Mihaela Ratiu, Nora Rat, Tiberiu Nyulas, Geanina Moldovan, Victoria Rus, Theodora Benedek and Imre Benedek
The aim of our study was to investigate the correlation between volumes of thoracic fat distributed in different compartments and the geometry of vulnerable coronary plaques assessed by coronary computed tomography angiography (CCTA), in patients with acute chest pain.
Methods: This was a non-randomized, observational, single-center study, including 50 patients who presented in the emergency department with acute chest pain who underwent 128-slice single-source CCTA. Plaque geometry was evaluated in transversal and longitudinal planes, and the assessment of adipose tissue was performed using the Syngo.via Frontier (Siemens AG, Healthcare Sector, Forchheim, Germany) research platform.
Results: Eccentric plaques presented a significantly higher incidence of spotty calcification (40% vs. 22%, p = 0.018), whereas positive remodeling, volume of low attenuation plaque, and incidence of napkin-ring sign were not significantly different between the study groups or in ascending versus descending plaques. The volume of pericoronary fat around the plaque was significantly larger near eccentric lesions (707.68 ± 454.08 mm3 vs. 483.25 ± 306.98 mm3, p = 0.046) and descendent plaques (778.26 ± 479.37 mm3 vs. 473.60 ± 285.27 mm3, p = 0.016). Compared to ascending lesions, descendent ones presented a significantly larger volume of thoracic fat (1,599.25 ± 589.12 mL vs. 1,240.71 ± 291.50 mL), while there was no significant correlation between thoracic fat and cross-sectional eccentricity.
Conclusions: The phenotype of plaque distribution and geometry seems to be associated with a higher vulnerability of coronary lesions and may be influenced by the local accumulation of inflammatory mediators released by the pericoronary epicardial adipose tissue.
Szilamér Korodi, Theodora Benedek, Lehel Bordi, István Kovács, Nora Rat, Emese Márton, Mihaela Rațiu and Imre Benedek
Atrial fibrillation (AF) is the most frequent form of supraventricular arrhythmia in medical practice. It is characterized by chaotic electrical activity in the atria, which often leads to irregular and fast ventricular contractions. Pulmonary veins (PV) play an essential part in the genesis of AF. There are a series of risk factors that trigger the development and recurrence of AF after PV isolation. Despite advanced medical technology, the success rate of AF ablation is not satisfactory. The purpose of this study is to assess the preprocedural imaging and serum biomarkers linked to an increased recurrence of AF after PV isolation. The primary endpoint is represented by AF recurrence after PV isolation. In addition, the rate of cardiovascular death and the rate of major adverse cardiovascular events will be assessed in relation to the enlargement of the left atrium and the volume of epicardial adipose tissue surrounding the heart.
Alexandra Stănescu, Imre Benedek, Mirabela Morariu, Mihaela Rațiu, Ramona Zavate, András Mester and Theodora Benedek
Hybrid imaging represents a combination of two different imaging techniques resulting in a single image that contains all the information provided by the two investigations. Hybrid imaging tends to improve the accuracy of the diagnosis in many diseases. Coronary computed tomography angiography (CCTA) has unquestionable abilities in highlighting coronary artery diseases (CAD). Cardiac magnetic resonance imaging (MRI) also has a powerful predictive role in assessing the functionality of the myocardial tissue.
The aim of the study is to develop new imaging markers for a complex evaluation of myocardial viability (MV) after an acute myocardial infarction (AMI), using hybrid technology.
Material and methods: This study will enroll 100 patients at one month after an AMI. CCTA, MRI, 3D echocardiography, and blood tests will be performed in all patients. All the acquisitions will be processed using a supercomputer, and MV and other parameters will be assessed on hybrid images. A secondary objective will be to correlate the level of inflammatory markers with the outcome of patients, left ventricular function, ischemic time, and the rate of major adverse cardiovascular events.
