Applicability of Bosniak 2019 for renal mass classification on portal venous phase at the era of spectral CT imaging using rapid kV-switching dual-energy CT.

OBJECTIVES: To evaluate the applicability of Bosniak 2019 criteria on a monophasic portal venous phase using rapid kilovoltage-switching DECT (rsDECT). MATERIALS AND METHODS: One hundred twenty-seven renal masses assessed on rsDECT were included, classified according to Bosniak 2019 classification using MRI as the reference standard. Using the portal venous phase, virtual monochromatic images at 40, 50, and 77 keV; virtual unenhanced (VUE) images; and iodine map images were reconstructed. Changes in attenuation values between VUE and 40 keV, 50 keV, and 77 keV measurements were computed and respectively defined as ∆HU40keV, ∆HU50keV, and ∆HU77keV. The values of ∆HU40keV, ∆HU50keV, and ∆HU77keV thresholds providing the optimal diagnostic performance for the detection of internal enhancement were determined using Youden index. RESULTS: Population study included 25 solid renal masses (25/127, 20%) and 102 cystic renal masses (102/127, 80%). To differentiate solid to cystic masses, the specificity of the predefined 20 HU threshold reached 88% (95%CI: 82, 93) using ∆HU77keV and 21% (95%CI: 15, 28) using ∆HU40keV. The estimated optimal threshold of attenuation change was 19 HU on ∆HU77keV, 69 HU on ∆HU50eV, and 111 HU on ∆HU40eV. The rsDECT classification was highly similar to that of MRI for solid renal masses (23/25, 92%) and for Bosniak 1 masses (62/66, 94%). However, 2 hyperattenuating Bosniak 2 renal masses (2/26, 8%) were classified as solid renal masses on rsDECT. CONCLUSION: DECT is a promising tool for Bosniak classification particularly to differentiate solid from Bosniak I-II cyst. However, known enhancement thresholds must be adapted especially to the energy level of virtual monochromatic reconstructions. CLINICAL STATEMENT: DECT is a promising tool for Bosniak classification; however, known enhancement thresholds must be adapted according to the types of reconstructions used and especially to the energy level of virtual monochromatic reconstructions. KEY POINTS: • To differentiate solid to cystic renal masses, predefined 20 HU threshold had a poor specificity using 40 keV virtual monochromatic images. • Most of Bosniak 1 masses according to MRI were also classified as Bosniak 1 on rapid kV-switching dual-energy CT (rsDECT). • Bosniak 2 hyperattenuating renal cysts mimicked solid lesion on rsDECT.

Pulmonary Valve Replacement and Redo Pulmonary Valve Replacement via Ministernotomy.

Minimally invasive cardiac surgery is mainly dedicated to acquired left-sided valve diseases. Ministernotomy is widely used for aortic valve repair or replacement, whereas pulmonary valve repair via this approach has been reported only recently. This article aims to describe the use of ministernotomy for pulmonary valve replacement in adult congenital patients.

The natural history of a family with aortic dissection associated with a novel ACTA2 variant.

Disease-causing heterozygous variants in the ACTA2 gene cause an autosomal dominant heritable thoracic aortic disease (HTAD) with thoracic aortic aneurysm and dissection as main phenotype, and occasional extravascular abnormalities such as livedo reticularis. ACTA2-HTAD accounts for an important part of non-syndromic HTAD, with detection rates varying between 1.5-21% according to different studies. A consensus statement for the screening and management of patients with pathogenic ACTA2 variants has been recently published by the European reference network for rare vascular diseases (VASCERN). However, management of ACTA2 patients is often challenged by extremely variable inter- and intra-familial clinical courses of the disease. Here we report a family harboring a disease-causing ACTA2 variant. The proband and two siblings presented with acute type A aortic dissection and rupture involving nondilated aortic segments before the age of 30. Their mother died at 49 years-old from type B aortic dissection and rupture. Genetic testing revealed the heterozygous novel p.(Pro335Arg) variant in the ACTA2 gene in the proband and in the affected siblings. The clinical history of this family highlights the difficulty of adopting effective prevention strategies in ACTA2 patients.

