CT annulus sizing prior to transcatheter aortic valve replacement (TAVR): evaluation of free-breathing versus breath-holding acquisition.

OBJECTIVES: To assess feasibility and accuracy of aortic annulus measurements using cardiac computed tomography angiography (CTA) performed during free-breathing prior to transcatheter aortic valve replacement (TAVR). MATERIALS AND METHODS: Sixty consecutive TAVR candidates underwent free-breathing wide-detector cardiac CTA, followed by a percutaneous valve replacement. For each, a theoretical valve size was suggested through CT measurements of the annulus, then compared to the size of the actual implanted transcatheter heart valve (THV). The procedural success and the 30-day outcomes were collected. Image quality of the annulus was also studied according to subjective and objective criteria. Data of a control group of 60 patients previously evaluated on breath-holding were also evaluated. RESULTS: A total of 120 patients (mean age, 83 years ± 7, 60 men) were evaluated. All CT acquisitions provided sufficient image quality allowing precise annulus measurements. Mean attenuation (p < 0.001) and image noise (p = 0.01) were higher in the free-breathing group, while image quality was comparable (p = 0.36). The agreement rate between CT-suggested valve size and THV implanted size was comparable, estimated at 87% (κ = 0.79, 95%CI 0.566, 0.908) on free-breathing vs. 82% (κ = 0.78, 95%CI 0.634, 0.904) on breath-holding. The procedure was successful for all patients without increase in 30-day mortality or adverse events. CONCLUSIONS: Free-breathing cardiac CTA allows accurate aortic annulus measurements without compromising image quality or patients' outcome after TAVR. Elderly patients experiencing dyspnea, discomfort, or hearing loss that could prevent proper breath-holding should not be excluded from CT prior to TAVR. CLINICAL RELEVANCE STATEMENT: To decrease elderly patients' discomfort, MDCT evaluation prior to transcatheter aortic valve replacement (TAVR) may be performed on quiet breathing with no significant impact on the outcome. KEY POINTS: • Adhering to CT breathing commands can be challenging for patients with dyspnea, hearing impairment, agitation, or pulmonary diseases. • Free-breathing cardiac CT may be an alternative to breath-holding for patients unable to follow the breathing commands. • Wide-detector CT acquisition on free-breathing does not impair annulus measurements and prosthesis sizing in patients scheduled for TAVR.

Safety and performance of MR-conditional pacing systems with automated MRI mode at 1.5 and 3 Tesla.

OBJECTIVES: To evaluate at 1.5 and 3 T MRI the safety and performance of trademarked ENO®, TEO®, or OTO® pacing systems with automated MRI Mode and the image quality of non-enhanced MR examinations. METHODS: A total of 267 implanted patients underwent MRI examination (brain, cardiac, shoulder, cervical spine) at 1.5 (n = 126) or 3 T (n = 141). MRI-related device complications, lead electrical performances stability at 1-month post-MRI, proper functioning of the automated MRI mode and image quality were evaluated. RESULTS: Freedom from MRI-related complications at 1 month post-MRI was 100% in both 1.5 and 3 T arms (both p < 0.0001). The stability of pacing capture threshold was respectively at 1.5 and 3 T (atrial:: 98.9% (p = 0.001) and 100% (p < 0.0001); ventricular: both 100% (p < 0001)). The stability of sensing was respectively at 1.5 and 3 T (atrial: 100% (p = 0.0001) and 96.9% (p = 0.01); ventricular: 100% (p < 0.0001) and 99.1% (p = 0.0001)). All devices switched automatically to the programmed asynchronous mode in the MRI environment and to initially programmed mode after the MRI exam. While all MR examinations were assessed as interpretable, artifacts deteriorated a subset of examinations including mostly cardiac and shoulder ones. CONCLUSION: This study demonstrates the safety and electrical stability of ENO®, TEO®, or OTO® pacing systems at 1 month post-MRI at 1.5 and 3 T. Even if artifacts were noticed in a subset of examinations, overall interpretability was preserved. CLINICAL RELEVANCE STATEMENT: ENO®, TEO®, and OTO® pacing systems switch to MR-mode when detecting magnetic field and switch back on conventional mode after MRI. Their safety and electrical stability at 1 month post MRI were shown at 1.5 and 3 T. Overall interpretability was preserved. KEY POINTS: • Patients implanted with an MRI conditional cardiac pacemaker can be safely scanned under 1.5 or 3 Tesla MRI with preserved interpretability. • Electrical parameters of the MRI conditional pacing system remain stable after a 1.5 or 3 Tesla MRI scan. • The automated MRI mode enabled the automatic switch to asynchronous mode in the MRI environment and to initial settings after the MRI scan in all patients.

