Aortic Calcification in Takayasu Arteritis: Risk Factors and Relationship With Activity and Vascular Lesion. It Is Not Only an Aging Question.

INTRODUCTION: Aortic calcification is a frequent finding in Takayasu arteritis (TA). The aim of this study was to evaluate the risk factors for aortic calcification in TA and its relationship with disease activity and the presence and type of vascular lesion. METHODS: Nineteen patients with TA underwent nonenhanced computed tomography to measure the calcium score of the aorta and its main branches, which were divided into 13 segments. In each segment, the type of vascular lesion was evaluated by noninvasive angiography. Clinical risk factors and disease activity scores were recorded. RESULTS: Eighteen of 19 patients (95%) were women, with a median age of 25 years. Median of calcium score was 69 AU (0-12,465 AU). Eleven of 19 patients (57.9%) had calcium score greater than 0. Age, evolution time, and dyslipidemia were higher in patients with calcium, whereas the National Institutes Health and Dabague disease activity scores were lower. There was no association between the presence of calcium and vascular lesion: 60 of 160 segments (37.5%) without calcium had some lesion, compared with 24 of 68 (35.3%) with calcium score greater than 0, p = 0.75. However, occlusion was more frequent in patients with calcium, whereas wall thickening was in those without calcium. CONCLUSIONS: Aortic calcification in TA is related to age, evolution time, and abnormalities in lipid profile and occlusion and, inversely with some activity scores. Identification of calcification could be useful in identifying patients that even without significant lesions might have accelerated atherosclerosis, and who might be benefited with specific treatment.

Comparison of the amount and patterns of late enhancement in Chagas disease according to the presence and type of ventricular tachycardia.

BACKGROUND: Ventricular tachycardia (VT) is one of the main predictors of mortality in Chagas cardiomyopathy (CC). Although the substrate of sustained and nonsustained-VT (NS-VT) seems to be the same, little is known about the distribution of late enhancement (LE). Our aim was to compare the clinical findings and the amount and patterns of LE in Chagas disease according to the presence and type of VT. METHODS AND RESULTS: Magnetic resonance imaging was performed in 54 Chagas seropositive patients: 8 indeterminate and 46 with CC of whom 15 were without VT, 13 with NS-VT, and 18 with sustained-VT (S-VT). There were 31 males (57%), mean age was 55.9 ± 12.2 years. LE was found in 87% of all patients and in 50%, 80%, and 100% of the indeterminate, without VT and VT groups, respectively. The percentage of LE increased progressively in the indeterminate, CC without VT, and CC with VT groups; without a significant difference between NS-VT and S-VT (0.93%, 15.2%, 23.2%, and 21.4%, respectively). The amount of LE increased with the functional class. LE in the basal and mid lateral wall was more frequent in VT, without difference between S-VT and NS-VT. The only predictor of VT was the percentage of LE, odds ratio (OR), 6.2; (95% confidence interval [CI], 3.7-28.4; P = .01) with a cutoff of Odds Ratio 17.1%. CONCLUSIONS: The amount of LE increases in relation to the clinical stage of the disease and its functional class in Chagas seropositive patients. The amount of LE was the main predictor of VT, without difference between S-VT and NS-VT.

Functional compared to anatomical imaging in the initial evaluation of patients with suspected coronary artery disease: An international, multi-center, randomized controlled trial (IAEA-SPECT/CTA study).

OBJECTIVE: To test the hypothesis that, in the initial evaluation of patients with suspected coronary artery disease (CAD), stress myocardial perfusion imaging (MPI) would result in less downstream testing than coronary computed tomographic angiography (CCTA). METHODS: In this international, randomized trial, mildly symptomatic patients with an intermediate likelihood of having CAD, and asymptomatic patients at intermediate risk of cardiac events, underwent either initial stress-rest MPI or CCTA. The primary outcome was downstream noninvasive or invasive testing at 6 months. Secondary outcomes included cumulative effective radiation dose (ERD) and costs at 12 months. RESULTS: We recruited 303 patients (151 MPI and 152 CTA) from 6 centers in 6 countries. The initial MPI was abnormal in 29% (41/143) and CCTA in 56% (79/141) of patients. Fewer patients undergoing initial stress-rest MPI had further downstream testing at 6 months (adjusted OR 0.51, 95% CI 0.28-0.91, P = 0.023). There was a small increase in the median cumulative ERD with MPI (9.6 vs. 8.8 mSv, P = 0.04), but no difference in costs between the two strategies at 12 months. CONCLUSION: In the management of patients with suspected CAD, a strategy of initial stress MPI is substantially less likely to require further downstream testing than initial testing with CCTA. TRIAL REGISTRATION: clinicaltrials.gov identification number NCT01368770.

