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09:56 CET
MS 4 - The heart team: coronary imaging and treatment
Wednesday, February 28, 16:00 - 17:30
Room: F2
Moderator: E. A. Mershina (Moscow/RU)

Chairperson's introduction
E. A. Mershina; Moscow/RU
Learning Objectives

1. To recognise the possibilities of modern coronary imaging modalities.
2. To explain possible discrepancies in the results of different diagnostic investigations and clinical picture.
3. To understand how to translate the results of coronary imaging into clinical practice.


Due to the rapid technological progress of non-invasive methods of cardiac visualisation frequent updates on the clinical indications to perform coronary CT angiography (cCTA) and cardiac magnetic resonance (CMR) are required. The role of each method including invasive coronary angiography in diagnostic algorithm in the patients with different degree of coronary artery disease (CAD) probability will be underlined. Various challenges still exist in acquiring high-quality imaging in cardiac CT, such as artifacts due to calcification and metallic densities, motion, noise and poor contrast enhancement. Nevertheless cCTA is the first-line diagnostic tool for low-to-intermediate risk CAD patients. On the other hand an invasive angiography supported by FFR is the method of choice for the patients with high probability of CAD. CMR myocardial perfusion imaging produces accurate information on the presence of myocardial ischemia. As a means of guiding the initial management of patients with stable angina and an intermediate-to-high risk of CAD, noninvasive CMR perfusion imaging is comparable to a strategy with invasive angiography supported by FFR. The implementation of different methods for coronary imaging will be illustrated by clinical examples.

Non-invasive cardiac imaging
V. Sinitsyn; Moscow/RU
Learning Objectives

1. To get knowledge about modern technology and protocols used in coronary/cardiac CT and MRI in coronary artery disease (CAD).
2. To learn about scientific evidence (including results of major clinical trials) supporting use of these technologies in CAD.
3. To be aware about new developments in non-invasive cardiac imaging including studies of coronary flow, myocardial perfusion and hybrid imaging.
4. To understand the role of co-operation between radiologists and cardiologists in non-invasive cardiac imaging for benefit of CAD patients.


Major indications for cardiac CT angiography are imaging of coronary arteries in suspected coronary artery disease, visualization of pulmonary veins and planning of endovascular surgical procedures (such as TAVI). Modern types of CT scanners open up the opportunity to reach significant improvements of image quality of coronary arteries and heart structures even in "difficult" patients and to get high quality diagnostic images with very low radiation exposure and less volume of contrast media. The contemporary standard of coronary CTA (CCTA) is prospective-gated or high pitch wide detector or dual source acquisition with iterative image reconstruction. There are some new technologies for assessment of coronary or myocardial blood flow with the help of CCTA such as perfusion CT, CT-FFR, dual-energy CT. Major indications for cardiac MR (CMR) are cardiomyopathies, myocarditis or coronary artery disease (imaging of scars and perfusion). Selection of cardiac MR protocols is dependent on the main indication for examination. Cine-MR, black-blood sequences, perfusion and late gadolinium enhancement modules together with blood flow analysis are the most used ones. Today the tissue characterization modules (T1, T2 mapping) have become the essential part of CMR protocols. Recent changes in cardiological paradigms about approaches to diagnosis, treatment, and assessment of prognosis in patients with coronary artery disease (CAD ) together with the technical development of CCTA and CMR and accumulation of scientific data proving the high diagnostic value of both imaging modalities have shown their high value in assessment of prognosis and selection of the optimal therapy.

Interventional treatment/percutaneous
A. Osiev; Moscow/RU
Learning Objectives

1. To learn about the current indications for diagnostic coronary catheterisation and transluminal interventions.
2. To know about the latest innovations in percutaneous coronary revascularisation technique.
3. To understand difficulties in assessment of stenosis and occlusions during coronary interventions.
4. To be aware how combined analysis of coronary CTA and invasive coronary angiography could help in planning of interventional treatment of coronary lesions.