State-of-the-art CT and MR imaging and assessment of atherosclerotic carotid artery disease: the reporting-a consensus document by the European Society of Cardiovascular Radiology (ESCR).

The European Society of Cardiovascular Radiology (ESCR) is the European specialist society of cardiac and vascular imaging. This society's highest priority is the continuous improvement, development, and standardization of education, training, and best medical practice, based on experience and evidence. The present intra-society consensus is based on the existing scientific evidence and on the individual experience of the members of the ESCR writing group on carotid diseases, the members of the ESCR guidelines committee, and the members of the executive committee of the ESCR. The recommendations published herein reflect the evidence-based society opinion of ESCR. The purpose of this second document is to discuss suggestions for standardized reporting based on the accompanying consensus document part I. KEY POINTS: • CT and MR imaging-based evaluation of carotid artery disease provides essential information for risk stratification and prediction of stroke. • The information in the report must cover vessel morphology, description of stenosis, and plaque imaging features. • A structured approach to reporting ensures that all essential information is delivered in a standardized and consistent way to the referring clinician.

State-of-the-art CT and MR imaging and assessment of atherosclerotic carotid artery disease: standardization of scanning protocols and measurements-a consensus document by the European Society of Cardiovascular Radiology (ESCR).

The European Society of Cardiovascular Radiology (ESCR) is the European specialist society of cardiac and vascular imaging. This society's highest priority is the continuous improvement, development, and standardization of education, training, and best medical practice, based on experience and evidence. The present intra-society consensus is based on the existing scientific evidence and on the individual experience of the members of the ESCR writing group on carotid diseases, the members of the ESCR guidelines committee, and the members of the executive committee of the ESCR. The recommendations published herein reflect the evidence-based society opinion of ESCR. We have produced a twin-papers consensus, indicated through the documents as respectively "Part I" and "Part II." The first document (Part I) begins with a discussion of features, role, indications, and evidence for CT and MR imaging-based diagnosis of carotid artery disease for risk stratification and prediction of stroke (Section I). It then provides an extensive overview and insight into imaging-derived biomarkers and their potential use in risk stratification (Section II). Finally, detailed recommendations about optimized imaging technique and imaging strategies are summarized (Section III). The second part of this consensus paper (Part II) is focused on structured reporting of carotid imaging studies with CT/MR. KEY POINTS: • CT and MR imaging-based evaluation of carotid artery disease provides essential information for risk stratification and prediction of stroke. • Imaging-derived biomarkers and their potential use in risk stratification are evolving; their correct interpretation and use in clinical practice must be well-understood. • A correct imaging strategy and scan protocol will produce the best possible results for disease evaluation.

Prognostic value of cardiovascular magnetic resonance T1 mapping and extracellular volume fraction in nonischemic dilated cardiomyopathy.