Prognostic value of cardiovascular CT: is coronary artery calcium screening enough? The added value of CCTA.

Coronary artery disease (CAD) is the primary cause of death in adults in the United States. Only 50% of patients who present with a myocardial infarction have a prior history of CAD. Non-invasive cardiac imaging tests have been developed to diagnose CAD. Current guidelines and systematic reviews have tried to determine the prognostic value of the coronary artery calcium (CAC) scoring and the coronary computed tomography angiography (CCTA) for major adverse cardiovascular events. Several studies support the roles of CCTA and CAC scoring for the diagnosis of CAD in asymptomatic patients. Further studies are needed to confirm the superior role of CCTA over CAC scoring in symptomatic patients.

Automatic alignment of myocardial perfusion PET and 64-slice coronary CT angiography on hybrid PET/CT.

BACKGROUND: Hybrid PET/CT allows for acquisition of cardiac PET and coronary CT angiography (CCTA) in one session. However, PET and CCTA are acquired with differing breathing protocols and require software registration. We aimed to validate automatic correction for breathing misalignment between PET and CCTA acquired on hybrid scanner. METHODS: Single-session hybrid PET/CT studies of rest/stress (13)N-ammonia PET and CCTA in 32 consecutive patients were considered. Automated registration of PET left ventricular (LV) surfaces with CCTA volumes was evaluated by comparing with expert manual alignment by two observers. RESULTS: The average initial misalignments between the position of LV on PET and CCTA were 27.2 ± 11.8, 13.3 ± 11.5, and 14.3 ± 9.1 mm in x, y, and z axes on rest, and 26.3 ± 10.2, 11.1 ± 9.5, and 11.7 ± 7.1 mm in x, y, and z axes on stress, respectively. The automated PET-CCTA co-registration had 95% agreement as judged visually. Compared with expert manual alignment, the translation errors of the algorithm were 5.3 ± 2.8 mm (rest) and 6.0 ± 3.5 mm (stress). 3D visualization of combined coronary vessel anatomy and hypoperfusion from PET could be made without further manual adjustments. CONCLUSION: Software co-registration of CCTA and PET myocardial perfusion imaging on hybrid PET/CT scanners is necessary, but can be performed automatically, facilitating integrated 3D display on PET/CT.

Evaluation of the endothelial function in hypertensive patients with 13N-ammonia PET.

BACKGROUND: Essential hypertension is one of the main risk factors for the development of coronary artery disease (CAD). Hypertension causes endothelial dysfunction which is considered an early sign for the development of CAD. Positron emission tomography is a non-invasive imaging technique that measures myocardial blood flow (MBF), allowing us to identify patients with endothelial dysfunction. METHODS AND RESULTS: 19 patients without comorbidities recently diagnosed hypertensive, as well as 21 healthy volunteers were studied. A three-phase (rest, cold pressor test, and adenosine-induced hyperemia) (13)N-ammonia PET was performed, and MBF was measured. Endothelial-Dependent Vasodilation Index, ΔMBF, and coronary flow reserve (CFR) were calculated for each patient. Hypertensive patients had a significantly higher systolic and diastolic blood pressures compared with the control group (134.6 ± 11.7/86.4 ± 10.6 mm Hg and 106.0 ± 11.8/71.4 ± 6.6 mm Hg, respectively, P < .001). The ENDEVI (1.28 ± 0.26 vs 1.79 ± 0.30, P < .001), the ΔMBF (0.81 ± 0.50 vs 0.25 ± 0.21, P < .001) and the CFR (2.18 ± 0.88 vs 3.17 ± 0.68, P = .001) were significantly lower in the hypertensive patients compared to the control group, 84% of the former group had endothelial dysfunction i.e., ENDEVI < 1.5 and 58% had vasomotor abnormalities, i.e., CFR < 2.5. CONCLUSIONS: In this study, we showed that recently diagnosed hypertensive patients have coronary endothelial dysfunction and vasomotor disturbances which are early signs for the development of CAD.

