Computed tomography criteria for discrimination of adrenal adenomas and adrenocortical carcinomas: analysis of the German ACC registry.

OBJECTIVE: Thresholds of 2-20 hounsfield units (HU) in unenhanced computed tomography (CT) are suggested to discriminate benign adrenal tumors (BATs) from malignant adrenal tumors. However, these studies included only low numbers of adrenocortical carcinomas (ACCs). This study defines a HU threshold by inclusion of a large cohort of ACCs. DESIGN: Retrospective, blinded, comparative analysis of CT scans from 51 patients with ACCs (30 females, median age 49 years) and 25 patients with BATs (12 females, median age 64 years) diagnosed during the period of 2005-2010 was performed. METHODS: Tumor density was evaluated in unenhanced CT by two blinded investigators. RESULTS: Median tumor size was 9 cm (range 2.0-20) for ACCs vs 4 cm (2.0-7.5) for BATs (P<0.0001). In ACCs, the median unenhanced HU value was 34 (range 14-74) in comparison with 5 (-13 to 40) in BATs (P<0.0001). ROC analysis revealed a HU of 21 as threshold with the best diagnostic accuracy (sensitivity 96%, specificity 80%, and AUC 0.89). However, two ACCs that were 5 and 6 cm in size would have been missed. Setting the threshold to 13.9 allowed for 100% sensitivity, but a lower specificity of 68%. CONCLUSIONS: This first large study on ACCs confirmed that the vast majority of ACCs have unenhanced HU >21. However, to avoid misdiagnosing an ACC as benign, a threshold of 13 should be used.

Transesophageal echocardiography: a follow-up tool after catheter ablation of atrial fibrillation and interventional therapy of pulmonary vein stenosis and occlusion.

BACKGROUND: Pulmonary vein stenosis (PVS) has been described as a complication after primary catheter ablation of atrial fibrillation (Afib). The purpose of this study was to evaluate the utility of transesophageal echocardiography (TEE) as follow-up tool after catheter ablation of Afib and interventional therapy of PVS and pulmonary vein occlusion (PVO). METHODS: We report on 28 patients with stenosis (PVS) of 33 pulmonary veins (PVs) and total PVO of 4 veins complicating ablation of Afib assessed by angiography and/or magnetic resonance imaging (MRI). Subsequently, transseptal PV angiograms were performed, followed by recanalization of three totally occluded PVs and balloon dilatation of seven severe PVS (in four cases combined with PV stenting). PVs were analyzed by multiplane TEE in an intraindividual comparison of preablation/preintervention and follow-up measurements of mean and peak flow velocity, velocity time integrals, and diameters. RESULTS: Of a total of 28 patients, 14 had mild PVS (n = 14), 9 had moderate PVS (n = 10), 6 had severe PVS (n = 8), and 4 patients showed totally occluded PVs (n = 4). In multivariate analysis flow velocities and vessel diameters showed significant differences (mild, moderate, and severe PVS and PVO; p = 0.001). Interventional benefits of balloon dilatation (n = 10) and stent implantation (n = 4), as well as in-stent restenosis could be detected (p = 0.014). In all recanalized vessels TEE showed reestablished flow. In occluded PVs no flow was detectable. The TEE vessel diameters correlated with angiography data (r = 0.87) and computed tomography/MRI (r = 0.90). CONCLUSIONS: TEE can be used as a follow-up tool after interventional therapy in patients after catheter ablation and acquired PVS/PVO. Restenosis/in-stent restenosis can be identified by analyzing the vessel diameters and blood flow characteristics.

External and endoluminal analysis of left atrial anatomy and the pulmonary veins in three-dimensional reconstructions of magnetic resonance angiography: the full insight from inside.

