Over the past twenty years, technical advances in coronary arteriography have contributed to our understanding of the pathophysiologic aspects and natural history of coronary artery disease. Probably more than 700. 000 coronary arterio grams are performed annually throughout the world. Usually, these arteriograms are interpreted visually to determine the morphologic extent and severity of coronary artery disease. These subjective determinations, which are hampered . by relatively large intra- and interobserver variations, are used as a basis for critically important therapeutic decisions: Which arteries are to be revascular ized, which lesions are suitable for coronary bypass surgery or for percutaneous coronary angioplasty? To improve on this clinical decision making, on the treat ment and follow-up of such patients, new, objective and reproducible techniques for the assessment of the extent and severity of coronary artery disease, both in terms of anatomy and functional significance of the lesions, must be made widely available. With such new procedures and technologies the efficacy of new thera peutic procedures, the effects of vasodilating and constricting drugs, and the results of long-term studies on the regression and progression of atherosclerotic plaque can be determined in an objective and cost-effective manner.

This book consists of a total of 32 chapters subdivided into seven Parts, being: Coronary quantitation by QCA and intracoronary ultrasound (QCU), angiographic trials, progress in intravascular ultrasound, magnetic resonance (MR) coronary and vascular imaging, nuclear cardiovascular imaging, echocardiography, and cine and spiral CT coronary imaging. In general, each Part begins with a chapter that provides a broad overview of the advances in the field described in that particular Part, as well as a view towards the future. In the following chapters in such a Part, individual topics are described in further detail by leading authorities. In this way, the book should be of great interest to the more generalist' reader as well as to the more specialist' reader. It has been quite obvious for a long time that cardiovascular imaging is a field in which quantitative analysis of the corresponding images is a must for clinical research studies. One such example is the quantitative coronary arteriography for the accurate assessment of vessel morphology and their changes over time in interventional cardiology. Particularly with the increasing use of three-dimensional (3D) data as well as 4D ( 3D plus time ), it has been quite clear that the amount of information is so large that the conventional visual interpretation is not suitable anymore, and otherwise would result in unacceptably high inter- and intra-observer variabilities and underutilization of the data. Fortunately, (semi)-automated analysis techniques preferably with automated edge detection approaches begin to appear, thereby providing a wealth of information with small systematic and random errors. Therefore, What's New in Cardiovascular Imaging? will assist the cardiologist, the radiologist, the nuclear medicine physician, the image processing specialist, the physicist, the basic scientist, and the fellow, who is in training for those specialties, in understanding the most recent achievements in cardiovascular imaging techniques and their impact on cardiovascular medicine.

In recent years there have been major advances in the fields of cardiovascular nuclear medicine and cardiac magnetic resonance imaging. In nuclear cardiology more adequate tomographic systems have been designed for routine cardiac use, as well as new or improved quantitative analytic software packages both for planar and tomographic studies implemented on modern state-of-the-art workstations. In addition, artificial intelligence techniques are being applied to these images in attempts to interpret the nuclear studies in a more objective and reproducible manner. Various new radiotracers have been developed, such as antimyosin, labeled isonitriles, metabolic compounds, etc. Furthermore, alternative stress testing with dipyridamole and dobutamine has received much attention in clinical cardiac practice. Magnetic resonance imaging is a relative newcomer in cardiology and has already shown its merits, not only for anatomical information but increasingly for the functional aspects of cardiac performance. This book covers almost every aspect of quantitative cardiovascular nuclear medicine and magnetic resonance imaging. It will assist the nuclear medicine physician, the radiologist, the physicist/image processing specialist and the clinical cardiologist in understanding the nuclear medicine techniques used in cardiovascular medicine, and in increasing our knowledge of cardiac magnetic resonance imaging.

