Abstract
Background and aim
To assess the prevalence of incidental extracardiac findings in patients who underwent cardiac CT for the evaluation of left atrial (LA) anatomy before atrial fibrillation (AF) catheter ablation. We also aimed to determine the independent predictors of relevant extracardiac alterations.
Patients and methods
We studied consecutive patients who underwent cardiac CT with a 256-slice scanner for the visualization of LA anatomy before AF ablation. Prevalence of clinically significant and not significant extracardiac findings were recorded. Moreover, we determined the variables associated with relevant extracardiac alterations with uni- and multivariate logistic regression analyses.
Results
In total, 1,952 consecutive patients who underwent cardiac CT examination between 2010 and 2020 were included in our study (mean age 61.2 ± 10.6 years; 66.2% male). Incidental extracardiac findings were detected in 820 (42.0%; 95%CI = 0.40–0.44%) patients, while clinically significant alterations were reported in 416 (21.3%; 95%CI = 20.0–23.2%) patients. When analyzing the predictors of clinically relevant alterations, age (OR = 1.04; 95%CI = 1.03–1.05), male sex (OR = 1.39; 95%CI = 1.12–1.73), chest pain (OR = 1.46; 95%CI = 1.09–1.93), hypertension (OR = 1.42; 95%CI = 1.12–1.81), heart failure (OR = 1.68; 95%CI = 1.09–2.53), obstructive CAD (OR = 1.56; 95%CI = 1.16–2.09) and prior stroke/TIA (OR = 1.56; 95%CI = 1.04–2.30) showed association with clinically significant incidental findings in the univariate analysis (all P < 0.05). In the multivariate analysis, age (OR = 1.04; 95%CI = 1.02–1.06; P < 0.001) proved to be the only significant predictor of clinically relevant extracardiac finding.
Conclusion
Cardiac CT performed before AF ablation is not only helpful in understanding LA anatomy, but might also identify clinically significant pathologies. These incidental findings might have further diagnostic or therapeutic consequences.
Introduction
Atrial fibrillation (AF) is the most common cardiac arrhythmia [1]. Catheter ablation has become a well-established therapeutic approach for the prevention of AF recurrences [1]. Cardiac computed tomography (CT) is frequently performed before catheter ablation to assess the anatomy of the left atrium (LA) and pulmonary veins (PVs) for preprocedural planning and to help precise intraprocedural catheter navigation [2–6]. As compared to other imaging modalities, cardiac CT not only proved to have better diagnostic value in the assessment of LA and PV anatomy, but it is better tolerated, cheaper and faster [7, 8]. Moreover, the evolution of the CT scanners allows better spatial and temporal resolution even at lower radiation exposures [9]. Therefore, cardiac CT is considered as the gold standard for the visualization of LA and PV anatomy prior to AF ablation. The analysis of extracardiac structures may identify incidental findings, defined as unsuspected findings, and some of these might be clinically relevant, or can even reveal malignant disease at a subclinical stage [10]. Prior studies have shown that incidental extracardiac findings are frequently detected in preablation cardiac CT scans [11–20]. However, these studies included smaller patient populations. Moreover, it is controversial whether reading cardiac CT for extracardiac findings is necessary. While some authors recommend reporting alterations of the adjacent structures in order not to miss important findings, others worry about the additional cost and radiation exposure, which might be unnecessary without proven benefit [21–25]. Even if pulmonary nodules are by far the most frequent extracardiac collateral findings, the vast majority of them is benign [26].
Therefore, we aimed to describe and quantify the spectrum of extracardiac incidental findings in patients who underwent ECG-gated cardiac CT before AF catheter ablation. Our secondary aim was to identify clinically significant findings, which lead to a change in patient management. In addition, we aimed to study confounders associated with the detection of clinically relevant incidental extracardiac findings.
Patients and methods
study population
We retrospectively included patients who underwent cardiac CT with a 256-slice CT scanner to assess LA and PV anatomy before first catheter ablation for AF at our centre between 2010 and 2020. Flowchart of the excluded patients is reported in Fig. 1. Preablation anthropometric and clinical data were reported in a structured reporting platform (Axis, Neumann Medical Ltd, Budapest, Hungary). Clinical characteristics and cardiovascular risk factors were obtained from medical reports. The study protocol was reviewed and approved by the institutional review board (SE RKEB 142/2019) and was in accordance with the Declaration of Helsinki and Institutional Guidelines.