Compressed sensing real-time cine imaging for assessment of ventricular function, volumes and mass in clinical practice.

OBJECTIVES: This study was conducted in order to evaluate the accuracy of a compressed sensing (CS) real-time single-breath-hold cine sequence for the assessment of left and right ventricular functional parameters in daily practice. METHODS: Cardiac magnetic resonance (CMR) cine images were acquired from 100 consecutive patients using both the reference segmented multi-breath-hold steady-state free precession (SSFP) acquisition and a prototype single-breath-hold real-time CS sequence, providing the same slice number, position, and thickness. For both sequences, the left (LV) and right ventricular (RV) ejection fractions (EF) and end-diastolic volumes (EDV) were assessed as well as LV mass (LVM). The visualization of wall-motion disorders (WMD) and signal void related to mitral or tricuspid regurgitation was also analyzed. RESULTS: The CS sequence mean scan time was 23 ± 6 versus 510 ± 109 s for the multi-breath-hold SSFP sequence (p < 0.001). There was an excellent correlation between the two sequences regarding mean LVEF (r = 0.995), LVEDV (r = 0.997), LVM (r = 0.981), RVEF (r = 0.979), and RVEDV (r = 0.983). Moreover, inter- and intraobserver agreements were very strong with intraclass correlations of 0.96 and 0.99, respectively. On CS images, mitral or tricuspid regurgitation visualization was good (AUC = 0.85 and 0.81, respectively; ROC curve analysis) and wall-motion disorder visualization was excellent (AUC ≥ 0.97). CONCLUSION: CS real-time single-breath-hold cine imaging reduces CMR scan duration by almost 20 times in daily practice while providing reliable measurements of both left and right ventricles. There was no clinically relevant information loss regarding valve regurgitation and wall-motion disorder depiction. KEY POINTS: • Compressed sensing single-breath-hold real-time cine imaging is a reliable sequence in daily practice. • Fast CS real-time imaging reduces CMR scan time and improves patient workflow. • There is no clinically relevant information loss with CS regarding heart valve regurgitation or wall-motion disorders.

Left atrial epicardial adipose tissue radiodensity is associated with electrophysiological properties of atrial myocardium in patients with atrial fibrillation.

OBJECTIVE: To evaluate whether the epicardial adipose tissue (EAT) phenotype is associated with the electrophysiological properties of adjacent atrial myocardium in patients with atrial fibrillation (AF). METHODS: Between January and May 2017, 30 consecutive patients referred for a first AF catheter ablation were prospectively included. For each patient, a pre-procedural computed tomography scan was performed to assess total and left atrial (LA) EAT amount and radiodensity. A detailed point-by-point voltage mapping using an electroanatomic mapping system was realized to assess the presence of LA low-voltage zone (LVZ). RESULTS: Ten patients (33.3%) presented at least one LVZ. Older age (65 ± 7 vs. 58 ± 10 years, p = 0.05) was the only clinical parameter associated with LVZ. Despite no greater LA-EAT thickness by CT scan (3.0 [2.6-3.5] mm vs. 2.8 [2.2-3.1] mm, p = 0.354), patients with LA-LVZ presented significantly lower LA-EAT radiodensity than patients with no LA-LVZ (- 101.8 ± 12.5 HU vs. - 90.4 ± 6.3 HU, p = 0.004). No difference between total-EAT volume (131 ± 61 cm3 vs.107 ± 58 cm3, p = 0.361) and total-EAT radiodensity (- 106.8 ± 4.3 HU vs. - 102.4 ± 6.9 HU, p = 0.119) was found. CONCLUSION: Low LA-EAT radiodensity is associated with the presence of LVZ in patients with medical history of AF. KEY POINTS: • Cardiovascular risk factors are associated with low adipose tissue computed tomography attenuation. • Epicardial adipose tissue (EAT) has emerged as an important factor in the pathogenesis of metabolic-related cardiac diseases such as atrial fibrillation. • We showed that low left atrial EAT attenuation is associated with the presence of low-voltage zone, a surrogate for atrial fibrosis, within the adjacent myocardium.