In this fourth book in the series on quantitative coronary arteriography (QCA) with the earlier three volumes published in 1986, 1988 and 1991, the latest developments in this exciting field are covered. Both the methodolog ical and clinical application aspects of these advances are presented in a comprehensive manner in a total of 37 chapters by world renowned experts. The book is subdivided into a total of eight parts, beginning with the more methodological issues, such as QCA and other modalities (3 chapters), cine film versus digital arteriography (3 chapters), quality control in QCA (4 chapters), and coronary blood flow and flow reserve (3 chapters). Since QCA has been well established as the technique for the assessment of regression and progression in atherosclerotic disease, and of restenosis after recanaliz ation procedures, major clinical trials in both groups are described extensively by their principal investigators in a total of 11 chapters. In addition, the QCA results after the application of various recanalization techniques are presented in another eight chapters. In the last part the experiences with various intracoronary prostheses with the emphasis on QCA are discussed in five chapters. This large increase in application oriented chapters means that QCA is well alive and gaining momentum. Although the accuracy and precision of the analytical methods steadily improve with the increasing complexity of the algorithms, there is still always the human factor involved in these processes in terms of frame selection, segment definition, etc.

In recent years there have been tremendous advances in cardiac imaging techniques covering the complete spectrum from echocardiography, nuclear cardiology, magnetic resonance imaging to contrast angiography. With respect to these noninvasive and invasive cardiac imaging modalities, marked technological developments have allowed the cardiologist to visualize the myocardium in a far more refined manner than conventional imaging was capable of. Echocardiography has extended its domain with intravascular ultrasound, cardiovascular nuclear imaging has added positron emission tomography to its line of research, magnetic resonance imaging has been broadened with magnetic resonance angiography and spectroscopy, and finally contrast angiograp hy has widened its scope with excellent quantitation programs. For all these imaging modalities it is true that the application of dedicated quantitative analytic software packages enables the evaluation of the imaging studies in a more accurate, reliable, and reproducible manner. It goes without saying that these extensions and achievements have resulted in improved diagnostics and subsequently in improved patient care. Particularly in patients with ischemic heart disease, major progress has been made to detect coronary artery disease in an early phase of the disease process, to follow the atherosclerotic changes in the coronary arteries, to establish the functional and metabolic consequences of the luminal obstructions, and to accurately assess the results of interventional therapy.

This is the fifth volume in this series on quantitative coronary arteriography (QCA) published over the last nine years. Research and applications in this exciting, field are covered in a total of 26 chapters by world renowned experts. This book is subdivided into a total of 6 parts, each emphasizing the latest progress in these respective fields. In Part One a comprehensive overview is given of the current knowledge and research in endothelial function, which is of eminent importance for the further understanding of the pathophysiology of coronary artery disease in patients. Fortunately, the use of QCA tools is not limited anymore to leading research institutes; over the last several years these tools have been installed in many cardiology centers world wide. To understand the current possibili ties, limitations and future expectations of QCA, several relevant topics are presented in Part Two. First of all, the questions about why and how QCA systems should be validated both at the development site and at the appli cation sites, and whether data from different vendors and core laboratories can be pooled, are discussed. As the X-ray cardiovascular world steadily moves into the digital imaging era, differences and similarities between the conventional cinefilm and the modern digital approaches are presented. Cur rently. the widespread use of digital imaging is still hindered by the lack of proper archival and exchange media. Requirements and possible solutions for this problem are handled in this section as well.

In June 1989, a third conference concentrating on the progress in quantita tive coronary angiography and related techniques was held in Rotterdam, again very successful as the two preceding events in 1985 and 1987. Tech nical as well as clinical aspects of digital and digitized coronarography, morphometry, parametric imaging and functional quantification of the human coronary circulation were presented and discussed by prominent exponents of those groups who have been active in this particular field for many years. This book contains the chapters representing the lectures held by leading experts during the symposium that update the knowledge currently available, including most recent aspects in angioscopy and intravascular ultrasound imaging. It also includes a historical review on the development of angiogra phic techniques from the very early days on to our times given by one of the pioneers in heart catheterization and angiography, Dr. Kurt Amplatz. Those who had the chance to listen to his talk, will surely remember his impressive, humorous lecture as one of the highlights of this meeting."

