RPS 503 - Trials and meta-analyses: cardiac CT and MRI

Author Block: F. Catapano¹, L. J. Moser², M. Francone¹, R. Vliegenthart³, C. Catalano⁴, M. Gutberlet⁵, H. Alkadhi²; ¹Milan/IT, ²Zürich/CH, ³Groningen/NL, ⁴Rome/IT, ⁵Leipzig/DE
Purpose: The aim of this study was to provide an overview of advanced cardiovascular imaging practices in Europe using structured data from the European society of cardiovascular radiology (ESCR) registry.
Methods or Background: Numbers on cardiovascular CT and MRI examinations were extracted from the ESCR-registry between 2009 and October 2023. Data collection included the total/annual numbers of examinations, indications, complications, and reporting habits.
Results or Findings: The ESCR registry demonstrates a 6.8-fold increase of annually submitted CT examinations from 2,244 to 15,267, and a 4.7-fold increase of MRI examinations from 2,803 to 13,183 between 2010 and 2022. Reporting of CT (76%) and MRI (71%) was mostly performed by radiologists, and, to a lesser degree, in consensus with non-radiologists (19% and 27%, respectively). Main indications for cardiac CT were suspected coronary artery disease (CAD) (59%), TAVI-planning (21%), valve disease (7%) and preablation (6%). Main MRI indications were myocarditis (26%), suspected CAD (including stress-imaging) (21%), and cardiomyopathy (19%). Adverse event rates were very low for CT (0.3%) and MRI (0.7%).
Conclusion: The largest available registry on Cardiovascular CT and MRI in Europe demonstrates a considerable increase in exam numbers, in particular for CAD and CT. These findings collectively contribute to our understanding of the current state of cardiovascular imaging in Europe.
Limitations: Our data, extracted from an ESCR registry, may inherently favour a radiological perspective in the representation of clinical practice in cardiac imaging. Nevertheless, they do represent the largest cases archive in Europe.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: The study is retrospective or educational.

Author Block: M. Bosserdt¹, M. Mohamed¹, K. Neumann¹, N. Rieckmann¹, H. Dreger¹, V. Brodszky², T. Reinhold¹, A-M. Mielke¹, M. Dewey¹; ¹Berlin/DE, ²Budapest/HU
Purpose: Is coronary computed tomography (CT) cost-effective compared with invasive coronary angiography (ICA) in patients with atypical chest pain who are clinically referred for ICA?
Methods or Background: A prespecified cost-effectiveness analysis of 329 patients with atypical angina or chest pain from a randomised pragmatic trial comparing CT and ICA conducted at a university hospital in Germany was performed. Cost-effectiveness was analysed for up to 3 years of follow-up from the health sector perspective using quality-adjusted life years (QALYs) derived from the EQ-5D-3L questionnaire. Costs were obtained from each individual's outpatient and inpatient billing data and included cardiovascular medications, hospitalisations, emergency department visits, cardiologist visits, and cardiac examinations. Data analysis included 500 multiple imputations followed by 1,000 bootstrapping iterations for each imputed data set, and the net monetary benefit was calculated.
Results or Findings: There was no statistically significant difference in mean QALYs at either one-year or three-year follow-up, while the mean cost per patient was significantly lower in the CT group compared with the ICA group, both at one year (difference in €: -1,647.8, -2,198.3 to -1,937.0) and at three years (difference in €: -1,543.3, -2,228.0 to -830.0). At a willingness-to-pay threshold of €20,000/QALY, the average incremental net monetary benefit of CT over ICA was €1,256.5 (164.8 to 2331.8) at one year and €1202.0 (-1,378.7 to 3,961) at three years. The incremental net monetary benefit of CT over ICA at three years was the highest in patients with a pretest probability of CAD above 30% (€ 1445.6, -1803.1 to 4637.0).
Conclusion: A CT-first strategy for the management of patients with atypical angina or chest pain was more cost-effective than a direct-to-ICA strategy.
Limitations: This analysis considered only cost from the health sector perspective.
Funding for this study: This study was funded by a grant of the Heisenberg programme of the German Research Foundation to Marc Dewey.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: This trial was approved by the ethics committee of the Charité –Universitätsmedizin Berlin (EA1-1-080-08) and by the German Federal Office for Radiation Protection (Z5–22462/2–2008-048). Before the randomisation all participants gave written informed consent.

