66 results found
Mittal TK, Hothi SS, Venugopal V, et al., 2023, The Use and Efficacy of FFR-CT: Real-World Multicenter Audit of Clinical Data With Cost Analysis., JACC Cardiovasc Imaging, Vol: 16, Pages: 1056-1065
BACKGROUND: Fractional flow reserve-computed tomography (FFR-CT) is endorsed by UK and U.S. chest pain guidelines, but its clinical effectiveness and cost benefit in real-world practice are unknown. OBJECTIVES: The purpose of this study was to audit the use of FFR-CT in clinical practice against England's National Institute for Health and Care Excellence guidance and assess its diagnostic accuracy and cost. METHODS: A multicenter audit was undertaken covering the 3 years when FFR-CT was centrally funded in England. For coronary computed tomographic angiograms (CCTAs) submitted for FFR-CT analysis, centers provided data on symptoms, CCTA and FFR-CT findings, and subsequent management. Audit standards included using FFR-CT only in patients with stable chest pain and equivocal stenosis (50%-69%). Diagnostic accuracy was evaluated against invasive FFR, when performed. Follow-up for nonfatal myocardial infarction and all-cause mortality was undertaken. The cost of an FFR-CT strategy was compared to alternative stress imaging pathways using cost analysis modeling. RESULTS: A total of 2,298 CCTAs from 12 centers underwent FFR-CT analysis. Stable chest pain was the main symptom in 77%, and 40% had equivocal stenosis. Positive and negative predictive values of FFR-CT were 49% and 76%, respectively. A total of 46 events (2%) occurred over a mean follow-up period of 17 months; FFR-CT (cutoff: 0.80) was not predictive. The FFR-CT strategy costs £2,102 per patient compared with an average of £1,411 for stress imaging. CONCLUSIONS: In clinical practice, the National Institute for Health and Care Excellence criteria for using FFR-CT were met in three-fourths of patients for symptoms and 40% for stenosis. FFR-CT had a low positive predictive value, making its use potentially more expensive than conventional stress imaging strategies.
Mittal TK, Hothi SS, Nicol ED, et al., 2023, Reply: Functional Testing vs FFR-CT in Intermediate Stenosis: The Cost of Forgetting Bayes' Theorem., JACC Cardiovasc Imaging, Vol: 16
Lota A, Hazebroek M, Theotokis P, et al., 2022, Genetic architecture of acute myocarditis and the overlap with inherited cardiomyopathy, Circulation, Vol: 146, Pages: 1123-1134, ISSN: 0009-7322
Background: Acute myocarditis is an inflammatory condition that may herald the onset of dilated (DCM) or arrhythmogenic cardiomyopathy (ACM). We investigated the frequency and clinical consequences of DCM and ACM genetic variants in a population-based cohort of patients with acute myocarditis. Methods: Population-based cohort of 336 consecutive patients with acute myocarditis enrolled in London and Maastricht. All participants underwent targeted DNA-sequencing for well-characterised cardiomyopathy-associated genes with comparison to healthy controls (n=1053) sequenced on the same platform. Case ascertainment in England was assessed against national hospital admission data. The primary outcome was all-cause mortality. Results: Variants that would be considered pathogenic if found in a patient with DCM or ACM were identified in 8% of myocarditis cases compared to <1% of healthy controls (p=0.0097). In the London cohort (n=230; median age 33years; 84% men), patients were representative of national myocarditis admissions (median age 32years; 71% men; 66% case ascertainment), and there was