In recent years methods have been developed to study cardiac function, myocardial blood flow and myocardial metabolism with radionuclides. These developments have been facilitated through the introduction of new radiopharmaceuticals, the design of special gamma cameras and dedicated computer systems. However, part of the information provided by nuclear cardiology can also be obtained through other investigations such as echocardiography, exercise electrocardiography and cardiac catheterisation with ventriculography and coronary arteriography. Thus the practising physician must select the most appropriate methodes) of investigation for each patient. Such choices should be based on proper understanding of both the value and the restrictions of each method. In this book the state-of-the-art in nuclear cardiology is reviewed, including radionuclide angiography for analysis of left and right ventricu lar function and for measurement of shunts and regurgitation volumes, perfusion scintigraphy and other methods for measurement of myocardial bloodflow and metabolism and computer processing of radio nuclide Images. Each chapter has been written by an expert from either Europe or the USA, who has contributed to the developments in his particular field. The principles of each method of investigation are described, as well as the precautions that should be taken in order to obtain high quality data. Guidelines are provided for the interpretation ofthe data based on studies in various centers where the methods were developed and tested.

There are few techniques that have influenced therapeutic strategies in modem cardiology to a similar extent as coronary arteriography. Bypass surgery as well as transluminal coronary angioplasty would not have been possible without coronary angiography serving as a 'midwife' in their evolu tion. Despite the widespread and long-standing use in clinical practice, however, the interpretation of coronary angiograms has not changed very much since the early days. Most angiogr s are still reviewed in a visual and semi-quantitative and thus often very subjective way. In the face of an almost exploding field for interventional catheterization including thrombolysis, balloon dilatation, and other rapidly evolving techniques for transluminal revascularization or recanalization, a more detailed and quantitative analysis of coronary arteriograms is urgently required. In addition to the delineation of coronary morphology, we need dynamic and functional information about flow and perfusion to understand the physiological significance of anatomic abnormalities. Coronary arteriography contains and can provide most of this information. With the application of appropriate techniques, it can be made available in the catheterization laboratory even during the patient's investiga tion, thus facilitating and improving clinical decision making. Objective and reproducible analysis will furthermore enhance our understanding about the pathophysiology of coronary disease."

In recent years there has been an increasing interest in quantitative analysis of coronary cineangiograms and already for a longer time of left ventricular cin- eangiograms. The needfor quantitationofcoronary arterialdimensions has been stimulated by the introduction ofnew therapeutic procedures in the catheteriza- tionlaboratory, suchas the balloon dilatationtechnique (PTCA) and thromboly- tic therapy, by the need to study the vasoactive responses of pharmaceutical agents, and also by the desire to study the progressive nature ofcoronary artery disease with the ultimate goal to find ways to bring a halt to the progression of coronary atherosclerosis or even achieve regression of the disease. Parallel with these clinical developments, rapid technical developments in computerarchitect- ures and semiconductor memories have made it possible to digitize and store cineframesor selected portions thereof in image processors and to analyze these pictorial data quantitatively at affordable prices. More than 15 years of research have been directed by various groups towards the semi- or fully-automated delineation of the left ventricular boundaries on a frame-to-frame basis. Yet not a single system with fully-automated capability is commercially available. In the mean time many different left ventricular wall motion models have been developed, again with little consensuson which model is to be preferred as no golden standard exists.

In the past, coronary arteriography was the only modality available to provide high quality images of the coronary anatomy. Quantitative coronary arteriography (QCA) was developed, implemented, validated and extensively applied to obtain accurate and reproducible data about coronary morphology and the functional significance of coronary obstructions. Over the last few years extensive basic technological research supported by clinical investigations has created competing modalities to visualize coronary morphology and the associated perfusion of the myocardial muscle. Currently, the following modalities are available: X-ray coronary arteriography, intracoronary ultrasound, contrast- and stress-echocardiography, angioscopy, nuclear cardiology, magnetic resonance imaging, and cine and spiral CT imaging. For all these imaging modalities, the application of dedicated quantitative analytical software packages enables the evaluation of the imaging studies in a more accurate, reliable, and reproducible manner. These extensions and achievements have resulted in improved diagnostics and subsequently in improved patient care. Particularly in patients with ischaemic heart disease, major progress has been made to detect coronary artery disease in an early phase of the disease process, to follow the atherosclerotic changes in the coronary arteries, to establish the functional and metabolic consequences of the luminal obstructions, and accurately to assess the results of interventional therapy. Aside from all these high-tech developments in cardiac imaging techniques, the transition from the analogue to the digital world has been going on for some time now. For the future, it has been predicted that the CD-R will be the exchange medium for cardiac images and DICOM-3 the standard file format. This has been a major achievement in the field of standardization activities. Since these developments will have a major impact on the way images will be stored, reviewed and exchanged in the near future, an important part of this book has been dedicated to DICOM and the filmless catheterization laboratory. Cardiovascular Imaging will assist cardiologists, radiologists, nuclear medicine physicians, image processing specialists, physicists, basic scientists, and fellows in training for these specialties to understand the most recent achievements in cardiac imaging techniques and their impact on cardiovascular medicine.