Author Block: K. Schulze¹, B. Föllmer¹, F. Biavati¹, R. Bockelmann¹, M. Bosserdt¹, F. Michallek¹, J. D. Dodd², K. F. Kofoed³, M. Dewey¹; ¹Berlin/DE, ²Dublin/IE, ³Copenhagen/DK
Purpose: The aim of this study was to assess the feasibility of assessing calcified coronary artery plaques on CT angiography (CTA) compared to non-contrast CT (NCCT) in a multicentre study.
Methods or Background: This study included 47 patients from the DISCHARGE trial subgroup (mean age 62.0 ± 11.0 years, 57.4% male) with available thin-slice (< 0.7 mm) NCCT and CTA. The diagnostic accuracy and detection of manually segmented coronary calcified plaques was automatically assessed for CTA and NCCT using a definition of a volume of at least 1 mm³. Plaques on CTA were defined as missed if there was no spatial overlap with a calcified plaque on NCCT after registration. Sensitivity and specificity were calculated using NCCT as reference standard. Lesion level statistics were analysed for plaque density and volume parameters, with plaques categorised into the groups 'all' and 'missed'.
Results or Findings: NCCT identified 314 coronary calcified plaques of which 213 (32% sensitivity) were missed in CTA alone. CTA was not associated with false positive calcified plaques. Missed coronary calcified plaques on CTA had higher density (537.3 HU ± 224.9 HU) compared to NCCT (467.9 HU ± 215.3 HU). These plaques were detectable on NCCT based on density, while CTA density was closer to aortic density (393.4 HU ± 101.0 HU). Additionally, missed plaques were smaller in volume (7.15 mm³ ± 9.0 mm³) compared to all plaques (21.0 mm³ ± 57.3 mm³). Overlooking calcified coronary plaques would have led to the omission of 11 out of 47 (23%) patients with CAD-RADS 1, incorrectly categorising them as CAD-RADS 0.
Conclusion: CTA can miss up to two thirds of coronary calcified plaques visible on NCCT, highlighting the important role of NCCT.
Limitations: This study involved a small subset of 47 patients from three of the 26 DISCHARGE trial centres.
Funding for this study: This study was funded by grants from the EU-FP7 Framework Program (FP 2007-2013, EC-GA 603266) and
funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) in the graduate program on quantitative biomedical imaging (BIOQIC, DFG project number: 289347353, GRK 2260/1).
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The DISCHARGE trial was approved by the ethics committee at
Charité–Universitätsmedizin Berlin as the coordinating centre, by the German
Federal Office for Radiation Protection, and by local or national ethics
committees.

Author Block: D. Han¹, M. Vonder¹, C. Van Der Aalst², A. Schmitz³, J. W. C. Gratama⁴, M. Silva⁵, H. J. De Koning², M. Oudkerk¹; ¹Groningen/NL, ²Rotterdam/NL, ³Amsterdam/NL, ⁴Apeldoorn/NL, ⁵Parma/IT
Purpose: The 4-IN-THE-LUNG-RUN (4ITLR) trial, which was recently started and aims to enroll 26,000 participants, offers the opportunity for prospective cardiovascular screening within a lung cancer screening program. Although current guidelines advise the assessment of coronary calcifications on chest CT scans of any kind, this requires specific imaging acquisition and reconstruction for accurate Agatston score evaluation. This study explores the potential benefits of cardiovascular screening within the initial participants of 4ITLR trial.
Methods or Background: The inclusion criteria were: age 60-79 years, smoking history of ≥35 pack-years, and current smoking or quitting within the last 10 years. High-temporal-resolution low-dose chest CT scans using a third-generation dual-source CT scanner were performed on 443 participants between January 15th and March 29th, 2023, at a single centre. An automatic assessment of the Agatston score was conducted on dedicated cardiac reconstructions that utilised a slice thickness/increment of 3.0/1.5 mm, a medium-sharp kernel, and high-pitch acquisition, with an FBP algorithm and 120 kVp. This allowed for the reliable categorisation of the participants' risk based on their Agatston score, with categories being low risk (0 score), moderate risk (1-99), high risk (100-399), and very high risk (≥400).
Results or Findings: The mean age was 68.6 years (SD 4.9), with 56.9% male. Median Agatston scores were 242.1 (IQR 34.8-939.9) for men and 56.3 (IQR 2.5-365.0) for women. 16.0%, 30.7%, 19.6%, and 33.6% of participants were at low, moderate, high, and very high CHD risk, respectively. About 47% fell into low/moderate CHD risk categories.
Conclusion: The initial lung cancer screening identified one third of participants at significantly high CHD risk, while half were suitable for preventive CHD treatment. Notably, 16% had a low CHD risk, exempting them from CHD preventive medication as per existing guidelines.
Limitations: No limitations were identified.
Funding for this study: This project has received funding from the European Union's Horizon 2020 programme under grant agreement no 848294.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: The minister of public health, well-being and sport has approved the execution of the 4-IN-THE-LUNG-RUN study.