enrichment of rare truncating variants (tv) in ACM-associated genes (3.1% cases vs 0.4% controls; odds ratio 8.2; p=0.001). This was driven predominantly by desmoplakin (DSP)-tv in patients with normal LV ejection fraction and ventricular arrhythmia. In Maastricht (n=106; median age 54years; 61% men), there was enrichment of rare truncating variants in DCM-associated genes, particularly TTN-tv found in 7% (all with LVEF<50%) compared to 1% in controls (OR 3.6; p=0.0116). Across both cohorts over a median of 5.0 years (IQR 3.9-7.8), all-cause mortality was 5.4%. Two thirds of deaths were cardiovascular, due to worsening heart failure (92%) or sudden cardiac death (8%). The 5-year mortality risk was 3.3% in genotype negative patients versus 11.1% for genotype positive patients (Padjusted=0.08). Conclusions: We identified DCM- or ACM-associated genetic variants in 8% of patients wit
Mittal TK, Evans E, Pottle A, et al., 2022, Mindfulness-based intervention in patients with persistent pain in chest (MIPIC) of non-cardiac cause: a feasibility randomised control study, OPEN HEART, Vol: 9, ISSN: 2053-3624
Rajani P, ElMorsy ElMaghawry M, Mittal T, et al., 2021, Anomalous Left Coronary Artery Arising From Right Coronary Sinus in the Setting of Anterior STEMI., JACC Case Rep, Vol: 3, Pages: 1182-1186
We present the case of a 55-year-old man who had a diagnosis of an acute anterior ST-segment elevation myocardial infarction. Emergency angiography demonstrated that both coronary systems originated from the right coronary sinus with a culprit proximal left anterior descending artery lesion, which was stented. This is a rare presentation, with only 1 similar case found in published reports. (Level of Difficulty: Intermediate.).
Mittal TK, Marcus N, 2021, Imaging diagnosis of aortic stenosis, CLINICAL RADIOLOGY, Vol: 76, Pages: 3-14, ISSN: 0009-9260
Nazir MS, Mittal TK, Weir-McCall J, et al., 2020, Opportunities and challenges of implementing computed tomography fractional flow reserve into clinical practice, HEART, Vol: 106, Pages: 1387-1393, ISSN: 1355-6037
Smail H, Stock UA, De Robertis F, et al., 2020, Cardiac surgery during the COVID-19 pandemic: from vita minima to recovery, BRITISH JOURNAL OF SURGERY, Vol: 107, Pages: E481-E483, ISSN: 0007-1323
Sabry H, Baltabaeva A, Gkikas A, et al., 2020, Rapid deployment aortic valve replacement through anterior right thoracotomy: Clinical outcomes and haemodynamic performance, JOURNAL OF CARDIAC SURGERY, Vol: 35, Pages: 1420-1424, ISSN: 0886-0440
Mittal TK, 2020, Cardiac Computed Tomography and Magnetic Resonance Imaging, Cardiac Surgery: A Complete Guide, Pages: 41-54, ISBN: 9783030241735
Cardiac computerized tomography (CT) and magnetic resonance imaging (MRI) now form an important part of evaluation of patients with diseases of the heart and aorta. This has become possible due to improvements in technology. ECG-gated CT has become the non-invasive technique of choice for assessment of coronary artery disease while MRI allows accurate assessment of ventricular function, ischaemia, viability and tissue characterisation in patients with heart failure, cardiomyopathy, valvular heart disease. Both techniques are valuable in assessment of cardiac masses, congenital heart conditions as well as diseases of the pericardium and aorta. CT has an important role in patients with acute aortic syndromes and post-surgical patients. This chapter will discuss the essential technical aspects underlying cardiac CT and MRI scanning and their clinical applications.
