018-5546-4DOI Listing
January 2019

Coronary Computed Tomography Angiography Versus Stress Echocardiography in Acute Chest Pain: A Randomized Controlled Trial.

JACC Cardiovasc Imaging 2018 09 13;11(9):1288-1297. Epub 2018 Jun 13.

Department of Radiology, Division of Cardiothoracic Imaging, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York; Department of Internal Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.

Objectives: This study sought to compare early emergency department (ED) use of coronary computed tomography angiography (CTA) and stress echocardiography (SE) head-to-head.

Background: Coronary CTA has been promoted as the early ED chest pain triage imaging method of choice, whereas SE is often overlooked in this setting and involves no ionizing radiation.

Methods: The authors randomized 400 consecutive low- to intermediate-risk ED acute chest pain patients without known coronary artery disease and a negative initial serum troponin level to immediate coronary CTA (n = 201) or SE (n = 199). The primary endpoint was hospitalization rate. Secondary endpoints were ED and hospital length of stay. Safety endpoints included cardiovascular events and radiation exposure.

Results: Mean patient age was 55 years, with 43% women and predominantly ethnic minorities (46% Hispanics, 32% African Americans). Thirty-nine coronary CTA patients (19%) and 22 SE patients (11%) were hospitalized at presentation (difference 8%; 95% confidence interval: 1% to 15%; p = 0.026). Median ED length of stay for discharged patients was 5.4 h (interquartile range [IQR]: 4.2 to 6.4 h) for coronary CTA and 4.7 h (IQR: 3.5 to 6.0 h) for SE (p < 0.001). Median hospital length of stay was 58 h (IQR: 50 to 102 h) for coronary CTA and 34 h (IQR: 31 to 54 h) for SE (p = 0.002). There were 11 and 7 major adverse cardiovascular events for coronary CTA and SE, respectively (p = 0.47), over a median 24 months of follow-up. Median/mean complete initial work-up radiation exposure was 6.5/7.7 mSv for coronary CTA and 0/0.96 mSv for SE (p < 0.001).

Conclusions: The use of SE resulted in the hospitalization of a smaller proportion of patients with a shorter length of stay than coronary CTA and was safe. SE should be considered an appropriate option for ED chest pain triage (Stress Echocardiography and Heart Computed Tomography [CT] Scan in Emergency Department Patients With Chest Pain; NCT01384448).
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http://dx.doi.org/10.1016/j.jcmg.2018.03.024DOI Listing
September 2018

Cardiothoracic MRI in the ICU: A 10-Year Experience.

Acad Radiol 2018 Mar 6;25(3):359-364. Epub 2018 Feb 6.

Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467.

Rationale And Objective: The objective of this study was to identify the feasibility and pitfalls of cardiothoracic magnetic resonance imaging (MRI) in intensive care unit (ICU) patients.

Materials And Methods: This retrospective study identified adult ICU patients scheduled for cardiothoracic MRIs during a 10-year study period. ICU patients scheduled for brain MRIs served as a comparison group. A chart review was performed to identify factors impacting a patient's ability to undergo an MRI. Differences between completed and canceled examinations for both cardiothoracic and brain MRIs were evaluated. For the cardiothoracic group, clinical indications and the diagnostic value of the study performed were also identified.

Results: A total of 143 cardiothoracic MRIs and 1011 brain MRIs were requested. Cardiothoracic MRI patients were less frequently completed (52% vs 62%), more frequently men (64% vs 43%), younger (55 vs 63 years), less likely mechanically ventilated (8% vs 29%), more likely to require intravenous contrast (83% vs 23%), and had longer examination times compared to brain MRI patients (64 vs 21 minutes). Successful completion of cardiothoracic MRI was associated with lower serum creatinine, higher glomerular filtration rate, and the absence of mechanical ventilation; significant differences were not seen with regard to gender and use of vasoactive agents. Cardiothoracic MRI results were diagnostic in 69% of examinations, most frequently when performed for myocardial disease (84%) and aortic disease (33%), and less frequently for viability (33%).

Conclusions: In an ICU population, successful completion of cardiothoracic MRI is challenging but feasible in patients with intact renal function and the absence of mechanical ventilation. Examinations were most frequently diagnostic for myocardial and aortic disease indications.
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http://dx.doi.org/10.1016/j.acra.2017.09.017DOI Listing
March 2018

Patent foramen ovale in patients with pulmonary embolism: A prognostic factor on CT pulmonary angiography?

J Cardiovasc Comput Tomogr 2018 Jul - Aug;12(4):271-274. Epub 2017 Dec 2.