Cardiac CT acquisition
Cardiac CT examinations were performed with a 256-slice scanner (Brilliance iCT 256, Philips Healthcare, Best, The Netherlands) or 280-slice scanner (GE Cardiographe, GE Healthcare, Boston, USA) with prospective ECG-triggered axial acquisition mode with 100–120 kV and 200–300 mAs tube current depending on patient anthropometrics. Field of view ranged between 190 and 320 mm Image acquisition was performed with 128 × 0.625 mm detector collimation, and 270 msec gantry rotation time. For heart rate control, a maximum of 50–100 mg metoprolol was given orally and 5–20 mg intravenously, if necessary. In patients with a heart rate of <80/min−1, mid-diastolic triggering was applied with 3–5% padding (73–83% of the R-R interval), and in those with ≥80/min−1, systolic triggering was chosen (35–45% of the R-R interval). Iomeprol contrast material (Iomeron 400, Bracco Ltd, Milan, Italy) was used with 85–95 ml contrast agent at a flow rate of 4.5–5.5 ml s−1 from antecubital vein access via 18-gauge catheter using a four-phasic protocol [27]. Bolus tracking in the LA was used to obtain proper scan timing. Non-contrast data sets were reconstructed with a slice thickness and increment of 2.5 mm, while cardiac CT data sets were reconstructed with 0.8 mm slice thickness and 0.4 mm increment.
Assessment of extracardiac findings
All images were analyzed using a commercially available software (Comprehensive Cardiac Analysis, Philips IntelliSpace Portal, Philips Healthcare, Best, The Netherlands). Images were displayed in the original two-dimensional format in the mediastinal windows, as well as in the two-dimensional multiplanar and three-dimensional reconstruction views. Extracardiac findings were validated by 15 radiologists using cardiac, mediastinal, lung, bone and liver windows.
Incidental extracardiac findings were defined as any unsuspected abnormality depicted outside of the pericardium. The following CT findings were reported: pattern of pulmonary parenchymal abnormalities (nodules, air-space opacities, ground-glass attenuation, emphysema), mediastinal lymph node enlargement, aortic aneurysm, pleural effusion, diaphragmatic hernia, degenerative spine disease. Findings of the upper abdominal region, such as the liver, were also reported. Clinically relevant or potentially relevant incidental findings included alterations requiring further examination or follow-up to confirm the diagnosis. These alterations included lung nodules over 6 mm, air-space opacity, ground-glass attenuation, moderate or severe emphysema, aortic aneurysm (defined as aortic dilatation over 40 mm), enlarged mediastinal lymph nodes over 10 mm, pleural effusion, diaphragmatic hernia over 20 mm, and moderate or severe degenerative spine disease. Non-significant findings included small linear lung opacities, small (less than 6 mm) or calcified nodules, mediastinal lymph nodes less than 10 mm and pleural thickening. This classification is based on the one applied by Sohns C et al. [16] Entirely normal CT scans were also noted.
Statistical analysis
All continuous variables are reported as mean ± standard deviation or numbers and proportions. Prevalence and 95% confidence intervals (CIs) were calculated. Due to the very low proportions, CIs were calculated based on Wilson’s formula. Thus, better coverage could be obtained as compared to normal approximations [28]. We examined the association of clinically relevant collateral extracardiac findings with potential confounders using uni- and multivariate logistic regression analyses. In the multivariate analysis adjustment was made for age, sex, body mass index (BMI), type of AF, smoking status chest pain, hypertension, hyperlipidemia, diabetes mellitus, heart failure, obstructive coronary artery disease (CAD), valve disease, cardiomyopathy, prior stroke or transient ischemic attack (TIA), thromboembolic disease, peripheral vasculopathy, thyroid gland disease or chronic kidney disease. Data regarding smoking status were missing in 325 (16.6%) patients; therefore multivariate analyses were performed in the remaining 1,627 patients. Statistical analysis was performed in R environment (version 4.0.2). All P values were two-sided and statistical significance was established at P < 0.050.
