Safety of meglumine gadoterate (Gd-DOTA)-enhanced MRI compared to unenhanced MRI in patients with chronic kidney disease (RESCUE study).

OBJECTIVE: To prospectively compare the renal safety of meglumine gadoterate (Gd-DOTA)-enhanced magnetic resonance imaging (MRI) to a control group (unenhanced MRI) in high-risk patients. METHODS: Patients with chronic kidney disease (CKD) scheduled for MRI procedures were screened. The primary endpoint was the percentage of patients with an elevation of serum creatinine levels, measured 72 ± 24 h after the MRI procedure, by at least 25 % or 44.2 µmol/l (0.5 mg/dl) from baseline. A non-inferiority margin of the between-group difference was set at -15 % for statistical analysis of the primary endpoint. Main secondary endpoints were the variation in serum creatinine and eGFR values between baseline and 72 ± 24 h after MRI and the percentage of patients with a decrease in eGFR of at least 25 % from baseline. Patients were screened for signs of nephrogenic systemic fibrosis (NSF) at 3-month follow-up. RESULTS: Among the 114 evaluable patients, one (1.4 %) in the Gd-DOTA-MRI group and none in the control group met the criteria of the primary endpoint [Δ = -1.4 %, 95%CI = (-7.9 %; 6.7 %)]. Non-inferiority was therefore demonstrated (P = 0.001). No clinically significant differences were observed between groups for the secondary endpoints. No serious safety events (including NSF) were noted. CONCLUSION: Meglumine gadoterate did not affect renal function and was a safe contrast agent in patients with CKD. KEY POINTS: • Contrast-induced nephropathy (CIN) is a potential problem following gadolinium administration for MRI. • Meglumine gadoterate (Gd-DOTA) appears safe, even in patients with chronic kidney disease. • Gd-DOTA only caused a temporary creatinine level increase in 1/70 such patients. • No case or sign of NSF was detected at 3-month follow-up.

Impact of Calcium Score on Agreement Between Multidetector Computed Tomography and Invasive Coronary Angiography.

INTRODUCTION AND OBJECTIVES: Multidetector computed tomography (MDCT) has been demonstrated as a feasible alternative to invasive coronary angiography (ICA). However, contradictory results have been reported regarding the effect of coronary artery calcium score (CS) on the diagnostic accuracy of MDCT. Our aim was to assess the agreement of MDCT and ICA and to evaluate the influence of CS on this agreement. METHODS: We enrolled 266 consecutive patients who underwent evaluation with 64-slice MDCT and ICA. Standard CS software tools were used to calculate the Agatston score. Stenosis was qualitatively classified as mild, moderate, or severe by 1 blinded observer and the results were compared with those of ICA, which was used as the gold standard. RESULTS: The mean age of the patients was 65.4 ± 11.2 years, and 188 patients (70.3%) were men. A total of 484 segments with coronary stenosis ≥ mild were qualitatively evaluated and quantified with MDCT. Noninvasive measurements were concordant with ICA in 402 stenoses (83.05%; Kappa, 0.684), with no significant differences between vessels and with no statistically significant influence of CS on this agreement (OR, 0.93; 95%CI, 0.76-1.09; P = .21). Multidetector computed tomography had high sensitivity, specificity, positive predictive value, and negative predictive value on a per-segment, per-vessel, and per-patient basis. CONCLUSIONS: Non-ICA using MDCT showed good agreement with ICA in the qualitative quantification coronary stenosis and CS had no significant impact on this agreement.

MR angiographic evaluation of complications in surgically treated type A aortic dissection.

Thoracic aortic dissection is a life-threatening disease with a high mortality rate and an elevated incidence of early and long-term complications. Advances in surgical treatment of ascending (Stanford type A) aortic dissection have helped improve patient survival, but follow-up imaging is critically important for the identification of postsurgical complications. Gadolinium-enhanced three-dimensional (3D) magnetic resonance (MR) angiography, along with multisection computed tomography, is the technique of choice for this purpose. For accurate assessment of 3D MR angiograms, it is important to know what surgical procedure was performed and to be familiar with the appearance of the normal postsurgical anatomy. A thorough understanding of potential postsurgical complications also is essential. Some complications (eg, formation of a periprosthetic hematoma or pseudoaneurysm, stenosis in a graft anastomosis) may derive from the prosthesis. Complications also may occur in the remnant of the native aorta, where persistent dissection distal to the prosthesis is common and may result in false channel thrombosis or aneurysmatic dilatation with collapse of the true lumen. Residual dissection that involves the supra-aortic trunks or the visceral aortic branches may produce neurologic effects or renal and mesenteric ischemia, respectively.

