Imaging

SAN DIEGO – Interim results from an ongoing study demonstrated that that a higher pretreatment Alberta Stroke Program Early CT Score on computed tomography angiogram images is associated with better outcome following endovascular therapy.

"There is no standard imaging approach for endovascular therapy patient selection," Dr. Donald Frei said at the annual meeting of the Society of Neurointerventional Surgery. "We’re trying to improve time from door to CT imaging and time from imaging to groin puncture, but we also need to be a little bit more sophisticated about patient selection. That’s what we tried to do in this study."

For the analysis, Dr. Frei, director of neurointerventional surgery for Radiology Imaging Associates/Swedish Medical Center in Denver, and his associates at 15 centers evaluated the influence of pretreatment ASPECTS from CTA source image on outcomes following endovascular therapy in the START (Stroke Treatment and Revascularization Therapy) trial, a prospective, single-arm multicenter trial that set out to study the influence of pretreatment core infarct size in 147 patients undergoing endovascular stroke therapy with the Penumbra system.

Imaging methods were at the direction of each investigator and included noncontrast CT, CTA-SI (CTA source images), CT perfusion, or MRI diffuse imaging. The current analysis focused on the preliminary CTA-SI results. ASPECTS was graded in a blinded fashion and analyzed according to a prior classification (0-4, 5-7, or 8-10) and the entire scale. Clinical outcomes were dichotomized as 90-day modified Rankin Scale (mRS) scores of 0-2 (good) vs. 3-6.

Dr. Frei reported interim results from 77 patients who met study criteria. Their mean age was 66 years, 56% were women, and their mean National Institutes of Health Stroke Scale score was 19. The majority of target vessel occlusions were in the middle cerebral artery (75.3%), followed by internal carotid artery (22.1%), and other areas (2.6%). (Dr. Frei noted that results from all 147 patients are expected to be presented at the upcoming International Stroke Conference.)

The median pre-ASPECTS on CTA-SI was 6. Of the 77 patients, 20 (26%) had a score of 0-4, 43 (56%) had a score of 5-7, and 14 (18%) had a score of 8-10.

Dr. Frei, who is also a member of the SNIS Executive Committee, reported that the rate of TIMI (Thrombolysis in Myocardial Infarction) 2-3 revascularization was 85.3%, the median time from groin puncture to aspiration discontinuation was 71.5 minutes, and 48.1% of patients achieved a good 90-day clinical outcome.

The mortality rate was 28.6%, and 32.5% suffered from intracranial hemorrhage. Of these, 20.8% were asymptomatic.

In general, the higher the pretreatment ASPECTS on CTA-SI, the better the outcome. For example, the rate of good outcomes was 20% for those with a pretreatment ASPECTS of 0-4, 56% for 5-7, and 64% for 8-10 (P = .08 for all). After adjusting for age and stroke severity, the researchers determined that a pre-ASPECTS score of 5-10 was an independent predictor of good outcome (odds ratio, 6.8; P = .006).

Univariate analysis demonstrated the following significant predictors of good outcomes: pretreatment ASPECTS greater than 4 (P = .0043), younger age (P = .01), lower pretreatment NIHSS (P = .04), shorter time from groin puncture to discontinuation of aspiration (P = .0004), and revascularization time (P = .0001).

In a prepared statement, Dr. Frei noted that although thousands of men and women suffer a stroke every day, "only a small percentage of those affected are treated with endovascular therapy. This study strongly suggests that a simple ASPECTS reading from a fast, easy-to-obtain CTA source image can guide patient selection for endovascular therapy, particularly those most likely to benefit from the Penumbra System" beyond the 3- to 4.5-hour window.

The START trial was sponsored by Penumbra Inc.

Dr. Frei said that he had no relevant financial disclosures to make.

SAN DIEGO – Interim results from an ongoing study demonstrated that that a higher pretreatment Alberta Stroke Program Early CT Score on computed tomography angiogram images is associated with better outcome following endovascular therapy.

"There is no standard imaging approach for endovascular therapy patient selection," Dr. Donald Frei said at the annual meeting of the Society of Neurointerventional Surgery. "We’re trying to improve time from door to CT imaging and time from imaging to groin puncture, but we also need to be a little bit more sophisticated about patient selection. That’s what we tried to do in this study."

For the analysis, Dr. Frei, director of neurointerventional surgery for Radiology Imaging Associates/Swedish Medical Center in Denver, and his associates at 15 centers evaluated the influence of pretreatment ASPECTS from CTA source image on outcomes following endovascular therapy in the START (Stroke Treatment and Revascularization Therapy) trial, a prospective, single-arm multicenter trial that set out to study the influence of pretreatment core infarct size in 147 patients undergoing endovascular stroke therapy with the Penumbra system.

Imaging methods were at the direction of each investigator and included noncontrast CT, CTA-SI (CTA source images), CT perfusion, or MRI diffuse imaging. The current analysis focused on the preliminary CTA-SI results. ASPECTS was graded in a blinded fashion and analyzed according to a prior classification (0-4, 5-7, or 8-10) and the entire scale. Clinical outcomes were dichotomized as 90-day modified Rankin Scale (mRS) scores of 0-2 (good) vs. 3-6.

Dr. Frei reported interim results from 77 patients who met study criteria. Their mean age was 66 years, 56% were women, and their mean National Institutes of Health Stroke Scale score was 19. The majority of target vessel occlusions were in the middle cerebral artery (75.3%), followed by internal carotid artery (22.1%), and other areas (2.6%). (Dr. Frei noted that results from all 147 patients are expected to be presented at the upcoming International Stroke Conference.)

The median pre-ASPECTS on CTA-SI was 6. Of the 77 patients, 20 (26%) had a score of 0-4, 43 (56%) had a score of 5-7, and 14 (18%) had a score of 8-10.