Theodora Benedek, Ioana Rodean, Mihaela Ratiu, Nora Rat, Lia Yero Eremie, Carmen Biriș, Luminița Lazăr, Mariana Păcurar and Imre Benedek
Recent studies have shown that systemic inflammation caused by periodontal disease (PD) can determine important changes in the coronary arteries, favoring atherosclerosis progression and the development of acute coronary syndromes (ACS). The aim of the ATHERODENT study (Protocol Record Number CM0117-ATD) is to assess the interrelation between PD, inflammation, and the progression of coronary atherosclerosis in patients with ACS.
Material and methods: This case-control observational study will enroll 100 patients (group 1 – ACS and associated PD, and group 2 – ACS and no PD), in whom the following data will be collected: (1) demographic and clinical data; (2) cardiovascular risk factors; (3) full characterization of PD markers; (4) systemic inflammatory biomarkers; (5) imaging biomarkers derived from transthoracic echocardiography, computed tomography, coronary angiography, optical coherence tomography, and intravascular ultrasound; and (6) assessment of the presence of specific oral bacteria in samples of coronary plaques collected by coronary atherectomy, which will be performed during percutaneous revascularization interventions, when indicated in selected cases, in the atherectomy sub-study. The follow-up will be performed at 1, 3, 6, 12, 15, 18, and 24 months. The primary endpoint of the study will be represented by the rate of major adverse cardiovascular events (MACE) in PD vs. non-PD patients and in correlation with: (1) the level of systemic inflammation triggered by PD and/or by ACS at baseline; (2) the vulnerability degree of atheromatous plaques in the coronary tree (culprit and non-culprit lesions); and (3) the presence and burden of oral bacteria in atheromatous plaques. Secondary endpoints will be represented by: (1) the rate of progression of vulnerability degree of non-culprit coronary plaques; (2) the rate of progression of atheromatous burden and calcium scoring of the coronary tree; and (3) the rate of occurrence of left ventricular remodeling and post-infarction heart failure. The ATHERODENT study has been registered in clinicaltrials.gov (ClinicalTrials.gov Identifier: NCT03395041).
Tiberiu Nyulas, Mirabela Morariu, Nora Rat, Emese Marton, Victoria Ancuta Rus, Mihaela Ratiu, Theodora Benedek and Imre Benedek
Background: Epicardial adipose tissue (EAT) has been recently identified as a major player in the development of the atherosclerotic process. This study aimed to investigate the role of EAT as a marker associated with a higher vulnerability of atheromatous coronary plaques in patients with acute myocardial infarction (AMI) as compared to patients with stable angina.
Material and methods: This analysis enrolled a total of 89 patients, 47 with stable angina (SA) and 42 with AMI, who underwent echocardiographic investigations and epicardial fat measurement in 2D-parasternal long axis view. The study lot was divided as follows: Group 1 included patients with prior AMI, and Group 2 included patients with SA.
Results: There were no significant differences between the two groups regarding cardiovascular risk factors, excepting smoking status, which was recorded more frequently in Group 1 as compared to Group 2 (36.17% vs. 11.63%, p = 0.02). The mean epicardial fat diameter was 9.12 ± 2.28 mm (95% CI: 8.45–9.79 mm) in Group 1 and 6.30 ± 2.03 mm (95% CI: 5.675–6.93 mm) in Group 2, the difference being highly significant statistically (p <0.0001). The mean value of left ventricular ejection fraction was significantly lower in patients with AMI (Group 1 – 47.60% ± 7.96 vs. Group 2 – 51.23% ± 9.05, p = 0.04). EAT thickness values showed a weak but significant positive correlation with the level of total cholesterol (r = −0.22, p = 0.03) and with the value of end-systolic left ventricle diameter (r = 0.33, = 0.001).
Conclusions: The increased thickness of EAT was associated with other serum- or image-based biomarkers of disease severity, such as the left ventricular ejection fraction, end-systolic diameter of the left ventricle, and total cholesterol. Our results indicate that EAT is significantly higher in patients with acute coronary syndrome, proving that EAT could serve as a marker of vulnerability in cardiovascular diseases.
