Diagnosis and staging of cardiac masses: additional value of CMR with 18F-FDG-PET compared to CMR with CECT.

PURPOSE: Characterization of malignant cardiac masses is usually performed with cardiac magnetic resonance (CMR) and staging with whole-body contrast-enhanced computed tomography (CECT). In this study, our objective was to evaluate the role of 18Fluor-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) with CMR for both characterization and staging of cardiac masses. METHODS: Patients with cardiac masses who underwent CMR, CECT, and 18F-FDG-PET were retrospectively identified. For the characterization of cardiac masses, we calculated the respective performances of CMR alone, 18F-FDG-PET alone, and the combination of 18F-FDG-PET and CMR. For staging, we compared head-to-head the respective performances of 18F-FDG-PET and CECT. Histology served as gold standard for malignancy, and response to anticoagulation for thrombus. RESULTS: In a total of 28 patients (median age 60.5 years, 60.7% women), CMR accurately distinguished malignant from benign masses with sensitivity (Se) of 86.7%, specificity (Sp) of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 86.7%, and accuracy of 92.9%. 18F-FDG-PET demonstrated 93.3% Se, 84.6% Sp, 87.5% PPV, 91.7% NPV, and 89.3% accuracy. Combining CMR with 18F-FDG-PET allowed to benefit from the high sensitivity of 18F-FDG-PET (92.9%) and the excellent specificity of CMR (100%) for malignant diseases. For staging, 18F-FDG-PET outperformed CECT on per-patient (66.7% vs 55.6% correct diagnosis, respectively), per-organ (10 vs 7 organs, respectively), and per-lesion basis (> 29 vs > 25 lesions, respectively). CONCLUSION: Combining 18F-FDG-PET with CMR improved the characterization of cardiac masses compared to each modality alone. Additionally, the diagnostic performance of 18F-FDG-PET was better than CECT for staging. This study suggests that the combination of CMR and 18F-FDG-PET is the most effective for the characterization of cardiac masses and the staging of these lesions.

"Unusual Pattern of Cerebral Microbleeds and Petechial Hemorrhages after Veno-Arterial Extracorporeal Membrane Oxygenation Support. A Report of 2 Cases".

OBJECTIVE: to report an unusual pattern of brain petechial hemorrhages in 2 patients after veno-arterial extracorporeal membrane oxygenation support (VA-ECMO) CASE 1: a 28-year-old man (Marfan disease) presented in the early post-operative period a multi-organ failure associated with a disseminated intravascular coagulation (DIC). He was placed on continuous veno-venous hemofiltration and VA-ECMO. He was weaned from ECMO 4 days later. He then developed bacterial pneumoniae leading to respiratory failure and requiring mechanical ventilation. MRI 30 days later showed widespread petechial hemorrhages in the subcortical and deep white matter (WM) (optic radiations, corpus callosum, predominantly in the splenium, internal and external capsules), caudate nuclei, basal ganglia, frontal and parietal cortex and in infratentorial structures. These hemorrhages were bilateral and almost symmetric and marked at the border zones of the carotid arteries territories. CASE 2: a 60-year-old man presented an out-of-hospital refractory hypothermic cardiac arrest. At arrival, cardiopulmonary resuscitation was continued; he presented bleeding at the puncture sites related to DIC and associated with multi-organ failure. VA-ECMO was implanted. After ECMO removal (day 7) he presented a severe spatial orientation deficit. MRI showed petechial hemorrhages in both hippocampi and microbleeds at the cerebral cortex and the juxta-cortical WM. Both patients had good functional outcome. CONCLUSION: Two unusual presentations of brain hemorrhages in patients who underwent VA-ECMO are reported. If their specific cause remains unclear, there seems to be a relationship in time between DIC and microhemorrhages in these cases, even if in case 1 brain hemorrhages seem to have a multifactorial cause.