BACKGROUND: Heart failure- (HF) and arrhythmia-related complications are the main causes of morbidity and mortality in patients with nonischemic dilated cardiomyopathy (NIDCM). Cardiovascular magnetic resonance (CMR) imaging is a noninvasive tool for risk stratification based on fibrosis assessment. Diffuse interstitial fibrosis in NIDCM may be a limitation for fibrosis assessment through late gadolinium enhancement (LGE), which might be overcome through quantitative T1 and extracellular volume (ECV) assessment. T1 and ECV prognostic value for arrhythmia-related events remain poorly investigated. We asked whether T1 and ECV have a prognostic value in NIDCM patients. METHODS: This prospective multicenter study analyzed 225 patients with NIDCM confirmed by CMR who were followed up for 2 years. CMR evaluation included LGE, native T1 mapping and ECV values. The primary endpoint was the occurrence of a major adverse cardiovascular event (MACE) which was divided in two groups: HF-related events and arrhythmia-related events. Optimal cutoffs for prediction of MACE occurrence were calculated for all CMR quantitative values. RESULTS: Fifty-eight patients (26%) developed a MACE during follow-up, 42 patients (19%) with HF-related events and 16 patients (7%) arrhythmia-related events. T1 Z-score (p = 0.008) and global ECV (p = 0.001) were associated with HF-related events occurrence, in addition to left ventricular ejection fraction (p < 0.001). ECV > 32.1% (optimal cutoff) remained the only CMR independent predictor of HF-related events occurrence (HR 2.15 [1.14-4.07], p = 0.018). In the arrhythmia-related events group, patients had increased native T1 Z-score and ECV values, with both T1 Z-score > 4.2 and ECV > 30.5% (optimal cutoffs) being independent predictors of arrhythmia-related events occurrence (respectively, HR 2.86 [1.06-7.68], p = 0.037 and HR 2.72 [1.01-7.36], p = 0.049). CONCLUSIONS: ECV was the sole independent predictive factor for both HF- and arrhythmia-related events in NIDCM patients. Native T1 was also an independent predictor in arrhythmia-related events occurrence. The addition of ECV and more importantly native T1 in the decision-making algorithm may improve arrhythmia risk stratification in NIDCM patients. Trial registration NCT02352129. Registered 2nd February 2015-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02352129.

Cutaneous vascularization of the proximal two-thirds of the dorsal aspect of the hand: descriptive anatomical study of a perforating arterial arch.

PURPOSE: Several reports have suggested that transverse arches between the radial and ulnar sides of dorsal hand skin supply the proximal part of the skin. The main objective of the study was to provide an anatomical and radiological description of a superficial vascular arch in the proximal third of the metacarpals of the long fingers. METHODS: We dissected 11 hands after injection with a mixture of lead and resin. A CT scan was performed before dissection. All vessels supplying the skin were individualized on the back of the hand and measured. RESULTS: A superficial perforating dorsal arch of the hand was present in all cases in this study. It was supplied by a dorsal radial perforating artery arising from the radial artery and by a dorsal ulnar perforating artery arising from the dorsal carpal arch. The distal recurrences of the intermetacarpal spaces communicated with this arch. This arch was the only source of vascularization of thess proximal third of the third space and presented a dominant ulnar side in the majority of cases. It presented numerous anatomical variations. The source vessels had mean diameters of 0.5 mm. There was an excellent radiological-anatomical correlation on CT scan. CONCLUSION: Given the constancy of this arch in the study, perforating flaps not yet described could be considered, having as pivot points the ulnar or radial origin of this arch.

Multichamber Dysfunction in Children and Adolescents With Severe Obesity: A Cardiac Magnetic Resonance Imaging Myocardial Strain Study.