Single-breath-hold 3-D CINE imaging of the left ventricle using Cartesian sampling.

OBJECTIVES: Our objectives were to evaluate a single-breath-hold approach for Cartesian 3-D CINE imaging of the left ventricle with a nearly isotropic resolution of [Formula: see text] and a breath-hold duration of [Formula: see text]19 s against a standard stack of 2-D CINE slices acquired in multiple breath-holds. Validation is performed with data sets from ten healthy volunteers. MATERIALS AND METHODS: A Cartesian sampling pattern based on the spiral phyllotaxis and a compressed sensing reconstruction method are proposed to allow 3-D CINE imaging with high acceleration factors. The fully integrated reconstruction uses multiple graphics processing units to speed up the reconstruction. The 2-D CINE and 3-D CINE are compared based on ventricular function parameters, contrast-to-noise ratio and edge sharpness measurements. RESULTS: Visual comparisons of corresponding short-axis slices of 2-D and 3-D CINE show an excellent match, while 3-D CINE also allows reformatting to other orientations. Ventricular function parameters do not significantly differ from values based on 2-D CINE imaging. Reconstruction times are below 4 min. CONCLUSION: We demonstrate single-breath-hold 3-D CINE imaging in volunteers and three example patient cases, which features fast reconstruction and allows reformatting to arbitrary orientations.

Performance Comparison of Augmented Reality Versus Ultrasound Guidance for Puncture: A Phantom Study.

PURPOSE: Augmented reality (AR) is an innovative approach that could assist percutaneous procedures; by directly seeing "through" a phantom, targeting a lesion might be more intuitive than using ultrasound (US). The objective of this study was to compare the performance of experienced interventional radiologists and operators untrained in soft tissue lesion puncture using AR guidance and standard US guidance. MATERIAL AND METHODS: Three trained interventional radiologists with 5-10 years of experience and three untrained operators performed punctures of five targets in an abdominal phantom, with US guidance and AR guidance. Correct targeting, accuracy (defined as the Euclidean distance between the tip and the center of the target), planning time, and puncture time were documented. RESULTS: Accuracy was higher for the trained group than the untrained group using US guidance (1 mm versus 4 mm, p = 0.001), but not when using AR guidance (4 mm vs. 4 mm, p = 0.76). All operators combined, no significant difference was found concerning accuracy between US and AR guidance (2 mm vs. 4 mm, p = 0.09), but planning time and puncture time were significantly shorter using AR (respectively, 15.1 s vs. 74 s, p < 0.001; 16.1 s vs. 59 s; p < 0.001). CONCLUSION: Untrained and trained operators obtained comparable accuracy in percutaneous punctures when using AR guidance whereas US performance was better in the experienced group. All operators together, accuracy was similar between US and AR guidance, but shorter planning time, puncture time were found for AR guidance.

A new compressed sensing cine cardiac MRI sequence with free-breathing real-time acquisition and fully automated motion-correction: A comprehensive evaluation.

