Combination Application Of Echocardiography, Dual-source Computed Tomography And 3.0T Contrast Enhanced Whole-heart Coronary Magnetic Resonance Angiography To Detect Coronary Stenosis, Myocardial Infarction Transmurality And Anomalous Coronary Arteries

OBJECTIVE Dual-source computed tomography(DSCT),3.0T contrast enhanced whole-heart coronary magnetic resonance angiography(whole-heart CE-CMRA)and transthoracic doppler echocardiography ( TTE) are emerging non-invasive modalities to detect coronary stenosis.Yet,to our knowledge,there has been no prospective ,simultaneous comparison of these three imaging approaches for detecting significant coronary stenosis..Therefore , we conducted a study to determine the diagnostic accuracy of DSCT,3.0T whole-heart CE-CMRA and TTE for the detection significant coronary stenosis.METHODS A prospective,simultaneous and blind study was performed in 51 consecutive patients with suspected or known coronary artery diseases who underwent DSCT,3.0T whole-heart CE-CMRA and TTE within one day before invasive coronary angiography. The diagnostic accuracy of the 3 modalities for detecting significant coronary stenosis (≥50% luminal diameter stenosis) was compared blindly with quantitative invasive coronary angiography as the reference standard.RESULTS 1. DSCT had similar interpretable segments (486/512,96.0%) as 3.0T whole-heart CE-CMRA(479/512,93.6%),higher than TTE did(398/512,77.7%) 2.According to the quantitative coronary angiography,on a per-vessel basis,DSCT and 3.0T whole-heart CE-CMRA had similar sensitivity (94% vs. 88%, p>0.05), specificity (90% vs. 88%, p>0.05), PPV (82%, vs. 78%, p>0.05) and NPV (97%, vs. 95%, p>0.05) for detection of≥50% coronary stenosis, although 3.0T whole-heart CE-CMRA showed a slight trend of inferiority. TTE had significantly lower sensitivity(65%, p<0.05) ,specificity ( 72% ,p<0.05) ,PPV(52%,p<0.05) and NPV(81%,p<0.05) for the detection of≥50% coronary stenosis as compared with DSCT and 3.0T whole-heart CE-CMRA. 3. On a per-segment basis, DSCT and 3.0T whole-heart CE-CMRA had similar sensitivity (95% vs. 89%, p>0.05), specificity (90% vs. 90%, p>0.05), PPV (86%, vs. 85%, p>0.05) and NPV (97%, vs. 93%, p>0.05) for detection of≥50% LM +LAD stenosis, DSCT and 3.0T whole-heart CE-CMRA had similar sensitivity (95% vs. 85%, p>0.05),specificity (95% vs. 92%, p>0.05), PPV (90%, vs. 79%, p>0.05) and NPV (97%, vs. 95%, p>0.05) for detection of≥50% Cx stenosis . DSCT and 3.0T whole-heart CE-CMRA had similar sensitivity (94% vs. 88%, p>0.05),specificity (85% vs. 82%, p>0.05), PPV (70%, vs. 71%, p>0.05) and NPV (97%, vs. 93%, p>0.05) for detection of≥50% RCA stenosis. As compared with DSCT and 3.0T whole-heart CE-CMRA,TTE had significantly lower sensitivity(79%, p<0.05) ,specificity(78% ,p<0.05) , PPV(68%,p<0.05) and NPV(86%,p<0.05) for the detection of≥50% LM +LAD stenosis; significantly lower sensitivity(46%, p<0.05) ,specificity ( 68% ,p<0.05) , PPV(33%,p<0.05) and NPV(79%,p<0.05) for the detection of≥50% Cx stenosis; and significantly lower sensitivity(65%, p<0.05) ,specificity ( 69% ,p<0.05) ,PPV (52%,p<0.05) and NPV(79%,p<0.05) for the detection of≥50% RCA stenosis. TTE had higher sensitivity(79%)for the detection of≥50% LM +LAD stenosis than that of RCA(65%)and Cx(46%) . 4. By echocardiography,stenotic max diastolic velocity (MDV) for LAD was 3.6±1.9M/S,prestenotic to stenotic MDV ratio was 3.3±1.2;MDV for Cx was 3.0±0.5M/S,prestenotic to stenotic MDV ratio was 2.8±0.6;MDV for Cx was 2.8±0.6M/S,prestenotic to stenotic MDV ratio was 2.7±0.3. There were no significant differences in the MDV, and no significant differences in the prestenotic to stenotic MDV among LAD,Cx and RCA .CONCLUSIONS Visual assessment of coronary diameter stenosis severity by DSCT or 3.0T whole-heart CE-CMRA allows identification of significant(≥50%)coronary stenosis with a similar high diagnostic accuracy.Although DSCT showed slightly superior to 3.0T whole-heart CE-CMRA ,there was no significant difference. Because of the lower success rate and less number of interpretable segments, TTE performed worse than DSCT or 3.0T whole-heart. 