Mirabela Morariu, Emese Márton, András Mester, Mihaela Rațiu and Imre Benedek
Background: The inflammatory response of the immune system plays a major role in the period following an acute myocardial infarction (MI), as it coordinates the formation of the fibrous scar tissue that replaces the infarcted myocardial cells and ultimately leads to healing and remodeling of the affected zone. Along with other pro- and anti-inflammatory cytokines and acute phase proteins, interleukin-6 (IL-6) and C-reactive protein (CRP) are associated with the extent of the infarct size (IS) and may serve as predictors for remodeling and adverse left ventricular (LV) function. Material and methods: A single-center, non-randomized, observational prospective study was conducted, which included 75 patients with primary revascularized ST-elevation myocardial infarction (STEMI). High-sensitivity CRP (hs-CRP) serum levels were determined on day 1 and day 5 following the acute event. IL-6 was also determined on day 1. All patients underwent cardiac magnetic resonance imaging (CMR) at 1-month follow-up with determination of LV function and quantification of the scar tissue using late gadolinium enhancement imaging. The patients were divided into 2 groups based on baseline hs-CRP values. Results: Patients with higher baseline hs-CRP levels presented significantly higher infarct size (p = 0.0003), higher transmural extent (p <0.0001), lower LV ejection fraction (p = 0.0024), end-systolic (p = 0.0021) and end-diastolic (p = 0.0065) volumes. Small IS (<10%) recorded the lowest levels of hs-CRP, while IS >20% presented the highest levels of hs-CRP, at baseline and day 5 (p = 0.4 and 0.001). IL-6 levels were also associated with the magnitude of infarct scar: 2.17 pg/mL for IS <10%, 15.52 pg/mL for IS between 10% and 20%, and 24.52 pg/mL for IS >20%, p = 0.002. Conclusion: hs-CRP and IL-6 serum levels following an MI are correlated with IS, transmurality extent of the scar tissue, as well as with altered systolic and diastolic LV function determined by CMR at 1-month follow-up.
Ioan Ferenț, András Mester, Monica Chițu, Annabella Benedek, Mihaela Rațiu, Roxana Hodas and Imre Benedek
Background: Computed tomography angiography (CTA) occupies an important place in the evaluation of coronary atherosclerotic lesions, both before and after the implantation of bioresorbable stents (BVS), providing an accurate assessment of the treated lesions.
Aim of the study: This study aims the prospective follow-up of atherosclerotic plaques electively treated with BVS implantation via CTA evaluation in terms of morphological and virtual histology aspects.
Material and methods: This is a prospective observational study which enrolled 30 patients electively treated with BVS implantation, in whom CTA was performed after PTCA in order to assess the morphological and virtual histology aspects of coronary plaques. In order to evaluate the impact determined by pre- and post-implantation procedures, statistical analysis was performed among 6 subgroups.
Results: After BVS implantation, a significant reduction was observed in terms of stenosis % (61.63 ± 12.63% in subgroup 1A vs. 24.41 ± 12.48% in subgroup 1B, p <0.0001) and eccentricity index (0.46 ± 0.24 in subgroup 1A vs. 0.43 ± 0.24 in subgroup 1B, p <0.0001). In terms of plaque components, there were significant differences with regard to lipid volume and lipid % (20.07 ± 15.67 mm3 in subgroup 1A vs. 11.05 ± 10.83 mm3 in subgroup 1B, p = 0.01), which presented a significant reduction after BVS implantation. The calcium score evaluated locally (82.97 ± 107.5 in subgroup 1A vs. 96.54 ± 85.73 in subgroup 1B, p = 0.25) and on the target coronary artery (148.2 ± 222.3 in subgroup 1A vs. 206.6 ± 224.0 in subgroup 1B, p = 0.10), as well as the total calcium score (377.6 ± 459.5 in subgroup 1A vs. 529.5 ± 512.9 in subgroup 1B, p = 0.32), presented no significant differences when compared with and without post-dilatation lesions. As far as CT vulnerability markers are concerned, the study groups presented significant differences only in terms of spotty calcifications (66.66% in subgroup 1A vs. 79.16% in subgroup 1B, p = 0.05) and low attenuation (37.5% in subgroup 1A vs. 20.83% in subgroup 1B, p = 0.01).
