Hiatal hernia after robotic-assisted coronary artery bypass graft surgery.

BACKGROUND: The aim of the present study is to determine the incidence/progression of hiatal hernia (HH) after robotic-assisted coronary artery bypass grafting (RA-CABG) surgery. METHODS: We reviewed the pre- and post-operative computed tomography (CT) of 491 patients who underwent RA-CABG between 2000 and 2017. Post-operative CT was acquired prospectively in a research protocol. CT was reviewed to assess the presence and the size of HH. RESULTS: We found 444/491 (90.4%) had pre-operative CT, while 201/491 (40.9%) had post-operative CT. In total, 155/491 (31.6%) had both pre- and long-term post-operative CT with a mean follow-up of 6.2 (±3.5) years. HH was more prevalent on post-operative CT, 64/155 (41.3%) compared to pre-operative CT, 44/155 (28.4%), P<0.0001. The diameter of pre-existing HH 2.8 (±1.8) cm was significantly greater after surgery 3.9 (±2.5) cm, P<0.0001. As well the volume of the pre-existing HH 5.8 (4.4-9.2) mL (quartile) was significantly greater after surgery 14.1 (7.2-64.9) mL, P<0.0001. 20/155 (12.9%) had a newly developed HH after RA-CABG. A binary multivariate regression including HH risk factors showed that male gender is a predictor of developing a HH after RA-CABG with Hazard Ratio of 3.038, confidence interval (1.10-8.43), P=0.033. CONCLUSIONS: RA-CABG is associated with an increased risk of developing HH and increases the size of pre-existing HH.

Technical Note: Comparison of megavoltage, dual-energy, and single-energy CT-based µ-maps for a four-channel breast coil in PET/MRI.

PURPOSE: The purpose of this study was to describe and evaluate methods for calculating a megavoltage computed tomography (MVCT)-derived MR hardware attenuation map (µ-map) and dual-energy CT (DECT) for 511 keV photons. METHODS: Phantom measurements were acquired on a whole-body hybrid PET/MRI system, using a four-channel receive-only MR radiofrequency (RF) breast coil. Two acquisitions were performed: with the phantoms positioned in the four-channel RF breast coil, and without the breast coil. PET attenuation from the breast coil was corrected using three different CT-derived hardware µ-maps: (a) Single-energy CT (SECT), (b) DECT, and (c) MVCT. Each attenuation-corrected (AC) PET volume was evaluated and compared with the acquisition performed without the breast coil. RESULTS: The breast coil attenuated PET photons by 10% overall. Threshold values were applied to the SECT µ-map to reduce the effects of metal artifacts, but overcorrection occurred in more highly attenuated regions. The DECT-derived virtual monochromatic image reduced beam-hardening artifacts, but other metal artifacts remained. Despite the remaining metal artifacts in the DECT image, it led to an improvement in the more attenuated regions. The MVCT images appear to be free from metal artifacts leading to an artifact-free µ-map and a further improvement AC-PET images. CONCLUSIONS: Our MVCT-based approach for creating µ-maps for MR RF coils greatly reduces artifacts produced by metal in a SECT approach. This eliminates the need for other artifact reduction methods, including the application of a threshold of narrow beam attenuation coefficients, or disassembling hardware to remove high-Z components before imaging with a kilovoltage source.

Quantifying public radiation exposure related to lutetium-177 octreotate therapy for the development of a safe outpatient treatment protocol.

OBJECTIVES: Radionuclide therapies, including treatment of neuroendocrine tumors with lutetium-177 (Lu-177) octreotate, often involve hospital admission to minimize radiation exposure to the public. Overnight admission due to Lu-177 octreotate therapy incurs additional cost for the hospital and is an inconvenience for the patient. This study endeavors to characterize the potential radiation risk to caregivers and the public should Lu-177 octreotate therapies be performed on an outpatient basis. MATERIALS AND METHODS: Dose rate measurements of radiation emanating from 10 patients were taken 30 min, 4, and 20 h after initiation of Lu-177 octreotate therapy. Instadose radiation dose measurement monitors were also placed around the patients' rooms to assess the potential cumulative radiation exposure during the initial 30 min-4 h after treatment (simulating the hospital-based component of the outpatient model) as well as 4-20 h after treatment (simulating the discharged outpatient portion). RESULTS: The mean recorded dose rate at 30 min, 4, and 20 h after therapy was 20.4, 14.0, and 6.6 µSv/h, respectively. The majority of the cumulative dose readings were below the minimum recordable threshold of 0.03 mSv, with a maximum dose recorded of 0.18 mSv. CONCLUSION: Given the low dose rate and cumulative levels of radiation measured, the results support that an outpatient Lu-177 octreotate treatment protocol would not jeopardize public safety. Nevertheless, the concept of ALARA still requires that detailed radiation safety protocols be developed for Lu-177 octreotate outpatients to minimize radiation exposure to family members, caregivers, and the general public.