INTRODUCTION: The detailed knowledge of the individual pulmonary vein (PV) anatomy may help to prevent serious complications during PV isolation (PVI). The purpose of this study was to determine the geometry of the PV ostia and their spatial relation to adjacent structures in external (ex 3D) and endoluminal (en 3D) three-dimensional reconstructions of magnetic resonance angiographies (MRAs). METHODS AND RESULTS: Ex 3D and en 3D of the left atrium (LA) and the PVs of 28 patients were calculated. Diameters and the shape of PV ostia were assessed. In addition, the distances between ipsilateral PV ostia, the LA isthmus line, the roof line and the distance between the left PV and the LA appendage (LAA) were measured. Both ex 3D and en 3D are useful tools to determine the dimensions and the geometry of PVs. En 3D facilitates the identification of common PV ostia (15/28 patients). In en 3D, ipsilateral PV ostia are separated by a narrow myocardial ridge of less than 4 mm in 19/38 PVs (mean 4.3 +/- 1 mm; 4.6 +/- 2 mm with ex 3D). LAA and the LPV ostia are separated by a ridge of less than 4 mm in 12/28 PVs measured with en 3D (4.8 +/- 2 mm; 6.4 +/- 2 mm with ex 3D). CONCLUSIONS: Both ex 3D and en 3D reconstructions of MRA precisely visualize the complex LA anatomy. Exact determination of PV ostial geometry is facilitated with en 3D and provides important anatomical information for the PVI strategy. According to our data, individual encircling of every PV is strongly discouraged.

Spontaneous retraction of an intramyocardial dissecting hemorrhage and multiple left ventricular thrombus formations in subacute myocardial infarction and antiphospholipid syndrome: a case report with long-term follow-up.

This report describes a 68-year-old patient with a subacute myocardial infarction and antiphosholipid syndrome. He developed an intramyocardial dissecting hemorrhage involving the left ventricular apex and multiple left ventricular thrombus formations, documented by contrast echocardiography and magnetic resonance imaging. By use of transthoracic echocardiography, spontaneous retraction of the dissecting hemorrhage could be detected. Severe coronary 3-vessel disease was successfully treated by coronary artery bypass grafting. During follow-up of 16 months, the dissecting hematoma could not been detected. Under initiation of anticoagulant treatment with Coumadin, the patient was in stable clinical condition and improved in New York Heart Association class from III to II. The pathophysiology, diagnosis, and management of this potentially highly lethal complication is reviewed.

[Three-dimensional reconstruction of pulmonary veins and left atrium. Implications for catheter ablation of atrial fibrillation]. / Dreidimensionale Rekonstruktion der Pulmonalvenen und des linken AtriumsBedeutung für die Katheterablation von Vorhofflimmern.

BACKGROUND: Selective pulmonary vein (PV) isolation to eliminate triggers is commonly used for curative catheter ablation of atrial fibrillation guided by two-dimensional (2-D) PV angiography, which is somewhat limited to depict the complex morphology of the PVs. 3-D mapping systems are limited to reconstruct the complete "true" anatomy by the reach of the mapping electrode related to catheter properties (maximum deflection and curve). New 3-D imaging systems (spiral computed tomography [CT] or magnetic resonance imaging [MRI]) provide detailed knowledge of the individual left atrial and PV morphology. Especially with the tampering, funnel-shaped PV ostia, identification of the PV ostium in selective PV isolation procedures aiming at the interruption of myocardial fibers is rather challenging using the 2-D imaging technique of contrast angiography. PATIENTS AND METHODS: In a total of 16 patients (13 male, three female, mean age 57 +/- 8 years), cardiac 3-D magnetic resonance angiography (MRA; 1.5 T, ACS Intera Philips, Germany) using an ECG-gated technique (1.3-1.7 mm slices) was performed. Using the postprocessing software Leonardo (Siemens, Germany), all adjacent anatomic structures such as the pulmonary artery were cut off to focus on the left atrium (LA) and PV anatomy. RESULTS: Left-sided PVs always entered in close proximity into the LA (common ostium in two patients). The right PVs entered more separately into the LA with a predominance of oval shapes. CONCLUSION: MRA is a noninvasive tool providing knowledge of the individual 3-D anatomy in a photorealistic fashion. Ultimately, image fusion with 3-D mappings systems would allow for true 3-D electrophysiologic mapping and could facilitate further understanding of the underlying substrate of so far "unsolved" complex arrhythmias such as atrial fibrillation in the future.