Dr. Frei, who is also a member of the SNIS Executive Committee, reported that the rate of TIMI (Thrombolysis in Myocardial Infarction) 2-3 revascularization was 85.3%, the median time from groin puncture to aspiration discontinuation was 71.5 minutes, and 48.1% of patients achieved a good 90-day clinical outcome.

The mortality rate was 28.6%, and 32.5% suffered from intracranial hemorrhage. Of these, 20.8% were asymptomatic.

In general, the higher the pretreatment ASPECTS on CTA-SI, the better the outcome. For example, the rate of good outcomes was 20% for those with a pretreatment ASPECTS of 0-4, 56% for 5-7, and 64% for 8-10 (P = .08 for all). After adjusting for age and stroke severity, the researchers determined that a pre-ASPECTS score of 5-10 was an independent predictor of good outcome (odds ratio, 6.8; P = .006).

Univariate analysis demonstrated the following significant predictors of good outcomes: pretreatment ASPECTS greater than 4 (P = .0043), younger age (P = .01), lower pretreatment NIHSS (P = .04), shorter time from groin puncture to discontinuation of aspiration (P = .0004), and revascularization time (P = .0001).

In a prepared statement, Dr. Frei noted that although thousands of men and women suffer a stroke every day, "only a small percentage of those affected are treated with endovascular therapy. This study strongly suggests that a simple ASPECTS reading from a fast, easy-to-obtain CTA source image can guide patient selection for endovascular therapy, particularly those most likely to benefit from the Penumbra System" beyond the 3- to 4.5-hour window.

The START trial was sponsored by Penumbra Inc.

Dr. Frei said that he had no relevant financial disclosures to make.

SAN DIEGO – Interim results from an ongoing study demonstrated that that a higher pretreatment Alberta Stroke Program Early CT Score on computed tomography angiogram images is associated with better outcome following endovascular therapy.

"There is no standard imaging approach for endovascular therapy patient selection," Dr. Donald Frei said at the annual meeting of the Society of Neurointerventional Surgery. "We’re trying to improve time from door to CT imaging and time from imaging to groin puncture, but we also need to be a little bit more sophisticated about patient selection. That’s what we tried to do in this study."

For the analysis, Dr. Frei, director of neurointerventional surgery for Radiology Imaging Associates/Swedish Medical Center in Denver, and his associates at 15 centers evaluated the influence of pretreatment ASPECTS from CTA source image on outcomes following endovascular therapy in the START (Stroke Treatment and Revascularization Therapy) trial, a prospective, single-arm multicenter trial that set out to study the influence of pretreatment core infarct size in 147 patients undergoing endovascular stroke therapy with the Penumbra system.

Imaging methods were at the direction of each investigator and included noncontrast CT, CTA-SI (CTA source images), CT perfusion, or MRI diffuse imaging. The current analysis focused on the preliminary CTA-SI results. ASPECTS was graded in a blinded fashion and analyzed according to a prior classification (0-4, 5-7, or 8-10) and the entire scale. Clinical outcomes were dichotomized as 90-day modified Rankin Scale (mRS) scores of 0-2 (good) vs. 3-6.

Dr. Frei reported interim results from 77 patients who met study criteria. Their mean age was 66 years, 56% were women, and their mean National Institutes of Health Stroke Scale score was 19. The majority of target vessel occlusions were in the middle cerebral artery (75.3%), followed by internal carotid artery (22.1%), and other areas (2.6%). (Dr. Frei noted that results from all 147 patients are expected to be presented at the upcoming International Stroke Conference.)

The median pre-ASPECTS on CTA-SI was 6. Of the 77 patients, 20 (26%) had a score of 0-4, 43 (56%) had a score of 5-7, and 14 (18%) had a score of 8-10.

Dr. Frei, who is also a member of the SNIS Executive Committee, reported that the rate of TIMI (Thrombolysis in Myocardial Infarction) 2-3 revascularization was 85.3%, the median time from groin puncture to aspiration discontinuation was 71.5 minutes, and 48.1% of patients achieved a good 90-day clinical outcome.

The mortality rate was 28.6%, and 32.5% suffered from intracranial hemorrhage. Of these, 20.8% were asymptomatic.

In general, the higher the pretreatment ASPECTS on CTA-SI, the better the outcome. For example, the rate of good outcomes was 20% for those with a pretreatment ASPECTS of 0-4, 56% for 5-7, and 64% for 8-10 (P = .08 for all). After adjusting for age and stroke severity, the researchers determined that a pre-ASPECTS score of 5-10 was an independent predictor of good outcome (odds ratio, 6.8; P = .006).

Univariate analysis demonstrated the following significant predictors of good outcomes: pretreatment ASPECTS greater than 4 (P = .0043), younger age (P = .01), lower pretreatment NIHSS (P = .04), shorter time from groin puncture to discontinuation of aspiration (P = .0004), and revascularization time (P = .0001).

In a prepared statement, Dr. Frei noted that although thousands of men and women suffer a stroke every day, "only a small percentage of those affected are treated with endovascular therapy. This study strongly suggests that a simple ASPECTS reading from a fast, easy-to-obtain CTA source image can guide patient selection for endovascular therapy, particularly those most likely to benefit from the Penumbra System" beyond the 3- to 4.5-hour window.

The START trial was sponsored by Penumbra Inc.

Dr. Frei said that he had no relevant financial disclosures to make.

Potentially practice-changing new techniques for improving cardiovascular CT imaging quality were hot topics at this years meeting of the Society of Cardiovascular Computed Tomography. Here’s a rundown of techniques that you can expect to see more frequently.