Description and assessment of a registration-based approach to include bones for attenuation correction of whole-body PET/MRI.

PURPOSE: Attenuation correction for whole-body PET/MRI is challenging. Most commercial systems compute the attenuation map from MRI using a four-tissue segmentation approach. Bones, the most electron-dense tissue, are neglected because they are difficult to segment. In this work, the authors build on this segmentation approach by adding bones using a registration technique and assessing its performance on human PET images. METHODS: Twelve oncology patients were imaged with FDG PET/CT and MRI using a Turbo-FLASH pulse sequence. A database of 121 attenuation correction quality CT scans was also collected. Each patient MRI was compared to the CT database via weighted heuristic measures to find the "most similar" CT in terms of body geometry. The similar CT was aligned to the MRI with a deformable registration method. Two MRI-based attenuation maps were computed. One was a standard four-tissue segmentation (air, lung, fat, and lean tissue) using basic image processing techniques. The other was identical, except the bones from the aligned CT were added. The PET data were reconstructed with the patient's CT-based attenuation map (the silver standard) and both MRI-based attenuation maps. The relative errors of the MRI-based attenuation corrections were computed in 14 standardized volumes of interest, in lesions, and over whole tissues. The squared Pearson correlation coefficient was also calculated over whole tissues. Statistical testing was done with ANOVAs and paired t-tests. RESULTS: The MRI-based attenuation correction ignoring bone had relative errors ranging from -37% to -8% in volumes of interest containing bone. By including bone, the magnitude of the relative error was reduced in all cases (p<0.001), ranging from -3% to 4%. Further, the relative error in volumes of interest adjacent to bone was improved from a mean of -7.5% to 2% (p<0.001). In the other seven volumes of interest, including bone reduced the magnitude of relative error in three cases (p<0.001), had no effect in three cases, and increased relative error in one case. There was no statistically significant difference in the relative error in lesions. Over whole tissues, including bone slightly increased relative error in lung from 7.7% to 8.0% (p=0.002), in fat from 8.5% to 9.2% (p<0.001), and in lean tissue from -2.1% to 2.6% (p<0.001), but reduced the magnitude of relative error in bone from -14.6% to 1.3% (p<0.001). The correlation coefficient was essentially unchanged in all tissues regardless of whether bone was included or not. CONCLUSIONS: The approach to include bones in MRI-based attenuation maps described in this work improves quantification of whole-body PET images in and around bony anatomy. The reduction in error is often large (tens of percents), and could alter image interpretation and subsequent patient care. Changes in other parts of the PET image are minimal and likely not of clinical significance.

Comparison of the myocardial clearance of endothelial progenitor cells injected early versus late into reperfused or sustained occlusion myocardial infarction.

Stem cell transplantation following AMI has shown promise for the repair or reduction of the amount of myocardial injury. There is some evidence that these treatment effects appear to be directly correlated to cell residence time. This study aims to assess the effects of (a) the timing of stem cell injection following myocardial infarction, and (b) flow milieu, on cell residence times at the site of transplantation by comparing three time points (day of infarction, week 1 and week 4-5), and two models of acute myocardial infarction (sustained occlusion or reperfusion). Twenty-one dogs received 2 injections of 30 million endothelial progenitor cells. The first injections were administered by epicardial (n = 8) or endocardial injection (n = 13) either on the day of infarction (n = 15) or at 1 week (n = 6). The second injections were administered by only endocardial injection (n = 18) 4 weeks following the first injection. Cell clearance half-lives were comparable between early and late injections. However, transplants into sustained occlusion infarcts resulted in slower cell clearance 77.1 ± 6.1 (n = 18) versus reperfused 59.4 ± 2.9 h (n = 21) p = 0.009. Sustained occlusion infarcts had longer cell retention in comparison to reperfusion whereas the timing of injection did not affect clearance rates. If the potential for myocardial regeneration associated with cell transplantation is, at least in part, linked to cell residence times, then greater benefit may be observed with transplants into infarcts associated with persistent coronary artery occlusion.

Variable lung density consideration in attenuation correction of whole-body PET/MRI.

