The role of cardiac computed tomography in diagnostic and prognostic assessment of pregnancy related spontaneous coronary artery dissection: a case report.

Spontaneous coronary artery dissection (SCAD) is the most common cause of myocardial infarction during pregnancy or the postpartum period and has a major impact on cardiovascular morbidity and death in pregnant women. A 38-year-old woman with sudden cardiac arrest ten days postpartum urgently underwent coronarography, which showed an intraparietal hematoma of the left anterior descending (LAD) artery. Two days later, coronary computed tomography angiography (CCTA) was performed, which showed the evidence of SCAD in the mid-distal tract of LAD and the presence of transmural ischemic infarction in the apex and mid antero-septal wall in delayed acquisition. The patient was treated with a beta-blocker. Four months later CCTA showed complete resolution of SCAD and evolution of the infarcted areas. Given the high accuracy and noninvasiveness of CCTA, our case highlights the potential role of this imaging modality in the diagnosis and follow-up of pregnancy associated SCAD.

The Impact of Nitroglycerin on the Evaluation of Coronary Stenosis in Coronary-CT: Preliminary Study in 131 Patients.

BACKGROUND: The sublingual administration of short-acting nitroglycerin (NTG) before coronary computed tomography (CCT) improves the visualization of coronary arteries, causing vasodilatation. The aim of this study was to evaluate whether and how nitroglycerin can influence the concordance between radiologists and cardiologists in the evaluation of vessel stenosis measured in CCT by the former and during the following coronarography by the latter. METHODS: We conducted a retrospective analysis of 131 patients who underwent CCT for cardiac symptoms in 2022, followed by coronarography performed six months later because of significant stenosis revealed by the CCT. First, the patients were divided into two groups: an NTG group who received sublingual nitroglycerin before CCT and a non-NTG group who did not because of contraindications. Second, 254 stenoses were measured by two radiologists after CCT and by two interventional cardiologists during the next coronarography; moreover, stenoses were classified on the basis of their location and plaque pattern (calcific, mixed and lipidic). Third, the strength of agreement was evaluated between the two radiologists, between the two cardiologists and finally between the radiologists and cardiologists in order to evaluate whether and how the interdisciplinary discrepancy in stenosis evaluation could change with or without the use of nitroglycerin before CCT and in relation to the different plaque pattern. RESULTS: In the NTG group, the use of nitroglycerine reduced the agreement between radiologists and cardiologists in calcific stenosis but did not change the concordance in the case of mixed or lipidic plaques on the same vessels. CONCLUSIONS: The use of sublingual nitroglycerin before CCT may lead to a radiological overestimation of calcific stenosis.

Radiological findings in Erdheim Chester disease: A very rare multisistemic disease.

Erdheim-Chester disease is an uncommon non-Langerhans cell histiocytosis affecting multiple systems. There is limited knowledge on the imaging capabilities of this disease. We present an extremely rare case of Erdheim-Chester illness in a 67-year-old man with multisystem involvement, including the cardiovascular system, skeleton, retroperitoneum (renal and adrenal infiltration) and the neurologic system. The involvement of the various organs was thoroughly assessed using multimodal imaging modalities such as computed tomography, magnetic resonance imaging, positron emission tomography and bone scintigraphy. Erdheim-Chester illness was revealed by a bone biopsy. Especially when there is cardiac and cerebral involvement, Erdheim-Chester illness is a rare condition with a poor prognosis. Knowing the imaging characteristics of Erdheim-Chester disease may be helpful in understanding the radiological results of many organs affected by the disease as described and discussed in the current case report.

Cardiac lipoma of the interventricular septum presenting with chest pain.

In this case report, we describe an incidental finding of interventricular septum lipoma in a 55-year-old man who came to our attention for chest pain. The ECG showed no changes compatible with ongoing ischemia. While laboratory tests documented increased troponin levels with normal D-dimer levels. Due to the technical difficulties encountered during the performance of the transthoracic echocardiogram, a cardiac CT scan was requested, which ruled out significant coronary artery disease and acute aortic syndromes and showed the presence of a circumscribed fat-dense mass located in the basal portion of the interventricular septum. Subsequent cardiac MRI confirmed the diagnosis of lipoma of the interventricular septum.

