Objective: While the risk of acute coronary events has been associated with biological variability of circulating cholesterol, the association with variability of other atherogenic lipids remains less understood. We evaluated the longitudinal variability of 284 lipids and investigated their association with asymptomatic coronary atherosclerosis. Approach and Results: Circulating lipids were extracted from fasting blood samples of 83 community-sampled symptom-free participants (age 41–75 years), collected longitudinally over 6 months. Three types of coronary plaque volume (calcified, lipid-rich, and fibrotic) were quantified using computed tomography coronary angiogram. We first deconvoluted between-subject (CV _g ) and within-subject (CV _w ) lipid variabilities. We then tested whether the mean lipid abundance was different across groups categorized by Framingham risk score and plaques phenotypes (lipid-rich, fibrotic, and calcified). Finally, we investigated whether visit-to-visit variability of each lipid was associated with plaque burden. Most lipids (72.5%) exhibited higher CV _g than CV _w . Among the lipids (n=145) with 1.2-fold higher CV _g than CV _w , 26 species including glycerides and ceramides were significantly associated with Framingham risk score and the 3 plaque phenotypes (false discovery rate <0.05). In an exploratory analysis of person-specific visit-to-visit variability without multiple testing correction, high variability of 3 lysophospholipids (lysophosphatidylethanolamines 16:0, 18:0, and lysophosphatidylcholine O-18:1) was associated with lipid-rich and fibrotic (noncalcified) plaque volume while high variability of diacylglycerol 18:1_20:0, triacylglycerols 52:2, 52:3, and 52:4, ceramide d18:0/20:0, dihexosylceramide d18:1/16:0, and sphingomyelin 36:3 was associated with calcified plaque volume. Conclusions: High person-specific longitudinal variation of specific nonsterol lipids is associated with the burden of subclinical coronary atherosclerosis. Larger studies are needed to confirm these exploratory findings.

Wee CF, et al. J Cardiovasc Imaging. 2022 Jul;30(3):153-168. https://doi.org/10.4250/jcvi.2021.0159

Purpose To develop a new coronary CT angiography (CCTA)-based index, α×LL/MLD⁴, that considers lesion entrance angle (α) in addition to lesion length (LL) and minimal lumen diameter (MLD) and to evaluate its efficacy in predicting hemodynamically significant coronary stenosis compared with invasive coronary angiography (ICA)-derived fractional flow reserve (FFR). Materials and Methods This prospective study enrolled participants (September 2016-March 2020) from two centers who underwent CCTA followed by ICA (ClinicalTrials.gov identifier: NCT03054324). CCTA images were processed semiautomatically to measure LL, MLD, and α for calculating α×LL/MLD⁴. Diagnostic performance and accuracy of α×LL/MLD⁴ and LL/MLD⁴ in detecting hemodynamically significant coronary stenosis were compared against the reference standard (invasive FFR ≤ 0.80). Results In total, 133 participants (mean age, 63 years ± 9 [SD]; 99 [74%] men) with 210 stenosed coronary arteries were analyzed. Median α×LL/MLD⁴ was 54.0 degree/mm³ (IQR, 25.3-128.7) in participants with invasive FFR of 0.80 or less and 6.7 degree/mm³ (IQR, 3.3-12.8) in participants with invasive FFR of more than 0.80 (P < .001). The per-vessel accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for discriminating ischemic lesions were 86.2%, 83.1%, 88.4%, 84.1%, and 87.7% for α×LL/MLD⁴ and 80.5%, 66.3%, 90.9%, 84.3%, and 78.6% for LL/MLD⁴, respectively. Area under the receiver operating characteristic curve for discriminating hemodynamically significant stenosis was 0.93 for α×LL/MLD⁴, which was significantly greater than the values of 0.84 for LL/MLD⁴ and 0.63 for diameter stenosis (both P < .001). Conclusion The new morphologic index, α×LL/MLD⁴, incorporating lesion entrance angle achieved higher diagnostic performance in detecting hemodynamically significant lesions compared with diameter stenosis and LL/MLD⁴. Keywords: CT Angiography, Cardiac, Coronary Arteries, Ischemia, Infarction, Technology Assessment Clinical trial registration no. NCT03054324 Supplemental material is available for this article. © RSNA, 2023 See also the commentary by Fairbairn and Nørgaard in this issue.

Introduction: Computed tomography angiography of the aorta (CTAA) is the modality of choice for investigating aortic disease. Our aim was to evaluate the image quality, contrast enhancement and radiation dose of electrocardiograph (ECG)-triggered and non-ECG-triggered CTAA on a 256-slice single-source CT scanner. This allows the requesting clinician and the radiologist to balance radiation risk and image quality. Methods: We retrospectively assessed the data of 126 patients who had undergone CTAA on a single-source CT scanner using ECG-triggered (group 1, n = 77) or non-ECG-triggered (group 2, n = 49) protocols. Radiation doses were compared. Qualitative (4-point scale) and quantitative image quality assessments were performed. Results: The mean volume CT dose index, dose length product and effective dose in group 1 were 12.4 ± 1.9 mGy, 765.8 ± 112.4 mGy cm and 13.0 ± 1.9 mSv, respectively. These were significantly higher compared to group 2 values (9.1 ± 2.6 mGy, 624.1 ± 174.8 mGy cm and 10.6 ± 3.0 mSv, respectively) (P < 0.001). Qualitative assessment showed the image quality at the aortic root–proximal ascending aorta was significantly higher in group 1 (median 3) than in group 2 (median 2, P < 0.001). Quantitative assessment showed significantly better mean arterial attenuation, signal-to-noise ratio and contrast-to-noise ratio in ECG-triggered CTAA compared to non-ECG-triggered CTAA. Conclusion: ECG-triggered CTAA in a single-source scanner has superior image quality and vessel attenuation of aortic root/ascending aorta, but a higher radiation dose of approximately 23%. Its use should be considered specifically when assessing aortic root/ascending aorta pathology.

Partial anomalous pulmonary venous return (PAPVR) is a rare congenital heart condition which is often asymptomatic and hence remains undiagnosed, but could occasionally be detected on thoracic imaging as an incidental finding. For rare cases of newly diagnosed pulmonary hypertension with concurrent PAPVRs, the diagnostic workup and subsequent management are more complicated, requiring a thorough evaluation of secondary causes of pulmonary hypertension, and assessing relative PAPVR shunt contribution to the pulmonary hypertension. We herein report a case of a 74-year-old Chinese male patient, a chronic smoker of 50 pack-years, and past medical history of hypertension and diabetes mellitus, who was admitted to our intensive care unit with acute decompensated type 2 respiratory failure, and subsequently found to have newly diagnosed pulmonary hypertension with right heart failure and an incidental PAPVR identified on inadvertent central venous cannulation (CVC) of the anomalous pulmonary vein draining into the left internal jugular vein. There are a few key learning points from this case study: firstly, we profile the characteristics and clinical outcomes of cases of incidental CVC cannulation of undiagnosed PAPVR from a literature review; and secondly, we discuss the diagnostic and management approach to newly diagnosed pulmonary hypertension with concomitant, incidental PAPVR that may be useful for internists and critical care physicians.