Departments of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, 111 E 210th St, Bronx NY 10467, United States; Medicine - Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, 111 E 210th St, Bronx NY 10467, United States. Electronic address:

Background: Patent foramen ovale (PFO) in patients with acute pulmonary embolism (PE) represents a risk factor for mortality, but this has not been evaluated for CT pulmonary angiography (CTPA). The purpose of the present study was to assess the relationship between PFO and mortality in patients with acute PE diagnosed on CTPA.

Materials And Methods: This retrospective study included 268 adults [173 women, mean age 61 (range 22-98) years] diagnosed with acute PE on non-ECG-gated 64-slice CTPA in 2012 at our medical center. The images were reviewed for PFO by a panel of cardiothoracic radiologists with an average of 11 years of experience (range 1-25 years). CT signs of right heart strain and PE level were noted. Transthoracic echocardiograms (TTE), when available (n = 207), were reviewed for PFO by a cardiologist with subspecialty training in advanced imaging and with 3 years of experience. The main outcome was 30-day mortality. Fischer's exact test was utilized to compare mortality.

Results: PFO prevalence on CTPA was 22% (58/268) and 4% (9/207) on TTE. Overall 30-day mortality was 6% (16/268), 9% (5/58) for patients with PFO and 5% (11/210) for those without (p = 0.35). CT signs of right heart strain trended with higher mortality, but statistically significant only for hepatic vein contrast reflux [14% (6/44) vs 4% (10/224), p = 0.03]; right ventricular (RV) to left ventricular (LV) diameter ratio >1 [8% (13/156) vs RV:LV ≤ 1 3% (3/112), p = 0.07], septal bowing [10% (4/42) vs without 5% (12/226), p = 0.30].

Conclusion: PFO was demonstrated on CTPA in a proportion similar to the known population prevalence, while routine TTE was less sensitive. Mortality was non-significantly higher in patients with acute PE and PFO in this moderate-sized study. A larger study to answer this clinically important question is worthwhile.
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http://dx.doi.org/10.1016/j.jcct.2017.11.009DOI Listing
November 2018

Circumferential strain acquired by CMR early after acute myocardial infarction adds incremental predictive value to late gadolinium enhancement imaging to predict late myocardial remodeling and subsequent risk of sudden cardiac death.

J Interv Card Electrophysiol 2017 Dec 15;50(3):211-218. Epub 2017 Nov 15.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.

Purpose: Late adverse myocardial remodeling after acute myocardial infarction (AMI) is strongly associated with sudden cardiac death (SCD). Cardiac magnetic resonance (CMR) performed early after AMI can predict late remodeling and SCD risk with moderate accuracy. This study assessed the ability of CMR-measured circumferential strain (CS) to add incremental predictive information to late gadolinium enhancement (LGE).

Methods: Patients with an AMI and LVEF < 50% were screened for inclusion. A total of 27 patients, totaling 432 myocardial segments, prospectively underwent CMR 7 ± 5 days after percutaneous coronary intervention (PCI). LGE, microvascular obstruction (MVO), and myocardial CS were measured for each segment. The primary endpoint was late segmental adverse remodeling defined as segmental wall motion score (WMS) > 1 measured by echocardiography 3 months after PCI.

Results: A total of 141 segments experienced the primary endpoint at 3 months. The mean LGE volume was higher in these segments, but LGE was also present in many segments with normal WMS (40 ± 28 versus 20 ± 26%, p < 0.01). Segments that met the primary endpoint also showed greater impairment of CS. Segments with both LGE > 17% and impaired CS >- 7.2% on CMR were more likely to experience late adverse remodeling (73%) as compared to segments with neither (9%, p < 0.001) or one abnormal parameter (36%, p < 0.001). CS >- 7.2% also added incremental accuracy to LGE > 17% for predicting late adverse remodeling (AUC 0.81 from 0.70, p < 0.001).

Conclusions: When performed early after AMI, LGE is a moderate predictor of late remodeling and CS is a powerful predictor of late myocardial remodeling. When combined, they can predict late remodeling, a surrogate of SCD, with high accuracy.
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http://dx.doi.org/10.1007/s10840-017-0296-9DOI Listing
December 2017

Performance of a simple robust empiric timing protocol for CT pulmonary angiography.

Clin Imaging 2018 Mar - Apr;48:17-21. Epub 2017 Sep 14.

Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States. Electronic address:

Objective: We instituted a new, simple CT pulmonary angiography (CTPA) contrast material timing protocol using a standard empiric delay to replace our previous timing bolus method. This study tests the hypothesis that the empiric protocol more consistently produces diagnostic quality images of both the pulmonary arteries and the aorta with lower radiation exposure.

Materials And Methods: We performed a retrospective review of consecutive CTPAs for 2months both before and after the protocol change. Pulmonary artery and aortic enhancement, patient characteristics, radiation exposure and results of CTPA were analyzed.

Results: There were 182 patients in the timing bolus group and 164 in the empiric timing group. Both groups had a female majority (59%) and a similar mean age (58 and 57years, respectively). Enhancement was significantly higher both for the pulmonary artery (median 400HU versus 359HU, P<0.001) and aorta (median 381HU versus 218HU, P<0.01) in the empiric timing group versus the timing bolus group, respectively. Radiation exposure was lower (5.3mSv versus 6.0mSv, P=0.05) in the empiric timing group, despite a higher body-mass-index (31 versus 29kg/m, P<0.01). Pulmonary embolism positivity rate was non-significantly higher in the timing bolus vs the empiric timing group (19% and 13%, P=0.1).

Conclusion: A simple empiric timing protocol for CTPA has robust performance compared to a timing bolus protocol. Empiric timing preserves the required high diagnostic quality for evaluation of the pulmonary arteries with the added benefits of aortic enhancement and lower radiation exposure.
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http://dx.doi.org/10.1016/j.clinimag.2017.09.006DOI Listing
August 2018

Does ischemic burden on stress testing influence patient survival in subjects with known severe multi-vessel CAD?

Am J Cardiovasc Dis 2017 15;7(2):48-52. Epub 2017 Apr 15.

Montefiore Medical Center/Albert Einstein College of MedicineBronx, NY, USA.

Background: Ischemic burden observed during stress testing has been postulated to predict prognosis irrespective of anatomic atherosclerotic burden observed on angiography. However, it is not known if the stress test result influences the long-term prognosis of subjects with diffuse coronary artery disease. We sought to determine the prognostic importance of stress test false negativity amongst patients with severe multi-vessel coronary artery disease (CAD) undergoing stress testing in the previous decade.

Methods: We selected subjects from the dates of 1/1/2000 to 12/31/2005 who underwent a nuclear stress test (MPI) or stress echocardiogram (SE) within six months of a coronary angiogram demonstrating severe, multi-vessel CAD. We excluded those with a prior MI, PCI, CABG, resting wall motion abnormality, or perfusion defect at rest. Determination of patient death during the followup period was performed using the U.S. social security index.

Results: 139 subjects (MPI 81, SE 58) were studied; stress tests were positive for ischemia in 80%. Rates of death were similar at 1 year (MPI 9%, SE 5%, -value 0.44), 5 years (MPI 20%, SE 14%, -value 0.36) and 10 years (MPI 30%, SE 26%, -value 0.63). Using multivariate analysis, mortality at each time period was not affected by stress test positivity.

Conclusion: Amongst subjects with diffuse and severe atherosclerosis with preserved ventricular function, ischemic burden on stress testing did not influence short or long-term survival.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435604PMC
April 2017

Prospective study of a non-restrictive decision rule for acute aortic syndrome.

Am J Emerg Med 2017 Sep 6;35(9):1309-1313. Epub 2017 Apr 6.

Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States; Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY 10467, United States. Electronic address:

Objectives: To determine the impact of a non-restrictive clinical decision rule on CT utilization for Emergency Department patients suspected of having an acute aortic syndrome (AAS).

Methods: We prospectively assessed the performance of a previously described, collaboratively designed, non-restrictive clinical decision rule for AAS. Emergency Department patients with suspected AAS were stratified into low and high-risk groups based on decision rule results, from July 2013-August 2014. Patients with acute trauma, prior AAS or aortic surgery were excluded. CT dose reduction protocols were concurrently implemented as a quality improvement measure. Bivariate analysis was performed to compare the prospective cohort with the historical derivation cohort for CT utilization rates, results of CT, AAS incidence and radiation exposure. The performance of the clinical decision rule was evaluated.

Results: Compared with the historic cohort, the study cohort demonstrated a lower CT utilization rate [0.344% (427/124,093) versus 0.477% (1465/306,961), (p<0.001)], a trend toward higher CT diagnostic yield [4.4% (19/427) versus 2.7% (40/1465), (p=0.08)]. AAS incidence was similar [0.015% (19/124,093) versus 0.013% (40/306,961), (p=0.57)]. The mean effective radiation dose was markedly lower [12±5.5mSv versus 43±20mSv, (p<0.0001)]. The clinical decision rule correctly stratified only 56% (10/18) of patients with AAS as high-risk.