Cardiac Computed Tomography Evaluation of Association of Left Ventricle Disfunction and Epicardial Adipose Tissue Density in Patients with Low to Intermediate Cardiovascular Risk.

Background and objectives: Epicardial adipose tissue density (EAD) has been associated with coronary arteries calcium score, a higher load of coronary artery disease (CAD) and plaque vulnerability. This effect can be related to endocrine and paracrine effect of molecules produced by epicardial adipose tissue (EAT), that may influence myocardial contractility. Using coronary computed tomography angiography (CCT) the evaluation of EAD is possible in basal scans. The aim of the study is to investigate possible associations between EAD and cardiac function. Material and Methods: 93 consecutive patients undergoing CCT without and with contrast medium for known or suspected coronary CAD were evaluated. EAD was measured on basal scans, at the level of the coronary ostia, the lateral free wall of the left ventricle, at the level of the cardiac apex, and at the origin of the posterior interventricular artery. Cardiac function was evaluated in post-contrast CT scans in order to calculate ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), and stroke volume (SV). Results: A statistically significant positive correlation between EAD and ejection fraction (r = 0.29, p-value < 0.01) was found. Additionally, a statistically significant negative correlation between EAD and ESV (r = -0.25, p-value < 0.01) was present. Conclusion: EAD could be considered a new risk factor associated with reduced cardiac function. The evaluation of this parameter with cardiac CT in patients with low to intermediate cardiovascular risk is possible.

Quantification of Extracellular Volume in CT in Neoadjuvant Chemotherapy in Breast Cancer: New Frontiers in Assessing the Cardiotoxicity of Anthracyclines and Trastuzumab.

Breast cancer patients undergoing neoadjuvant chemotherapy with anthracyclines or trastuzumab can suffer cardiotoxic issues. Nowadays, the markers of cardiac damage are still not reliable, and extracellular volume (ECV) calculated from CT could be a promising cardiotoxic marker. Eighty-two patients, treated with two different chemotherapy regimens based on doxorubicin (DOX) or epirubicin-trastuzumab (EPI-TRAS), were retrospectively selected and the variations in extracellular volume (ECV) values were measured and analyzed. Whole Body CT (WB-CT) scans were acquired after 1 min, in the portal phase (PP), and after 5 min, in the delayed phases (DP), at the baseline (T0), after one year (T1) and after five years (T5) from the end of chemotherapies. The values measured by two radiologists with different levels of experience were evaluated in order to assess the inter-reader reproducibility assessment (ICC = 0.52 for PP and DP). Further, we performed a population-based analysis and a drug-oriented subgroup analysis in 54 DOX-treated and 28 EPI-TRAS-treated patients. In the general cohort of women treated with any of the two drugs, we observed in the lapse T0-T1 a relative increase (RI) of 25% vs. 20% (PP vs. DP, p < 0.001) as well as in the lapse T0-T5 an RI of 17% vs. 15% (PP vs. DP, p < 0.01). The DOX-treated patients reported in the lapse T0-T1 an RI of 22% (p < 0.0001) in PP and an RI of 16% (p = 0.018) in the DP, with ECV values remaining stably high at T5 both in PP (RI 14.0%, p < 0.0001) and in DP (RI 17%, p = 0.005) highlighting a possible hallmark of a persisting CTX sub-damage. On the other hand, ECV measured in EPI-TRAS-treated women showed an RI in T0-T1 of 18% (p = 0.001) and 29% (p = 0.006) in PP and DP, respectively, but the values returned to basal levels in T5 both in the PP (p = 0.12) and in DP setting (p = 0.13), suggesting damage in the first-year post-treatment and a possible recovery over time. For the 82 patients, an echocardiography was performed at T0, T1= 12 m + 3 m and T5 = 60 m + 6 m with LVEF values at T0 (64% ± 5%), T1 (54% ± 6%) and T5 (53% ± 8%). WB-CT-derived ECV values could provide a valid imaging marker for the early diagnosis of cardiotoxic damage in BC patients undergoing oncological treatments. We detected different patterns during the follow-up, with stably high values for DOX, whereas EPI-TRAS showed a peak within the first year, suggesting different mechanisms of cardiac damage.