Results
Study population and prevalence of extracardiac findings
Altogether 1,952 patients were included in our analysis (mean age was 61.2 ± 10.6 years and 66.2% were male). Detailed demographic and clinical characteristics of the included patients are reported in Table 1. Total mean dose length product was 319.1 ± 110.1 mGy x cm. Overall, incidental extracardiac findings were detected in 820 (42.0%; 95%CI = 0.40–0.44%) patients. Clinically significant alterations were reported in 416 (21.3%; 95%CI = 20.0–23.2%) and non-relevant findings were depicted in 658 (33.7%; 95%CI = 31.7–35.8%) patients. Extracardiac alterations affecting the lungs and pleura were the most common incidental findings. Lung nodules over 6 mm were detected in 62 cases (3.2%; 95%CI = 2.5–4.1%), air-space opacities in 3 cases (0.2%; 95%CI = 0.0–0.5%), ground-glass opacities in 31 cases (1.6%; 95%CI = 1.1–2.3%), moderate or severe emphysema in 122 cases (6.3%; 95%CI = 5.3–7.4%), moderate or severe athelectasia in 12 cases (0.6%; 95%CI = 0.3–1.1%). Aorta aneurysm over 40 mm was discovered in 16 cases (0.8%; 95%CI = 0.5–1.3%). Lymph nodes in the mediastinum over 10 mm were identified in 50 cases (2.6%; 95%CI = 2.0–3.4%). Pleura effusion was diagnosed in 13 cases (0.7%; 95%CI = 0.4–1.1%). Diaphragmatic hernia over 20 mm was described in 80 cases (4.1%; 95%CI = 3.3–5.1%). Moderate or severe degenerative disease in the spine was found in 27 patients (1.4%; 95%CI = 1.0–2.0%). Detailed results on incidental extracardiac findings by the affected organ can be seen in Table 2. Representative examples of incidental extracardiac findings showed in Figs 2–4.
Demographic and clinical characteristics of the patient population
| Patients (n = 1,952) | |
| Age (years) | 61.2 ± 10.6 |
| Male sex, n (%) | 1,292 (66.2) |
| Type of AF | |
| Paroxysmal, n (%) | 1,324 (68.0) |
| Persistent, n (%) | 625 (32.0) |
| Chest pain, n (%) | 275 (14.1) |
| BMI (kg m−2) | 28.7 ± 4.9 |
| Hypertension, n (%) | 1,365 (69.9) |
| Hyperlipidemia, n (%) | 514 (26.3) |
| Diabetes, n (%) | 313 (16.0) |
| Smokers, n (%)* | 499 (30.7) |
| Heart failure, n (%) | 106 (5.4) |
| Obstructive CAD, n (%) | 247 (12.7) |
| Valve disease, n (%) | 113 (5.8) |
| Cardiomyopathy, n (%) | 94 (4.8) |
| Dilatative cardiomyopathy, n (%) | 81 (4.1) |
| Hypertrophic cardiomyopathy, n (%) | 10 (0.5) |
| Hypertensive cardiomyopathy, n (%) | 3 (0.2) |
| Prior stroke/TIA, n (%) | 124 (6.4) |
| Thromboembolic disease, n (%) | 35 (1.8) |
| Peripheral vasculopathy, n (%) | 59 (3.0) |
| Thyroid gland disease, n (%) | 194 (10.0) |
| Hypothyreosis, n (%) | 126 (6.5) |
| Hyperthyreosis, n (%) | 68 (3.5) |
| Chronic kidney disease, n (%) | 60 (3.1) |
| LVEF (%) | 57.2 ± 15.5 |
| CHA2DS2-VASc score | |
| 0 | 260 (13.3) |
| 1–3 | 1,345 (68.9) |
| 4–6 | 335 (17.2) |
| 7–9 | 12 (0.6) |
*Data regarding smoking status was available in 1,627 patients. Abbreviations: AF = Atrial fibrillation; BMI = Body mass index; CAD = Coronary artery disease; LVEF = Left ventricular ejection fraction, TIA = Transient ischemic attack.
