Tissue characterization of acute lesions during cardiac magnetic resonance-guided ablation of cavo-tricuspid isthmus-dependent atrial flutter: a feasibility study.

AIMS: To characterize acute lesions during cardiac magnetic resonance (CMR)-guided radiofrequency (RF) ablation of cavo-tricuspid isthmus (CTI)-dependent atrial flutter by combining T2-weighted imaging (T2WI), T1 mapping, first-pass perfusion, and late gadolinium enhancement (LGE) imaging. CMR-guided catheter ablation offers a unique opportunity to investigate acute ablation lesions. Until present, studies only used T2WI and LGE CMR to assess acute lesions. METHODS AND RESULTS: Fifteen patients with CTI-dependent atrial flutter scheduled for CMR-guided RF ablation were prospectively enrolled. Directly after achieving bidirectional block of the CTI line, CMR imaging was performed using: T2WI (n = 15), T1 mapping (n = 10), first-pass perfusion (n = 12), and LGE (n = 12) imaging. In case of acute reconnection, additional RF ablation was performed. In all patients, T2WI demonstrated oedema in the ablation region. Right atrial T1 mapping was feasible and could be analysed with a high inter-observer agreement (r = 0.931, ICC 0.921). The increase in T1 values post-ablation was significantly lower in regions showing acute reconnection compared with regions without reconnection [37 ± 90 ms vs. 115 ± 69 ms (P = 0.014), and 3.9 ± 9.0% vs. 11.1 ± 6.8% (P = 0.022)]. Perfusion defects were present in 12/12 patients. The LGE images demonstrated hyper-enhancement with a central area of hypo-enhancement in 12/12 patients. CONCLUSION: Tissue characterization of acute lesions during CMR-guided CTI-dependent atrial flutter ablation demonstrates oedema, perfusion defects, and necrosis with a core of microvascular damage. Right atrial T1 mapping is feasible, and may identify regions of acute reconnection that require additional RF ablation.

The performance of non-ECG gated chest CT for cardiac assessment - The cardiac pathologies in chest CT (CaPaCT) study.

PURPOSE: Evaluating the prevalence of CAD on non-ECG gated chest CTs, image quality (IQ) and the clinical performance of the CAD-RADS classification for predicting cardiovascular events (CVE). METHODS: 215 consecutive patients referred for chest CTs between May 2016 and March 2018 were included (3rd-generation DSCT) using non-ECG gated acquisitions with automated tube voltage selection (110kVqual.ref/40mAsqual.ref), pitch 2.65-3.0 and individualized contrast media injection protocols. Dedicated cardiac post-processing reconstructions (0.6 mm/0.4 mm/Kernel Bv36) were added to standard chest reconstructions. Two independent cardiac radiologists performed a 3-step analysis. In case of discrepancy, a third reader gave the final decision. Step 1: visual presence of calcifications; 2: scans with calcifications assessed for IQ using a 5-point Likert scale (poor/sufficient/moderate/good/excellent); 3: stenosis severity was analysed in detail (if Likert sufficient-excellent using CAD-RADS). Electronic patient files were checked to see if pathology was previously mentioned (incidental) and whether patients developed an CVE during follow-up. RESULTS: 1: Calcifications were present in 156/215 cases (72.6 %), 74 of these were incidental. 2: In 68/156 (43.6 %) patients with calcifications IQ was rated sufficient-excellent. 3: CAD-RADS≥3 was seen in 39/68 patients (57.4 %), 12 times (30.8 %) findings were incidental. During follow-up (median 16 [0-35] months), 7/39 (18 %) patients with CAD-RADS≥3 developed a CVE. 17 patients died during follow-up. CONCLUSION: Coronary calcification on non ECG-gated chest CTs was detected in 72.6 % of patients, cardiac assessment was feasible in nearly half of these patients. Only patients with a CAD-RADS≥3 developed CVE, therefore the CAD-RADS may help identify and guide patients at risk of future CVE.

Personalization of CM Injection Protocols in Coronary Computed Tomographic Angiography (People CT Trial).