Author Block: X. He¹, Y. Li¹, Y. Wang¹, X. Lu¹, J. Nan¹, L. Cao¹, Y. Wang², G. Wang¹, Z. Chen¹; ¹Lan Zhou city/CN, ²Shanghai/CN
Purpose: The aim of this study was to investigate the prognostic value of CT-derived myocardium-related parameters in patients with severe aortic stenosis (AS) who have undergone aortic valve replacement (AVR).
Methods or Background: Four databases (PubMed, Web of Science, Embase, and Cochrane) were searched to identify studies investigating the prognostic performance of CT-derived myocardium-related parameters in patients with AS. A random effects model for meta-analysis was conducted to calculate pooled hazard ratios (HR) and 95% confidence intervals (CI) in order to assess the prognostic value. The I2 statistic was used to assess heterogeneity.
Results or Findings: In this analysis, ten studies were identified, six of which involved 662 patients reporting CT-derived extracellular volume fraction (ECV), and four studies, including 1244 patients reporting CT-derived left ventricular global longitudinal strain (LVGLS). The meta-analysis revealed that ECV, whether considered as a dichotomous variable (pooled HR: 4.12, 95% CI: 2.76-6.15, I2 =0%, P< 0.001), or as a continuous variable (pooled HR: 1.15, 95% CI: 1.05-1.25, I2 =74%, P=0.002), and LVGLS, whether considered as a dichotomous variable (pooled HR: 1.70, 95% CI: 1.31-2.19, I2 =0%, P< 0.001) or a continuous variable (pooled HR: 1.07, 95% CI: 1.05-1.10, I2=0%, P< 0.001) were all significant predictors for all-cause mortality in patients with AS after AVR.
Conclusion: This study has demonstrated the significant prognostic value of pre-AVR CT-derived ECV and LVGLS, both as dichotomous and continuous variables, in predicting all-cause mortality in patients with AS. These findings enhance our understanding of the pathophysiology of AS and assist in optimizing the timing of AVR.
Limitations: Limited number of studies in meta-analysis.
Funding for this study: This study is supported by the Lanzhou Science and technology project Foundation (2020-2D-80) and First Hospital of Lanzhou University Hospital Foundation (ldyyyn2019-78).
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: No information provided by the submitter.

Author Block: E. Bruno¹, A. Palmisano¹, S. Dell'Aversana², R. Faletti³, N. Galea⁴, M. Gatti³, C. Liguori², S. Pradella⁵, A. Esposito¹; ¹Milan/IT, ²Naples/IT, ³Turin/IT, ⁴Rome/IT, ⁵Florence/IT
Purpose: Mitral annular disjunction (MAD) is an anatomic variant characterised by the atrialisation of the mitral valve junction; its prevalence and pathological role are still debated.
The aim of the study is to evaluate the incidence of MAD in a vast cohort of patients who underwent cardiac magnetic resonance (CMR), defining the correlation with morpho-functional or myocardial tissue alterations and arrhythmias.
Methods or Background: Multi-center observational study involving 13 Italian hospitals. CMR from January to June 2019 were evaluated, assessing the presence of MAD, structural (prolapse, curling, regurgitation) and tissue alterations (LGE, T1, T2, ECV), volumetric and functional features, clinical suspicion, diagnosis, presence and type of arrhythmias.
Results or Findings: From a total of 2611 patients (67% XX, 53 [IQR 39-65] years old), 5.4% (142 patients, 65% XX, 52 [IQR39-63] year-old) had MAD. Of them, 8% underwent CMR for the suspicion of valvopathy, 5% for arrhythmias and 87% for other causes.
47/142 (33%) patients had arrhythmias, associated with valve prolapse (p=0.004) and bigger MAD length (p< 0.001).
83/142 (58%) had MAD without other cardiomyopathies, with prolapse in 43% of cases, associated with increased incidence of curling (64% vs 17%; p-value<0.001) and higher ECV values (29% vs 25%; p=0.003).
Bi-leaflet prolapse was associated to more severe MAD compared to patients with single-leaflet prolapse or without (6 vs 3.5 and 4 mm; p=0.083), bigger left atrial volume (40 mL/ m2 vs 2 mL/ m2 and 27 mL/ m2; p=0.011), left ventricle volume (170 mL vs 134 and 111 mL; p< 0.001), higher rate of moderate-severe regurgitation (45% vs 6% and 0%; p< 0.001) and arrhythmias (63% vs 36%; p=0.037), without significant differences in the presence of LGE, whereas more frequent (35% vs 25% and 27%; p=0.794).
Conclusion: MAD is frequent in the population even without valvopathies. Its severity, the association with structural alterations lead to a higher risk of myocardial remodelling and arrhythmias.
Limitations: Absence of follow-up data.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Yes
Ethics committee - additional information: Prot. MIAMI