Characteristic Features on Morphologic and Topographic Findings of Pulmonary Vein Orifices in Transition From Diastolic Dysfunction to Heart Failure: A Computerized Tomography Study.

BACKGROUND: Diastolic dysfunction (DD), a precursor to clinical heart failure (HF), has traditionally been evaluated by means of echocardiography. Data regarding morphologic descriptions of pulmonary vein (PV) orifices in transition from DD to HF have been lacking. METHODS AND RESULTS: We retrospectively studied 124 subjects with computerized tomography (CT)-derived PV parameters and echocardiography-derived diastolic indices. We categorized our subjects as 1) non-DD, 2) DD, or 3) heart failure with preserved ejection fraction (HFpEF) and observed a graded enlargement for 4 PV orifice areas across these groups. Positive linear relationship between the 4 PV orifice areas, echocardiography-derived mean pulmonary capillary wedge pressure (PCWP), and velocity of propagation (VP) were observed. Finally, maximum areas of left superior pulmonary vein (LSPV) and left inferior pulmonary vein (LIPV) significantly increased clinical diagnosis of HFpEF (likelihood-ratio χ(2): from 42.92 to 50.75 and 54.67 for LSPV and LIPV, respectively) when superimposed on left ventricular mass index, PCWP, and left atrial volume. CONCLUSIONS: PV size measurements with the use of CT are feasible and further aid in diseases discrimination between preclinical DD and those progressed into HF, even with preserved global pumping. Our data suggest that CT-based PV measures may help to identify subjects at risk for HF.

The association among MDCT-derived three-dimensional visceral adiposities on cardiac diastology and dyssynchrony in asymptomatic population.

BACKGROUND: Visceral adipose tissue, a biologically active fat depot, has been proposed as a reliable marker for visceral adiposity and metabolic abnormalities. Effects of such adiposity on LV diastolic function and dyssynchrony remained largely unknown. METHODS: We assessed pericardial fat (PCF) and thoracic peri-aortic fat (TPAF) by three-dimensional (3D) volume-vender multi-detector computed tomography (MDCT) (Aquarius 3D Workstation, TeraRecon, San Mateo, CA, USA). Echo-derived diastolic parameters and tissue Doppler imaging (TDI) defined mitral annular systolic (S'), early diastolic (E') velocities as well as LV filling (E/E') were all obtained. Intra-ventricular systolic (Sys-D) and diastolic (Dias-D) dyssynchrony were assessed by TDI method. RESULTS: A total of 318 asymptomatic subjects (mean age: 53.5 years, 36.8 % female) were eligible in this study. Greater PCF and TPAF were both associated with unfavorable diastolic indices and higher diastolic dyssynchrony (all p < 0.05). These associations remained relatively unchanged in multi-variate models. PCF and TPAF set at 81.68 & 8.11 ml yielded the largest sensitivity and specificity (78.6 and 60 % for PCF, 75 and 66.6 % for TPAF, respectively) in predicting abnormally high LV diastolic dyssynchrony, which was defined as Dias-D≧55 ms. CONCLUSION: Increasing visceral adiposity may be associated with adverse effects on myocardium, primarily featured by worse diastolic function and greater degree of dyssynchrony.

Qualitative and semi-quantitative evaluation of myocardium perfusion with 3 T stress cardiac MRI.