Lipomatous hypertrophy of the interatrial septum: A potential pitfall resolved on comparing previous PET/CT.

In this case report, we describe a rare case of inter-atrial septal lipomatosis occasionally found in a PET-CT scan performed in an 81-year-old patient with a history of periprosthetic endocarditis post aortic prosthesis implantation. The patient reappeared in 2022 in the emergency department complaining of symptomatology of worsening asthenia, fever, and elevated inflammatory indices. He was hospitalized in Cardiology department on suspect of recurrence of endocarditis and underwent PET-CT examination that showed an increased metabolic finding at the interatrial septum. On possible suspicion of recurrence of infective endocarditis or cardiac tumor pathology, further diagnostic investigation by cardio-RM examination was requested. However, after radiologic consultation, the previous performed FDG-PET/TC examinations were re-evaluated and a misdiagnosed uptake at this level was revealed, which was assumed to be due to the endocarditis condition because of widespread uptake throughout the perivalvular area.

Radiomics analysis of short tau inversion recovery images in cardiac magnetic resonance for the prediction of late gadolinium enhancement in patients with acute myocarditis.

RATIONALE AND OBJECTIVES: Cardiac Magnetic Resonance (CMR) imaging is recommended as the reference diagnostic non-invasive modality for myocarditis but is often limited by patients' compliance. The purpose of this study is to evaluate the validity of Radiomics applied to Short Tau Inversion Recovery (STIR) sequences, in predicting the presence of LGE in patients with suspected acute myocarditis. MATERIALS AND METHODS: 171 STIR images on short-axis view were segmented with "MaZda" software ver 4.6, by placing a region of interest (ROI) on the left ventricle by two radiologists in consensus. Images were classified according to the presence of LGE in the equivalent short-axis T1-IR slice. A total of 337 ROI features were extracted for each image. Dataset was then split into two parts (train and test set) with 70:30 ratio. RESULTS: Eleven classification models were trained. An Ensemble Machine Learning (EML) model was obtained by averaging the predictions of models with accuracy on test set >70%. The EML documented accuracy of 0.75, sensitivity of 0.8 and a specificity of 0.73 with a NPV of 0.81 and a PPV of 0.7, with AUC of 0.79 (95% CI: 0.66-0.92). CONCLUSION: Radiomics and machine learning analysis could be a promising approach in reducing scan times without reducing diagnostic accuracy in predicting LGE in patients with acute myocarditis.

Role of computed tomography in transcatheter replacement of 'other valves': a comprehensive review of preprocedural imaging.

Transcatheter procedures for heart valve repair or replacement represent a valid alternative for treating patients who are inoperable or at a high risk for open-heart surgery. The transcatheter approach has become predominant over surgical intervention for aortic valve disease, but it is also increasingly utilized for diseases of the 'other valves', that is the mitral and, to a lesser extent, tricuspid and pulmonary valve. Preprocedural imaging is essential for planning the transcatheter intervention and computed tomography has become the main imaging modality by providing information that can guide the type of treatment and choice of device as well as predict outcome and prevent complications. In particular, preprocedural computed tomography is useful for providing anatomic details and simulating the effects of device implantation using 3D models. Transcatheter mitral valve replacement is indicated for the treatment of mitral regurgitation, either primary or secondary, and computed tomography is crucial for the success of the procedure. It allows evaluating the mitral valve apparatus, the surrounding structures and the left heart chambers, identifying the best access route and the landing zone and myocardial shelf, and predicting obstruction of the left ventricular outflow tract, which is the most frequent postprocedural complication. Tricuspid valve regurgitation with or without stenosis and pulmonary valve stenosis and regurgitation can also be treated using a transcatheter approach. Computer tomography provides information on the tricuspid and pulmonary valve apparatus, the structures that are spatially related to it and may be affected by the procedure, the right heart chambers and the right ventricular outflow tract.

Cardiac Computed Tomography Radiomics-Based Approach for the Detection of Left Ventricular Remodeling in Patients with Arterial Hypertension.