PURPOSE: The purpose of this study was to compare a new free-breathing compressed sensing cine (FB-CS) cardiac magnetic resonance imaging (CMR) to the standard reference multi-breath-hold segmented cine (BH-SEG) CMR in an unselected population. MATERIALS AND METHODS: From January to April 2021, 52 consecutive adult patients who underwent both conventional BH-SEG CMR and new FB-CS CMR with fully automated respiratory motion correction were retrospectively enrolled. There were 29 men and 23 women with a mean age of 57.7 ± 18.9 (standard deviation [SD]) years (age range: 19.0-90.0 years) and a mean cardiac rate of 74.6 ± 17.9 (SD) bpm. For each patient, short-axis stacks were acquired with similar parameters providing a spatial resolution of 1.8 × 1.8 × 8.0 mm3 and 25 cardiac frames. Acquisition and reconstruction times, image quality (Likert scale from 1 to 4), left and right ventricular volumes and ejection fractions, left ventricular mass, and global circumferential strain were assessed for each sequence. RESULTS: FB-CS CMR acquisition time was significantly shorter (123.8 ± 28.4 [SD] s vs. 267.2 ± 39.3 [SD] s for BH-SEG CMR; P < 0.0001) at the penalty of a longer reconstruction time (271.4 ± 68.7 [SD] s vs. 9.9 ± 2.1 [SD] s for BH-SEG CMR; P < 0.0001). In patients without arrhythmia or dyspnea, FB-CS CMR provided subjective image quality that was not different from that of BH-SEG CMR (P = 0.13). FB-CS CMR improved image quality in patients with arrhythmia (n = 18; P = 0.002) or dyspnea (n = 7; P = 0.02), and the edge sharpness was improved at end-systole and end-diastole (P = 0.0001). No differences were observed between the two techniques in ventricular volumes and ejection fractions, left ventricular mass or global circumferential strain in patients in sinus rhythm or with cardiac arrhythmia. CONCLUSION: This new FB-CS CMR addresses respiratory motion and arrhythmia-related artifacts without compromising the reliability of ventricular functional assessment.

Transcatheter Aortic Valve Replacement in Patients With Reduced Ejection Fraction and Nonsevere Aortic Stenosis.

BACKGROUND: The potential benefit of transcatheter aortic valve replacement (TAVR) in patients with nonsevere aortic stenosis (AS) and heart failure is controversial. This study aimed to assess outcomes of patients with nonsevere low-gradient AS (LGAS) and reduced left ventricular ejection fraction undergoing TAVR or medical management. METHODS: Patients undergoing TAVR for LGAS and reduced left ventricular ejection fraction (<50%) were included in a multinational registry. True-severe low-gradient AS (TS-LGAS) and pseudo-severe low-gradient AS (PS-LGAS) were classified according to computed tomography-derived aortic valve calcification thresholds. A medical control group with reduced left ventricular ejection fraction and moderate AS or PS-LGAS was used (Medical-Mod). Adjusted outcomes between all groups were compared. Among patients with nonsevere AS (moderate or PS-LGAS), outcomes after TAVR and medical therapy were compared using propensity score-matching. RESULTS: A total of 706 LGAS patients undergoing TAVR (TS-LGAS, N=527; PS-LGAS, N=179) and 470 Medical-Mod patients were included. After adjustment, both TAVR groups showed superior survival compared with Medical-Mod patients (all P<0.001), while no difference was found between TS-LGAS and PS-LGAS TAVR patients (P=0.96). After propensity score-matching among patients with nonsevere AS, PS-LGAS TAVR patients showed superior 2-year overall (65.4%) and cardiovascular survival (80.4%) compared with Medical-Mod patients (48.8% and 58.5%, both P≤0.004). In a multivariable analysis including all patients with nonsevere AS, TAVR was an independent predictor of survival (hazard ratio, 0.39 [95% CI, 0.27-0.55]; P<0.0001). CONCLUSIONS: Among patients with nonsevere AS and reduced left ventricular ejection fraction, TAVR represents a major predictor of superior survival. These results reinforce the need for randomized-controlled trials comparing TAVR versus medical management in heart failure patients with nonsevere AS. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT04914481.

Stereotactic Radioablation for Ventricular Tachycardia in the Setting of Electrical Storm.