Comparison of left ventricular volumes and ejection fractions measured by three-dimensional echocardiography versus by two-dimensional echocardiography and cardiac magnetic resonance in patients with various cardiomyopathies.

End-diastolic volume and end-systolic volume were measured in 35 consecutive patients with cardiomyopathy using 2-dimensional (2-D) and 3-dimensional (3-D) echocardiography (2, 4, and 8 planes) and cardiac magnetic resonance imaging. Three-dimensional echocardiography correlates better with magnetic resonance imaging than does 2-D echocardiography. Its accuracy improves with the increase in the number of planes used. Two-dimensional echocardiography underestimates volumes, mainly in the subgroup with an ejection fraction of <50%, whereas 3-D echocardiography does not, if enough planes are used. However, in patients with an end-diastolic volume > or =150 ml, the underestimation of 3-D echocardiography is statistically significant. Increasing the number of planes to 8 reduces this bias. Conversely, patients with an end-diastolic volume <150 ml are accurately studied with just 4 planes.

Predictors of Luminal Loss in Pulmonary Veins After Radiofrequency Ablation.

INTRODUCTION AND OBJECTIVES: The reported incidences of stenosis after radiofrequency ablation of pulmonary veins are highly variable. Moreover, most studies have focused on severe stenosis and have overlooked mild stenosis. Our aims were to study postablation morphological changes in the pulmonary veins and to evaluate preablation magnetic resonance imaging predictors for stenosis. METHODS: Eighty consecutive patients with atrial fibrillation underwent cardiac magnetic resonance imaging before undergoing radiofrequency ablation. Magnetic resonance imaging was repeated a median of 95 days after ablation. Ostium area/ellipticity and atrial volume were blindly assessed. We evaluated the presence of stenosis and classified it as mild (< 50% area reduction), moderate (50%-70%), and severe (> 70%). RESULTS: Postablation stenosis was identified in 78 of 322 veins (24.2%). The stenosis was mild in 66 (84.6%), moderate in 11 (14.1%), and severe in 1 (1.3%). All of them were asymptomatic. The left inferior pulmonary vein showed the highest frequency of stenosis, which was detected in 26% of them (P < .001). A multiple regression analysis revealed that left inferior pulmonary vein (odds ratio = 3.089; P = .02) and a greater preablation ostium area (odds ratio = 1.009; P < .001) were independent predictors for postablation stenosis. Age (odds ratio = 1.033) showed a strong trend to statistical significance (P = .06). CONCLUSIONS: After ablation, vein ostia size is reduced and stenosis is detected in less than one third of patients. Most cases are mild, and severe stenosis is rare. Postablation stenosis is more likely to develop in older patients, those with larger vein ostia, and in the left inferior pulmonary veins.

Reason for discrepancies in identifying myocardial viability by thallium-201 redistribution, magnetic resonance imaging, and dobutamine echocardiography.

Dobutamine echocardiography (DE), magnetic resonance imaging (MRI), and thallium redistribution (TS) are used to assess cardiac viability. However, these modalities sometimes yield contradictory results. Our aim was to establish the degrees of agreement among DE, MRI, and TS in identifying myocardial viability and to analyze the minimum critical mass of live (viable) cells required for each test to identify viability. A prospective study was done in which DE, MRI, and TS were consecutively performed in 10 ischemic patients scheduled for heart transplantation. The explanted heart was analyzed to quantify the amount of live cells per segment. The pathologic data were compared with the test results to analyze the minimum mass of viable cells required by each technique to identify viability. Mean age was 58 +/- 8 years (8 men). The mean ejection fraction was 0.27 +/- 0.04. Seven patients had severe cardiac failure (New York Heart Association functional class IV) and 6 patients had refractory angina. A total of 150 cardiac segments were analyzed. Among the 150 segments, 107 (71.3%) showed some degree of myocardial necrosis. Mean total area, mean fatty area, and mean necrotic area per segment were 2.53 +/- 0.7, 0.13 +/- 0.2, and 0.55+/-0.5 cm(2), respectively. As expected, a higher amount of necrotic tissue was found in nonviable segments. From the 150 segments, DE identified 90 as viable and 60 as nonviable. These data were similar to that of MRI (98 viable and 52 nonviable). A higher proportion of viable segments was found by TS (117 viable vs 33 nonviable). The concordance between DE and TS was only moderate (kappa 0.49). The agreement between MRI and TS also showed moderate concordance (kappa 0.56). The highest agreement was found between DE and MRI (kappa 0.73). Thus, discrepancies in assessing viability by DE, MRI, and TS may be due to differences in the minimum critical mass of live myocytes required by each technique to diagnose viability. Thallium requires a lesser amount of live tissue than DE or MRI to detect viability; also, its maximum diagnostic efficiency is obtained with lesser amounts of live tissue on each segment. These considerations should be taken into account when these diagnostic tests are used for the detection of viability before revascularization procedures.