Aim: To evaluate the performance of three contrast media (CM) injection protocols for cardiac computed tomography angiography (CCTA) based on body weight (BW), lean BW (LBW), and cardiac output (CO). Materials and methods. A total of 327 consecutive patients referred for CCTA were randomized into one of the three CM injection protocols, where CM injection was based on either BW (112 patients), LBW (108 patients), or CO (107 patients). LBW and CO were calculated via formulas. All scans were ECG-gated and performed on a third-generation dual-source CT with 70-120 kV (automated tube voltage selection) and 100 kVqual.ref/330 mAsqual.ref. CM injection protocols were also adapted to scan time and tube voltage. The primary outcome was the proportion of patients with optimal intravascular attenuation (325-500 HU). Secondary outcomes were mean and standard deviation of intravascular attenuation values (HU), contrast-to-noise ratio (CNR), and subjective image quality with a 4-point Likert scale (1 = poor/2 = sufficient/3 = good/4 = excellent). The t-test for independent samples was used for pairwise comparisons between groups, and a chi-square test (χ2) was used to compare categorical variables between groups. All p values were 2-sided, and a p < 0.05 was considered statistically significant. Results: Mean overall HU and CNR were 423 ± 60HU/14 ± 3 (BW), 404 ± 62HU/14 ± 3 (LBW), and 413 ± 63HU/14 ± 3 (CO) with a significant difference between groups BW and LBW (p=0.024). The proportion of patients with optimal intravascular attenuation (325-500 HU) was 83.9%, 84.3%, and 86.9% for groups BW, LBW, and CO, respectively, and between-group differences were small and nonsignificant. Mean CNR was diagnostic (≥10) in all groups. The proportion of scans with good-excellent image quality was 94.6%, 86.1%, and 90.7% in the BW, LBW, and CO groups, respectively. The difference between proportions was significant between the BW and LBW groups. Conclusion: Personalization of CM injection protocols based on BW, LBW, and CO, and scan time and tube voltage in CCTA resulted in low variation between patients in terms of intravascular attenuation and a high proportion of scans with an optimal intravascular attenuation. The results suggest that personalized CM injection protocols based on LBW or CO have no additional benefit when compared with CM injection protocols based on BW.

Evaluation of various apparent diffusion coefficient measurement techniques in pre-operative staging of early cervical carcinoma.

PURPOSE: DW-MRI parameters such as ADC hold the potential for more reliable staging of cervical cancer. We compared 2D region of interest (ROI) measurement techniques to 3D tumor analysis in the evaluation of ADC for cervical cancer. Secondly, we evaluated the utility of ADC for assessing parametrial and/or lymph node involvement. METHOD: This prospective patient cohort registered cervical cancer patients who underwent pre-operative MRI with T1, T2W, and axial DWI. Retrospectively, two observers independently and blindly scored mean, minimum, and maximum ADC using three methods: a) 3D-Tumor analysis, b) single freehand ROI (2D-Slice), and c) single circular ROI (2D-Circle). Another observer scored parametrial and lymph node involvement on T1/T2W sequences. Parametrial and/or lymph node involvement were determined by surgical-pathologic results. The diagnostic performance of ADC for predicting the latter was evaluated by ROC curve, uni and multivariate analyses. RESULTS: Of 58 included patients, parametrial and/or lymph node involvement was found in 9 and 11 patients, respectively. Mean ADC (ADCMean) was least dependent on ROI technique, with interobserver variability (ICC: 0.88-0.90) and linear correlation (Pearson's r: 0.95-0.96). To the contrary, minimal and maximal ADC were significantly influenced by 2D-ROI techniques. ADCMean was shown to be an independent predictor of parametrial (AUC: 0.80-0.86; OR: 16, 1.4-178) and/or lymph node involvement (AUC: 0.74-0.79; OR: 5.1, 1.1-24). CONCLUSIONS: Single ROI measurements are a reliable method for determining ADCMean in cervical cancer. Second, ADCMean serves as a potential parameter for prediction of parametrial involvement prior to radical hysterectomy.

Assessment of parametrial invasion of cervical carcinoma, the role of T2-weighted MRI and diffusion weighted imaging with or without fusion.

AIM: To evaluate the diagnostic performance of diffusion-weighted imaging (DWI), with and without fusion images, in addition to regular T2-weighted (T2W) sequences for assessment of parametrial invasion. MATERIALS AND METHODS: This prospective cohort included cervical cancer patients who underwent preoperative magnetic resonance imaging (MRI) with T2W and axial DWI sequences prior to radical hysterectomy. Retrospectively, two radiologists independently and blindly scored the likelihood of parametrial invasion by means of a six-point confidence scale. Parametrial invasion was determined by surgical-pathological results. Performance indices for diagnostic tests and area under the receiver operating characteristic curve (AUC) analyses were performed. P-Values of <0.05 were considered statistical significant. Ethical board approval was obtained. RESULTS: Of 65 included patients, parametrial invasion was found in eight patients. A statistically significant increase in diagnostic performance for the assessment of parametrial invasion was found when T2W MRI was fused with DWI (fusion T2W/DWI), especially decreasing false-positive findings: the positive predictive value of parametrial invasion using T2W MRI versus fusion T2W MRI/DWI increased from 29% to 50% for observer 1 and from 23% to 50% for observer 2 (AUC=0.80-0.67 versus 0.94-0.94). CONCLUSIONS: Fusion T2W MRI/DWI shows a significant increase in diagnostic performance for the assessment of parametrial invasion in early-stage cervical carcinoma.