BACKGROUND: Stereotactic body radiotherapy (SBRT) has been reported as a safe and efficient therapy for treating refractory ventricular tachycardia (VT) despite optimal medical treatment and catheter ablation. However, data on the use of SBRT in patients with electrical storm (ES) is lacking. The aim of this study was to assess the clinical outcomes associated with SBRT in the context of ES. METHODS: This retrospective study included patients who underwent SBRT in the context of ES from March 2020 to March 2021 in one tertiary center (CHU Lille). The target volume was delineated according to a predefined workflow. The efficacy was assessed with the following end points: sustained VT recurrence, VT reduced with antitachycardia pacing, and implantable cardioverter defibrillator shock. RESULTS: Seventeen patients underwent SBRT to treat refractory VT in the context of ES (mean 67±12.8 age, 59% presenting ischemic heart disease, mean left ventricular ejection fraction: 33.7± 9.7%). Five patients presented with ES related to incessant VT. Among these 5 patients, the time to effectiveness ranged from 1 to 7 weeks after SBRT. In the 12 remaining patients, VT recurrences occurred in 7 patients during the first 6 weeks following SBRT. After a median 12.5 (10.5-17.8) months follow-up, a significant reduction of the VT burden was observed beyond 6 weeks (-91% [95% CI, 78-103]), P<0.0001). The incidence of implantable cardioverter defibrillator shock and antitachycardia pacing was 36% at 1 year. CONCLUSIONS: SBRT is associated with a significant reduction of the VT burden in the event of an ES; however, prospective randomized control trials are needed. In patients without incessant VT, recurrences are observed in half of patients during the first 6 weeks. VT tolerance and implantable cardioverter defibrillator programming adjustments should be integrated as part of an action plan defined before SBRT for each patient.

60-S Retrogated Compressed Sensing 2D Cine of the Heart: Sharper Borders and Accurate Quantification.

BACKGROUND AND OBJECTIVE: Real-time compressed sensing cine (CSrt) provides reliable quantification for both ventricles but may alter image quality. The aim of this study was to assess image quality and the accuracy of left (LV) and right ventricular (RV) volumes, ejection fraction and mass quantifications based on a retrogated segmented compressed sensing 2D cine sequence (CSrg). METHODS: Thirty patients were enrolled. Each patient underwent the reference retrogated segmented steady-state free precession cine sequence (SSFPref), the real-time CSrt cine and the segmented retrogated prototype CSrg sequence providing the same slices. Functional parameters quantification and image quality rating were performed on SSFPref and CSrg images sets. The edge sharpness, which is an estimate of the edge spread function, was assessed for the three sequences. RESULTS: The mean scan time was: SSFPref = 485.4 ± 83.3 (SD) s (95% CI: 454.3-516.5) and CSrg = 58.3 ± 15.1 (SD) s (95% CI: 53.7-64.2) (p < 0.0001). CSrg subjective image quality score (median: 4; range: 2-4) was higher than the one provided by CSrt (median: 3; range: 2-4; p = 0.0008) and not different from SSFPref overall quality score (median: 4; range: 2-4; p = 0.31). CSrg provided similar LV and RV functional parameters to those assessed with SSFPref (p > 0.05). Edge sharpness was significantly better with CSrg (0.083 ± 0.013 (SD) pixel-1; 95% CI: 0.078-0.087) than with CSrt (0.070 ± 0.011 (SD) pixel-1; 95% CI: 0.066-0.074; p = 0.0004) and not different from the reference technique (0.075 ± 0.016 (SD) pixel-1; 95% CI: 0.069-0.081; p = 0.0516). CONCLUSIONS: CSrg cine provides in one minute an accurate quantification of LV and RV functional parameters without compromising subjective and objective image quality.

Compressed Sensing Real-Time Cine Reduces CMR Arrhythmia-Related Artifacts.