Fractional Flow Reserve CT

One problem with coronary CT angiography (CCTA) has been that it does not define the hemodynamic significance of coronary lesions. Cardiologists have relied on fractional flow reserve (FFR) measured at the time of invasive coronary angiography to determine specifically the hemodynamic significance of coronary artery lesions (lesion-specific ischemia). FFR is defined as the ratio of maximal myocardial flow through a diseased artery to the blood flow in the hypothetical case that this artery is normal. Values less than or equal to 0.80 or 0.75 are considered to be diagnostic of lesion-specific ischemia. Assessment of lesion-specific ischemia improves event-free survival.

Courtesy the Society for Cardiovascular Computed Tomography

CT FFR uses some very sophisticated and complex computational methods which are applied to data from a normal CCTA. This allows cardiologists to quantify the FFR for each lesion seen on CCTA with the data taken from the same image. The result is that they are able to identify which stenoses are causing ischemia and should be treated – all noninvasively.

Dual-Source CT

Calcium and motion artifacts have long been a bane to cardiologists and radiologists. Calcium plaques have been shown to appear larger on CCTA. When calcium plaque volume is overestimated, luminal diameter is underestimated and the percentage of diameter stenosis is overestimated.

Dual-source CT has recently received Food and Drug Administration 510k clearance for cardiac CT studies. Basically the detector switches very quickly between two energies, improving the clarity of image of calcium plaque (reducing artifacts) and increasing accuracy.

Snapshot Freeze

Coronary motion can occur at high and low heart rates, resulting in both false positives and false negatives. SnapShot Freeze was developed to help significantly reduce coronary motion. By precisely detecting vessel motion and velocity, the SnapShot Freeze algorithm can determine actual vessel position and corrects the effects of motion during cardiac CT exams. The reduction of coronary motion artifacts increases interpretability and improves accuracy.

CT Perfusion

The assessment of the luminal coronary artery narrowing with CCTA has been a poor predictor of myocardial ischemia and has required additional perfusion imaging to identify patients who might benefit from revascularization.

Several trials have shown that CT perfusion imaging has a high sensitivity and negative predictive value when compared against SPECT. CT perfusion also appears to be an affective technique for noninvasively evaluating patients with abnormal CT scans. Data are expected next year from several multicenter clinical trials.

--By Kerri Wachter (on twitter @knwachter)

Potentially practice-changing new techniques for improving cardiovascular CT imaging quality were hot topics at this years meeting of the Society of Cardiovascular Computed Tomography. Here’s a rundown of techniques that you can expect to see more frequently.

Fractional Flow Reserve CT

One problem with coronary CT angiography (CCTA) has been that it does not define the hemodynamic significance of coronary lesions. Cardiologists have relied on fractional flow reserve (FFR) measured at the time of invasive coronary angiography to determine specifically the hemodynamic significance of coronary artery lesions (lesion-specific ischemia). FFR is defined as the ratio of maximal myocardial flow through a diseased artery to the blood flow in the hypothetical case that this artery is normal. Values less than or equal to 0.80 or 0.75 are considered to be diagnostic of lesion-specific ischemia. Assessment of lesion-specific ischemia improves event-free survival.

Courtesy the Society for Cardiovascular Computed Tomography

CT FFR uses some very sophisticated and complex computational methods which are applied to data from a normal CCTA. This allows cardiologists to quantify the FFR for each lesion seen on CCTA with the data taken from the same image. The result is that they are able to identify which stenoses are causing ischemia and should be treated – all noninvasively.

Dual-Source CT

Calcium and motion artifacts have long been a bane to cardiologists and radiologists. Calcium plaques have been shown to appear larger on CCTA. When calcium plaque volume is overestimated, luminal diameter is underestimated and the percentage of diameter stenosis is overestimated.

Dual-source CT has recently received Food and Drug Administration 510k clearance for cardiac CT studies. Basically the detector switches very quickly between two energies, improving the clarity of image of calcium plaque (reducing artifacts) and increasing accuracy.

Snapshot Freeze

Coronary motion can occur at high and low heart rates, resulting in both false positives and false negatives. SnapShot Freeze was developed to help significantly reduce coronary motion. By precisely detecting vessel motion and velocity, the SnapShot Freeze algorithm can determine actual vessel position and corrects the effects of motion during cardiac CT exams. The reduction of coronary motion artifacts increases interpretability and improves accuracy.

CT Perfusion

The assessment of the luminal coronary artery narrowing with CCTA has been a poor predictor of myocardial ischemia and has required additional perfusion imaging to identify patients who might benefit from revascularization.

Several trials have shown that CT perfusion imaging has a high sensitivity and negative predictive value when compared against SPECT. CT perfusion also appears to be an affective technique for noninvasively evaluating patients with abnormal CT scans. Data are expected next year from several multicenter clinical trials.

--By Kerri Wachter (on twitter @knwachter)

Potentially practice-changing new techniques for improving cardiovascular CT imaging quality were hot topics at this years meeting of the Society of Cardiovascular Computed Tomography. Here’s a rundown of techniques that you can expect to see more frequently.

Fractional Flow Reserve CT

One problem with coronary CT angiography (CCTA) has been that it does not define the hemodynamic significance of coronary lesions. Cardiologists have relied on fractional flow reserve (FFR) measured at the time of invasive coronary angiography to determine specifically the hemodynamic significance of coronary artery lesions (lesion-specific ischemia). FFR is defined as the ratio of maximal myocardial flow through a diseased artery to the blood flow in the hypothetical case that this artery is normal. Values less than or equal to 0.80 or 0.75 are considered to be diagnostic of lesion-specific ischemia. Assessment of lesion-specific ischemia improves event-free survival.