Incidental extracardiac findings by the affected organ
| Extracardiac findings | n | Prevalence | 95%CI |
| Clinically relevant extracardiac incidental findings | |||
| Lungs | |||
| Nodules over 6 mm | 62 | 3.2% | 2.5–4.1% |
| Air-space opacities | 3 | 0.2% | 0.0–0.5% |
| Ground-glass opacities | 31 | 1.6% | 1.1–2.3% |
| Moderate or severe emphysema | 122 | 6.3% | 5.3–7.4% |
| Moderate or severe atelectasia | 12 | 0.6% | 0.3–1.1% |
| Aorta | |||
| Aneurysm over 40 mm | 16 | 0.8% | 0.5–1.3% |
| Mediastinum | |||
| Lymph nodes over 10 mm | 50 | 2.6% | 2.0–3.4% |
| Pleura | |||
| Effusion | 13 | 0.7% | 0.4–1.1% |
| Diaphragma | |||
| Hernia over 20 mm | 80 | 4.1% | 3.3–5.1% |
| Spine | |||
| Moderate or severe degenerative disease | 27 | 1.4% | 1.0–2.0% |
| Number of patients with clinically relevant extracardiac finding | 416 | 21.3% | 20.0–23.2% |
| Clinically not relevant extracardiac incidental findings | |||
| Lungs | |||
| Nodules less than 6 mm | 190 | 9.7% | 8.5–11.1% |
| Small linear lung opacities | 315 | 16.1% | 14.6–17.8% |
| Mild emphysema | 352 | 18.0% | 16.4–19.8% |
| Pleura | |||
| Thickening | 20 | 1.0% | 0.7–1.6% |
| Aorta | |||
| Ectasia | 9 | 0.5% | 0.2–0.9% |
| Spine | |||
| Mild degenerative disease | 82 | 4.2% | 3.4–5.2% |
| Rib | |||
| Lesion | 4 | 0.2% | 0.1–0.5% |
| Liver | |||
| Cyst | 85 | 4.4% | 3.5–5.4% |
| Steatosis | 7 | 0.4% | 0.2–0.7% |
| Number of patients with clinically not relevant extracardiac finding | 658 | 33.7% | 31.7–35.8% |
Hiatal hernia. 65-year-old male patient with observed hiatal hernia above the diaphragma. His past medical history included controlled hypertension, gastroesophageal reflux disease, and paroxysmal atrial fibrillation since 2018
Citation: Imaging 14, 1; 10.1556/1647.2022.00057
Subpleural lung nodule. 51-year-old male with the history of controlled hypertension and paroxysmal atrial fibrillation since 2013. The CT scan showed a 7 mm, polygonal, residual-like, subpleural nodule presented in the left 5th segment of the lung
Citation: Imaging 14, 1; 10.1556/1647.2022.00057
Hypodens liver cysts. 74-year-old female patient. Her medical history included controlled hypertension, euthyroid struma, hysterectomy, and paroxysmal atrial fibrillation. The CT scan showed several cysts with well-defined margins demonstrated in both lobes of the liver
Citation: Imaging 14, 1; 10.1556/1647.2022.00057
Predictors of clinically relevant extracardiac findings
We aimed to determine the predictors of clinically relevant extracardiac findings. In the univariate analysis age (OR = 1.04; 95%CI = 1.03–1.05; P < 0.001), male sex (OR = 1.39; 95%CI = 1.12–1.73, P = 0.003), chest pain (OR = 1.46; 95%CI = 1.09–1.93; P = 0.009), hypertension (OR = 1.42; 95%CI = 1.12–1.81; P = 0.004), heart failure (OR = 1.68; 95%CI = 1.09–2.53; P = 0.015), obstructive CAD (OR = 1.56; 95%CI = 1.16–2.09, P = 0.003) and prior stroke/TIA (OR = 1.56; 95%CI = 1.04–2.30; P = 0.027) were associated with clinically significant incidental findings. In the multivariate model age (OR = 1.04; 95%CI = 1.02–1.06; P < 0.001) proved to be the only independent predictor of clinically relevant extracardiac alterations. Detailed results are reported in Table 3.