BACKGROUND: 3 T MRI has been adopted by some centers as the primary choice for assessment of myocardial perfusion over conventional 1.5 T MRI. However, there is no data published on the potential additional value of incorporating semi-quantitative data from 3 T MRI. This study sought to determine the performance of qualitative 3 T stress magnetic resonance myocardial perfusion imaging (3 T-MRMPI) and the potential incremental benefit of using a semi-quantitative perfusion technique in patients with suspected coronary artery disease (CAD). METHODS: Fifty eight patients (41 men; mean age: 59 years) referred for elective diagnostic angiography underwent stress 3 T MRMPI with a 32-channel cardiac receiver coil. The MR protocol included gadolinium-enhanced stress first-pass perfusion (0.56 mg/kg, dipyridamole), rest perfusion, and delayed enhancement (DE). Visual analysis was performed in two steps. Ischemia was defined as a territory with perfusion defect at stress study but no DE or a territory with DE but additional peri-infarcted perfusion defect at stress study. Semi-quantitative analysis was calculated by using the upslope of the signal intensity-time curve during the first pass of contrast medium during dipyridamole stress and at rest. ROC analysis was used to determine the MPRI threshold that maximized sensitivity. Quantitative coronary angiography served as the reference standard with significant stenosis defined as >70 % diameter stenosis. Diagnostic performance was determined on a per-patient and per-vessel basis. RESULTS: Qualitative assessment had an overall sensitivity and specificity for detecting significant stenoses of 77 % and 80 %, respectively. By adding MPRI analysis, in cases with negative qualitative assessment, the overall sensitivity increased to 83 %. The impact of MPRI differed depending on the territory; with the sensitivity for detection of left circumflex (LCx) stenosis improving the most after semi-quantification analysis, (66 % versus 83 %). CONCLUSIONS: Pure qualitative assessment of 3 T MRI had acceptable performance in detecting severe CAD. There is no overall benefit of incorporating semi-quantitative data; however a higher sensitivity can be obtained by adding MPRI, especially in the detection of LCx lesions.

High pericardial and peri-aortic adipose tissue burden in pre-diabetic and diabetic subjects.

BACKGROUND: Central obesity in relation to insulin resistance is strongly linked to the development of type 2 diabetes. However, data regarding the association between pericardial and peri-aortic adiposity, a potential estimate of visceral adipose tissue burden, and pre-diabetes status remains unclear.The aim of this study was to examine whether the degree of pericardial and thoracic peri-aortic adipose tissue, when quantified by multi-detector computed tomography (MDCT), differs significantly in a normal, pre-diabetic, and overtly diabetic population. METHODS: We studied 562 consecutive subjects including 357 healthy, 155 pre-diabetic, and 50 diabetic patients selected from participants who underwent annual health surveys in Taiwan. Pre-diabetes status was defined by impaired fasting glucose or impaired glucose intolerance according to American Diabetes Association guidelines. Pericardial (PCF) and thoracic peri-aortic (TAT) adipose tissue burden was assessed using a non-contrast 16-slice multi-detector computed tomography (MDCT) dataset with off-line measurement (Aquarius 3D Workstation, TeraRecon, San Mateo, CA, USA). Body fat composition, serum high-sensitivity C-reactive protein (hs-CRP) level and insulin resistance (HOMA-IR) were also assessed. RESULTS: Patients with diabetes and pre-diabetes had greater volume of PCF (89 ± 24.6, 85.3 ± 28.7 & 67.6 ± 26.7 ml, p < 0.001) as well as larger TAT (9.6 ± 3.1 ml vs 8.8 ± 4.2 & 6.6 ± 3.5 ml, respectively, p < 0.001) when compared to the normal group, although there were no significant differences in adiposity between the diabetic and pre-diabetic groups. For those without established diabetes in our study, increasing TAT burden, but not PCF, appear to correlate with insulin resistance (HOMA-IR) and hs-CRP in the multivariable models. CONCLUSIONS: Pre-diabetic and diabetic subjects, compared to normoglycemia, were associated with significantly higher pericardial and peri-aortic adipose tissue burden. In addition, visceral fat accumulation adjacent to the thoracic aorta seemed to exert a significant impact on insulin resistance and systemic inflammation.

Evaluation of arterial phase MDCT for the characterization of lower gastrointestinal bleeding in infants and children: Preliminary results.

OBJECTIVE: The purpose of this study was to prospectively evaluate the accuracy of MDCT for the characterization of occult lower gastrointestinal bleeding in infants and children. SUBJECTS AND METHODS: MDCT examinations were prospectively performed on 27 patients (2l boys, six girls; age range, 2 months-18 years). Patients with known causes of lower gastrointestinal bleeding were excluded from the study. Nonionic contrast medium was administered in an amount based on body weight. Images were obtained with a 16-MDCT scanner. For the arterial phase the section thickness was 1 mm; beam pitch, 1; and reconstruction interval, 0.7 mm. The scans were examined for abnormal vessels and extravasation of contrast medium. Two radiologists independently reviewed the images. The sensitivity, specificity, and diagnostic accuracy of MDCT were assessed with the pathologic findings or the final diagnosis as the reference standard. RESULTS: Twenty of 27 patients had abnormal MDCT findings: arteriovenous malformation in 17 patients and Meckel's diverticulum in three patients. Contrast extravasation was identified in four patients. Surgery was performed on 13 of the 27 patients, and the diagnosis was otherwise confirmed in two additional patients. In these 15 cases, the sensitivity, specificity, and diagnostic accuracy of MDCT were 82%, 50%, and 74%. The interobserver difference was not significant (McNemar exact test, p = 0.063). CONCLUSION: MDCT can be used to identify the location and source of lower gastrointestinal bleeding in infants and children.