Courtesy the Society for Cardiovascular Computed Tomography

CT FFR uses some very sophisticated and complex computational methods which are applied to data from a normal CCTA. This allows cardiologists to quantify the FFR for each lesion seen on CCTA with the data taken from the same image. The result is that they are able to identify which stenoses are causing ischemia and should be treated – all noninvasively.

Dual-Source CT

Calcium and motion artifacts have long been a bane to cardiologists and radiologists. Calcium plaques have been shown to appear larger on CCTA. When calcium plaque volume is overestimated, luminal diameter is underestimated and the percentage of diameter stenosis is overestimated.

Dual-source CT has recently received Food and Drug Administration 510k clearance for cardiac CT studies. Basically the detector switches very quickly between two energies, improving the clarity of image of calcium plaque (reducing artifacts) and increasing accuracy.

Snapshot Freeze

Coronary motion can occur at high and low heart rates, resulting in both false positives and false negatives. SnapShot Freeze was developed to help significantly reduce coronary motion. By precisely detecting vessel motion and velocity, the SnapShot Freeze algorithm can determine actual vessel position and corrects the effects of motion during cardiac CT exams. The reduction of coronary motion artifacts increases interpretability and improves accuracy.

CT Perfusion

The assessment of the luminal coronary artery narrowing with CCTA has been a poor predictor of myocardial ischemia and has required additional perfusion imaging to identify patients who might benefit from revascularization.

Several trials have shown that CT perfusion imaging has a high sensitivity and negative predictive value when compared against SPECT. CT perfusion also appears to be an affective technique for noninvasively evaluating patients with abnormal CT scans. Data are expected next year from several multicenter clinical trials.

--By Kerri Wachter (on twitter @knwachter)

BALTIMORE – Computed tomographic angiography can accurately and noninvasively measure the changes in overall and composition-specific plaque volume as a result of statin therapy.

At 1.2 years’ follow-up, there was a significant 38% decrease in total plaque volume in individuals on statin therapy compared with patients not on statin therapy. This difference remained significant after adjustment for age, gender, and conventional risk factors. Significant changes in noncalcified volume (a 73% decrease) and mixed-plaque volume (a 10% decrease) also were seen in those on statins compared with the nonstatin group. In addition, calcified plaque remained relatively stable, decreasing by 3.5% in the statin therapy group compared with the nonstatin group.

"Statin therapy was associated with a significant decrease in plaque volume, especially in noncalcified plaque volumes, and it was more prominent in women," Dr. Vahid Nabavi said at the annual meeting of the Society of Cardiovascular Computed Tomography.

Several cardiovascular imaging studies revealed that progression of coronary plaque volume over time is an independent predictor of cardiovascular mortality. Intravascular ultrasound (IVUS) provides high-resolution images capable of revealing early preclinical coronary artery disease. However, it is a highly invasive and expensive technique, and will be used only in conjunction with complex coronary interventions, noted Dr. Nabavi, who is a research fellow at the Los Angeles Biomedical Research Institute at Harbor–University of California, Los Angeles, Medical Center.

Quantitative measurements of coronary plaque made with cardiovascular CT angiography (CTA) correlate well with plaque measurements made using IVUS. Low-density noncalcified plaque on CTA correlates with necrotic core plus fibrofatty tissue on IVUS. CTA could be a less expensive, noninvasive alternative to IVUS, particularly for measuring changes in plaque associated with therapy, Dr. Nabavi noted.

In this study, 107 patients underwent serial, clinically indicated CTAs. Their mean age was 67 years, and 81% were men. The median follow-up was 1.2 years. The researchers collected data on risk factors, statin therapy, and laboratory findings.

They quantitatively measured the change in indexed total and composition-specific plaque volume of the target segment with luminal stenosis less than 50% in patients on statin therapy (40 mg of atorvastatin daily) or those with lifestyle changes only.

At baseline, there were no significant differences between groups in age, gender, clinical demographics, risk factors, or total and composition-specific plaque volumes. After adjustment, decreases in overall, mixed, calcified, and noncalcified plaque volumes between those on statins and those not on statins were 56%, 12%, 43%, and 144%. "More robust changes were seen in women," Dr. Nabavi said.

Dr. Nabavi did not report whether he had any conflicts of interest.

BALTIMORE – Computed tomographic angiography can accurately and noninvasively measure the changes in overall and composition-specific plaque volume as a result of statin therapy.

At 1.2 years’ follow-up, there was a significant 38% decrease in total plaque volume in individuals on statin therapy compared with patients not on statin therapy. This difference remained significant after adjustment for age, gender, and conventional risk factors. Significant changes in noncalcified volume (a 73% decrease) and mixed-plaque volume (a 10% decrease) also were seen in those on statins compared with the nonstatin group. In addition, calcified plaque remained relatively stable, decreasing by 3.5% in the statin therapy group compared with the nonstatin group.

"Statin therapy was associated with a significant decrease in plaque volume, especially in noncalcified plaque volumes, and it was more prominent in women," Dr. Vahid Nabavi said at the annual meeting of the Society of Cardiovascular Computed Tomography.

Several cardiovascular imaging studies revealed that progression of coronary plaque volume over time is an independent predictor of cardiovascular mortality. Intravascular ultrasound (IVUS) provides high-resolution images capable of revealing early preclinical coronary artery disease. However, it is a highly invasive and expensive technique, and will be used only in conjunction with complex coronary interventions, noted Dr. Nabavi, who is a research fellow at the Los Angeles Biomedical Research Institute at Harbor–University of California, Los Angeles, Medical Center.

Quantitative measurements of coronary plaque made with cardiovascular CT angiography (CTA) correlate well with plaque measurements made using IVUS. Low-density noncalcified plaque on CTA correlates with necrotic core plus fibrofatty tissue on IVUS. CTA could be a less expensive, noninvasive alternative to IVUS, particularly for measuring changes in plaque associated with therapy, Dr. Nabavi noted.