Predictors of clinically relevant extracardiac findings
| Univariate | Multivariate | |||
| OR (95%CI) | P | OR (95%CI) | P | |
| Age | 1.04 (1.03–1.05) | <0.001 | 1.04 (1.02–1.06) | <0.001 |
| Male sex | 1.39 (1.12–1.73) | 0.003 | 1.18 (0.86–1.62) | 0.306 |
| BMI | 1.01 (0.98–1.04) | 0.625 | 1.01 (0.98–1.04) | 0.507 |
| Persistent AF | 1.15 (0.92–1.44) | 0.214 | 1.06 (0.76–1.46) | 0.727 |
| Smokers | 1.20 (0.94–1.53) | 0.141 | 1.09 (0.78–1.51) | 0.595 |
| Chest pain | 1.46 (1.09–1.93) | 0.009 | 1.37 (0.95–1.96) | 0.087 |
| Hypertension | 1.42 (1.12–1.81) | 0.004 | 1.15 (0.80–1.67) | 0.441 |
| Hyperlipidemia | 0.99 (0.78–1.26) | 0.947 | 0.84 (0.59–1.18) | 0.326 |
| Diabetes | 0.98 (0.73–1.30) | 0.907 | 0.96 (0.64–1.42) | 0.838 |
| Heart failure | 1.68 (1.09–2.53) | 0.015 | 0.58 (0.21–1.37) | 0.241 |
| Obstructive CAD | 1.56 (1.16–2.09) | 0.003 | 1.19 (0.77–1.81) | 0.426 |
| Valve disease | 1.15 (0.73–1.75) | 0.533 | 1.20 (0.58–2.32) | 0.606 |
| Cardiomyopathy | 1.47 (0.92–2.30) | 0.097 | 1.58 (0.60–3.88) | 0.335 |
| Prior stroke/TIA | 1.56 (1.04–2.30) | 0.027 | 1.39 (0.79–2.38) | 0.242 |
| Thromboembolic disease | 1.15 (0.50–2.37) | 0.729 | 0.83 (0.27–2.17) | 0.728 |
| Peripheral vasculopathy | 1.47 (0.82–2.54) | 0.183 | 1.71 (0.73–3.79) | 0.195 |
| Thyroid gland disease | 1.26 (0.90–1.76) | 0.173 | 1.02 (0.63–1.62) | 0.923 |
| Chronic kidney disease | 1.55 (0.87–2.66) | 0.120 | 1.10 (0.48–2.32) | 0.819 |
Abbreviations: AF = Atrial fibrillation; BMI = Body mass index; CAD = Coronary artery disease; LVEF = Left ventricular ejection fraction, TIA = Transient ischemic attack.
Discussion
In the current study, 42.0% of patients who underwent cardiac CT before AF ablation had at least one incidental extracardiac finding and clinically significant alterations were reported in half of these cases. We demonstrated that only age was an independent predictor of clinically relevant extracardiac findings.
Cardiac CT is the gold standard for the precise visualization of the vascular and cardiac anatomy before AF catheter ablation [8]. However, based on previous reports, extracardiac findings were reported in 23–72% of the cases and 16–33% of the patients had clinically relevant extracardiac alterations [15–20]. Wissner et al. reported the prevalence of extracardiac collateral findings in 95 patients who underwent cardiac CT with a 16-slice and subsequently 64-slice CT scanner from 2003 to 2007 [15]. In their study, a total of 78 extracardiac findings were reported in 53% of the patients, among which 23 required additional tests. In 2011, a study of 158 patients undergoing preablation cardiac CT with a 64-slice scanner reported that 72% of the patients had at least one unsuspected extracardiac finding, of whom 31% had clinically significant alterations [16]. The same study group reported the incidence of cardiac and extracardiac collateral findings in 224 patients before AF catheter ablation [17]. This study was also based on a 64-slice CT scanner. In this study, at least one extracardiac finding was observed in 80% of the patients and 32% of the participants had clinically relevant extracardiac collateral findings. Similarly to these results, in a study population of 149 AF patients who underwent cardiac CT with a 16-slice scanner, the prevalence of overall extracardiac findings was 69% and 24% of the patients had at least one clinically significant finding [18]. Lower prevalence was reported in the analysis of 250 consecutive patients who underwent cardiac CT with a 64- slice scanner led by Martins et al. [19]. Only 23% of the patients had extracardiac collateral findings and 0.8% of the cases had malignancy. Casella et al. reported a prevalence of 55% overall and 33% clinically relevant extracardiac alterations in 173 patients who underwent CT examination with a 64-slice scanner before catheter ablation [20]. However, all these above-mentioned studies investigated prevalence in relatively low patient populations and with 16- or 64-slice CT scanners, while in our study we analyzed data of 1,952 patients who underwent cardiac CT with state-of-the-art 256-slice CT scanner. In our study population, 42% of the patients had at least one collateral extracardiac finding and 21% had clinically significant alterations. In the unadjusted analysis beyond age, male sex and chest pain, some comorbidities such as hypertension, obstructive CAD and prior stroke/TIA showed an association with at least one clinically relevant extracardiac finding. In the multivariate analysis, age proved to be the only independent predictor.
