Universitatea de Medicina si Farmacia Targu MuresSpitalul Judetean de Urgenta

Clinica de Cardiologie Prof. Dr. Benedek Imre, FESC

INCREMENTAL VALUE OF PREPROCEDURAL COORNARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY COMPLEXITY IN LEFT MAIN STENOSIS

BALAN DANIEL | MG, IV.

Coordinator : Prof. Dr. Benedek Imre,

Prof.Dr. Benedek Theodora,

Dr. Kovács István,

Co-authors: Diana Elena Opincariu , Ioan Sorin Pop,

Carmen Oana Moldovan

Introduction Coronary angiography has become nowadays the gold standard

technique for diagnosis of coronary artery stenoses

A positive coronary angiography showing severe narrowing of the LM indicates an urgent need for revascularization

The SYNTAX trial (The Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) revealed the role of percutaneous revascularization in several subsets of patients

Syntax trial led to development of the Syntax score complex angiographic score based on characterization of coronary lesions according to specific angiographic parameters -tortuosity, bifurcation, the presence of a total occlusion or intracoronary thrombus, calcification, the dominance, type and number of lesions

Objectives

1) To prove the correlation between CCTA Syntax score and coronarography Syntax score in low-, medium- and high-risk patients.

2) Correlation between CCTA Calcium scoring and CCTA/coronarographyc Syntax score.

3)Recognise those CCTA and angiographyc derived markers which indicate the complexity of the percutan intervention in patients with left main stenosis.

Material and methods

Thirty-six patients with LM disease at the clinical presentation were enrolled in the study, and each subject underwent 64 multi-slice CT followed by coronary angiography and percutaneous revascularization.

Based on the coronary Syntax score we distinguish

3 groups: high risk patients

medium risk patients

low risk patients

Material and methods

Coronarography

Parameters: coronary dominance,

number and location of lesions, presence of a total occlusion in one coronary

artery,

bifurcation,

presence of calcification or thrombus

Coronary Computed Tomographic Angiography

Parameters: degree of calcification in the left main lesion ,

calcium score,

coronary stenosis severity,

length and diameter of the left main,

dominance,

plaque volume.

Characteristic Values(%)

Age ,years 62,9 +/- 9.5 95% CI 59.7 -69.2Gender, male 29(67.4)Left Ventricular Ejection Fraction 49.2 +/-7.2 95% CI 46.7 – 51.7Cardiovascular risk factors

Hypertension 21 (58.3)Hyperlipidemia 15 (41.6)Diabetes 12 (33.3)Smoker 13 (36.1)Obesity(BMS>25 km/m2) 11 (30.5)

CCTA analysisCalcium scoring 784.9+/-77.6

95% CI 627.1 – 942.7LM plaque burden 224.3 +/-45.0

95% CI 132.8 – 315.8

We found a good correlation between the calcium score determined by CCTA and the Syntax scores, either as determined by Coronary Angiography (r=0.72, p<0.0001)

Results

Benedek I.,World Jurnal of Cardiovascular Diseases, 2013

ResultsAngiographic| Syntax CCTA | Syntax p value

Global population 0,4

Mean+/- SD 29,1 +/- 13,9 31,6 +/- 12,6

95% conf. Int. 24,4 – 33,8 27,3 – 35,9

Low risk group 0,03

Mean+/- SD 13,0 +/- 4,8 18,9 +/- 7,6

95% conf. Int. 9,9 – 16,1 14,1 – 23,7

Medium risk group 0,4

Mean+/- SD 28,2 +/- 4,1 30,7 +/- 8,1

95% conf. Int. 25,1 – 31,4 24,6 – 37,0

High risk group 0,8

Mean+/- SD 42,4 +/- 5,9 43 +/- 8,2

95% conf. Int. 39,2 – 45,7 38,5 – 47,5Benedek I.,World Jurnal of Cardiovascular Diseases, 2013

Results In the low risk group the angiographic

coronarography seems to underestimate the severity of the lesion as compared to CCTA.

(Angio Syntax : 13,0 +/- 4,8 | CCTA Syntax 18.9 +/- 7.6)

p=0.03

angio Syntax CCTA Syntax0.00

5.00

10.00

15.00

20.00

13,00

18.90

ResultsNo statistically significant difference in the medium and high risk groups.

p=0.4 p=0.8

Angiográfia | Syn-tax

CCTA | Syntax26.5027.0027.5028.0028.5029.0029.5030.0030.5031.00

28.2

30.7

Angiográfia | Syn-tax

CCTA | Syntax42.00

42.20

42.40

42.60

42.80

43.00

43.20

42.4

43

ResultsNon komplex PCI Komplex PCI p value

LM plaque volume 0,002

Mean+/- SD 79,7 +/- 28,5 108,7 +/- 25,3

95% conf. Int. 63,9 – 95,5 97,2 – 120,2

Angio Syntax score 0,09

Mean+/- SD 24,5 +/- 11,5 32,3 +/- 14,6

95% conf. Int. 18,1 – 30,9 25,7 – 38,9

CCTA Syntax score 0,01

Mean+/- SD 25,2 +/- 11,3 35,3 +/- 11,5

95% conf. Int. 18,9 – 31,5 30,1 – 40,5

Ca scoring 0,04

Mean+/- SD 599,5 +/- 359,6 917,3 +/- 495,4

95% conf. Int. 400,4 – 798,7 691 – 1142,8

Benedek I.,World Jurnal of Cardiovascular Diseases, 2013

Results Identification of complexity predictors (PCI)

Benedek I.,World Jurnal of Cardiovascular Diseases, 2013

Results

Benedek I.,World Jurnal of Cardiovascular Diseases, 2013

Results

Benedek I.,World Jurnal of Cardiovascular Diseases, 2013

Results

Benedek I.,World Jurnal of Cardiovascular Diseases, 2013

Results

Important LM stenosis with high Ca level and big volume plaque

(A) – 3D CCTA

(B) – multiplanar reconstruction

(C) – coronarography before PCI ...

(D) – ... and after.

The conventional angiography underestimates the severity of the lesion compared to the CCTA

Benedek I.,World Jurnal of Cardiovascular Diseases, 2013

Conclusion

CCTA derived parameters provide incremental information to classical Coronary Angiography for preoperative assessment of lesion severity in complex left main stenosis.

CCTA derived Syntax score significantly correlates with the classical Coronary Angiography Syntax score and identifies the subgroup of patients who will be more exposed to procedural complications during the revascularization interventions

Based on these findings, CCTA could represent a new noninvasive clinical tool, useful for preoperative evaluation of patient risk and for selection of the best therapeutic strategy in these cases.

Personal contribution

Patient data collection and interpretation

Participation at the calculation of Angiographic and CCTA Syntax Score

Familiarization with the advantages and the indications of invasive and non-invasive imaging solutions

PowerPoint presentation

The attendance at related courses and workshops with the members of Cardiology Scientific Group.

Thank you for your attention!