In this study, 107 patients underwent serial, clinically indicated CTAs. Their mean age was 67 years, and 81% were men. The median follow-up was 1.2 years. The researchers collected data on risk factors, statin therapy, and laboratory findings.

They quantitatively measured the change in indexed total and composition-specific plaque volume of the target segment with luminal stenosis less than 50% in patients on statin therapy (40 mg of atorvastatin daily) or those with lifestyle changes only.

At baseline, there were no significant differences between groups in age, gender, clinical demographics, risk factors, or total and composition-specific plaque volumes. After adjustment, decreases in overall, mixed, calcified, and noncalcified plaque volumes between those on statins and those not on statins were 56%, 12%, 43%, and 144%. "More robust changes were seen in women," Dr. Nabavi said.

Dr. Nabavi did not report whether he had any conflicts of interest.

BALTIMORE – Computed tomographic angiography can accurately and noninvasively measure the changes in overall and composition-specific plaque volume as a result of statin therapy.

At 1.2 years’ follow-up, there was a significant 38% decrease in total plaque volume in individuals on statin therapy compared with patients not on statin therapy. This difference remained significant after adjustment for age, gender, and conventional risk factors. Significant changes in noncalcified volume (a 73% decrease) and mixed-plaque volume (a 10% decrease) also were seen in those on statins compared with the nonstatin group. In addition, calcified plaque remained relatively stable, decreasing by 3.5% in the statin therapy group compared with the nonstatin group.

"Statin therapy was associated with a significant decrease in plaque volume, especially in noncalcified plaque volumes, and it was more prominent in women," Dr. Vahid Nabavi said at the annual meeting of the Society of Cardiovascular Computed Tomography.

Several cardiovascular imaging studies revealed that progression of coronary plaque volume over time is an independent predictor of cardiovascular mortality. Intravascular ultrasound (IVUS) provides high-resolution images capable of revealing early preclinical coronary artery disease. However, it is a highly invasive and expensive technique, and will be used only in conjunction with complex coronary interventions, noted Dr. Nabavi, who is a research fellow at the Los Angeles Biomedical Research Institute at Harbor–University of California, Los Angeles, Medical Center.

Quantitative measurements of coronary plaque made with cardiovascular CT angiography (CTA) correlate well with plaque measurements made using IVUS. Low-density noncalcified plaque on CTA correlates with necrotic core plus fibrofatty tissue on IVUS. CTA could be a less expensive, noninvasive alternative to IVUS, particularly for measuring changes in plaque associated with therapy, Dr. Nabavi noted.

In this study, 107 patients underwent serial, clinically indicated CTAs. Their mean age was 67 years, and 81% were men. The median follow-up was 1.2 years. The researchers collected data on risk factors, statin therapy, and laboratory findings.

They quantitatively measured the change in indexed total and composition-specific plaque volume of the target segment with luminal stenosis less than 50% in patients on statin therapy (40 mg of atorvastatin daily) or those with lifestyle changes only.

At baseline, there were no significant differences between groups in age, gender, clinical demographics, risk factors, or total and composition-specific plaque volumes. After adjustment, decreases in overall, mixed, calcified, and noncalcified plaque volumes between those on statins and those not on statins were 56%, 12%, 43%, and 144%. "More robust changes were seen in women," Dr. Nabavi said.

Dr. Nabavi did not report whether he had any conflicts of interest.

NATIONAL HARBOR – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after transcatheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE, according to a retrospective study.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Photo Courtesy of MGH Cardiac Ultrasound Laboratory

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality (N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid-systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

NATIONAL HARBOR – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after transcatheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE, according to a retrospective study.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Photo Courtesy of MGH Cardiac Ultrasound Laboratory

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality (N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid-systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

NATIONAL HARBOR – Measurements of aortic annular geometry, valve calcification, and final device position with two- and three-dimensional echocardiography are predictive of increased risk of leakage after transcatheter valve implantation, according to a retrospective study.

The study also showed that 3-D transesophageal echocardiography (3-D TEE) does a better job of measuring the aortic annulus, compared with 2-D TEE, according to a retrospective study.

The annular measurement is critical for optimal valve sizing and prevention of paravalvular aortic regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR).

Photo Courtesy of MGH Cardiac Ultrasound Laboratory

Paravalvular aortic regurgitation (PAR), is a known complication of TAVR, and according to 2-year analysis of the PARTNER trial, PAR after TAVR was associated with increased late mortality (N. Engl. J. Med. 2012;366:1686-95).

TAVR is in its infancy in the United States, compared with Europe, and experts are studying how and which imaging techniques could yield the best results before, during, and after TAVR (also called TAVI).

"Every center has their preference," said Dr. Praveen Mehrotra, a noninvasive cardiologist and the lead author of the study at Massachusetts General Hospital in Boston. "Some centers use CT and 2-D TEE. At Mass General, we integrate information obtained from 2-D and 3-D TEE."

Meanwhile, the role of 3-D TEE in TAVR hasn’t been adequately explored, added Dr. Mehrotra, who presented his poster at the annual meeting of the American Society of Echocardiography.

Dr. Mehrotra and his colleagues set out to retrospectively identify 2-D and 3-D TEE parameters that could predict significant PAR after TAVR.

They analyzed 2-D and 3-D TEE images from 94 patients undergoing TAVR between June 2008 and December 2011. The images were used to assess three parameters: annulus geometry, aortic valve apparatus calcification, and final device position.

Twenty one of the patients (22%) showed significant PAR after TAVR, but before postdilation.