Findings affecting the lungs were the most common extracardiac unsuspected alterations. In these cases further diagnostic workup is essential for detecting early lung cancer, even if prior studies have shown that 96.4% of the lung nodules are false positive findings [26]. In order to reduce unnecessary downstream testing, in 2017 the Fleischner Society has adjusted its guidelines for the management of incidental pulmonary nodules on CT images [29]. Compared to their previous guidelines, the minimum threshold size for routine follow-up has been increased and recommended follow-up intervals have been added. The guideline provides a simplified approach for the investigation of various nodules.
Even if many previous studies concluded that preablation cardiac CT images should be read thoroughly as they may serve as a screening tool for otherwise unrecognized alterations of the visualized organs without extra radiation, others worry about the initiation of unnecessary downstream testing without proven benefit resulting in additional costs and radiation exposure [24, 25]. However, with technical evolution modern scanners can obtain high-quality images with lower radiation exposures even in patients with AF. The Society of Cardiovascular Computed Tomography recommends that all structures within the reconstructed field of view should be examined and alterations should be reported with further reconstructions and expert consultations if needed [30].
Study strengths and limitations
To the best of our knowledge, this is the largest study investigating the prevalence of extracardiac findings in a cohort of 1,952 patients who underwent cardiac CT due to planned AF ablation. Moreover, detailed clinical data is available in our study population. However, there are some limitations that need to be acknowledged. First, extracardiac findings were collected from the medical reports without the rereading of the scans. However, in controversial cases when clinical significance was not evident, two radiologist experts (S.B. and J.Cs.) reanalyzed the cases. Second, there is a lack of a clear classification of what should be considered as a clinically relevant finding. We adopted the definitions from Sohns et al., as they previously reported two studies with relatively big patient numbers [16, 17]. Therefore, we could compare our results with previous findings more precisely. Moreover, 16.6% of the cases were not included in the multivariate analysis due to lack of data regarding smoking status. Furthermore, the non-randomized design of the study might lead to selection bias.
To our knowledge, this is the largest study to evaluate the prevalence of incidental extracardiac findings in patients undergoing cardiac CT due to planned AF ablation procedure. Cardiac CT images acquired before AF catheter ablation should be read thoroughly as they can provide otherwise unrecognized, clinically significant information in the depicted field of view.
Funding sources
Project no. NVKP_16-1–2016-0017 (‘National Heart Program’) has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. The research was financed by the Thematic Excellence Programme (2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging thematic programmes of the Semmelweis University. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.
Authors’ contribution
All authors contributed to the study conception, writing and revision of the manuscript. A.S.K., G.M., E.Zs., M.B., B.V. contributed to data curation and analysis. Radiologist experts who reanalyze the controversial cases: S.B., J.Cs. Design and writing of the manuscript were done by J.S., Sz.H., S.B., L.G., B.Sz., N.Sz. Proofreading and critical revision of the manuscript were performed by M.K., B.M., P.M.H. All authors reviewed the final version of the manuscript and agreed to submit it to IMAGING for publication.
Conflict of interests
One of the co-authors, Dr. Béla Merkely, is the Chair of the Editorial Board, the corresponding author, Dr. Pál Maurovich-Horvát is the Editor-in-Chief of IMAGING, therefore the submission was handled by a different member of the editorial team.