BACKGROUND AND OBJECTIVE: Cardiac magnetic resonance (CMR) is a key tool for cardiac work-up. However, arrhythmia can be responsible for arrhythmia-related artifacts (ARA) and increased scan time using segmented sequences. The aim of this study is to evaluate the effect of cardiac arrhythmia on image quality in a comparison of a compressed sensing real-time (CSrt) cine sequence with the reference prospectively gated segmented balanced steady-state free precession (Cineref) technique regarding ARA. METHODS: A total of 71 consecutive adult patients (41 males; mean age = 59.5 ± 20.1 years (95% CI: 54.7-64.2 years)) referred for CMR examination with concomitant irregular heart rate (defined by an RR interval coefficient of variation >10%) during scanning were prospectively enrolled. For each patient, two cine sequences were systematically acquired: first, the reference prospectively triggered multi-breath-hold Cineref sequence including a short-axis stack, one four-chamber slice, and a couple of two-chamber slices; second, an additional single breath-hold CSrt sequence providing the same slices as the reference technique. Two radiologists independently assessed ARA and image quality (overall, acquisition, and edge sharpness) for both techniques. RESULTS: The mean heart rate was 71.8 ± 19.0 (SD) beat per minute (bpm) (95% CI: 67.4-76.3 bpm) and its coefficient of variation was 25.0 ± 9.4 (SD) % (95% CI: 22.8-27.2%). Acquisition was significantly faster with CSrt than with Cineref (Cineref: 556.7 ± 145.4 (SD) s (95% CI: 496.7-616.7 s); CSrt: 23.9 ± 7.9 (SD) s (95% CI: 20.6-27.1 s); p < 0.0001). A total of 599 pairs of cine slices were evaluated (median: 8 (range: 6-14) slices per patient). The mean proportion of ARA-impaired slices per patient was 85.9 ± 22.7 (SD) % using Cineref, but this was figure was zero using CSrt (p < 0.0001). The European CMR registry artifact score was lower with CSrt (median: 1 (range: 0-5)) than with Cineref (median: 3 (range: 0-3); p < 0.0001). Subjective image quality was higher in CSrt than in Cineref (median: 3 (range: 1-3) versus 2 (range: 1-4), respectively; p < 0.0001). In line, edge sharpness was higher on CSrt cine than on Cineref images (0.054 ± 0.016 pixel-1 (95% CI: 0.050-0.057 pixel-1) versus 0.042 ± 0.022 pixel-1 (95% CI: 0.037-0.047 pixel-1), respectively; p = 0.0001). CONCLUSION: Compressed sensing real-time cine drastically reduces arrhythmia-related artifacts and thus improves cine image quality in patients with arrhythmia.

Right Ventricular Volume and Function Assessment in Congenital Heart Disease Using CMR Compressed-Sensing Real-Time Cine Imaging.

BACKGROUND AND OBJECTIVE: To evaluate the reliability of compressed-sensing (CS) real-time single-breath-hold cine imaging for quantification of right ventricular (RV) function and volumes in congenital heart disease (CHD) patients in comparison with the standard multi-breath-hold technique. METHODS: Sixty-one consecutive CHD patients (mean age = 22.2 ± 9.0 (SD) years) were prospectively evaluated during either the initial work-up or after repair. For each patient, two series of cine images were acquired: first, the reference segmented multi-breath-hold steady-state free-precession sequence (SSFPref), including a short-axis stack, one four-chamber slice, and one long-axis slice; then, an additional real-time compressed-sensing single-breath-hold sequence (CSrt) providing the same slices. Two radiologists independently assessed the image quality and RV volumes for both techniques, which were compared using the Wilcoxon test and paired Student's t test, Bland-Altman, and linear regression analyses. The visualization of wall-motion disorders and tricuspid-regurgitation-related signal voids were also analyzed. RESULTS: The mean acquisition time for CSrt was 22.4 ± 6.2 (SD) s (95% CI: 20.8-23.9 s) versus 442.2 ± 89.9 (SD) s (95% CI: 419.2-465.2 s) for SSFPref (p < 0.001). The image quality of CSrt was diagnostic in all examinations and was mostly rated as good (n = 49/61; 80.3%). There was a high correlation between SSFPref and CSrt images regarding RV ejection fraction (49.8 ± 7.8 (SD)% (95% CI: 47.8-51.8%) versus 48.7 ± 8.6 (SD)% (95% CI: 46.5-50.9%), respectively; r = 0.94) and RV end-diastolic volume (192.9 ± 60.1 (SD) mL (95% CI: 177.5-208.3 mL) versus 194.9 ± 62.1 (SD) mL (95% CI: 179.0-210.8 mL), respectively; r = 0.98). In CSrt images, tricuspid-regurgitation and wall-motion disorder visualization was good (area under receiver operating characteristic curve (AUC) = 0.87) and excellent (AUC = 1), respectively. CONCLUSIONS: Compressed-sensing real-time cine imaging enables, in one breath hold, an accurate assessment of RV function and volumes in CHD patients in comparison with standard SSFPref, allowing a substantial improvement in time efficiency.