Conclusions: Following the analysis of coronary artery plaques after the implantation of BVS, significant changes were noted both in the morphology of the atherosclerotic plaques treated with these devices and in the lumen and coronary wall.
Mirabela Morariu, Lehel Bordi, Diana Opincariu, Alexandra Mihaela Ratiu, Sebastian Condrea, Annabell Benedek and Theodora Benedek
Cardiac magnetic resonance imaging is an evolving imaging method that can be used in cardiovascular pathology evaluation. Technological developments have increased the clinical utility of cardiac magnetic resonance in the exploration of various cardiac abnormalities. The most important imaging techniques and their utility will be presented in this review, together with the advantages and limitations of cardiac magnetic resonance and with a brief presentation of common cardiac disorders that can be assessed by cardiac magnetic resonance including ischemic heart disease, cardiomyopathies and myocarditis.
Alexandra Stănescu, Elisabeta Himcinschi, Mirabela Morariu, Nora Rat, Lehel Bordi, Mihaela Rațiu, Annabella Benedek, Imre Benedek and Theodora Benedek
The diagnosis and treatment of acute coronary syndrome remain a challenge for clinicians in many clinical settings, especially in patients with previous low-to-intermediate risk. Due to its high specificity and sensitivity for detecting significant coronary artery stenoses, cardiac computed tomography angiography (CCTA) tends to be used more frequently in the emergency room (ER) in the last years. This technique has been associated with a higher rate of safe discharge in patients with chest pain, less time spent in the ER, and decreased costs related to further investigations. In cases positive for coronary artery stenosis, CCTA can accurately evaluate the indication for percutaneous coronary angioplasty and can offer relevant information related to the characteristics of the coronary plaques, being able to detect vulnerable coronary plaques. The aim of this manuscript is to highlight the possibility of using CCTA in the ER in the assessment of patients with chest pain and to show the benefits of the procedure regarding safety, costs, accuracy, and time.
Ioan Ferenț, András Mester, Monica Chițu, Annabella Benedek, Mihaela Rațiu, Roxana Hodas and Imre Benedek
Background: Computed tomography angiography (CTA) presents important limits in in-stent restenosis (ISR) evaluation in case of metallic coronary stents, due to the artifacts determined by stent struts, which alter in-stent plaque analysis. In case of bioresorbable scaffolds, stent strut resorption allows accurate evaluation of the vessel wall. Aim of the study: This study aims to compare the feasibility of CTA as a follow-up imaging method for ISR diagnosis following elective PTCA procedures, between bioresorbable scaffolds and metallic coronary stents.
Material and methods: We conducted a prospective, observational study on 73 patients with elective PTCA procedures in their medical history, in whom 113 stents were assessed via CTA in order to diagnose ISR. Based on stent type, the patients were divided into two groups: Group 1 – patients with bioresorbable vascular scaffolds (BVS) (n = 30); and Group 2 – patients with bare metal stents (BMS) (n = 43). Plaque analysis was possible only in the BVS group with a post-processing research-dedicated software, Syngo.via Frontier, which identified plaque morphology and virtual histology composition.
Results: After CTA evaluation, the BVS group presented a significantly higher incidence of severe coronary artery disease (CAD) (Group 1 – 73% vs. Group 2 – 30%, p <0.0001). The proximal part of the right coronary artery (RCA) presented a significantly higher percentage of metallic stents (14% BMS vs. 2% BVS, p = 0.0029). The comparative analysis of CTA sensibility for the visual evaluation of ISR identified a significantly higher percentage of diagnostic CT evaluations in the BVS group (Group 1 – 94% vs. Group 2 – 76.19%, p = 0.0006). CTA evaluation provided the most accurate results for the 3.0 and 3.5 mm devices. Regarding CTA sensibility for ISR diagnosis, the BVS group presented the smallest incidence of non-diagnostic CT evaluations.
Conclusions: CTA evaluation of bioresorbable scaffolds is superior to metallic stent assessment, the latter being influenced by numerous sources of error dependent mainly on the presence of the metal structure.