Visualisation of coronary venous anatomy by computed tomography angiography prior to cardiac resynchronisation therapy implantation.

BACKGROUND: The purpose of this study was to illustrate the additive value of computed tomography angiography (CTA) for visualisation of the coronary venous anatomy prior to cardiac resynchronisation therapy (CRT) implantation. METHODS: Eighteen patients planned for CRT implantation were prospectively included. A specific CTA protocol designed for visualisation of the coronary veins was carried out on a third-generation dual-source CT platform. Coronary veins were semi-automatically segmented to construct a 3D model. CTA-derived coronary venous anatomy was compared with intra-procedural fluoroscopic angiography (FA) in right and left anterior oblique views. RESULTS: Coronary venous CTA was successfully performed in all 18 patients. CRT implantation and FA were performed in 15 patients. A total of 62 veins were visualised; the number of veins per patient was 3.8 (range: 2-5). Eighty-five per cent (53/62) of the veins were visualised on both CTA and FA, while 10% (6/62) were visualised on CTA only, and 5% (3/62) on FA only. Twenty-two veins were present on the lateral or inferolateral wall; of these, 95% (21/22) were visualised by CTA. A left-sided implantation was performed in 13 patients, while a right-sided implantation was performed in the remaining 2 patients because of a persistent left-sided superior vena cava with no left innominate vein on CTA. CONCLUSION: Imaging of the coronary veins by CTA using a designated protocol is technically feasible and facilitates the CRT implantation approach, potentially improving the outcome.

Dehydration with high natriuretic peptide levels! A word of caution.

B-type natriuretic peptide is secreted primarily by cardiomyocytes in response to increased ventricular or atrial wall stress reflecting volume or pressure overload. The relationship between natriuretic peptides and the severity of heart failure is well established. We present here a case where natriuretic peptide levels were increased due to dehydration in the abscence of renal impairment. Normalization of natriuretic peptide level was achieved by stopping the diuretics and the administration of normal saline.

A rare coronary anomaly: one ostium fits all.

Coronary anomalies affect a small percentage of the general population. A solitary coronary ostium in the absence of other major congenital anomalies is very rare. We describe a case of a patient, admitted to our cardiology department with an acute myocardial infarction. A coronary angiogram shows a solitary ostium originating from the right sinus of Valsalva with the left anterior descending coronary artery (LAD) ventral to the pulmonary artery and the circumflex artery (Cx) following its course retroaortically. The theoretical variant of this type of malformation has been described but has not been reported in a clinical case before. Coronary anomalies are usually detected during coronary angiography, but exact course determination and relationships are difficult to visualize. The use of cardiac computed tomography (CCT) allows visualization of the coronary anatomy in a 3-dimensional image and demonstrated an added value to coronary angiography.

A challenging lead endocarditis.

Pacemaker/implantable cardioverter-defibrillator (ICD) lead endocarditis remains a challenging diagnosis in cardiology. Several parameters can be involved in the clinical path leading to the definite diagnosis. Clinical appearance and physical findings, together with transoesophageal echocardiography and serum levels of inflammatory parameters, are necessary in the workup towards the diagnosis. It is highly unlikely that ICD-lead vegetation is accompanied by positive blood cultures solely. We describe a case of ICD-infected endocarditis with positive blood cultures for Staphylococcus epidermidis without any physical findings or raised inflammatory parameters in serum plasma levels. In this case, three-dimensional echocardiography demonstrated an added value to two-dimensional echocardiography.

Cardiac remodelling: concentric versus eccentric hypertrophy in strength and endurance athletes.

Cardiac remodelling is commonly defined as a physiological or pathological state that may occur after conditions such as myocardial infarction, pressure overload, idiopathic dilated cardiomyopathy or volume overload. When training excessively, the heart develops several myocardial adaptations causing a physiological state of cardiac remodelling. These morphological changes depend on the kind of training and are clinically characterised by modifications in cardiac size and shape due to increased load. Several studies have investigated morphological differences in the athlete's heart between athletes performing strength training and athletes performing endurance training. Endurance training is associated with an increased cardiac output and volume load on the left and right ventricles, causing the endurance-trained heart to generate a mild to moderate dilatation of the left ventricle combined with a mild to moderate increase in left ventricular wall thickness. Strength training is characterised by an elevation of both systolic and diastolic blood pressure. This pressure overload causes an increase in left ventricular wall thickness. This may or may not be accompanied by a slight raise in the left ventricular volume. However, the development of an endurancetrained heart and a strength-trained heart should not be considered an absolute concept. Both forms of training cause specific morphological changes in the heart, dependent on the type of sport. (Neth Heart J 2008;16:129-33.).