Single breath-hold compressed sensing real-time cine imaging to assess left ventricular motion in myocardial infarction.

PURPOSE: To evaluate the reliability of a real-time compressed sensing (CS) cine sequence for the detection of left ventricular wall motion disorders after myocardial infarction in comparison with the reference steady-state free precession cine sequence. MATERIALS AND METHODS: One hundred consecutive adult patients referred for either initial work-up or follow-up by cardiac magnetic resonance (CMR) in the context of myocardial infarction were prospectively included. There were 77 men and 23 women with a mean age of 63.12±11.3 (SD) years (range: 29-89 years). Each patient underwent the reference segmented multi-breath-hold steady-state free precession cine sequence including one short-axis stack and both vertical and horizontal long-axis slices (SSFPref) and the CS real-time single-breath-hold evaluated sequence (CSrt) providing the same slices. Wall motion disorders were independently and blindly assessed with both sequences by two radiologists, using the American Heart Association left ventricle segmentation. Paired Wilcoxon signed-rank test was used to search for differences in wall motion disorders conspicuity between both sequences and receiver operating characteristic curve (ROC) analysis was performed to assess the diagnosis performance of CSrt sequence using SSFPref as the reference method. RESULTS: Each patient had at least one cardiac segment with wall motion abnormality on SSFPref and CSrt images. The 1700 segments analyzed with SSFPref were classified as normokinetic (360/1700; 21.2%), hypokinetic (783/1700; 46.1%), akinetic (526/1700; 30.9%) or dyskinetic (31/1700; 1.8%). Sensitivity and specificity of the CS sequence were 99.6% (95% CI: 99.1-99.9%) and 99.7% (95% CI: 98.5-100%), respectively. Area under ROC of CSrt diagnosis performance was 0.997 (95% CI: 0.993-0.999). CONCLUSION: CS real-time cine imaging significantly reduces acquisition time without compromising the conspicuity of left ventricular -wall motion disorders in the context of myocardial infarction.

Fatal Enterovirus-related Myocarditis in a Patient with Devic's Syndrome Treated with Rituximab.

Enteroviruses are a frequent source of infection and among the most common central nervous system viral pathogens. Enteroviruses - in particular, the Coxsackie B viruses - are a known cause of myocarditis. Rituximab is a genetically engineered chimeric anti-CD20 monoclonal antibody. Many reports in the literature suggest a higher risk of infection following repeated rituximab therapy, including viral infection. However, observations of enterovirus-related myocarditis in the context of rituximab treatment are scarce. The authors describe the case of a patient with neuromyelitis optica spectrum disorder who developed severe and fatal enterovirus-related myocarditis after rituximab therapy with a difficult differential diagnosis of autoimmune or giant-cell myocarditis. This case highlights the importance of complete diagnostic workup in difficult cases of myocarditis, including endomyocardial biopsies.