Abbreviations
| AF |
Atrial fibrillation |
| BMI |
Body mass index |
| CAD |
Coronary artery disease |
| LA |
Left atrium |
| LVEF |
Left ventricular ejection fraction |
| PV |
Pulmonary vein |
| TIA |
Transient ischemic attack |
References
- [1]↑
Hindricks G , Potpara T , Dagres N , Arbelo E , Bax J.J , Blomstrom-Lundqvist C , et al.: 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2021; 42(5): 373–498.
- [2]↑
Sra J : Cardiac image integration implications for atrial fibrillation ablation. J Interv Card Electrophysiol 2008; 22(2): 145–154.
- [3]
Dong J , Dickfeld T , Dalal D , Cheema A , Vasamreddy C.R , Henrikson C.A , et al.: Initial experience in the use of integrated electroanatomic mapping with three-dimensional MR/CT images to guide catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2006; 17(5): 459–466.
- [4]
Bertaglia E , Bella P.D , Tondo C , Proclemer A , Bottoni N , De Ponti R , et al.: Image integration increases efficacy of paroxysmal atrial fibrillation catheter ablation: results from the CartoMerge Italian registry. Europace 2009; 11(8): 1004–1010.
- [5]
Kottkamp H , Piorkowski C , Tanner H , Kobza R , Dorszewski A , Schirdewahn P , et al.: Topographic variability of the esophageal left atrial relation influencing ablation lines in patients with atrial fibrillation. J Cardiovasc Electrophysiol 2005; 16(2): 146–150.
- [6]
Martinek M , Nesser H.J , Aichinger J , Boehm G , Purerfellner H : Impact of integration of multislice computed tomography imaging into three-dimensional electroanatomic mapping on clinical outcomes, safety, and efficacy using radiofrequency ablation for atrial fibrillation. Pacing Clin Electrophysiol 2007; 30(10): 1215–1223.
- [7]↑
Jongbloed M.R , Bax J.J , Lamb H.J , Dirksen M.S , Zeppenfeld K , van der Wall E.E , et al.: Multislice computed tomography versus intracardiac echocardiography to evaluate the pulmonary veins before radiofrequency catheter ablation of atrial fibrillation: a head-to-head comparison. J Am Coll Cardiol 2005; 45(3): p. 343–350.
- [8]↑
Lacomis J.M , Pealer K , Fuhrman C.R , Barley D , Wigginton W , Schwartzman D : Direct comparison of computed tomography and magnetic resonance imaging for characterization of posterior left atrial morphology. J Interv Card Electrophysiol 2006; 16(1): 7–13.
- [9]↑
Investigators S.-H : CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. Lancet 2015; 385(9985): 2383–2391.
- [10]↑
Koonce J , Schoepf J.U , Nguyen S.A , Northam M.C , Ravenel J.G : Extra-cardiac findings at cardiac CT: experience with 1,764 patients. Eur Radiol 2009; 19(3): 570–576.
- [11]↑
Elgin E.E , O’Malley P.G , Feuerstein I , Taylor A.J : Frequency and severity of “incidentalomas” encountered during electron beam computed tomography for coronary calcium in middle-aged army personnel. Am J Cardiol 2002; 90(5): 543–545.
- [12]
Horton K.M , Post W.S , Blumenthal R.S , Fishman E.K : Prevalence of significant noncardiac findings on electron-beam computed tomography coronary artery calcium screening examinations. Circulation 2002; 106(5): 532–534.
- [13]
Hunold P , Schmermund A , Seibel R.M , Gronemeyer D.H , Erbel R : Prevalence and clinical significance of accidental findings in electron-beam tomographic scans for coronary artery calcification. Eur Heart J 2001; 22(18): 1748–1758.
- [14]
Schragin J.G , Weissfeld J.L , Edmundowicz D , Strollo D.C , Fuhrman C.R : Non-cardiac findings on coronary electron beam computed tomography scanning. J Thorac Imaging 2004; 19(2): 82–86.
- [15]↑
Wissner E , Wellnitz C.V , Srivathsan K , Scott L.R , Altemose G.T : Value of multislice computed tomography angiography of the thorax in preparation for catheter ablation for the treatment of atrial fibrillation: the impact of unexpected cardiac and extracardiac findings on patient care. Eur J Radiol 2009; 72(2): 284–288.