Pediatric Porcelain Aorta Secondary to Gaucher Disease Type 3C With Successful Aortic Replacement Surgery.

Gaucher type 3C disease with porcelain aorta can cause severe hemodynamic impairment. We report the first case, to our knowledge, of a 13-year-old Mexican girl with a GBA1 homozygous c.1342G>C [p.Asp448His] (commonly known as p.D409H) pathogenic variant who underwent extensive aortic replacement. She has been on enzyme replacement therapy and is alive 5 years after surgery. (Level of Difficulty: Intermediate.).

Effect of ezetimibe-simvastatine over endothelial dysfunction in dyslipidemic patients: assessment by 13N-ammonia positron emission tomography.

BACKGROUND: Dyslipidemias constitute an independent risk factor for the development of atherogenesis and they also predispose to the development of endothelial dysfunction (ED). Using PET with (13)N-ammonia, it is possible to quantify myocardial blood flow (MBF) in mL/min/g and to quantitatively evaluate ED. With the use of lipid lowering therapy it is possible to reduce ED and increase the MBF and the endothelial-dependent vasodilation index (ENDEVI). In this study, we aimed to evaluate with (13)N-ammonia PET the benefic effects of the combined treatment ezetimibe/simvastatine on the endothelial function of dyslipidemic patients after 8 weeks of treatment. MATERIAL AND METHODS: Fourteen consecutive patients with dyslipidemia diagnosis and 17 healthy volunteers were studied with a three phase [rest, Cold Pressor Test (CPT), and adenosine-induced hyperemia] (13)N-ammonia PET for MBF quantification assessment. A second PET study was performed in the dyslipidemic group after 8 weeks of treatment with ezetimibe/simvastatine (10/40 mg). Myocardial flow reserve (MFR), ENDEVI, and %ΔMBF were calculated. RESULTS: Total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides concentrations were markedly altered in the dyslipidemic group and after 8 weeks of treatment these values improved. Dyslipidemic patients showed endothelial dysfunction when compared with the control group, (MFR 2.79 ± 0.94 vs 3.15 ± 0.48, P < 0.05 ; ENDEVI 1.28 ± 0.25 vs 1.53 ± 0.24, P < 0.05; and %ΔMBF 29.08 ± 24.62 vs 53 ± 24.60%, P < 0.05, respectively). After 8 weeks of treatment, we found a significant increase in all the endothelial function markers (MFR: 3.14 ± 0.86, P < 0.05, ENDEVI 1.65 ± 0.23, P < 0.05; %ΔMBF: 65.21 ± 23.43, P < 0.05). CONCLUSIONS: Dyslipidemic patients show endothelial dysfunction measured with (13)N-ammonia PET. Treatment with ezetimibe/simvastatine was effective improving the lipid profile as well as the endothelial function of these patients. PET may be a useful tool to monitor vascular reactivity and regression/progression of coronary atherosclerosis after pharmacologic interventions.

Endothelial dysfunction in recently diagnosed type 2 diabetic patients evaluated by PET.