In 2-D TEE, the annulus geometry was assessed by measuring the largest anteroposterior annulus dimension at the aortic valve hinge points in mid-systole, the authors wrote. Using 3-D TEE, researchers measured or calculated four parameters for the aortic annulus geometry: minor axis, major axis, eccentricity index, and annular area.

The annular dimension measured by 2-D TEE was similar in the PAR (22.8 mm) and No PAR (22.4 mm) groups. But, the 3-D TEE measurements were significantly larger in the PAR group than in the No PAR group, as measured by annular minor axis (23.8 mm vs. 22.7 mm), major axis (27.0 mm vs. 25.3 mm), eccentricity index (0.88 vs. 0.90), and annular area (5.19 cm² vs. 4.52 cm²), the researchers reported.

The annular-prosthesis incongruence (API) index was also significantly higher in patients with PAR (1.07% vs. 0.93%), "indicating valve undersizing in this group," the authors wrote.

Using 3-D TEE, the researchers identified and graded significant areas of calcification in the aortic valve apparatus, which is also very important before TAVR, said Mehrotra.

The final device position was assessed using 2-D TEE images.

The results showed that higher API index, Aortic Valve Apparatus Calcification score, and final position of the device were predictors of significant PAR after TAVR, with odds ratios of 9.4, 3.6, and 1.2, respectively, the authors reported.

"Our study highlights the ability of 2-D and 3-D TEE for accurate annular sizing and optimal valve positioning during TAVR," they wrote.

The takeaway message, said Dr. Mehrotra in an interview, is that "the role of echo is essential before, during, and after TAVR.

He added that 3-D echocardiography has an emerging role in annular sizing. In particular, annular area by 3-D TEE may be more important than the anteroposterior dimension by 2-D TEE for accurate valve sizing, said Dr. Mehrotra. "Technologies like 3-D TEE and cardiac CT can help with preprocedural planning, but they should be used by people who understand how to use them."

While his study focused on 2-D and 3-D TEE, Dr. Mehrotra said he expected more studies begin comparing cardiac CT and 3-D TEE, which is more like, "comparing apples to apples."

In a discussion on TAVR imaging, Dr. Rebecca T. Hahn, director of interventional echocardiography at Columbia University, New York, said that cardiac CT and echocardiography are complementary. However, CT is less user-dependent, compared with 3-D TEE.

Dr. Mehrotra and Dr. Hahn had no relevant financial disclosures.

Transthoracic two-dimensional echocardiography appears to be inadequate for identifying cardiomyopathy in adults who survive childhood cancer, according to a cross-sectional study published online July 16 in the Journal of Clinical Oncology.

Compared with cardiac magnetic resonance imaging (CMRI), which is considered the reference standard to which other cardiac imaging techniques are compared, 2-D echocardiography had a sensitivity of only 25% and a false-negative rate of 75% in identifying cardiomyopathy in a study of 134 adult survivors of childhood cancer, said Dr. Gregory T. Armstrong of the department of epidemiology and cancer control at St. Jude Children’s Research Hospital, Memphis, and his associates.

In these relatively young and apparently healthy study subjects who had never been diagnosed as having any cardiac abnormality, nearly half (48%) were found to have the reduced cardiac mass indicative of cancer therapy–related injury. And fully 11% of subjects who were judged to have a normal ejection fraction (EF) on 2-D echocardiography were actually proved to have an EF of less than 50% on CMRI, the researchers noted.

That number easily could have been higher, but there happened to be a low absolute number of patients (16) with this degree of EF impairment in the small cohort, they pointed out.

Adults who survive childhood cancer are at risk for cardiomyopathy because of their exposure to chemotherapy and radiotherapy. Current guidelines recommend screening such adults by transthoracic 2-D echocardiography because it is noninvasive, widely available, and less expensive than other techniques.

However, the quality of the acoustic windows obtained on 2-D echo varies widely, and the method depends on geometric assumptions that may not be valid in patients who have dilated or remodeled ventricles. Three-dimensional echocardiography yields somewhat more accurate results but is not as widely available. CMRI is the most accurate noninvasive imaging technique, but is more expensive and is even less widely available, Dr. Armstrong and his colleagues explained.

They assessed the accuracy of 2-D and 3-D echocardiography against CMRI as a screen for cardiomyopathy in a longitudinal cohort of 134 adults who had been treated at St. Jude’s for childhood cancer 18-38 years earlier. All had received chest-directed radiotherapy and/or anthracycline chemotherapy, both of which are known to impair cardiac function during treatment and to raise the risk of reduced left ventricular function later in life.

The most common pediatric malignancies were acute lymphoblastic leukemia (44 subjects) and Hodgkin’s lymphoma (37 subjects).

The median age at echocardiographic screening in adulthood was 39 years (range, 22-53 years).

Of the study subjects, 20 were unable to complete CMRI for a variety of reasons. Future studies that compare imaging techniques should take into consideration this relatively high noncompletion rate (15%) for CMRI, especially in cost-benefit analyses, Dr. Armstrong and his colleagues said (J. Clin. Oncol. 2012 July 16 [doi:10.1200/JCO.2011.40.3584]).

In the remaining 114 subjects, 2-D echocardiography consistently overestimated left ventricular ejection fraction (LVEF) and underestimated both end-systolic and end-diastolic ventricular volumes.

In all, 16 subjects were identified as having markedly decreased LVEF (50% or more) by CMRI, but only 4 of them were so identified by 2-D echocardiography and only 11 of them by 3-D echocardiography.

Compared with CMRI, the sensitivity of 2-D echocardiography was only 25%; that of 3-D echo was better but still inadequate, at only 53%. And false-negative rates were high with both 2-D echocardiography (75%) and 3-D echocardiography (47%).

Of particular concern was the finding that on CMRI, 32% of the study subjects had an LVEF that was well below normal. The rate in the subgroup of patients who had received both chest irradiation and anthracycline during childhood cancer treatment was even higher, at 42%.