Bargellini C, Long Q, Mittal TK, 2020, CT-based FFR: paving the way to future hearts, Pages: 93-96
FFR (Fractional Flow Reserve) is the gold standard for guiding the diagnosis and management of stable CAD by estimating the haemodynamic or functional severity of coronary stenosis. As the index is an indicator of ischemia, it was found to overcome the poor diagnostic performance of the anatomical assessments, especially in the case of intermediate stenoses. Nevertheless, the procedure is time-consuming and invasive, with poor clinical uptake rate due to high short-term costs. Several research groups have implemented their own approach for a noninvasive alternative to the standard clinical procedure. Some of the solutions have also been recently commercialised. In this paper, further testing for the virtual estimation of fractional flow reserve is provided. Patient-specific coronary arterial trees are reconstructed from high-resolution CT images and analysed with a simplified methodology consisting of multiple, steady-state computational fluid dynamics (CFD) simulations for the evaluation of a “virtual” FFR (vFFR). 3D coronary models are obtained from four different cases of documented CAD and vFFR evaluations are presented for a total of ten lesions. 20% of the lesions turned out to be significant, with an average vFFR of 0.69, much lower than the cut-off value (0.75). Significant and mild stenoses were identified by pressure drops greater than 17 mmHg and lower than 12 mmHg, respectively. The variability of vFFR was explored with respect to coronary anatomy, boundary conditions and lesion geometry. Discrepancy with the anatomical assessment was also found, in accordance with the literature.
Mittal TK, Reichmuth L, Bhattacharyya S, et al., 2019, Inconsistency in aortic stenosis severity between CT and echocardiography: prevalence and insights into mechanistic differences using computational fluid dynamics, Open Heart, Vol: 6, ISSN: 2053-3624
Objectives The aims of this study were to evaluate the inconsistency of aortic stenosis (AS) severity between CT aortic valve area (CT-AVA) and echocardiographic Doppler parameters, and to investigate potential underlying mechanisms using computational fluid dynamics (CFD).Methods A total of 450 consecutive eligible patients undergoing transcatheter AV implantation assessment underwent CT cardiac angiography (CTCA) following echocardiography. CT-AVA derived by direct planimetry and echocardiographic parameters were used to assess severity. CFD simulation was performed in 46 CTCA cases to evaluate velocity profiles.Results A CT-AVA>1 cm2 was present in 23% of patients with echocardiographic peak velocity≥4 m/s (r=−0.33) and in 15% patients with mean Doppler gradient≥40 mm Hg (r=−0.39). Patients with inconsistent severity grading between CT and echocardiography had higher stroke volume index (43 vs 38 mL/m2, p<0.003) and left ventricular outflow tract (LVOT) flow rate (235 vs 192 cm3/s, p<0.001). CFD simulation revealed high flow, either in isolation (p=0.01), or when associated with a skewed velocity profile (p=0.007), as the main cause for inconsistency between CT and echocardiography.Conclusion Severe AS by Doppler criteria may be associated with a CT-AVA>1 cm2 in up to a quarter of patients. CFD demonstrates that haemodynamic severity may be exaggerated on Doppler analysis due to high LVOT flow rates, with or without skewed velocity profiles, across the valve orifice. These factors should be considered before making a firm diagnosis of severe AS and evaluation with CT can be helpful.