Partial splenic embolization: 12-month hematological effects and complications.

BACKGROUND/AIMS: To investigate the hematological effects and immediate postoperative complications of partial splenic embolization (PSE) in patients with liver cirrhosis. METHODOLOGY: Record of liver cirrhosis patients with thrombocytopenia and leukopenia in whom PSE was performed between June 1995 and June 2005 were reviewed. Peripheral blood counts were evaluated at baseline, at 1 week, and at months 1, 3, 6, and 12 months post-PSE and clinically significant complications were recorded. RESULTS: In the twenty patients who underwent PSE, significant improvements in thrombocyte and leukocyte levels were noted at all time points compared to baseline levels up to one year following PSE (P<0.01). The complication rate was 100% because all patients experienced fever and abdominal pain. Only 7 patients (35%) experienced additional, mild post-embolization complications, and only 2 (10%) experienced serious complications. The mortality rate in this study was 0%. CONCLUSIONS: PSE significantly improved thrombocytopenia and leukopenia. These results support the contention that PSE is effective and safe, and should be employed more widely in the management of thrombocytopenia in patients with liver cirrhosis, particularly higher-risk patients that may not be candidates for surgical splenectomy. Further studies evaluating risk factors, criteria for patient selection, and target embolization area are warranted.

Late onset of biliopleural fistula following percutaneous transhepatic biliary drainage: a case report.

Biliopleural fistula (BF) and formation of biliopleural effusion is a rare complication following percutaneous transhepatic biliary drainage (PTBD). It occurs when the pleura is traversed by the catheter before entering the bile duct. Biliopleural fistula should be suspected when right side pleural effusion develops following the PTBD procedure. The diagnosis of biliopleural fistula is made when greenish pleural fluid with high concentration of bilirubin is aspirated. Here we present a case where a patient develops a biliopleural fistula following PTBD due to obstructive jaundice caused by neuroendocrine tumor of pancreas. Biliopleural fistula was disclosed after a scheduled catheter replacement procedure. Treatments of biliopleural fistula include thoracentesis with drainage tube installation into pleural space. In addition, a drainage tube was installed through percutaneous transhepatic gallbladder drainage (PTGBD) to reduce the bile induced pressure. Surgical repair of fistula was performed after the conservative treatment was unsuccessful. The patient expired 5 days after surgery due to respiratory failure.

Hyperdense appendix on unenhanced CT: a sign of acute appendicitis.

The purpose of this study was to evaluate the presence of the hyperdense appendix in acute appendicitis. The CT scans of 183 patients with pathologically proven acute appendicitis were reviewed to determine the prevalence of a hyperdense appendix, defined as a high-attenuated appendix when compared with the adjacent cecal wall on precontrast CT. A control group consisted of 100 patients with CT examinations performed in the emergency department were also randomly allocated to search for any hyperdense appendix in other disease conditions. The images were reviewed by two radiologists who reached a decision by consensus. A hyperdense appendix sign was found in 61 of 183 (33%) patients, including 92 men and 91 women ranging in age from 17 to 85 years (mean 37 years). On the other hand, the sign was seen in only two (2%) of the 88 patients in whom appendicitis was not diagnosed. The hyperdense appendix sign on unenhanced CT is seen in about 33% of patients with acute appendicitis. The false-positive rate is very low, rendering it a very useful sign for diagnosis of acute appendicitis.

Convex-Optimization-Based Compartmental Pharmacokinetic Analysis for Prostate Tumor Characterization Using DCE-MRI.