A unique overview of all major angiographic lipid intervention trials, presented by their principal investigators. Basic mechanisms and methodological aspects, including biochemical as well as angiographic aspects, are discussed by experts in these fields. A careful comparison of all available data permits an analysis to be made of what may currently be considered proved, which aspects merit further investigation, and which hypotheses should be rejected. Audience: Clinicians involved in the practice of lipid lowering and investigators involved in lipid-lowering clinical trials. Scientists involved in other areas of lipid research and investigators conducting coronary angiographic trials designed to study the influence of different interventions will find a wealth of information and practical guidelines in this book.

In June 1989, a third conference concentrating on the progress in quantita tive coronary angiography and related techniques was held in Rotterdam, again very successful as the two preceding events in 1985 and 1987. Tech nical as well as clinical aspects of digital and digitized coronarography, morphometry, parametric imaging and functional quantification of the human coronary circulation were presented and discussed by prominent exponents of those groups who have been active in this particular field for many years. This book contains the chapters representing the lectures held by leading experts during the symposium that update the knowledge currently available, including most recent aspects in angioscopy and intravascular ultrasound imaging. It also includes a historical review on the development of angiogra phic techniques from the very early days on to our times given by one of the pioneers in heart catheterization and angiography, Dr. Kurt Amplatz. Those who had the chance to listen to his talk, will surely remember his impressive, humorous lecture as one of the highlights of this meeting."

This volume is the fifth in a series on quantitative coronary arteriography (QCA). The following topics, which all currently are and continue to be issues of extensive discussions in the research and clinical communities, are covered in great detail in this volume: endothelial function; comparisons between digital and cine coronary arteriography; inter-laboratory variation between QCA Core Laboratories; the developments in digital archival media; intracoronary pressure, coronary blood flow and flow reserve; quantitative and qualitative features in regression/progression studies; QCA in recanalization studies; and finally the current position of rivalling modalities as coronary angioscopy, intraluminal imaging with ultrasound and fluorescence spectroscopy. This book provides a comprehensive, overview for all clinicians and physicists actively involved or otherwise interested in current developments in quantitative coronary arteriography.

This volume is the fourth in a series on quantitative coronary arteriography (QCA) published over the last seven years. Every two years the advances in this exciting field are presented by their leading experts. There is a significant growth in this field which has translated into the increasing sizes of the volumes published over the years. In addition to covering the developments in the more traditional items such as QCA and other modalities, and coronary blood flow and flow reserve, the following subjects have been emphasized in this particular volume: quality control in QCA; QCA in the major regression/progression trials; QCA in the major restenoisis studies; QCA after recanalization techniques; and QCA and infracoronary prostheses. In addition, an extensive overview is given of ZCA equipment and technical requirements. The book provides a comprehensive, overview for all clinicians and physicists actively involved or otherwise interested in the developments in quantitative coronary arteriography.

In recent years there have been major advances in the fields of cardiovascular nuclear medicine and cardiac magnetic resonance imaging. In nuclear cardiology more adequate tomographic systems have been designed for routine cardiac use, as well as new or improved quatitative analytic software packages both for planar and tomographic studies implemented on modern state-of-the-art workstations. In addition, artificial intelligence techniques are being applied to these images in attempts to interpret the nuclear studies in a more objective and reproductive manner. Various new radiotracers have been developed, such as antimyosin, labelled isonitriles, metabolic compounds, etcetera. Furthermore, alternative stress testing with dipyridamole and dobutamine has received much attention in clinical cardiac practice. Magnetic resonance imaging is a relative newcomer in cardiology and has already shown its merits, not only for anatomical information but increasingly for the functional aspects of cardiac performance.