Conclusions: A non-restrictive, collaboratively designed, clinical decision rule for Emergency Department patients with suspected AAS performed poorly in risk-stratifying patients for AAS. However, its implementation was associated with a significant and safe decrease in CT utilization.
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http://dx.doi.org/10.1016/j.ajem.2017.04.014DOI Listing
September 2017

Cardiac CT: present and future applications.

Heart 2016 Nov 13;102(22):1840-1850. Epub 2016 Sep 13.

Division of Cardiology, Montefiore Medical Center-Albert Einstein College of Medicine, Bronx, New York, USA.

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http://dx.doi.org/10.1136/heartjnl-2015-307481DOI Listing
November 2016

Can Discrepancies Between Coronary Computed Tomography Angiography and Cardiac Catheterization in High-Risk Patients be Overcome With Consensus Reading?

J Comput Assist Tomogr 2017 Jan;41(1):159-164

From the Departments of *Radiology, †Medicine, and ‡Epidemiology and Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY.

Objective: To assess the incidence and cause of discrepancies between coronary computed tomography angiography (CTA) and catheterization in a high-risk, diverse, predominantly overweight inner-city population.

Methods: Ninety-two patients who underwent coronary CTA and catheterization on March 2007 to December 2012 were retrospectively identified. Clinical coronary CTA interpretation and reinterpretation by a review panel was compared with catheterization results.

Results: Severe stenosis was present on catheterization in 65% (60/92). Clinical coronary CTA was concordant with catheterization for severe stenosis in 78% (72/92), whereas panel interpretation was concordant in 77% (70/91). Sensitivity and specificity of clinical and panel coronary CTA interpretations were 92% (55/60) and 53% (17/32) versus 82% (48/59) and 68% (22/32), respectively.

Conclusions: Both coronary CTA interpretations were concordant with catheterization for severe stenosis in three quarters of patients. However, the diagnostic profile of the 2 interpretations differed, with higher sensitivity for the clinical report. This supports the clinical practice, which favored overestimation of difficult to quantify stenoses.
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http://dx.doi.org/10.1097/RCT.0000000000000481DOI Listing
January 2017

Illness Severity and Comorbidities Are Associated With Limitations in Computed Tomography Pulmonary Angiography.

J Thorac Imaging 2016 Sep;31(5):W60-1

Departments of *Radiology †Medicine, Albert Einstein College of Medicine, Montefiore Medical Center Bronx, NY.

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http://dx.doi.org/10.1097/RTI.0000000000000222DOI Listing
September 2016

Cardiothoracic CT and MRI in adults with tetralogy of Fallot: 11-year experience in a diverse, inner-city population.

Clin Imaging 2016 Sep-Oct;40(5):970-2. Epub 2016 May 3.

Department of Radiology, Albert Einstein College of Medicine Montefiore Medical Center, Bronx, NY; Department of Medicine, Albert Einstein College of Medicine Montefiore Medical Center, Bronx, NY. Electronic address:

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http://dx.doi.org/10.1016/j.clinimag.2016.04.018DOI Listing
May 2016

Surgical therapy for complications of pneumonia on extracorporeal membrane oxygenation can improve the ability to wean patients from support.

Heart Lung Vessel 2015 ;7(4):330-1

Children's Hospital at Montefiore, Montefiore Medical Center and The Albert Einstein College of Medicine, New York, New York, USA.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4712038PMC
January 2016

ACR White Paper-Based Comprehensive Dose Reduction Initiative Is Associated With a Reversal of the Upward Trend in Radiation Dose for Chest CT.

J Am Coll Radiol 2015 Dec 17;12(12 Pt A):1251-6. Epub 2015 Oct 17.

Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx New York.

Purpose: In 2010, the authors' department implemented a comprehensive dose reduction strategy based on the ACR white paper on radiation dose in medicine. The aim of this study was to evaluate the effectiveness of the dose reduction program.

Methods: In total, 1,234 adult chest CT scans from 2007 to 2012 were analyzed retrospectively, with institutional review board approval and a waiver of the requirement for informed consent. The primary outcome was effective dose in millisieverts during the three-year periods before (2007-2009) and after (2010-2012) dose reduction implementation. Dose trends were analyzed by fitted linear modeling. The use and effects on total exposure of dose reduction strategies (high pitch, adaptive statistical iterative reconstruction [ASIR], and low tube voltage) were analyzed.