3.0T whole-heart CE-CMRA permits reliable noninvasive detection of significant coronary stenosis without the use of radiation and potentially hazard iodine contrast agent. TTE can evaluate resting coronary flow dynamics by detection of stenotic coronary artery velocity ,while it is portable and not expensive. TTE can be a helpful supplement to DSCT and 3.0T whole-heart CE-CMRA. OBJECTIVE To identify the transmural extent of myocardial infarction (TME) is critical for making decision of revascularization and evaluating prognosis. However,it is not clear whether 2D-speckle tracking imaging(2D-STI) should be preferred in chronic myocardial infarction to estimate infarct size. In addition, the application method and value of 2D-STI is unclear.The objective of the present study was to investigate the feasibility of 2D-STI to evaluate the transmural myocardial infarction .METHODS A randomized,simultaneous and blind study was performed in 43 consecutive chronic myocardial infarction patients who underwent 2D-STI,delayed-enhanced magnetic resonance imaging ( DE-MRI ) and biochemical examination. On the global level of left ventricle,global longitudinal strain(GLS),rotation and torsion were separately measured. On the segmental level of left ventricle,segmental longitudinal,circumferencial and radial strain, rotation angle as well as diastolic wall thickness were separately analyzed.Global infart size was calculated as infarct volume( a percentage of total myocardial volume )and infart masses, Segmental transmurality was calculated in a 18-segment LV model as infarct volume divided by myocardial volume per segment. Segments with≥50% contrast enhancement were judged transmurally infracted, <50% contrast enhancement were judged non-transmurally infracted. Segments were divided into transmural myocardial infarction(TMI)group and non-transmural myocardial infarction(NTMI) group.Biochemical indices were detected meanwhile including high sensitive c-reactive protein,NT Pro BNP and homocysteine.RESULTS①On the global level, GLS significantly correlated with infarct volume (P=0.008),while the correlation coefficient was 0.620. GLS and maximal apical rotation rate were significant predictors of infarct volume (P=0.005,0.014), while the Beta was 0.720 and 0.592 respectively; GLS was significant predictors of infarct masses (P=0.024), while the Beta was 0.545.The biochemical indices mentioned above were not significant predictors for infarct volume and masses;②On the segmental level,compared with non-transmural infarct group,diastolic wall thickness ,SR(ES), SC(ES), SR Peak G, SL(ES), SC Peak, SL Peak G, SL Peak and SC Peak G (ranked in descending order according to the area under ROC curve, the same below) decreased significantly in apical anterior segments(P<0.05);SC(ES),SC Peak G,SC Peak and SL(ES) decreased significantly in apical lateral segments(P<0.05);SL Peak ,SL Peak G, SC Peak ,SL(ES),SC(ES) and SR(ES) decreased significantly in apical anteroseptal segments(P<0.05);SR Peak G,SR(ES)及SL(ES) decreased significantly in apical posterior segments(P<0.01);SC Peak G,SC Peak及SC(ES) decreased significantly in apical inferior segments(P<0.01);diastolic wall thickness decreased significantly in apical septal segments(P=0.007) ;there was no significant different in rotation angle between two groups.