Kalogeras K, Kabir T, Mittal T, et al., 2019, Real-world comparison of the new 34 mm self-expandable transcatheter aortic prosthesis Evolut R to its 31 mm core valve predecessor, CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Vol: 93, Pages: 685-691, ISSN: 1522-1946
Mittal T, Baltabaeva A, 2018, Comparison of Cardiac Functional Tests and Imaging, Core Topics in Preoperative Anaesthetic Assessment and Management, Pages: 63-67, ISBN: 9781107103313
Rogers P, Al-Aidrous S, Banya W, et al., 2018, Cardiac rehabilitation to improve health-related quality of life following trans-catheter aortic valve implantation: a randomised controlled feasibility study: RECOVER-TAVI Pilot, ORCA 4, For the Optimal Restoration of Cardiac Activity Group., Pilot Feasibility Stud, Vol: 4, ISSN: 2055-5784
OBJECTIVES: Transcatheter aortic valve implantation (TAVI) is often undertaken in the oldest frailest cohort of patients undergoing cardiac interventions. We plan to investigate the potential benefit of cardiac rehabilitation (CR) in this vulnerable population. DESIGN: We undertook a pilot randomised trial of CR following TAVI to inform the feasibility and design of a future randomised clinical trial (RCT). PARTICIPANTS: We screened patients undergoing TAVI at a single institution between June 2016 and February 2017. INTERVENTIONS: Participants were randomised post-TAVI to standard of care (control group) or standard of care plus exercise-based CR (intervention group). OUTCOMES: We assessed recruitment and attrition rates, uptake of CR, and explored changes in 6-min walk test, Nottingham Activities of Daily Living, Fried and Edmonton Frailty scores and Hospital Anxiety and Depression Score, from baseline (30 days post TAVI) to 3 and 6 months post randomisation. We also undertook a parallel study to assess the use of the Kansas City Cardiomyopathy Questionnaire (KCCQ) in the post-TAVI population. RESULTS: Of 82 patients screened, 52 met the inclusion criteria and 27 were recruited (3 patients/month). In the intervention group, 10/13 (77%) completed the prescribed course of 6 sessions of CR (mean number of sessions attended 7.5, SD 4.25) over 6 weeks. At 6 months, all participants were retained for follow-up. There was apparent improvement in outcome scores at 3 and 6 months in control and CR groups. There were no recorded adverse events associated with the intervention of CR. The KCCQ was well accepted in 38 post-TAVI patients: mean summary score 72.6 (SD 22.6). CONCLUSIONS: We have demonstrated the feasibility of recruiting post-TAVI patients into a randomised trial of CR. We will use the findings of this pilot trial to design a fully powered multicentre RCT to inform the provision of CR and support guideline development to optimise health-r
Mittal TK, Cleghorn CL, Cade JE, et al., 2017, A cross-sectional survey of cardiovascular health and lifestyle habits of hospital staff in the UK: Do we look after ourselves?, European Journal of Preventive Cardiology, Vol: 25, Pages: 543-550, ISSN: 2047-4873
Background A high prevalence of stress-related disorders is well known among healthcare professionals. We set out to assess the prevalence of cardiovascular risk factors and compliance with national dietary and physical activity recommendations in NHS staff in the UK with comparison between clinical and non-clinical staff, and national surveys. Design A multi-centre cross-sectional study. Methods A web-based questionnaire was developed to include anonymised data on demographics, job role, cardiovascular risk factors and diseases, dietary habits, physical activity and barriers towards healthy lifestyle. This was distributed to staff in four NHS hospitals via emails. Results A total of 1158 staff completed the survey (response rate 13%) with equal distribution between the clinical and non-clinical groups. Most staff were aged 26-60 years and 79% were women. Half of the staff were either overweight or obese (51%) with no difference between the groups ( P = 0.176), but there was a lower prevalence of cardiovascular risk factors compared to the general population. The survey revealed a low compliance (17%) with the recommended intake of five-a-day portions of fruit and vegetables, and that of moderate or vigorous physical activity (56%), with no difference between the clinical and non-clinical staff ( P = 0.6). However, more clinical staff were exceeding the alcohol recommendations ( P = 0.02). Lack of fitness facilities and managerial support, coupled with long working hours, were the main reported barriers to a healthy lifestyle. Conclusions In this survey of UK NHS staff, half were found to be overweight or obese with a lower prevalence of cardiovascular risk factors compared to the general population. There was a low compliance with the five-a-day fruit and vegetables recommendation and physical activity guidelines, with no difference between the clinical and non-clinical staff.