PURPOSE: To demonstrate the presence of endothelial dysfunction (ED) in asymptomatic patients with type 2 diabetes mellitus (DM) by using (13)N-ammonia-positron emission tomography (PET). PET can identify ED by quantifying myocardial blood flow (MBF) during rest, cold pressor test (CPT), and pharmacologic stress. The endothelial-dependent vasodilation index (EDVI), myocardial flow reserve (MFR), and the percentage of the change between rest and CPT (%DeltaMBF) are markers of endothelial function. PROCEDURES: Thirty-nine subjects were studied (19 women and 20 men); 22 recently diagnosed type 2 diabetic patients and 17 healthy controls (HC). A three-phase (13)N-ammonia-PET was performed. RESULTS: Mean EDVI was 1.208 +/- 0.34 vs. 1.55 +/- 0.37 (diabetic vs. HC group, respectively) (p = 0.002), MFR was 2.803 +/- 1.39 vs. 3.27 +/- 0.72 (p = NS), and the %DeltaMBF was 20 +/- 34% vs. 55 +/- 37% (p = 0.002). Rest MBF and CPT MBF were normalized to the rate pressure product (RPP). EDVI' and %DeltaMBF' were calculated using the corrected values for the RPP. Mean EDVI' was (0.864 +/- 0.250 vs. 1.110 +/- 0.238, p = 0.004) and mean %DeltaMBF' was (-8.2 +/- 14.7% vs. 4.5 +/- 12.1%, p = 0.005). CONCLUSIONS: Asymptomatic, recently diagnosed type 2 diabetes patients present ED that can be quantified by (13)N-ammonia-PET.

Coronary computed tomographic imaging in women: An expert consensus statement from the Society of Cardiovascular Computed Tomography.

This expert consensus statement from the Society of Cardiovascular Computed Tomography (SCCT) provides an evidence synthesis on the use of computed tomography (CT) imaging for diagnosis and risk stratification of coronary artery disease in women. From large patient and population cohorts of asymptomatic women, detection of any coronary artery calcium that identifies females with a 10-year atherosclerotic cardiovascular disease risk of >7.5% may more effectively triage women who may benefit from pharmacologic therapy. In addition to accurate detection of obstructive coronary artery disease (CAD), CT angiography (CTA) identifies nonobstructive atherosclerotic plaque extent and composition which is otherwise not detected by alternative stress testing modalities. Moreover, CTA has superior risk stratification when compared to stress testing in symptomatic women with stable chest pain (or equivalent) symptoms. For the evaluation of symptomatic women both in the emergency department and the outpatient setting, there is abundant evidence from large observational registries and multi-center randomized trials, that CT imaging is an effective procedure. Although radiation doses are far less for CT when compared to nuclear imaging, radiation dose reduction strategies should be applied in all women undergoing CT imaging. Effective and appropriate use of CT imaging can provide the means for improved detection of at-risk women and thereby focus preventive management resulting in long-term risk reduction and improved clinical outcomes.

Endothelial dysfunction in patients with antiphospholipid syndrome assessed with positron emission tomography.

BACKGROUND: There is limited knowledge about endothelial dysfunction in patients with primary antiphospholipid syndrome (PAPS). The purpose of this study was to evaluate endothelial function in patients with PAPS assessed by positron emission tomography. METHODS AND RESULTS: A 3-phase protocol--rest, cold pressor test (CPT), and adenosine positron emission tomography with nitrogen 13 ammonia--was used in 18 patients with PAPS and 18 healthy volunteers (HVs). Myocardial blood flow (MBF) was measured in each phase, with calculation of the endothelial-dependent vasodilation index, the increase in the MBF in response to CPT, and the myocardial flow reserve. An important trend was found in the myocardial flow reserve (2.76 +/- 1.04 in PAPS group vs 3.27 +/- 0.72 in HV group, P > .05), in the endothelial-dependent vasodilation index (1.19 +/- 0.31 in PAPS group vs 1.55 +/- 0.37 in HV group, P < .05), and in the percent change in the MBF in response to CPT (from rest) (19% +/- 31% in PAPS group vs 55% +/- 37% in HV group, P < .05). CONCLUSION: The CPT results obtained in this study showed that the PAPS patients studied have endothelial dysfunction.

Pre-pulseless Takayasu's arteritis evaluated with 18F-FDG positron emission tomography and gadolinium-enhanced magnetic resonance angiography.