UNLABELLED: Present attenuation-correction algorithms in whole-body PET/MRI do not consider variations in lung density, either within or between patients; this may adversely affect accurate quantification. In this work, a technique to incorporate patient-specific lung density information into MRI-based attenuation maps is developed and compared with an approach that assumes uniform lung density. METHODS: Five beagles were scanned with (18)F-FDG PET/CT and MRI. The relationship between MRI and CT signal in the lungs was established, allowing the prediction of attenuation coefficients from MRI. MR images were segmented into air, lung, and soft tissue and converted into attenuation maps, some with constant lung density and some with patient-specific lung densities. The resulting PET images were compared by both global metrics of quantitative fidelity (accuracy, precision, and root mean squared error) and locally with relative error in volumes of interest. RESULTS: A linear relationship was established between MRI and CT signal in the lungs. Constant lung density attenuation maps did not perform as well as patient-specific lung density attenuation maps, regardless of what constant density was chosen. In particular, when attenuation maps with patient-specific lung density were used, precision, accuracy, and root mean square error improved in lung tissue. In volumes of interest placed in the lungs, relative error was significantly reduced from a minimum of 12% to less than 5%. The benefit extended to tissues adjacent to the lungs but became less important as distance from the lungs increased. CONCLUSION: A means of using MRI to infer patient-specific attenuation coefficients in the lungs was developed and applied to augment whole-body MRI-based attenuation maps. This technique has been shown to improve the quantitative fidelity of PET images in the lungs and nearby tissues, compared with an approach that assumes uniform lung density.

Hybrid SPECT/cardiac-gated first-pass perfusion CT: locating transplanted cells relative to infarcted myocardial targets.

PURPOSE: A challenge with cardiac cell therapy is determining the location of cells relative to infarct tissue. As cells are viable following ¹¹¹In-labeling, and first-pass CT imaging can identify regions of myocardial infarction, we evaluated the feasibility of a SPECT/CT system to localize cells relative to infarcted myocardium in a canine model. METHODS: Ten canines underwent surgical ligation of the left-anterior-descending artery and endothelial progenitor cells labeled with ¹¹¹In-tropolone were transplanted endocardially or epicardially. SPECT/CT was performed on day of transplantation, 4 and 10 days post-transplantation. For each imaging session first-pass perfusion CT was performed to delineate the area of reduced perfusion. SPECT and first-pass CT images were fused and evaluated. Contrast-to-noise ratios (CNR) were calculated for ¹¹¹In-SPECT images to evaluate cell detection. RESULTS: The zone of reduced perfusion was well delineated on first-pass perfusion CT in all canines. The ¹¹¹In signal was visualized within this zone in all cases. Analysis of the CNRs suggests that cells may be followed for 11 effective half-lives using the images from first-pass perfusion CT to provide the anatomic landmarks. CONCLUSION: In the setting of an acute myocardial infarction SPECT/[first-pass perfusion CT] is an effective hybrid platform for the localization of cells in relation to the area of reduced blood flow.

Singular value decomposition analysis of a photoacoustic imaging system and 3D imaging at 0.7 FPS.

Photoacoustic imaging is a non-ionizing imaging modality that provides contrast consistent with optical imaging techniques while the resolution and penetration depth is similar to ultrasound techniques. In a previous publication [Opt. Express 18, 11406 (2010)], a technique was introduced to experimentally acquire the imaging operator for a photoacoustic imaging system. While this was an important foundation for future work, we have recently improved the experimental procedure allowing for a more densely populated imaging operator to be acquired. Subsets of the imaging operator were produced by varying the transducer count as well as the measurement space temporal sampling rate. Examination of the matrix rank and the effect of contributing object space singular vectors to image reconstruction were performed. For a PAI system collecting only limited data projections, matrix rank increased linearly with transducer count and measurement space temporal sampling rate. Image reconstruction using a regularized pseudoinverse of the imaging operator was performed on photoacoustic signals from a point source, line source, and an array of point sources derived from the imaging operator. As expected, image quality increased for each object with increasing transducer count and measurement space temporal sampling rate. Using the same approach, but on experimentally sampled photoacoustic signals from a moving point-like source, acquisition, data transfer, reconstruction and image display took 1.4 s using one laser pulse per 3D frame. With relatively simple hardware improvements to data transfer and computation speed, our current imaging results imply that acquisition and display of 3D photoacoustic images at laser repetition rates of 10Hz is easily achieved.

The detection threshold for extremely low frequency magnetic fields may be below 1000 nT-Hz in mice.