Mittal TK, Pottle A, Nicol E, et al., 2017, Prevalence of obstructive coronary artery disease and prognosis in patients with stable symptoms and a zero-coronary calcium score, EHJ Cardiovascular Imaging / European Heart Journal - Cardiovascular Imaging, Vol: 18, Pages: 922-929, ISSN: 2047-2412
Aims:CT calcium scoring (CTCS) and CT cardiac angiography (CTCA) are widely used in patients with stable chest pain to exclude significant coronary artery disease (CAD). We aimed to resolve uncertainty about the prevalence of obstructive coronary artery disease and long-term outcomes in patients with a zero-calcium score (ZCS).Methods and results:Consecutive patients with stable cardiac symptoms referred for CTCS or CTCS and CTCA from chest pain clinics to a tertiary cardiothoracic centre were prospectively enrolled. In those with a ZCS, the prevalence of obstructive CAD on CTCA was determined. A follow-up for all-cause mortality was obtained from the NHS tracer service. A total of 3914 patients underwent CTCS of whom 2730 (69.7%) also had a CTCA. Half of the patients were men (50.3%) with a mean age of 56.9 years. Among patients who had both procedures, a ZCS was present in 52.2%, with a negative predictive value of 99.5% for excluding ≥70% stenosis on CTCA. During a mean follow-up of 5.2 years, the annual event rate was 0.3% for those with ZCS compared with 1.2% for CS ≥1. The presence of non-calcified atheroma on CTCA in patients with ZCS did not affect the prognostic value (P = 0.98).Conclusion:In patients with stable symptoms and a ZCS, obstructive CAD is rare, and prognosis over the long-term is excellent, regardless of whether non-calcified atheroma is identified. A ZCS could reliably be used as a ‘gatekeeper’ in this patient cohort, obviating the need for further more expensive tests.
Mittal TK, Reichmuth L, Ariff B, et al., 2016, Imaging diagnoses and outcome in patients presenting for primary angioplasty but no obstructive coronary artery disease, Heart, Vol: 102, Pages: 1728-1734, ISSN: 1468-201X
OBJECTIVE: A proportion of patients with suspected ST-elevation myocardial infarction (STEMI) presenting for primary percutaneous coronary intervention (PPCI) do not have obstructive coronary disease and other conditions may be responsible for their symptoms and ECG changes. In this study, we set out to determine the prevalence and aetiology of alternative diagnoses in a large PPCI cohort as determined with multimodality imaging and their outcome. METHODS: From 2009 to 2012, 5238 patients with suspected STEMI were referred for consideration of PPCI. Patients who underwent angiography but had no culprit artery for revascularisation and no previous history of coronary artery disease were included in the study. Troponin values, imaging findings and all-cause mortality were obtained from hospital and national databases. RESULTS: A total of 575 (13.0%) patients with a mean age of 58±15 years (69% men) fulfilled the inclusion criteria. A specific diagnosis based on imaging was made in 237 patients (41.2%) including cardiomyopathies (n=104, 18%), myopericarditis (n=48, 8.4%), myocardial infarction/other coronary abnormality (n=27, 4.9%) and severe valve disease (n=23, 4%). Pulmonary embolism and type A aortic dissection were identified in seven (1.2%) and four (0.7%) cases respectively. A total of 40 (7.0%) patients died over a mean follow-up of 42.6 months. CONCLUSIONS: A variety of cardiac and non-cardiac conditions are prevalent in patients presenting with suspected STEMI but culprit-free angiogram, some of which may have adverse outcomes. Further imaging of such patients could thus be useful to help in appropriate management and follow-up.
Sarcoidosis is a multi-system disease with a wide range ofphenotypes. Pulmonary involvement is the most frequentlyidentified target for sarcoidosis and is responsible forthe majority of deaths. Cardiac sarcoid is less commonlyidentified, may be occult, is significantly influenced by race,and can portend an unpredictable and sometimes fataloutcome. Sarcoidosis remains an enigmatic disease spectrumof unknown aetiology, frequently difficult to diagnose andwith a variable disease course. This article summarises currentviews on the diagnosis and management of cardiopulmonaryinvolvement.