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is a powerful imaging modality to study the pharmacokinetics in a suspected cancer/tumor tissue. The pharmacokinetic (PK) analysis of prostate cancer includes the estimation of time activity curves (TACs), and thereby, the corresponding kinetic parameters (KPs), and plays a pivotal role in diagnosis and prognosis of prostate cancer. In this paper, we endeavor to develop a blind source separation algorithm, namely convex-optimization-based KPs estimation (COKE) algorithm for PK analysis based on compartmental modeling of DCE-MRI data, for effective prostate tumor detection and its quantification. The COKE algorithm first identifies the best three representative pixels in the DCE-MRI data, corresponding to the plasma, fast-flow, and slow-flow TACs, respectively. The estimation accuracy of the flux rate constants (FRCs) of the fast-flow and slow-flow TACs directly affects the estimation accuracy of the KPs that provide the cancer and normal tissue distribution maps in the prostate region. The COKE algorithm wisely exploits the matrix structure (Toeplitz, lower triangular, and exponential decay) of the original nonconvex FRCs estimation problem, and reformulates it into two convex optimization problems that can reliably estimate the FRCs. After estimation of the FRCs, the KPs can be effectively estimated by solving a pixel-wise constrained curve-fitting (convex) problem. Simulation results demonstrate the efficacy of the proposed COKE algorithm. The COKE algorithm is also evaluated with DCE-MRI data of four different patients with prostate cancer and the obtained results are consistent with clinical observations.

The Associations between Various Ectopic Visceral Adiposity and Body Surface Electrocardiographic Alterations: Potential Differences between Local and Remote Systemic Effects.

BACKGROUND: The associations between pericardial adiposity and altered atrial conduction had been demonstrated. However, data comparing differential effects of various body sites visceral adiposity on atrial and ventricular electrocardiographic alterations remains largely unknown. METHODS AND RESULTS: We assessed both peri-cardial fat (PCF) and peri-aortic visceral adiposity (TAT) using dedicated computed tomography (CT) software (Aquarius 3D Workstation, TeraRecon, San Mateo, CA, USA), with anthropometrics including body mass index (BMI) and biochemical data obtained. We further related PCF and TAT data to standardized 12-leads electrocardiogram (ECG), including P and QRS wave morphologies. Among 3,087 study subjects (mean age, 49.6 years; 28% women), we observed a linear association among greater visceral adiposity burden, leftward deviation of P and QRS axes, longer PR interval and widened QRS duration (all p<0.001). These associations became attenuated after accounting for BMI and baseline clinical co-variates, with greater PCF remained independently associated with prolonged QRS duration (ß = 0.91 [95% CI: 0.52, 1.31] per 1-SD increase in PCF, p<0.001). Finally, both PCF and TAT showed incremental value in identifying abnormally high PR interval (>200ms, likelihood-ratio: 33.17 to 41.4 & 39.03 for PCF and TAT) and widened QRS duration (>100ms, likelihood-ratio: 55.67 to 65.4 & 61.94 for PCF and TAT, all X2 p<0.05) when superimposed on age and BMI. CONCLUSION: We show in our data greater visceral fat burden may have differential associations on several body surface electrocardiographic parameters. Compared to remote adiposity, those surrounding the heart tissue demonstrated greater influences on altered cardiac activation or conduction, indicating a possible local biological effect.

Excessive interatrial adiposity is associated with left atrial remodeling, augmented contractile performance in asymptomatic population.