Results: The overall mean dose for chest CT was 7.3 ± 5.1 mSv. The mean dose decreased by 30%, from 9.2 mSv (2007-2009) to 6.5 mSv (2010-2012) (P < .001). From 2007 to 2009, the mean dose increased by 1.2 mSv per year (P < .01). From 2010 to 2012, the mean dose decreased by 1.1 mSv per year (P < 0.01). High-pitch technique, ASIR, and low tube voltage increased significantly after dose reduction implementation. High pitch and ASIR were significantly associated with a reduced dose, whereas the effect of reduced voltage was not significant.

Conclusions: Reductions in radiation exposure from medical imaging rely on ongoing technical developments and consistent, vigilant use of dose reduction strategies. This comprehensive dose reduction strategy significantly reduced radiation exposure from chest CT. Annual increases in radiation dose reversed after the strategy was implemented and continued to decline over the study period.
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http://dx.doi.org/10.1016/j.jacr.2015.07.022DOI Listing
December 2015

Is dedicated chest CT needed in addition to PET/CT for evaluation of pediatric oncology patients?

Clin Imaging 2015 Sep-Oct;39(5):794-8. Epub 2015 May 22.

111 E210 Street, Bronx, NY, 10467. Electronic address:

Purpose: To assess the computed tomography (CT) portion of a positron emission tomography (PET)/CT, at lower dose without breath holding, as compared to diagnostic chest CT (dCTC), performed at regular dose with breath holding, and question the necessity of both for patient care in pediatric oncology.

Materials And Methods: This retrospective study included 46 pediatric patients with histologically proven malignant tumors that had a total of 119 scans.

Results: A total of 29 discrepancies were found between dCTC and PET/CT reports.

Conclusion: In the evaluation of metastatic thoracic disease in pediatric oncology patients, the non-breath holding CT portion of PET/CT has sensitivity and specificity that approaches dCTC.
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http://dx.doi.org/10.1016/j.clinimag.2015.05.005DOI Listing
April 2016

Acute left circumflex coronary artery occlusion detected on nongated CT.

Clin Imaging 2015 Sep-Oct;39(5):897-900. Epub 2015 May 27.

Department of Radiology, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467-2490.

We describe a patient with chest pain and a nondiagnostic electrocardiogram in whom computed tomographic (CT) aortography demonstrated myocardial hypoperfusion in the distribution of the circumflex artery as well as an abrupt cutoff of contrast in the left circumflex artery. Subsequent cardiac catheterization confirmed occlusion of the circumflex artery and led to revascularization. The diagnosis of acute myocardial infarction on CT can dramatically alter the clinical management of a patient, especially in cases in which other tests are equivocal.
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http://dx.doi.org/10.1016/j.clinimag.2015.05.007DOI Listing
May 2016

Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry: A Randomized Trial.

Ann Intern Med 2015 Aug;163(3):174-83

Background: The role of coronary computed tomography angiography (CCTA) in the management of symptomatic patients suspected of having coronary artery disease is expanding. However, prospective intermediate-term outcomes are lacking.

Objective: To compare CCTA with conventional noninvasive testing.

Design: Randomized, controlled comparative effectiveness trial. (ClinicalTrials.gov: NCT00705458).

Setting: Telemetry-monitored wards of an inner-city medical center.

Patients: 400 patients with acute chest pain (mean age, 57 years); 63% women; 54% Hispanic and 37% African-American; and low socioeconomic status.

Intervention: CCTA or radionuclide stress myocardial perfusion imaging (MPI).

Measurements: The primary outcome was cardiac catheterization not leading to revascularization within 1 year. Secondary outcomes included length of stay, resource utilization, and patient experience. Safety outcomes included death, major cardiovascular events, and radiation exposure.

Results: Thirty (15%) patients who had CCTA and 32 (16%) who had MPI underwent cardiac catheterization within 1 year. Fifteen (7.5%) and 20 (10%) of these patients, respectively, did not undergo revascularization (difference, -2.5 percentage points [95% CI, -8.6 to 3.5 percentage points]; hazard ratio, 0.77 [CI, 0.40 to 1.49]; P = 0.44). Median length of stay was 28.9 hours for the CCTA group and 30.4 hours for the MPI group (P = 0.057). Median follow-up was 40.4 months. For the CCTA and MPI groups, the incidence of death (0.5% versus 3%; P = 0.12), nonfatal cardiovascular events (4.5% versus 4.5%), rehospitalization (43% versus 49%), emergency department visit (63% versus 58%), and outpatient cardiology visit (23% versus 21%) did not differ. Long-term, all-cause radiation exposure was lower for the CCTA group (24 versus 29 mSv; P < 0.001). More patients in the CCTA group graded their experience favorably (P = 0.001) and would undergo the examination again (P = 0.003).