- [16]↑
Sohns C , Sossalla S , Vollmann D , Luethje L , Seegers J , Schmitto J.D , et al.: Extra cardiac findings by 64-multidetector computed tomography in patients with symptomatic atrial fibrillation prior to pulmonal vein isolation. Int J Cardiovasc Imaging 2011; 27(1): 127–134.
- [17]↑
Sohns J.M , Menke J , Staab W , Spiro J , Fasshauer M , Kowallick J.T , et al.: Current role of cardiac and extra-cardiac pathologies in clinically indicated cardiac computed tomography with emphasis on status before pulmonary vein isolation. Rofo 2014; 186(9): 860–867.
- [18]↑
Schietinger B.J , Bozlar U , Hagspiel K.D , Norton P.T , Greenbaum H.R , Wang H , et al.: The prevalence of extracardiac findings by multidetector computed tomography before atrial fibrillation ablation. Am Heart J 2008; 155(2): 254–259.
- [19]↑
Martins R.P , Muresan L , Sellal J.M , Mandry D , Regent D , Jarmouni S , et al.: Incidental extracardiac findings in cardiac computed tomography performed before radiofrequency ablation of atrial fibrillation. Pacing Clin Electrophysiol 2011; 34(12): 1665–1670.
- [20]↑
Casella M , Perna F , Pontone G , Dello Russo A , Andreini D , Pelargonio G , et al.: Prevalence and clinical significance of collateral findings detected by chest computed tomography in patients undergoing atrial fibrillation ablation. Europace 2012; 14(2): 209–216.
- [21]↑
Kalra M.K , Abbara S , Cury R.C , Brady T.J : Interpretation of incidental findings on cardiac CT angiography. Catheter Cardiovasc Interv 2007; 70(2): 324–325. author reply 326- 8.
- [22]
Torres F.S : Extracardiac findings in cardiac CT. AJR Am J Roentgenol 2014; 202(4): W411.
- [23]
Kim, J.W , Kang E.Y , Yong H.S , Kim Y.K , Woo O.H , Oh Y.W , et al.: Incidental extracardiac findings at cardiac CT angiography: Comparison of prevalence and clinical significance between precontrast low-dose whole thoracic scan and postcontrast retrospective ECG-gated cardiac scan. Int J Cardiovasc Imaging 2009; 25(Suppl 1): 75–81.
- [24]↑
Budoff M.J , Fischer H , Gopal A : Incidental findings with cardiac CT evaluation: should we read beyond the heart? Catheter Cardiovasc Interv 2006; 68(6): 965–973.
- [25]↑
Budoff M.J , Gopal A : Incidental findings on cardiac computed tomography. Should we look? J Cardiovasc Comput Tomogr 2007; 1(2): 97–105.
- [26]↑
National Lung Screening Trial Research, T , Aberle D.R , Adams A.M , Berg C.D , Black W.C , Clapp J.D , et al.: Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011; 365(5): 395–409.
- [27]↑
Karady J , Panajotu A , Kolossvary M , Szilveszter B , Jermendy A.L , Bartykowszki A , et al.: The effect of four-phasic versus three-phasic contrast media injection protocols on extravasation rate in coronary CT angiography: a randomized controlled trial. Eur Radiol 2017; 27(11): 4538–4543.
- [28]↑
Tsai W.Y , Chi Y , Chen C.M : Interval estimation of binomial proportion in clinical trials with a two-stage design. Stat Med 2008; 27(1): 15–35.
- [29]↑
MacMahon H , Naidich D.P , Goo J.M , Lee K.S , Leung A.N.C , Mayo J.R , et al.: Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner society 2017. Radiology 2017; 284(1): 228–243.
- [30]↑
Leipsic J , Abbara S , Achenbach S , Cury R , Earls J.P , Mancini G.J , et al.: SCCT guidelines for the interpretation and reporting of coronary CT angiography: a report of the society of cardiovascular computed tomography guidelines committee. J Cardiovasc Comput Tomogr 2014; 8(5): 342–358.