Quantification of left atrial volumes using three-dimensional wall motion tracking echocardiographic technology: comparison with cardiac magnetic resonance.

BACKGROUND: Left atrium (LA) size assessment is clinically relevant, but the accuracy of two-dimensional echocardiographic (2D-echo) methods is limited. Three-dimensional (3D) echocardiography is an excellent alternative but is far from being used in daily clinical practice. Three-dimensional-wall motion tracking (3D-WMT) allows us to obtain volumes in a very simple and rapid manner. The aims of this study were to evaluate the accuracy of 3D-WMT technology to assess LA volume using cardiac magnetic resonance (CMR) as a reference method, to evaluate its reproducibility, and to determine its added clinical value to classify the LA enlargement severity. METHODS AND RESULTS: Seventy consecutive patients referred for a CMR study were prospectively enrolled. They underwent LA volume assessment by means of 2D-echo, 3D-WMT, and CMR. Inter-methods agreement was assessed. The mean age was 56 ± 18 years and 42 patients (60%) were males. Average maximal LA volume obtained by 2D-echo, 3D-WMT, and CMR were 63.33 ± 26.82, 79.80 ± 29.0, and 79.80 ± 28.99 mL, respectively. Univariate linear regression analysis showed a good correlation between 3D-WMT and CMR (r = 0.83; P < 0.001). The agreement analysis showed a similar result (ICC = 0.83; 95% CI = 0.74-0.89; P < 0.001). Furthermore, the LA enlargement degree was better evaluated with 3D-WMT than with 2D-echo. CONCLUSION: This study validates LA volume measurements obtained using the new and fast 3D-WMT technology, compared with CMR. This method is fast, accurate, and reproducible, and it allows a better classification of left LA enlargement severity compared with 2D-echo.

3D color-Doppler echocardiography and chronic aortic regurgitation: a novel approach for severity assessment.

BACKGROUND: 3D echocardiography provides a complete evaluation of the aortic valve and adjacent structures and it improves the assessment of this cardiac region. Three-dimensional color-Doppler echocardiography (3DCDE) evaluation might improve the measurements of the functional regurgitant orifice in patients with Chronic Aortic Regurgitation (CAR). OBJECTIVES: Our aim was to compare the accuracy of current echo-Doppler methods and 3DCDE for the assessment of CAR severity. The reference method used in this work was the CAR severity determined by means of cardiac magnetic resonance (CMR) METHODS: Thirty-two consecutive patients with an established diagnosis of CAR recruited in our institution comprised our study group. CAR severity was determined by conventional Echo-Doppler methods and by 3DCDE and their results were compared with those obtained by means of CMR. RESULTS: Mean age was 63.0 ± 13.5 years. Twenty-two patients (68.8%) were men. Compared with the traditional echo-Doppler methods, 3DCDE evaluation had the best linear association with CMR results (3D vena contracta cross sectional area method: r = 0.88; r square = 0.77; p < 0.001. 3D vena contracta cross sectional area/left ventricular outflow tract cross sectional area method: r = 0.87; r square = 0.75; p < 0.001). The ROC analysis showed an excellent area under curve for detection of severe CAR (3D vena contracta cross sectional area method = 0.97; 3D vena contracta cross sectional area/left ventricular outflow tract cross sectional area method = 0.98). Inter- and intra-observer variability for the 3DCDE evaluation was good (ICC = 0.89 and ICC = 0.91 for inter and intra observer variability respectively). CONCLUSIONS: 3DCDE is an accurate and highly reproducible diagnostic tool for estimating CAR severity. Compared with the traditional echo-Doppler methods, 3DCDE has the best agreement with the CMR determined CAR severity. Thus, 3DCDE is a diagnostic method that may improve the therapeutic management of patients with CAR.

Left ventricular trabeculae: quantification in different cardiac diseases and impact on left ventricular morphological and functional parameters assessed with cardiac magnetic resonance.