Bhattacharyya S, Mittal T, Abayalingam M, et al., 2015, Classification of Aortic Stenosis by Flow and Gradient Patterns Provides Insights into the Pathophysiology of Disease, Angiology, Vol: 67, Pages: 664-669, ISSN: 1940-1574
Different patterns of flow and valve gradients can lead to diagnostic uncertainty about the severity of aortic stenosis (AS). Consecutive patients with severe AS (valve area <1 cm(2)) underwent echocardiography and computed tomography. Patients were classified into 4 groups (high-gradient/normal flow [HGNF], high-gradient/low flow [HGLF], low-gradient/normal flow [LGNF], and low-gradient/low flow [LGLF]). Low flow was defined as stroke volume index <35 mL/m(2) and low gradient as a mean aortic gradient <40 mm Hg. Aortic valve calcification (AVC) was calculated using the Agatston score. Of 181 patients, 56, 30, 46, and 49 had HGNF, HGLF, LGNF and LGLF with median AVC of 2048, 2015, 1366, and 1178 AU/m(2) (P < .0001) and valvuloarterial impedance of 4.5, 6.4, 4.2, and 5.9, respectively (P < .0001). Among those with LGLF, AVC was lower in patients with preserved compared to reduced left ventricular ejection fraction (1018 vs 2550 AU/m(2); P < .0001), but valvuloarterial impedance was similar (P = .33). The LGLF AS with preserved ejection fraction is associated with lower AVC and may identify patients with less severe AS in association with an adaptive ventricular response to high afterload.
Callington A, Long Q, Mohite P, et al., 2015, Computational fluid dynamic study of hemodynamic effects on aortic root blood flow of systematically varied left ventricular assist device graft anastomosis design, JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY, Vol: 150, Pages: 696-704, ISSN: 0022-5223
Rahman MS, Mittal T, Chandrasekaran V, et al., 2015, The role of multi-modality imaging to investigate and manage anomalous right coronary artery originating from the pulmonary artery (ARCAPA) anomaly with associated coronary aneurysms presenting as acute left ventricular failure., European Heart Journal, Vol: 36, ISSN: 1522-9645
Dubrey SW, Grocott-Mason R, Ghonim S, et al., 2015, Takayasu's arteritis in an active man: burnt out or quiescent?, Br J Hosp Med (Lond), Vol: 76, Pages: 364-365, ISSN: 1750-8460
Mittal TK, Reichmuth L, Chana H, et al., 2015, Discrepancy in the severity of aortic valve stenosis between Echocardiography and CT cardiac angiography and evaluation of potential mechanism using computational flow dynamics., Annual Scientific Meeting of Society of Cardiovascular Computed Tomography
Mittal TK, Chana H, Reichmuth L, 2015, The optimal cardiac phase for measuring annulus size prior to transcatheter aortic valve implantation, Annual Scientific Meeting of Society of Cardiovascular Computed Tomography
Costopoulos C, Wong J, Mittal T, et al., 2015, Multi-modality imaging aids the diagnosis of bilateral coronary-cameral fistulae with involvement of the left ventricle, INTERNATIONAL JOURNAL OF CARDIOLOGY, Vol: 182, Pages: 166-167, ISSN: 0167-5273
Ali OF, Schultz C, Jabbour A, et al., 2015, Predictors of paravalvular aortic regurgitation following self-expanding Medtronic CoreValve implantation: The role of annulus size, degree of calcification, and balloon size during pre-implantation valvuloplasty and implant depth, INTERNATIONAL JOURNAL OF CARDIOLOGY, Vol: 179, Pages: 539-545, ISSN: 0167-5273
Kanaganayagam GS, An TN, Alsafi A, et al., 2014, CT coronary angiography in the investigation of chest pain - Beyond coronary artery atherosclerosis; A pictorial review, INTERNATIONAL JOURNAL OF CARDIOLOGY, Vol: 176, Pages: 618-629, ISSN: 0167-5273
Mittal TK, Mitchell AG, Banner NR, 2014, Untitled, RADIOLOGY, Vol: 271, Pages: 308-309, ISSN: 0033-8419
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