The strategy of diagnosis of coronary artery disease (CAD) was changed since non-invasive multi-detector computed tomography (MDCT) had been introduced into the common clinical practice. However, in case of high coronary calcium score the invasive coronary angiography remains the “Gold standard” in CAD diagnostics. Randomised clinical studies demonstrated that primary PCI significantly improve the outcomes in pts with ACS especially presenting with STEMI, but influence of PCI on long-term prognosis in pts with stable CAD is still unclear. Today the most controversial issues are the management of the Left Main CAD and strategy selection of myocardial revascularisation in pts with multivessel disease (MVD). According to recent research data in these cases, we shouldn’t make a decision if not to consider SYNTAX Score and SYNTAX score II. As well, the questions of chronic total occlusion revascularisation remain unresolved and require meticulous preliminary non-invasive assessment of myocardial viability. The innovative methods of visualisation are helpful in decision-making in the presence of complex cases. Fractional flow reserve (FFR) measurement provides important information about lesion severity especially in the presence of MVD. Indications for stenting and result assessment can be evaluated by intravascular ultrasound imaging (IVUS) and optical coherent tomography (OCT). MDCT allows the physicians to verify the anatomical features of culprit lesion and key criteria of strategy definition and prediction of procedure success.

The role of coronary imaging in the coronary artery bypass and valve surgery
K. Mershin; Moscow/RU
Learning Objectives

1. To learn about surgeon's opinion and the possibilities of different methods of coronary imaging.
2. To understand which coronary imaging modality should be the best in complicated cases.
3. To be aware of CT coronary angiography benefits in the redo procedures.


Coronary angiography (CAG) is a golden standard in diagnosis of coronary artery disease (CAD) especially for patients referred to open cardiac procedures. Is it always indispensable tool in cardiac surgery? Apart from obvious advantages of CAG, there are a lot of drawbacks of the method. Failing of 3D anatomy and surrounding structures, poor enhancement of occluded vessels, poor assessment of the vessel wall, contrast wash-out should be underlined. That can create serious discrepancies between preoperative and intraoperative views, especially in complex lesions, which can change operative planning. Since grafts are to be harvested earlier, that can lead to unnecessary trauma on the harvest sites or excessive nervousness by harvesting additional ones during aortic crossclamping. Coronary CTA (CCTA) gives a lot of additional information regarding coronary and thoracic anatomy. It can reliably demonstrate deep intramyocardial and “intra-fatty” course of CA, show 3D relations between the arteries and surrounding structures, give additional information about occluded artery and vessel wall. It can help in diagnosing ostial stenotic lesions of the left main stem artery and relevant atheromatosis of the ascending aorta. In redo surgery CCTA shows possibilities of safe sternum reentry, course of functioning grafts and landing zones of occluded grafts. CCTA can be used to exclude significant asymptomatic CAD in patients referred to other types of surgery. If no proximal CAD detected - there is only minimal risk of perioperative ischemia in this cohort. We think that CCTA should be used in a wider range of indications for patients undergoing cardiac procedures.

Multidisciplinary case presentation and discussion
Y. Ashikhmin; Moscow/RU
Learning Objectives

1. To outline the rational diagnostics pathways in typical situations: following the guidelines.
2. To learn how to manage the difficult diagnostic cases: beyond the guidelines.
3. To explain how to switch clinicians from invasive procedures to cardiac MRI and CT when it is the best bet.
4. To discuss the future in imaging technologies translation: from the technology-driven to the unmet clinical need-driven progress in imagine tools.


At present time, non-invasive cardiac imaging tools intensively penetrate clinical guidelines. Nevertheless, use of modern imaging devices capabilities by majority of cardiologists are still scanty. On the other hand, some physicians have many footless expectations about potential of conventional scanners. The rational diagnostics pathways in typical clinical situations and difficult diagnostic cases will be highlighted within multidisciplinary discussion. An important place will be given to the discussion of implementation of the current guidelines in the real world clinical practice, mentioning the areas of uncertainty and discrepancies in the guidelines as well as evidence-based personalized diagnostic strategies. Furthermore, attention will be paid to cardiovascular prophylaxis, in particular, the usefulness of the coronary calcium scoring will be highlighted. It will be explained how to switch clinicians from invasive procedures to cardiac MRI and CT when it is the best bet. At last, the future of imaging technologies will be discussed, including the present transition from the technology-driven model to the unmet clinical need-driven progress in imagine tools.

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