A total of 48% of the study subjects had a cardiac mass that was at least 2 standard deviations below normal for their age and sex, a clear sign of cardiotoxicity from their childhood cancer treatment. "Notably, even patients who received less than 150 mg/m² of anthracyclines had a high prevalence of reduced EF (27%), stroke volume (29%), or cardiac mass (56%)," the investigators said.

Estimates derived from Medicare data suggest that at roughly $449 each, CMRI examinations cost about $217 more than does echocardiography ($232 each). Given the high rate of cardiomyopathy discovered in this cohort, and the poor sensitivity of echocardiography as a screening tool, this cost difference may be small enough to warrant a switch in the current screening recommendations from echocardiography to CMRI.

The additional cost of a CMRI-only screening strategy per case of cardiotoxicity correctly identified would be only $1,973, they noted.

The study findings suggest that in this high-risk patient population that was exposed to cardiotoxic therapy during childhood, "consideration should be given to referring survivors with an EF of 50%-59% on [2-D echocardiography] for comprehensive cardiology assessment that includes cardiac history, symptom index, and examination; biomarker assessment; consideration of [CMRI]; functional assessment by treadmill testing; and possibly medical therapy to prevent progression of disease," Dr. Armstrong and his associates said.

This study was supported by the American Society of Clinical Oncology and the American Lebanese-Syrian Associated Charities. Dr. Armstrong’s associates reported ties to General Electric and Philips Healthcare.

Transthoracic two-dimensional echocardiography appears to be inadequate for identifying cardiomyopathy in adults who survive childhood cancer, according to a cross-sectional study published online July 16 in the Journal of Clinical Oncology.

Compared with cardiac magnetic resonance imaging (CMRI), which is considered the reference standard to which other cardiac imaging techniques are compared, 2-D echocardiography had a sensitivity of only 25% and a false-negative rate of 75% in identifying cardiomyopathy in a study of 134 adult survivors of childhood cancer, said Dr. Gregory T. Armstrong of the department of epidemiology and cancer control at St. Jude Children’s Research Hospital, Memphis, and his associates.

In these relatively young and apparently healthy study subjects who had never been diagnosed as having any cardiac abnormality, nearly half (48%) were found to have the reduced cardiac mass indicative of cancer therapy–related injury. And fully 11% of subjects who were judged to have a normal ejection fraction (EF) on 2-D echocardiography were actually proved to have an EF of less than 50% on CMRI, the researchers noted.

That number easily could have been higher, but there happened to be a low absolute number of patients (16) with this degree of EF impairment in the small cohort, they pointed out.

Adults who survive childhood cancer are at risk for cardiomyopathy because of their exposure to chemotherapy and radiotherapy. Current guidelines recommend screening such adults by transthoracic 2-D echocardiography because it is noninvasive, widely available, and less expensive than other techniques.

However, the quality of the acoustic windows obtained on 2-D echo varies widely, and the method depends on geometric assumptions that may not be valid in patients who have dilated or remodeled ventricles. Three-dimensional echocardiography yields somewhat more accurate results but is not as widely available. CMRI is the most accurate noninvasive imaging technique, but is more expensive and is even less widely available, Dr. Armstrong and his colleagues explained.

They assessed the accuracy of 2-D and 3-D echocardiography against CMRI as a screen for cardiomyopathy in a longitudinal cohort of 134 adults who had been treated at St. Jude’s for childhood cancer 18-38 years earlier. All had received chest-directed radiotherapy and/or anthracycline chemotherapy, both of which are known to impair cardiac function during treatment and to raise the risk of reduced left ventricular function later in life.

The most common pediatric malignancies were acute lymphoblastic leukemia (44 subjects) and Hodgkin’s lymphoma (37 subjects).

The median age at echocardiographic screening in adulthood was 39 years (range, 22-53 years).

Of the study subjects, 20 were unable to complete CMRI for a variety of reasons. Future studies that compare imaging techniques should take into consideration this relatively high noncompletion rate (15%) for CMRI, especially in cost-benefit analyses, Dr. Armstrong and his colleagues said (J. Clin. Oncol. 2012 July 16 [doi:10.1200/JCO.2011.40.3584]).

In the remaining 114 subjects, 2-D echocardiography consistently overestimated left ventricular ejection fraction (LVEF) and underestimated both end-systolic and end-diastolic ventricular volumes.

In all, 16 subjects were identified as having markedly decreased LVEF (50% or more) by CMRI, but only 4 of them were so identified by 2-D echocardiography and only 11 of them by 3-D echocardiography.

Compared with CMRI, the sensitivity of 2-D echocardiography was only 25%; that of 3-D echo was better but still inadequate, at only 53%. And false-negative rates were high with both 2-D echocardiography (75%) and 3-D echocardiography (47%).

Of particular concern was the finding that on CMRI, 32% of the study subjects had an LVEF that was well below normal. The rate in the subgroup of patients who had received both chest irradiation and anthracycline during childhood cancer treatment was even higher, at 42%.

A total of 48% of the study subjects had a cardiac mass that was at least 2 standard deviations below normal for their age and sex, a clear sign of cardiotoxicity from their childhood cancer treatment. "Notably, even patients who received less than 150 mg/m² of anthracyclines had a high prevalence of reduced EF (27%), stroke volume (29%), or cardiac mass (56%)," the investigators said.

Estimates derived from Medicare data suggest that at roughly $449 each, CMRI examinations cost about $217 more than does echocardiography ($232 each). Given the high rate of cardiomyopathy discovered in this cohort, and the poor sensitivity of echocardiography as a screening tool, this cost difference may be small enough to warrant a switch in the current screening recommendations from echocardiography to CMRI.