The aim of the study is to verify the feasibility of a radiomics based approach for the detection of LV remodeling in patients with arterial hypertension. Cardiac Computed Tomography (CCT) and clinical data of patients with and without history of arterial hypertension were collected. In one image per patient, on a 4-chamber view, left ventricle (LV) was segmented using a polygonal region of interest by two radiologists in consensus. A total of 377 radiomics features per region of interest were extracted. After dataset splitting (70:30 ratio), eleven classification models were tested for the discrimination of patients with and without arterial hypertension based on radiomics data. An Ensemble Machine Learning (EML) score was calculated from models with an accuracy >60%. Boruta algorithm was used to extract radiomic features discriminating between patients with and without history of hypertension. Pearson correlation coefficient was used to assess correlation between EML score and septum width in patients included in the test set. EML showed an accuracy, sensitivity and specificity of 0.7. Correlation between EML score and LV septum width was 0.53 (p-value < 0.0001). We considered LV septum width as a surrogate of myocardial remodeling in our population, and this is the reason why we can consider the EML score as a possible tool to evaluate myocardial remodeling. A CCT-based radiomic approach for the identification of LV remodeling is possible in patients with past medical history of arterial hypertension.

Postmortem CT pulmonary findings in SARS-CoV-2-positive cases: correlation with lung histopathological findings and autopsy results.

INTRODUCTION/PURPOSE: Postmortem computed tomography (PMCT) is a valuable tool for analyzing the death of patients with SARS-CoV-2 infection. The purpose of this study was to investigate the correlation between PMCT lung findings in autopsy cadavers positive for SARS-CoV-2 infection and the severity of COVID-19 lung disease by histopathological analysis. MATERIALS AND METHODS: We reviewed chest PMCT findings, paying particular attention to the lung parenchyma, in 8 autopsy cases positive for SARS-CoV-2. Correlations between chest PMCT and histopathological findings were assessed. Clinical conditions and comorbidities were also recorded and discussed. The primary cause of death was finally considered. RESULTS: In 6/8 cases, pulmonary PMCT findings were massive consolidation (4/8) and bilateral diffuse mixed densities with a crazy-paving pattern (2/8). These cases showed severe pulmonary signs of COVID-19 at histopathological analysis. In the remaining 2/8 cases, pulmonary PMCT findings were scant antideclive ground-glass opacities in prevalent gradient densities attributed to hypostasis. In 4/8 cases with massive consolidations, important comorbidities were noted. In 6/8 cases with severe pulmonary histopathological signs of lung COVID-19, autopsy found that the cause of death was cardiorespiratory failure. In the remaining 2/8 cases, histopathological analysis revealed lung alterations due to edema and some signs of SARS-CoV-2 infection; the cause of death was not attributed to SARS-CoV-2 infection (Table 1). DISCUSSION AND CONCLUSION: Chest PMCT findings correlate with the severity of COVID-19 lung disease at histopathology examination. According to our results, there may also be a relationship between cause of death and PMCT findings in COVID-19, which must be critically analyzed considering clinical antemortem data.

Cardiac Magnetic Resonance Tissue Characterization in Ischemic Cardiomyopathy.

Ischemic cardiomyopathy (ICM) is one of the most common causes of congestive heart failure. In patients with ICM, tissue characterization with cardiac magnetic resonance imaging (CMR) allows for evaluation of myocardial abnormalities in acute and chronic settings. Myocardial edema, microvascular obstruction (MVO), intracardiac thrombus, intramyocardial hemorrhage, and late gadolinium enhancement of the myocardium are easily depicted using standard CMR sequences. In the acute setting, tissue characterization is mainly focused on assessment of ventricular thrombus and MVO, which are associated with poor prognosis. Conversely, in chronic ICM, it is important to depict late gadolinium enhancement and myocardial ischemia using stress perfusion sequences. Overall, with CMR's ability to accurately characterize myocardial tissue in acute and chronic ICM, it represents a valuable diagnostic and prognostic imaging method for treatment planning. In particular, tissue characterization abnormalities in the acute setting can provide information regarding the patients that may develop major adverse cardiac event and show the presence of ventricular thrombus; in the chronic setting, evaluation of viable myocardium can be fundamental for planning myocardial revascularization. In this review, the main findings on tissue characterization are illustrated in acute and chronic settings using qualitative and quantitative tissue characterization.

Transcatheter aortic valve implantation in patients with unruptured aortic root pseudoaneurysm: an observational study.