Takayasu's arteritis is a primary vasculitis that affects large vessels and is characterized by chronic granulomatous inflammation. Diagnosis has been primarily clinical, with verification by angiography as the gold standard. More recently, however, it has become apparent that positron emission tomography enables better evaluation of vascular inflammation. This study presents 2 cases of Takayasu's arteritis. Magnetic resonance angiography was used to evaluate aortic anatomy by analyzing vascular wall thickness and also to quantify disease activity by measuring gadolinium enhancement. Positron emission tomography was used to evaluate active vascular inflammation by quantifying fluorodeoxyglucose F18 uptake. We conclude that both techniques support clinical diagnosis and aid in the evaluation of disease activity during and after treatment.

[Nuclear magnetic resonance in ischemic cardiopathy]. / Resonancia magnética: su aportación en cardiopatía isquémica.

Nuclear magnetic resonance is the "gold standard" technique to quantify the ventricular volume, the ejection fraction, and the myocardial mass. In patients suffering from ischemic cardiopathy, the ejection fraction is the most important prognostic parameter, even above from lessoned arteries index. An adequate diagnose between a non-viable and a viable myocardium is of great importance in the therapeutic approach for ischemic cardiopathy. By administrating a paramagnetic contrast media named gadolinium, fist pass and late-reinforcement techniques, are applied. With these, it is possible to evaluate the perfusion as well as necrotic areas. In order to identify sub-endocardium ischemia, drugs such as adenosine and dipiridamol, are employed as vasodilators. This technique allows the definition of reinforcement extension, being sub-endocardiac, which is an ailment which affects 50% of the myocardium depth, or even, transmural compromise.

[Detection of inflammation in an atherosclerose plaque: the role of the positron emission tomography and C reactive protein]. / Detección de inflamación en placa aterosclerosa: rol de la tomografía por emisión de positrones y de la proteína C reactiva.

OBJECTIVES: To demonstrate that inflammatory atheromatose carotid plaques can be visualized with positron emission tomography with 18F-fluorodeoxyglucose (18FDG PET) in symptomatic patients, in order to correlate them with systemic inflammatory markers, such as CRP. METHOD: Fifteen patients with cerebral ischemia due to atherosclerotic carotid disease were studied. 18FDG uptake with PET was considered and blood samples were taken for determining high sensibility C reactive protein (HsCRP). RESULTS: The mean age of the patients was 66 years; 11 of them were males (73%) and 4 were females (27%). 18FDG PET was positive in 12 patients (80%), while 100% of the studied population had low risk HsCRP with normal white cell count. CONCLUSIONS: 18FDG PET proves active inflammation in carotid atheromatose plaques. There was no significant correlation between the presence of ahteromatose carotid plaques, HsCRP serum levels, and 18FDG PET study.

[Application of cardiovascular magnetic resonance in congenital heart disease]. / Aplicación del método de resonancia magnética cardiovascular en el estudio de las cardiopatías congénitas.

Cardiovascular magnetic resonance (CVMR) is the best non invasive imaging technique for the diagnosis of congenital heart disease (CHD) as it gives important information concerning anatomy and function of the heart in the same exploration. This method is useful for the follow up of the patient with congenital heart disease. The most important benefits of CVMR are the non invasiveness of the same and the lack of ionic radiation. The objective of this article is to demonstrate that congenital heart disease can be diagnosed with CVMR with a higher precision compared with other cardiovascular imaging techniques.

[Ischemic heart disease: anatomic and functional evaluation in a single exploration with multi-slice PET-CT]. / Cardiopatía isquémica: evaluación anatomofuncional en una sola exploración con PET-CT multicorte.

A complete evaluation of the patient with ischemic heart disease requires an anatomical and functional assessment of the myocardium and coronary arteries. Recent technological advances have allowed a quantitative and physiological evaluation of the cardiovascular system with Positron Emission Tomography (PET). This method is a valuable tool for the assessment of heart metabolism, myocardial perfusion, ventricular function, coronary blood flow, myocardial viability and endothelial function. One of the major limitations of a PET study is its low spatial resolution. Cardiac Computed Tomography (CCT) is an anatomic study used for coronary calcium quantification, evaluation of wall and lumen of coronary arteries, study of vascular permeability and assessment of composition, extension and severity of atherosclerotic plaques. The main limitation of CCT is the lack of functional information that is obtained with this technique. Both methods are complementary in many ways. That is the reason of the wide spread of PET-CT hybrid equipments that can provide very useful functional and anatomic information of patients with ischemic heart disease in a single exploration.