It has been clear for a long time that cardiovascular imaging is a field in which quantitative analysis of the corresponding images is a must for clinical research studies. One such example is the quantitative coronary arteriography for the accurate assessment of vessel morphology and their changes over time in interventional cardiology. Particularly with the increasing use of three-dimensional (3D) data as well as 4D (3D plus time), it has been clear that the amount of information is so large that the conventional visual interpretation is not suitable anymore, and otherwise would result in unacceptably high inter- and intra-observer variabilities and under-utilization of the data. Fortunately, (semi)-automated analysis techniques, preferably with automated edge detection approaches, begin to appear, thereby providing a wealth of information with small systematic and random errors. This text should assist the cardiologist, the radiologist, the nuclear medicine physician, the image processing specialist, the physicist, the basic scientist, and the fellow training for those specialties, in understanding the most recent achievements in cardiovascular imaging techniques and their impact on cardiovascular medicine. This text consists of a total of 32 chapters subdivided into seven Parts.

In the past, coronary arteriography was the only modality available to provide high quality images of the coronary anatomy. Quantitative coronary arteriography (QCA) was developed, implemented, validated and extensively applied to obtain accurate and reproducible data about coronary morphology and the functional significance of coronary obstructions. Over the last few years extensive basic technological research supported by clinical investigations has created competing modalities to visualize coronary morphology and the associated perfusion of the myocardial muscle. Currently, the following modalities are available: X-ray coronary arteriography, intracoronary ultrasound, contrast- and stress-echocardiography, angioscopy, nuclear cardiology, magnetic resonance imaging, and cine and spiral CT imaging. For all these imaging modalities, the application of dedicated quantitative analytical software packages enables the evaluation of the imaging studies in a more accurate, reliable, and reproducible manner. These extensions and achievements have resulted in improved diagnostics and subsequently in improved patient care. Particularly in patients with ischaemic heart disease, major progress has been made to detect coronary artery disease in an early phase of the disease process, to follow the atherosclerotic changes in the coronary arteries, to establish the functional and metabolic consequences of the luminal obstructions, and accurately to assess the results of interventional therapy. Aside from all these high-tech developments in cardiac imaging techniques, the transition from the analogue to the digital world has been going on for some time now. For the future, it has been predicted that the CD-R will be the exchange medium for cardiac images and DICOM-3 the standard file format. This has been a major achievement in the field of standardization activities. Since these developments will have a major impact on the way images will be stored, reviewed and exchanged in the near future, an important part of this book has been dedicated to DICOM and the filmless catheterization laboratory. Cardiovascular Imaging will assist cardiologists, radiologists, nuclear medicine physicians, image processing specialists, physicists, basic scientists, and fellows in training for these specialties to understand the most recent achievements in cardiac imaging techniques and their impact on cardiovascular medicine.

There are few techniques that have influenced therapeutic strategies in modem cardiology to a similar extent as coronary arteriography. Bypass surgery as well as transluminal coronary angioplasty would not have been possible without coronary angiography serving as a 'midwife' in their evolu­ tion. Despite the widespread and long-standing use in clinical practice, however, the interpretation of coronary angiograms has not changed very much since the early days. Most angiogr~s are still reviewed in a visual and semi-quantitative and thus often very subjective way. In the face of an almost exploding field for interventional catheterization including thrombolysis, balloon dilatation, and other rapidly evolving techniques for transluminal revascularization or recanalization, a more detailed and quantitative analysis of coronary arteriograms is urgently required. In addition to the delineation of coronary morphology, we need dynamic and functional information about flow and perfusion to understand the physiological significance of anatomic abnormalities. Coronary arteriography contains and can provide most of this information. With the application of appropriate techniques, it can be made available in the catheterization laboratory even during the patient's investiga­ tion, thus facilitating and improving clinical decision making. Objective and reproducible analysis will furthermore enhance our understanding about the pathophysiology of coronary disease.