Previous experiments with mice have shown that a repeated 1 h daily exposure to an ambient magnetic field shielded environment induces analgesia (anti-nociception). This shielding reduces ambient static and extremely low frequency magnetic fields (ELF-MF) by approximately 100 times for frequencies below 120 Hz. To determine the threshold of ELF-MF amplitude that would attenuate or abolish this effect, 30 and 120 Hz magnetic fields were introduced into the shielded environment at peak amplitudes of 25, 50, 100 and 500 nT. At 30 Hz, peak amplitudes of 50, 100, and 500 nT attenuated this effect in proportion to the amplitude magnitude. At 120 Hz, significant attenuation was observed at all amplitudes. Exposures at 10, 60, 100, and 240 Hz with peak amplitudes of 500, 300, 500, and 300 nT, respectively, also attenuated the induced analgesia. No exposure abolished this effect except perhaps at 120 Hz, 500 nT. If the peak amplitude frequency product was kept constant at 6000 nT-Hz for frequencies of 12.5, 25, 50, and 100 Hz, the extent of attenuation was constant, indicating that the detection mechanism is dependent on the nT-Hz product. A plot of effect versus the induced current metric nT-Hz suggests a threshold of ELF-MF detection in mice at or below 1000 nT-Hz.

The response of the human circulatory system to an acute 200-µT, 60-Hz magnetic field exposure.

PURPOSE: Recent research by the authors on the effects of extremely low-frequency (ELF) magnetic field (MF) exposure on human heart rate (HR), heart rate variability (HRV), and skin blood perfusion found no cardiovascular effects of exposure to an 1,800-µT, 60-Hz MF. Research from our group using rats, however, has suggested a microcirculatory response to a 200-µT, 60-Hz MF exposure. The present pilot study investigated the effects of 1 h of exposure to a 200-µT, 60-Hz MF on the human circulation. Microcirculation (as skin blood perfusion) and HR were measured using laser Doppler flowmetry. Mean arterial pressure was monitored with a non-invasive blood pressure system. METHODS: Ten volunteers were recruited to partake in a counterbalanced, single-blinded study consisting of two testing sessions (real and sham exposure) administered on separate days. Each session included four consecutive measurement periods separated by rest, allowing assessment of cumulative and residual MF effects. RESULTS: A within-subjects analysis of variance did not reveal session by time period interactions for any of the parameters which would have been suggestive of a MF effect (p > 0.05). Perfusion, HR, and skin surface temperature decreased over the course of the experiment (p < 0.05). CONCLUSIONS: The MF used in this experiment did not affect perfusion, HR, or mean arterial pressure. Decreasing perfusion and HR trends over time were similar to our previous results and appear to be associated with a combination of inactivity (resulting in decreasing body temperatures) and reduced physiological arousal.

Analysis of a photoacoustic imaging system by the crosstalk matrix and singular value decomposition.

Photoacoustic imaging is a hybrid imaging modality capable of producing contrast similar to optical imaging techniques but with increased penetration depth and resolution in turbid media by encoding the information as acoustic waves. In general, it is important to characterize the performance of a photoacoustic imaging system by parameters such as sensitivity, resolution, and contrast. However, system characterization can extend beyond these metrics by implementing advanced analysis via the crosstalk matrix and singular value decomposition. A method was developed to experimentally measure a matrix that represented the imaging operator for a photoacoustic imaging system. Computations to produce the crosstalk matrix were completed to provide insight into the spatially dependent sensitivity and aliasing for the photoacoustic imaging system. Further analysis of the imaging operator was done via singular value decomposition to estimate the capability of the imaging system to reconstruct objects and the inherent sensitivity to those objects. The results provided by singular value decomposition were compared to SVD results from a de-noised imaging operator to estimate the number of measurable singular vectors for the system. These characterization techniques can be broadly applied to any photoacoustic system and, with regards to the studied system, could be used as a basis for improvements to future iterations.

3D versus 2D dynamic 82Rb myocardial blood flow imaging in a canine model of stunned and infarcted myocardium.

PURPOSE: Previous studies have shown the ability of rubidium-82 ((82)Rb) positron emission tomography (PET) imaging to quantitatively measure myocardial blood flow (MBF), many of which are performed using two-dimensional (2D) imaging. Three-dimensional (3D) imaging provides increased sensitivity and may result in decreased costs owing to a reduction in the required injected activity of radiotracer. This study compares 2D and 3D (82)Rb PET MBF results obtained in the same imaging session. METHODS: Three-dimensional and 2D (82)Rb perfusion imaging was performed in canines on a GE Discovery LS PET/CT scanner at rest and during hyperemia in stunned and infarcted tissue. MBF (ml/min/g) was determined using a 1-compartment model and an extraction correction of the uptake rate and analyzed using a standard 17-segment model. RESULTS: A strong, significant correlation was present (rho = 0.95, P<0.0001). Average 3D MBF values were slightly lower at rest and higher during stress versus 2D. MBF results in normal, stunned, and infarcted tissue differed by 7% on average and significant increases in MBF from rest to hyperemia were noted with both the techniques. CONCLUSION: These results imply that MBF results obtained in 3D are comparable with traditional 2D imaging. Therefore, it may be possible to use 3D imaging with lower administered activity, helping to reduce costs and patient dose without compromising quantitative information.