AIMS: Unruptured aortic root pseudoaneurysm (UARP) is a rare complication of aortic valve endocarditis. Infectious spread to the valvular annulus or myocardium can cause septic complications that manifest as wall thickening, and spontaneous abscess drainage leads to pseudoaneurysm formation. We report the first patient series in which transcatheter aortic valve implantation (TAVI) using a single valve-resolved aortic valvulopathy associated with UARP was performed. METHODS: At our center, from December 2017 to October 2019, 138 patients underwent TAVI for aortic valve stenosis and/or regurgitation, 20 of whom (12 female patients, 8 male patients) had associated incidental UARP and were considered as our study population. The average age of these patients was 76.9 ±â€Š5.2 years. All patients were assessed using preprocedural and postprocedural multimodality imaging, including transthoracic echocardiography, transesophageal echocardiography, and cardiac computed tomography angiography (CCTA). RESULTS: In all cases, the final angiographic examination showed correct valve positioning with complete coverage of the false aneurysm. Post-TAVI CCTA showed presence of total or subtotal UARP thrombosis. The mean follow-up period was 17.5 months (12-23 months). During follow-up, imaging showed normal prosthetic valve function, no significant leakage (trace or mild), and complete UARP exclusion in all patients, without any complications. CONCLUSION: In conclusion, percutaneous valve positioning can simultaneously solve pseudoaneurysm complications by excluding the sac and promoting thrombosis.

Pseudoaneurysm of the aortic root following aortic valve endocarditis - a case with 2 rare life - threatening complications.

Infective endocarditis can have peri-annular spread and involve the valvular annulus and adjacent cardiac structures, leading to tissue necrosis and peri-annular abscess. This process may cause pseudoaneurysm formation and other rare and potentially life-threatening complications, so their identification and correct diagnosis are crucial. We describe a case of an 81-year-old woman, with a history of aortic valve replacement and worsening of symptoms, that presents at the imaging a pseudoaneurysm of the aortic root complicated at the same time by 2 life-threatening conditions: fistulization in the Right Ventricular Outflow Tract (RVOT) and the compression of Right Coronary Artery (RCA). This case underlines the importance of imaging, especially Coronary Computed Tomography Angiography (CCTA), in the diagnosis and follow-up of infective endocarditis and its complications, especially in a patient not eligible for surgery.

Relationship between septo-valvular angle and risk of pacemaker implantation after transcatheter aortic valve implantation: a preliminary study.

AIM: Pre-transcatheter aortic valve implantation (TAVI) computed tomography (CT) has proven to be crucial in identifying pre- and post-procedural predicting factors predisposing the onset of major arrhythmias that require permanent pacemaker (PPM) implantation caused by the compressive effects of the prostheses on the conduction system at the membranous septum (MS) and the muscular crest of the interventricular septum.Our analysis aims to verify if the pre-TAVI assessment of the angle between the MS and the aortic annulus (SVA) might be a predictive factor for the onset of arrhythmias that requires PPM. METHODS: Two cardiovascular specialist radiologists retrospectively and double-blind evaluated a randomized list of preprocedural CT of 57 patients who underwent TAVI with a self-expandable valve from April 2019 to February 2020. Two anatomical features were measured by readers: width of the SVA and MS length (MSL). RESULTS: A PPM was implanted in 18 patients (31%) after the procedure. There was no significant difference in the anatomical measurements performed between the two observers, regarding both anatomical measurements (intraclass correlation coefficient was 0.944 for the SVA and 0.774 for the MSL]. Receiver-operating characteristic curves (ROC) performed for both measurements have documented: for the SVA sensitivity 94% and Negative predictive value (NPV) 96% (area under the curve: 0.77; 95% confidence interval 0.66-0.90). The MSL ROC was not significant. The mean SVA value stratified for patients who did not undergo PPM implantation and patients who did resulted as significant (P < 0.005). CONCLUSION: Measurement of the SVA performed in preprocedural CT scans has proven to be related to the onset of major arrhythmias after TAVI requiring permanent pacemaker implantation with high sensitivity (94%) and NPV (96%).

A rare case of a giant circumflex coronary artery aneurysm 10 years after bentall surgery.