The additional cost of a CMRI-only screening strategy per case of cardiotoxicity correctly identified would be only $1,973, they noted.

The study findings suggest that in this high-risk patient population that was exposed to cardiotoxic therapy during childhood, "consideration should be given to referring survivors with an EF of 50%-59% on [2-D echocardiography] for comprehensive cardiology assessment that includes cardiac history, symptom index, and examination; biomarker assessment; consideration of [CMRI]; functional assessment by treadmill testing; and possibly medical therapy to prevent progression of disease," Dr. Armstrong and his associates said.

This study was supported by the American Society of Clinical Oncology and the American Lebanese-Syrian Associated Charities. Dr. Armstrong’s associates reported ties to General Electric and Philips Healthcare.

Transthoracic two-dimensional echocardiography appears to be inadequate for identifying cardiomyopathy in adults who survive childhood cancer, according to a cross-sectional study published online July 16 in the Journal of Clinical Oncology.

Compared with cardiac magnetic resonance imaging (CMRI), which is considered the reference standard to which other cardiac imaging techniques are compared, 2-D echocardiography had a sensitivity of only 25% and a false-negative rate of 75% in identifying cardiomyopathy in a study of 134 adult survivors of childhood cancer, said Dr. Gregory T. Armstrong of the department of epidemiology and cancer control at St. Jude Children’s Research Hospital, Memphis, and his associates.

In these relatively young and apparently healthy study subjects who had never been diagnosed as having any cardiac abnormality, nearly half (48%) were found to have the reduced cardiac mass indicative of cancer therapy–related injury. And fully 11% of subjects who were judged to have a normal ejection fraction (EF) on 2-D echocardiography were actually proved to have an EF of less than 50% on CMRI, the researchers noted.

That number easily could have been higher, but there happened to be a low absolute number of patients (16) with this degree of EF impairment in the small cohort, they pointed out.

Adults who survive childhood cancer are at risk for cardiomyopathy because of their exposure to chemotherapy and radiotherapy. Current guidelines recommend screening such adults by transthoracic 2-D echocardiography because it is noninvasive, widely available, and less expensive than other techniques.

However, the quality of the acoustic windows obtained on 2-D echo varies widely, and the method depends on geometric assumptions that may not be valid in patients who have dilated or remodeled ventricles. Three-dimensional echocardiography yields somewhat more accurate results but is not as widely available. CMRI is the most accurate noninvasive imaging technique, but is more expensive and is even less widely available, Dr. Armstrong and his colleagues explained.

They assessed the accuracy of 2-D and 3-D echocardiography against CMRI as a screen for cardiomyopathy in a longitudinal cohort of 134 adults who had been treated at St. Jude’s for childhood cancer 18-38 years earlier. All had received chest-directed radiotherapy and/or anthracycline chemotherapy, both of which are known to impair cardiac function during treatment and to raise the risk of reduced left ventricular function later in life.

The most common pediatric malignancies were acute lymphoblastic leukemia (44 subjects) and Hodgkin’s lymphoma (37 subjects).

The median age at echocardiographic screening in adulthood was 39 years (range, 22-53 years).

Of the study subjects, 20 were unable to complete CMRI for a variety of reasons. Future studies that compare imaging techniques should take into consideration this relatively high noncompletion rate (15%) for CMRI, especially in cost-benefit analyses, Dr. Armstrong and his colleagues said (J. Clin. Oncol. 2012 July 16 [doi:10.1200/JCO.2011.40.3584]).

In the remaining 114 subjects, 2-D echocardiography consistently overestimated left ventricular ejection fraction (LVEF) and underestimated both end-systolic and end-diastolic ventricular volumes.

In all, 16 subjects were identified as having markedly decreased LVEF (50% or more) by CMRI, but only 4 of them were so identified by 2-D echocardiography and only 11 of them by 3-D echocardiography.

Compared with CMRI, the sensitivity of 2-D echocardiography was only 25%; that of 3-D echo was better but still inadequate, at only 53%. And false-negative rates were high with both 2-D echocardiography (75%) and 3-D echocardiography (47%).

Of particular concern was the finding that on CMRI, 32% of the study subjects had an LVEF that was well below normal. The rate in the subgroup of patients who had received both chest irradiation and anthracycline during childhood cancer treatment was even higher, at 42%.

A total of 48% of the study subjects had a cardiac mass that was at least 2 standard deviations below normal for their age and sex, a clear sign of cardiotoxicity from their childhood cancer treatment. "Notably, even patients who received less than 150 mg/m² of anthracyclines had a high prevalence of reduced EF (27%), stroke volume (29%), or cardiac mass (56%)," the investigators said.

Estimates derived from Medicare data suggest that at roughly $449 each, CMRI examinations cost about $217 more than does echocardiography ($232 each). Given the high rate of cardiomyopathy discovered in this cohort, and the poor sensitivity of echocardiography as a screening tool, this cost difference may be small enough to warrant a switch in the current screening recommendations from echocardiography to CMRI.

The additional cost of a CMRI-only screening strategy per case of cardiotoxicity correctly identified would be only $1,973, they noted.

The study findings suggest that in this high-risk patient population that was exposed to cardiotoxic therapy during childhood, "consideration should be given to referring survivors with an EF of 50%-59% on [2-D echocardiography] for comprehensive cardiology assessment that includes cardiac history, symptom index, and examination; biomarker assessment; consideration of [CMRI]; functional assessment by treadmill testing; and possibly medical therapy to prevent progression of disease," Dr. Armstrong and his associates said.

This study was supported by the American Society of Clinical Oncology and the American Lebanese-Syrian Associated Charities. Dr. Armstrong’s associates reported ties to General Electric and Philips Healthcare.