③ROC analysis showed diastolic wall thickness had the best ability to identify transmural infarction both in apical anterior and septal segments,using a cut-off of 5.5MM,diastolic wall thickness had a sensitivity of 83.3% and specificity of 85.7% for apical anterior segments;while a sensitivity of 100% and specificity of 61.5% for apical septal segments. SC(ES)had the best ability to identify transmural infarction in apical lateral segments,using a cut-off of -5.4650,SC(ES)had a sensitivity of 83.3% and specificity of 85.7%. SR Peak G had the best ability to identify transmural infarction in apical posterior segments,using a cut-off of 12.265,SR Peak G had a sensitivity of 100% and specificity of 80.0%,Both SC Peak G and SC Peak S had the best ability to identify transmural infarction in apical inferior segments,using a cut-off of -5.3200,SC Peak G and SC Peak S had a sensitivity of 100% and specificity of 88.8%.CONCLUSIONS①On the global level,GLS correlated significantly with global infarct size.Apical rotation rate is better than torsion angle and torsion rate in predicting infarct size.②On the segmental level , longitudinal strain ,circumferencial strain and radial strain discriminated between non-transmural and transmural infarction in different apical segment respectively.The discriminating ability was different for different strain indices,which may reflect the complexity of heterogeneity in myocardial fibers direction and transmural strain of different apical segments. OBJECTIVE Arterial switch operation (ASO) is the anatomical correction procedure of transposition of great arteries (d-TGA).Accurate preoperative identification of anomalous coronary artery anatomy pattern is critical for the success of ASO. We conducted the study to evaluate the diagnostic value on defining coronary artery anatomy by transthoracic echocardiography(TTE) and dual- source CT(DSCT),and to conclude how to improve the preoperative diagnostic accuracy of coronary artery anatomy by TTE.METHODS 164 patients underwent TTE before ASO. Diagnostic accuracy of TTE was evaluated using surgical diagnosis as a reference. 49 patients had TGA with intact ventricular septum (TGA/IVS),77 patients had TGA with ventricular septum defect(TGA/VSD),38 patients had double outlet right vetricle with TGA(DORV/TGA).Among 164 patients,there were 53 consecutive patients underwent both TTE and DSCT within 3 days before ASO. A blind study was performed using surgical diagnosis as a reference.RESULTS According to surgical diagnosis ,among 164 patents,there were 124 case(s75.61%) with normal coronary artery,and 40 case(s24.39%) with anomalous coronary arteries,The incidences of anomalous coronary artery were significantly higher in TGA/VSD combined with DORV/TGA than that in TGA/IVS ( 80.00%, 32 cases versus 20.00%,8 cases,P<0.05). There were 10 different anomalous coronary patterns found in this study.The incidence of the anatomical pattern with all coronary arteries originated from one coronary sinus was the highest(17 cases,42.5%).Among them, 1LCx1R ranked the first(25%), 2LCx2R ranked the second(17.5%).The incidence was significant different as compared with other anomalous patterns(P<0.05). According to surgical diagnosis, in the patient-based analysis, TTE diagnostic sensitivity, specificity, PPV, NPV in 164 patients were 90.0% , 95.2%, 85.7%及96.7% respectively. On a patient basis, DSCT and TTE had similar sensitivity ( 94.7% versus 94.7%, P>0.05) , specificity (94.1% versus 91.7%, P>0.05) , PPV ( 90.0% versus 85.7%, P>0.05) and NPV(96.7% versus 96.9% , P>0.05) for detection of coronary anatomical pattern in 53 cases.CONCLUSIONS 1. Coronary anatomical pattern in TGA could be accurately by TTE for most of cases. TTE and DSCT had similar diagnostic accuracy.TTE could be used as a preoperative diagnostive modality in stead of DSCT.There were 10 different types of anomalous coronary patterns found in this study ,which could benefit understanding the pathogenesis of anomalous coronary pattern in TGA...