PURPOSE: Pericardial adipose tissue had been shown to exert local effects on adjacent cardiac structures. Data regarding the mechanistic link between such measures and left atrial (LA) structural/functional remodeling, a clinical hallmark of early stage heart failure (HF) and atrial fibrillation (AF) incidence, in asymptomatic population remain largely unexplored. METHODS: This retrospective analysis includes 356 subjects free from significant valvular disorders, atrial fibrillation, or clinical HF. Regional adipose tissue including pericardial and periaortic fat volumes, interatrial septal (IAS), and left atrioventricular groove (AVG) fat thickness were all measured by multidetector computed tomography (MDCT) (Aquarius 3D Workstation, TeraRecon, San Mateo, CA, USA). We measured LA volumes, booster performance, reservoir capacity as well as conduit function, and analyzed their association with adiposity measures. RESULTS: All four adiposity measures were positively associated with greater LA volumes (all P < 0.05), while IAS and AVG fat were also related to larger LA kinetic energy and worse reservoir capacity (both P < 0.01). In multivariate models, IAS fat thickness remained independently associated with larger LA volumes, increased LA kinetic energy and ejection force (ß-coef: 0.17 & 0.15, both P < 0.05), and impaired LA reservoir and conduit function (ß-coef: -0.20 & -0.12, both P < 0.05) after adjusting for clinical variables. CONCLUSION: Accumulated visceral adiposity, especially interatrial fat depots, was associated with certain LA structural/functional remodeling characterized by impaired LA reservoir and conduit function though augmented kinetic energy and ejection performance. Our data suggested that interatrial fat burden may be associated with certain detrimental LA functions with compensatory LA adaptation in an asymptomatic population.

The association among peri-aortic root adipose tissue, metabolic derangements and burden of atherosclerosis in asymptomatic population.

AIM: To describe the relationship between a novel measurement of peri-arotic root fat and ultrasound measures of carotid artery remodeling. MATERIALS AND METHODS: We studied 1492 consecutive subjects (mean age: 51.04 ± 8.97 years, 27% females) who underwent an annual cardiovascular risk survey in Taiwan. Peri-aortic root fat (PARF) was assessed by cardiac CT using three-dimensional (3D) volume assessment. Carotid artery morphology and remodeling were assessed by ultrasound. We explored the relationships between PARF volumes, cardiometabolic risk profiles and carotid morphology and remodeling. RESULTS: Mean PARF volume in current study was 20.8 ± 10.6 ml. PARF was positively correlated with measures of general adiposity, systemic inflammation, and several traditional cardiometabolic risk profiles (all p < 0.001) and successfully predicted metabolic syndrome (MetS) (AUROC: 0.75, 95%, confidence interval: 0.72-0.77). Higher PARF was independently associated with increased carotid artery intima-media thickness (IMT) (ß-coef.: 0.08) and diameter (ß-coef.: 0.08, both p < 0.05) after accounting for age, sex, BMI and other cardiovascular risk factors. The addition of PARF beyond metabolic syndrome components significantly provided incremental prediction value for abnormal IMT (ΔAUROC: 0.053, p = 0.0021). CONCLUSION: Peri-aortic root fat is associated with carotid IMT, even after adjustment for cardiometabolic risks, age and coronary atherosclerosis. Further research studies are warranted to identify the mediators of downstream pathophysiologic effects on carotid arteries by PARF and understand the mechanisms related to this correlation.

Biloma following repeated transcatheter arterial embolization and complicated by intrahepatic duct stones: a case report.

Biloma is an encapsulated bile collection outside the biliary tree due to a bile leak. It is occasionally found following traumatic liver injury or iatrogenic injury to the biliary tract, induced either during an endoscopic or surgical procedure. It is a rare complication of transcatheter arterial embolization (TAE). Although biloma can be shrunk by appropriate aspiration or drainage in majority of cases, we report a case of intrahepatic biloma following repeated TAE for hepatocellular carcinoma (HCC) and complicated by infection and intrahepatic stones. This particular constellation of problems has not been reported before and the intrahepatic stones need to be removed by percutaneous procedure.

Quantification of peri-aortic root fat from non-contrast ECG-gated cardiac computed tomography.

In this data, we present the details of the cross-sectional study from Mackay Memorial Hospital, Taipei, Taiwan that examined the relationship between three-dimensional (3D) peri-aortic root fat (PARF) volumes, cardiometabolic risk profiles, carotid artery morphology and remodeling. Our sample is composed of a total 1492 adults who underwent an annual cardiovascular risk survey in Taiwan. PARF was measured using images of gated non-contrast cardiac computed tomography (CT) and a dedicated workstation (Aquarius 3D Workstation, TeraRecon, San Mateo, CA, USA). The stratified analyses were performed in order to assess the association between carotid morphology, remodeling and PARF by tertile. For further analyses and discussion, please see "The Association among Peri-Aortic Root Adipose Tissue, Metabolic derangements and Burden of Atherosclerosis in Asymptomatic Population" by Yun et al. (2015) [1].