Limitation: This was a single-site study, and the primary outcome depended on clinical management decisions.

Conclusion: The CCTA and MPI groups did not significantly differ in outcomes or resource utilization over 40 months. Compared with MPI, CCTA was associated with less radiation exposure and with a more positive patient experience.

Primary Funding Source: American Heart Association.
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http://dx.doi.org/10.7326/M14-2948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4703121PMC
August 2015

A default normal chest CT structured reporting field for coronary calcifications does not cause excessive false-negative reporting.

J Am Coll Radiol 2015 Aug 16;12(8):783-7. Epub 2015 May 16.

Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. Electronic address:

Purpose: The aim of this study was to compare the accuracy of coronary atherosclerosis reporting before and after the implementation of a structured reporting chest CT template.

Methods: A noncardiac, noncontrast chest CT structured reporting template was developed and mandated for department-wide use at a large academic center. The template included the statement "There are no coronary artery calcifications." All noncardiac, noncontrast chest CT examinations reported over 3 days, 1 month after template implementation (structured template group), and from a 3-day period 1 year prior (control group) were retrospectively collected. Final radiology reports were reviewed and designated positive or negative for coronary calcifications. CT images were reviewed in consensus by 2 radiologists, who scored each case for the presence or absence of coronary calcifications, blinded to the original report. Statistical analysis was performed using Pearson χ(2) and Fisher exact tests.

Results: Sixty-five percent (69 of 106) of structured template group and 58% (62 of 106) of control group cases had coronary calcifications. Reports from the structured template group were more likely to correctly state the presence or absence of coronary atherosclerosis compared with those from the control group (96.2% vs 85.8%; odds ratio, 4.2; 95% confidence interval, 1.3-13.1; P = .008). Structured template group reports were less likely to be falsely negative compared with control group reports (3.8% vs 11.7%; odds ratio, 3.4; 95% confidence interval, 1.0-10.8; P = .03).

Conclusions: Implementing a structured reporting template improves reporting accuracy of coronary calcifications.
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http://dx.doi.org/10.1016/j.jacr.2015.03.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4529794PMC
August 2015

Non-invasive assessment of low risk acute chest pain in the emergency department: A comparative meta-analysis of prospective studies.

Int J Cardiol 2015 22;187:565-80. Epub 2015 Jan 22.

Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA. Electronic address:

Background: The aim of this meta-analysis was to compare the diagnostic accuracy of cardiac computed tomographic angiography (CCTA), stress echocardiography (SE) and radionuclide single photon emission computed tomography (SPECT) for the assessment of chest pain in emergency department (ED) setting.

Methods: A systematic review of Medline, Cochrane and Embase was undertaken for prospective clinical studies assessing the diagnostic efficacy of CCTA, SE or SPECT, as compared to intracoronary angiography (ICA) or the later presence of major adverse clinical outcomes (MACE), in patients presenting to the ED with chest pain. Standard approach and bivariate analysis were performed.

Results: Thirty-seven studies (15 CCTA, 9 SE, 13 SPECT) comprising a total of 7800 patients fulfilled inclusion criteria. The respective weighted mean sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and total diagnostic accuracy for CCTA were: 95%, 99%, 84%, 100% and 99%, for SE were: 84%, 94%, 73%, 96% and 96%, and for SPECT were: 85%, 86%, 57%, 95% and 88%. There was no significant difference between modalities in terms of NPV. Bivariate analysis revealed that CCTA had statistically greater sensitivity, specificity, PPV and overall diagnostic accuracy when compared to SE and SPECT.

Conclusions: All three modalities, when employed by an experienced clinician, are highly accurate. Each has its own strengths and limitations making each well suited for different patient groups. CCTA has higher accuracy than SE and SPECT, but it has many drawbacks, most importantly its lack of physiologic data.
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http://dx.doi.org/10.1016/j.ijcard.2015.01.032DOI Listing
May 2016

Computed tomographic pulmonary angiography: clinical implications of a limited negative result.

JAMA Intern Med 2015 Mar;175(3):447-9

Departments of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York2Department Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.

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http://dx.doi.org/10.1001/jamainternmed.2014.7202DOI Listing
March 2015