Computed tomography and magnetic resonance imaging evaluation of pericardial disease.

Pericardial diseases are commonly encountered in clinical practice and may present as an isolated process or in association with various systemic conditions. Traditionally transthoracic echocardiography (TTE) has been the method of choice for the evaluation of suspected pericardial disease but increasingly computed tomography (CT) and magnetic resonance imaging (MRI) are also being used as part of a rational multi-modality imaging approach tailored to the specific clinical scenario. This paper reviews the role of CT and MRI across the spectrum of pericardial diseases.

MRI assessment of cardiac tumours: part 1, multiparametric imaging protocols and spectrum of appearances of histologically benign lesions.

Cardiac magnetic resonance imaging (MRI) is the reference standard technique for assessment and characterization of a suspected cardiac tumour. It provides an unrestricted field of view, high temporal resolution and non-invasive tissue characterization based on multi-parametric assessment of the chemical micro-environment. MRI exploits differences in hydrogen proton density in conjunction with T1 and T2 relaxation properties of different tissues to help differentiation normal from abnormal and benign from malignant lesions. In this article we review specific cardiac MRI techniques, tumour protocol design and the appearance of the spectrum of histologically benign tumours.

MRI assessment of cardiac tumours: part 2, spectrum of appearances of histologically malignant lesions and tumour mimics.

Cardiac magnetic resonance imaging (MRI) is the reference standard technique for assessment and characterization of a suspected cardiac tumour. It provides an unrestricted field of view, high temporal resolution and non-invasive tissue characterization based on multi-parametric assessment of the chemical micro-environment. Sarcomas account for around 95% of all primary malignant cardiac tumours with lymphoma, and primary pericardial mesothelioma making up most of the remainder of cases. By contrast cardiac metastases are much more common. In this article we review the MRI features of the spectrum of histologically malignant cardiac and pericardial tumours as well as some potential tumour mimics.

The role of magnetic resonance imaging in hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is the most common inheritable cardiac disorder, with an estimated prevalence of 1:500 in the general population. Most cases of HCM are phenotypically expressed in adolescence or early adulthood but age-related penetrance with certain phenotypes is increasingly recognized. Clinical manifestations of HCM are usually the result of systolic and/or diastolic dysfunction, left ventricular outflow tract (LVOT) obstruction, arrhythmias and sudden cardiac death (SCD). In recent years magnetic resonance imaging (MRI) has become established as an important tool for the evaluation of suspected HCM as it can reliably establish the diagnosis, help distinguish HCM from other causes of left ventricular hypertrophy (LVH) and identify those patients at greatest risk of SCD. This article reviews the current status of MRI in the evaluation of the HCM patient including imaging protocols, disease characterization and the emerging role of MRI for risk stratification and proband screening.

Aortic intramural haematoma: pathogenesis, clinical features and imaging evaluation.

Intramural haematoma (IMH) is a localised haemorrhage within the aortic wall. Imaging plays a central role in diagnosing IMH, differentiating it from aortic dissection (AD) and assessing for complications. Imaging is also important for prognostication and to help guide clinical decision making as a number of imaging characteristics have been correlated with increased mortality rates including location, mural thickness and aortic diameter. Multidetector CT is the leading technique for diagnosis and classification of IMH owing to speed of image acquisition, multiplanar capabilities and excellent spatial resolution. MRI is rarely used to investigate the initial presentation of IMH but is frequently used for serial follow-up studies. The clinical outcome of IMH may be favourable, with spontaneous regression over time, or it may be complicated by pericardial tamponade, aortic regurgitation and development of AD. Early surgical management is the treatment of choice for patients with Stanford type A IMH whereas most patients with Stanford type B IMH have a good short-term outcome with aggressive control of hypertension. This article reviews the pathogenesis, clinical features and complications of IMH as well as the role of advanced imaging techniques in its evaluation.

The role of multi-modality imaging for sinus of Valsalva aneurysms.

Sinus of Valsalva aneurysms (SVAs) are uncommon but important entities. They are most often congenital in origin, resulting from incomplete fusion of the aortic media to the aortic valve annulus. Less frequently, they may be acquired, usually secondary to infective endocarditis. Unruptured aneurysms may be clinically silent and diagnosed incidentally, but can also produce symptoms as a consequence of mass effect on related structures. Rupture may present with sudden hemodynamic collapse but can have a more insidious onset depending upon the site and size of the perforation. Early diagnosis is imperative and can usually be made reliably by transthoracic echocardiography. However, transesophageal echocardiography may sometimes be required for confirmation. Cardiovascular magnetic resonance imaging (CMRI) and multi-detector computed tomography are being increasingly utilized for evaluation of SVAs and can offer valuable complimentary information. CMRI in particular enables a comprehensive assessment of anatomy, function and flow in a single sitting. Surgical repair forms the mainstay of treatment for both ruptured and unruptured aneurysms and has low complication rates. This article provides an overview of the pathological and clinical aspects of SVAs and discusses in detail the role of advanced imaging modalities in their evaluation.

Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy.

The BSAC guidelines on treatment of infectious endocarditis (IE) were last published in 2004. The guidelines presented here have been updated and extended to reflect developments in diagnostics, new trial data and the availability of new antibiotics. The aim of these guidelines, which cover both native valve and prosthetic valve endocarditis, is to standardize the initial investigation and treatment of IE. An extensive review of the literature using a number of different search criteria has been carried out and cited publications used to support any changes we have made to the existing guidelines. Publications referring to in vitro or animal models have only been cited if appropriate clinical data are not available. Randomized, controlled trials suitable for the development of evidenced-based guidelines in this area are still lacking and therefore a consensus approach has again been adopted for most recommendations; however, we have attempted to grade the evidence, where possible. The guidelines have also been extended by the inclusion of sections on clinical diagnosis, echocardiography and surgery.

Cardiovascular MRI for assessment of infectious and inflammatory conditions of the heart.

OBJECTIVE: This article reviews the role of cardiovascular MRI in the diagnosis and characterization of the spectrum of infectious and inflammatory disorders of the heart. An imaging protocol is described, and typical MRI findings are discussed and illustrated. CONCLUSION: Radiologists should be aware of the spectrum of infectious and inflammatory conditions that can affect the heart and the role of MRI in conjunction with other imaging techniques in their assessment.

Role of troponin I in active infective endocarditis.

Infective endocarditis (IE) remains a disease associated with high morbidity and mortality rates. In this pilot study, the role of troponin I in IE was assessed. Myocardial involvement distal to the site of infection in IE has been previously described. Elevated troponin was demonstrated in 11 of 15 patients diagnosed with the condition. Patients diagnosed with staphylococcal endocarditis were more likely to have elevated troponin (3 of 3 patients). Patients with elevated troponin I were not more likely to need valve replacement. Troponin I levels did not predict perivalvular extension. It is hypothesized that elevated troponin I is a reflection of myocardial involvement.