Utility of Three-Dimensional Transesophageal Echocardiography for Mitral Annular Sizing in Transcatheter Mitral Valve Replacement Procedures: A Cardiac Computed Tomographic Comparative Study.

BACKGROUND: Three-dimensional (3D) transesophageal echocardiographic (TEE) imaging is frequently used as an initial screening tool in the evaluation of patients who are candidates for transcatheter mitral valve replacement (TMVR). However, little is known about the imaging correlation with the gold standard, computed tomographic (CT) imaging. The aims of this study were to test the quantitative differences between these two modalities and to determine the best 3D TEE parameters for TMVR screening. METHODS: Fifty-seven patients referred to the heart valve clinic for TMVR with prostheses specifically designed for the mitral valve were included. Mitral annular (MA) analyses were performed using commercially available software on 3D TEE and CT imaging. RESULTS: Three-dimensional TEE imaging was feasible in 52 patients (91%). Although 3D TEE measurements were slightly lower than those obtained on CT imaging, measurements of both projected MA area and perimeter showed excellent correlations, with small differences between the two modalities (r = 0.88 and r = 0.92, respectively, P < .0001). Correlations were significant but lower for MA diameters (r = 0.68-0.72, P < .0001) and mitroaortic angle (r = 0.53, P = .0001). Receiver operating characteristic curve analyses showed that 3D TEE imaging had a good ability to predict TMVR screening success, defined by constructors on the basis of CT measurements, with ranges of 12.9 to 15 cm2 for MA area (area under the curve [AUC] = 0.88-0.91, P < .0001), 128 to 139 mm for MA perimeter (AUC = 0.85-0.91, P < .0001), 35 to 39 mm for anteroposterior diameter (AUC = 0.79-0.84, P < .0001), and 37 to 42 mm for posteromedial-anterolateral diameter (AUC = 0.81-0.89, P < .0001). CONCLUSIONS: Three-dimensional TEE measurements of MA dimensions display strong correlations with CT measurements in patients undergoing TMVR screening. Three-dimensional TEE imaging should be proposed as a reasonable alternative to CT imaging in this vulnerable population.

Transcatheter mitral valve replacement: factors associated with screening success and failure.

AIMS: Transcatheter mitral valve replacement (TMVR) is a promising therapeutic solution to treat high-risk patients with severe mitral regurgitation (MR) contraindicated to surgery. Optimal selection of patients who will benefit from the procedure is of paramount importance. We aimed to investigate factors associated with TMVR screening. METHODS AND RESULTS: From November 2016 to July 2018, we examined conditions associated with TMVR screening success in patients referred to the two French heart valve clinics with the greatest TMVR experience. Among a total of 40 consecutively screened patients, 16 (40%) were selected for TMVR (8 Twelve Intrepid, 7 Tendyne and 1 HighLife), while 24 patients (60%) were refused for TMVR mainly because of a too large mitral annulus (MA) (n=15, 62% of those refused), or too small anatomy and risk of neo-left ventricular outflow tract (LVOT) obstruction (n=6, 25% of those refused). Patients with suitable anatomy for TMVR were more often male and more frequently suffered from secondary MR (p=0.01) associated with previous myocardial infarction and presented a commissure-to-commissure diameter less than 39 mm (AUC=0.72, p=0.0085) and LVESD greater than 32 mm (AUC=0.83, p<0.0001) on transthoracic echocardiography, and an MA area less than 17.6 cm² (AUC=0.95, p<0.0001) and anteroposterior diameter greater than 41.6 mm (AUC=0.87, p<0.001) on CT scan. CONCLUSIONS: Despite several prostheses being available, most patients referred to heart valve clinics who are good candidates with regard to their clinical profile cannot have TMVR because of mismatch between their anatomy and prosthesis characteristics. Our findings suggest the need to develop new prostheses adapted to larger mitral annuli but with a lower impact on the LVOT.