OBJECTIVES: Left ventricle trabeculae (LVT) are frequently seen in different cardiac diseases. Normal reference values of LVT in different cardiac conditions are not known. The aim of the study was to quantify with cardiac magnetic resonance (CMR), LVT mass (LVTM) and LVTM percentage (LVTM%) in different heart diseases and to evaluate their influence on left ventricular morphological and functional parameters. METHODS: Fifty-nine patients (14 controls, 17 ischemic cardiomyopathy, 15 nonischemic dilated cardiomyopathy, 7 valvular heart disease and 6 with left ventricle hypertrophy) were enrolled. Cine-MR images were acquired with steady-state free-precession sequence in a short-axis view. LVTM was calculated as the difference between LVM excluding/including trabecuale from the blood cavity. LVTM% was calculated as the percentage of the whole left ventricle mass excluding trabeculae from the blood cavity. RESULTS: Mean age was 47.60 +/- 22.03 years; male 62.7%. Mean LVTM was of 33.38 +/- 16.1 g with mean LVTM% of 19.22 +/- 6.5%. Significant differences between groups for both parameters with P values of 0.02 were obtained. Nonischemic dilated cardiomyopathy showed the highest degree of LVTM (44.73 +/- 16.0 g) and LVTM% (23.26 +/- 6%). Significant differences were noted in left ventricular morphological and functional parameters with inclusion/exclusion of LVT in the myocardial mass. CONCLUSIONS: Reference values and differences of LVTM and LVTM% in various cardiac conditions are given for the first time. Quantification of these parameters with CMR may be clinically useful in the differential diagnosis between left ventricular noncompaction and other cardiac diseases. Exclusion of LVT from myocardium alters left ventricular morphological and functional parameters, which have significant clinical importance.

[Thrombosis of an apparently normal thoracic aorta and arterial embolism]. / Trombosis en aorta torácica aparentemente normal y embolias arteriales.

With the advent of new imaging techniques, the aorta has been increasingly identified as a source of arterial embolism. The majority of thrombi occur in aneurysms or are adherent to atherosclerotic lesions in the abdominal aorta. Thrombi in the thoracic aorta are much less common, particularly in apparently normal aortas. Consequently, the natural history and optimal treatment of these lesions are not well-defined. The aim of this article was to describe the clinical characteristics, treatment, and outcome in three patients with thoracic aorta thrombosis and arterial embolism. Currently available literature on this pathology is reviewed and the differential diagnosis of these lesions is discussed.

[Intramural aortic hematoma and anticoagulation]. / Hematoma intramural aórtico y anticoagulación.

Intramural aortic hematoma is one of a group of conditions covered by the term acute aortic syndrome. Many aspects of its natural history remain poorly understood, and the best treatment is not known. The aim of this study was to describe the clinical and radiological characteristics and follow-up of a group of patients with intramural aortic hematoma who received anticoagulant therapy during hospitalization. We selected a prospective cohort of patients with a diagnosis of intramural aortic hematoma and carried out an analysis of those who received anticoagulation treatment during the acute phase of the illness. Patients received anticoagulation for a range of different reasons. In all patients, the intramural aortic hematoma was observed to undergo gradual regression despite anticoagulation therapy.

Malignant degeneration of presacral teratoma in the Currarino anomaly.

The autosomal dominant Currarino anomaly (CA) comprises a presacral mass, partial sacral agenesis, and anorectal defects. Chronic constipation in childhood related to anorectal defects is the most common presenting symptom and hemisacrum the most frequent malformation. The presacral mass may be an anterior meningomyelocele, teratoma, hamartoma, dermoid cyst, neuroenteric cyst, or a combination of these. Sepsis and meningitis are frequent serious problems related to the anterior meningomyelocele, whilst malignant transformation of presacral teratoma is a rare, severe complication in CA. Here, we report on a three-generation family segregating the CA, presenting with anorectal defects, severe constipation, and sacral involvement in affected relatives. Teratoma was the most frequent component of the presacral mass. In this kindred a 22-year-old man died of a neuroendocrine tumor, probably related to malignant change in a presacral teratoma. A novel mutation in HLXB9 consisting of a 24-bp deletion and insertion of 2-bp into exon 1, was identified in all patients and in also three asymptomatic members of this family. Anterior meningomyelocele is the most frequently reported component of the presacral masses in CA; however, presacral teratomas carry an inherent risk for malignancy that must be considered in the counseling, surgical treatment options, and follow-up of CA patients.