In this paper, we describe a rare case of coronary artery aneurysms occasionally found on a pre interventional Coronary Computed Tomography Angiography performed on a 67-year-old man with a history of aneurysm of the ascending aorta previously treated with Bentall surgery, who arrived at our hospital to have a percutaneous valve-in-valve implantation procedure. Even though the patient was considered not eligible for the procedure, due to his many comorbidities, and conservatively managed, at 1-year followup his angiographic condition remained stable.

Effects on pain of percutaneous treatment of cervical disc herniations using DiscoGel: A retrospective analysis.

BACKGROUND AND PURPOSE: Cervical discogenic pain originates from degenerated intervertebral discs and is a common condition in the middle-aged population. Cervical discs may herniate and give compressions to cervical nerves, with pain and functional limitation of the arms. DiscoGel is a device that can be useful in the treatment of cervical disc herniation, with very short operating time and low radiation dose. MATERIAL AND METHODS: Between March 2018 and April 2019 we performed this procedure on 38 patients with non-fissurated cervical herniation using 0.3-0.4 mL of DiscoGel injected under fluoroscopic guidance. The most common discs affected were C5-C6, C6-C7 and C4-C5. Outcomes were evaluated with Visual Analogue Scale (VAS) and Neuropathic Pain Symptom Inventory (NPSI) scores at 3, 6 and 12 months follow-up. A magnetic resonance imaging (MRI) scan of the cervical spine was performed 3 months after the procedure. RESULTS: Postoperative examinations showed: VAS 2.15 ± 1.34 and NPSI 2.29 ± 0.71.Postoperative MRI performed 3 months after the procedure showed a good improvement of cervical disc herniation or bulging or protrusion. The mean dose area product (DAP) was 2803 mGy/cm2 with a mean fluoroscopy time of 4 minutes 22 seconds.Conclusion DiscoGel is a suitable approach for non-fissurated cervical disc herniations, especially in patients that are not suitable for open surgery, with excellent postoperative results, fast recovery and a low radiation dose.

Chest Computed Tomography Scoring in Patients With Novel Coronavirus-infected Pneumonia: Correlation With Clinical and Laboratory Features and Disease Outcome.

BACKGROUND/AIM: This study investigated the correlation of chest computed tomography (CT), findings, graded using two different scoring methods, with clinical and laboratory features and disease outcome, including a novel clinical predictive score, in patients with novel coronavirus-infected pneumonia (NCIP). PATIENTS AND METHODS: In this retrospective, observational study, CT scan of 92 NCIP patients admitted to Policlinico Tor Vergata, were analyzed using a quantitative, computed-based and a semiquantitative, radiologist-assessed scoring system. Correlations of the two radiological scores with clinical and laboratory features, the CALL score, and their association with a composite adverse outcome were assessed. RESULTS: The two scores correlated significantly with each other (ρ=0.637, p<0.0001) and were independently associated with age, LDH, estimated glomerular filtration rate, diabetes, and with the composite outcome, which occurred in 24 patients. CONCLUSION: In NCIP patients, two different radiological scores correlated with each other and with several clinical, laboratory features, and the CALL score. The quantitative score was a better independent predictor of the composite adverse outcome than the semiquantitative score.

Ascending aorta pseudoaneurysm simulating mediastinal lymphoma in computed tomography, a possible diagnostic error: a case report.

BACKGROUND: An ascending aortic pseudoaneurysm is a severe and rare complication following cardiothoracic surgery. This case report demonstrates its possible misinterpretation and the consequent importance of multidisciplinary evaluation. CASE PRESENTATION: We present a case of an 18-year-old Caucasian man with Marfan syndrome who developed an ascending aortic pseudoaneurysm about 1 year after undergoing cardiac surgery with the Bentall procedure. Computed tomographic examination of the thoracic aorta and positron emission tomography-computed tomography initially suggested a lymphomatous pathology. However, these imaging results were in contrast to the transesophageal echocardiogram and the laboratory data that showed negative results for hematological pathology. A second computed tomographic scan redirected the diagnosis toward a pseudoaneurysm. CONCLUSION: This case demonstrates the utility of close communication and interdisciplinary consultation between cardiovascular radiologists and the cardiac surgery team, which are mandatory in order to maximize their diagnostic skills in identifying postoperative complications.