[Identification of acute myocardial infarction with PET and CT multislice]. / Identificación del infarto agudo del miocardio mediante PET y CT multicorte.

Today non invasive cardiovascular imaging techniques exist, such as positron emission tomography (PET) and 16 multislice computed tomography (16-MSCT). With these studies, it is possible to evaluate the function and anatomy of the heart respectively. There is not enough information in the literature about the usefulness for 16-MSCT in the evaluation of infarcts. In this article, we show images of a patient who arrived to our institution and in whom it was possible to obtain important information with both imaging techniques. With the results, we obtained a good correlation of an infarct zone with PET and 16-MSCT. 16-MSCT is a good technique for observing infarcted zones of the heart. PET/CT is a non invasive cardiovascular imaging technique capable of giving enough anatomic and functional information.

Comparison of 18FDG PET with thallium SPECT in the assessment of myocardial viability. A segmental model analysis.

BACKGROUND: In patients with myocardial infarction and left ventricular dysfunction, the evidence of myocardial viability is primordial. There are some methods to detect the presence of myocardial viability, 201 thallium reinjection SPECT protocol represents the most common radioisotopic technique to evaluate it. Positron emission tomography (PET) using FDG is considered the gold standard. The aim of this study was to compare globally and by segments the value of both techniques in the detection of viable myocardium. METHODS: Twenty-three consecutive patients with previous myocardial infarction and left ventricular dysfunction were studied. All of them underwent into a SPECT perfusion scan and a FDG PET study to asses myocardial viability. Each study was performed in less than one week between the other. For the analysis, the myocardium was divided into 17 segments. A visual semi-quantitative analysis was carried out according to the following score indicating radiotracer uptake: O = normal to 4 = absent. Myocardial viability was defined as the presence of normal, mildly or moderately reduced radiotracer uptake. The scores obtained by PET were compared to those obtained in SPECT. A statistical analysis was performed using the SPSS v. 10. RESULTS: 391 segments were analyzed. PET detected viability in 130 segments that had been defined as non-viable by SPECT. No differences in the analysis by vascular territories were found. Thirty percent of the segments that were defined as non viable by SPECT were viable by PET, meanwhile only 1% of the segments detected viable by SPECT were considered non viable with PET. CONCLUSIONS: FDG PET study represents a better technique to detect myocardial viability, compared to thallium reinjection SPECT protocol. By this study we have demonstrated that more of 3 of each 10 studies may be diagnosed as non viable where viability is present.

[Anomalous origin of the right pulmonary artery and left pulmonary vein stenosis]. / Origen anómalo de la arteria pulmonar derecha y estenosis de vena pulmonar superior izquierda.

We present a case of a 9 month old female with a history of cyanosis. The cardiovascular evaluation included angiocardiogram and magnetic resonance. The diagnosis was: origin of the right pulmonary artery from the ascending aorta, stenosis of the left superior pulmonary vein, patent ductus arteriosus and severe pulmonary hypertension. Surgical treatment consisted in correcting all congenital heart defects. The patient is doing well at home.

[Myocardial viability, its importance for the therapeutic decision]. / Viabilidad miocárdica, su importancia en la decisión terapéutica.

Myocardial viability detection is essential in patients with history of myocardial infarction whom develop ventricular dysfunction. Its detection influences the therapeutic decisions and the prognosis. Medical therapy in patients with ventricular dysfunction due to myocardial infarction and myocardial viability has been associated with higher morbidity and mortality rates than revascularization therapy, as well as improvements in the systolic function. Several imaging techniques used in the recognition of myocardial viability are available; these techniques are based on the assessment of the ventricular motion posterior to inotropic agents stimulation or on the demonstration of metabolic activity at the dysfunctional regions. In this study, some important aspects of each technique are reviewed, doing special emphasis in the utility of the Positron Emission Tomography (PET) which has been considered as the "gold standard" in the detection of myocardial viability.