Vascular complications in percutaneous transhepatic management of complicated hepatolithiasis with difficult intrahepatic biliary strictures: are they avoidable?

Little has been reported about hemobilia in the management of complicated residual or recurrent hepatolithiasis with intrahepatic biliary strictures by percutaneous stricture dilation and percutaneous transhepatic cholangioscopic lithotomy. To analyze retrospectively the incidence, possible factors, and management of hemobilia in such patients, a consecutive series of 177 patients was studied from 1983 to 2001: 90 patients in the early, 7.5-year period and 87 patients in the later period, in which some procedures were modified. Minor hemobilia occurred during percutaneous puncture in 6 patients: 4 (4.4%) in the early period and 2 (2.3%) in the later period. Massive hemobilia developed in 14 patients (15.5%) in only the early period, during stricture dilation, lithotripsy, or lithotomy. Immediate arteriography revealed arterial bleeding (7), extravasation (3), pseudoaneurysm (3), or an undetermined source (1). Transcatheter arterial intervention enabled successful hemostasis. Massive hemobilia is a potential serious complication of percutaneous stricture dilation and percutaneous transhepatic cholangioscopic lithotomy but is avoidable.

Idiopathic hepatic arterio-portal fistula: report of one case.

Hepatic arterio-portal fistula is a rare cause of portal hypertension in children; it is an abnormal communication of hepatic artery and portal venous system, the most common causes being trauma or malignancy. There were only 11 cases reported in English literature and were not ever reported in Taiwan. We report a 9-year old boy with idiopathic hepatic arterio-portal fistula presented as intractable hematemesis due to esophageal and gastric varices. He had received sclerotherapy twice, and Sugiura operation (resection of the lower part of esophagus, devasculization of the stomach and splenectomy). Idiopathic hepatic arterio-portal fistula was found in angiography examination and the esophageal and gastric varices disappeared after transarterial embolization (TAE). We conclude that angiography is the golden diagnostic method for portal hypertension when the etiology is hepatic arterio-portal fistula and TAE will provide immediately therapy.

The normal limits, subclinical significance, related metabolic derangements and distinct biological effects of body site-specific adiposity in relatively healthy population.

BACKGROUND: The accumulation of visceral adipose tissue that occurs with normal aging is associated with increased cardiovascular risks. However, the clinical significance, biological effects, and related cardiometabolic derangements of body-site specific adiposity in a relatively healthy population have not been well characterized. MATERIALS AND METHODS: In this cross-sectional study, we consecutively enrolled 608 asymptomatic subjects (mean age: 47.3 years, 27% female) from 2050 subjects undergoing an annual health survey in Taiwan. We measured pericardial (PCF) and thoracic peri-aortic (TAT) adipose tissue volumes by 16-slice multi-detector computed tomography (MDCT) (Aquarius 3D Workstation, TeraRecon, San Mateo, CA, USA) and related these to clinical characteristics, body fat composition (Tanita 305 Corporation, Tokyo, Japan), coronary calcium score (CCS), serum insulin, high-sensitivity C-reactive protein (Hs-CRP) level and circulating leukocytes count. Metabolic risk was scored by Adult Treatment Panel III guidelines. RESULTS: TAT, PCF, and total body fat composition all increased with aging and higher metabolic scores (all p<0.05). Only TAT, however, was associated with higher circulating leukocyte counts (ß-coef.:0.24, p<0.05), serum insulin (ß-coef.:0.17, p<0.05) and high sensitivity C-reactive protein (ß-coef.:0.24, p<0.05). These relationships persisted after adjustment in multivariable models (all p<0.05). A TAT volume of 8.29 ml yielded the largest area under the receiver operating characteristic curve (AUROC: 0.79, 95%CI: 0.74-0.83) to identify metabolic syndrome. TAT but not PCF correlated with higher coronary calcium score after adjustment for clinical variables (all p<0.05). CONCLUSION: In our study, we observe that age-related body-site specific accumulation of adipose tissue may have distinct biological effects. Compared to other adiposity measures, peri-aortic adiposity is more tightly associated with cardiometabolic risk profiles and subclinical atherosclerosis in a relatively healthy population.