BACKGROUND: In severe obesity, left ventricular (LV) and right ventricular (RV) remodeling and contractile dysfunction have been documented, but less is known regarding left atrial (LA) dysfunction and its association with LV/RV remodeling, especially in children. PURPOSE: To assess the effects of severe childhood obesity on cardiac function by using multichamber strain analysis with MRI. STUDY TYPE: Prospective. SUBJECTS: Forty-five children aged 7-18 years (including 20 with severe obesity, defined as a body mass index values above the 99th percentile). FIELD STRENGTH: 5 T. SEQUENCE: Steady-state-free-precession (SSFP) images in short-axis views and longitudinal two- and four-chamber views. ASSESSMENT: Cardiac strain measurements were derived from standard SSFP cine images by using a dedicated MR imaging feature tracking software. Inter- and intra-rater reliability were evaluated. STATISTICAL TESTS: Independent sample t test, Spearman's correlation coefficient, principal component analysis, Bland-Altman analysis, and intra-class correlation coefficients (ICC). A P value <0.05 was considered statistically significant. RESULTS: As compared to children without obesity, those with obesity showed significantly reduced LA reservoir function (22.2% ± 6.4% vs. 33.8% ± 9.0%) and contractile function (5.4% ± 3.2% vs. 13.3% ± 8.0%) as well as significantly decreased absolute values for LA longitudinal strain in reservoir and contraction phases and LA radial motion fraction in reservoir and contraction phases. Children with severe obesity showed significantly reduced absolute RV radial motion fraction (-10.6% ± 2.9% vs. -18.2% ± 2.9%) and circumferential strain (-10.6% ± 2.9% vs. -16% ± 2.5%) as well as higher LV mass index (28.7% ± 5.1% vs. 21.7 ± 4.6 g/m2 ) along with significantly reduced LV ejection fraction (56.4% ± 3.9% vs. 60% ± 4.1%), LV radial strain (56% ± 6% vs. 61.8% ± 11.3%), and longitudinal strain (-17.8% ± 1.8% vs. -20.3% ± 3.2%). Reliability was good to excellent, with ICC ranging from 79.1% to 97.7%. DATA CONCLUSION: MR feature-tracking strain analysis revealed multichamber dysfunction in severely obese children with impaired LA reservoir and atrial contraction phases, which suggest an early loss in the compensatory ability of atrial contraction with severe obesity. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY STAGE: 3.

Abdominopelvic CT-scan in emergency departments for patients with suspected complications of Crohn's disease: a single tertiary center experience.

BACKGROUND: Crohn's disease (CD) is a chronic disorder with frequent complications. The objective of this study was to assess the predictive factors of finding a complication of CD using abdominopelvic CT-scan in patients with a visit to the emergency department. METHODS: Patients with at least one visit to the gastroenterology department of our University hospital during the year with a CD were retrospectively included. All visits to the emergency department of the hospital during the follow-up of these patients were identified. RESULTS: A total of 638 patients were included and 318 (49.8%) had at least one visit to the emergency department since the beginning of their follow-up. Abdominopelvic CT-scan was performed in 141 (23.7%) of the 595 visits for digestive symptoms. Only 4.3% of these CT-scans were considered as normal; there was luminal inflammation without complication in 24.8%, abscess, fistula or perforation in 22.7%, mechanical bowel obstruction in 36.9% and diagnosis unrelated to CD in 11.3%. In univariate analysis, stricturing phenotype (OR, 2.48; 95% CI, 1.16-5.29; p = 0.02) and previous surgery (OR, 2.90; 95% CI, 1.37-6.14; p = 0.005) were predictive factors of finding a complication of CD using abdominopelvic CT-scan, whereas no independent predictive factor was statistically significant in multivariate analysis. CONCLUSION: In CD patients consulting in emergency department, CT-scan examination was performed in 24% of visits for digestive symptoms and complications of CD were found in 60%. Complications were more frequent in patients with stricturing phenotype and previous surgery.

Correction to: CT and MR imaging prior to transcatheter aortic valve implantation: standardisation of scanning protocols, measurements and reporting-a consensus document by the European Society of Cardiovascular Radiology (ESCR).

The original version of this article, published on 05 September 2019, unfortunately contained a mistake. The image of "Jena Valve" in Table 3 was incorrect.

CT and MR imaging prior to transcatheter aortic valve implantation: standardisation of scanning protocols, measurements and reporting-a consensus document by the European Society of Cardiovascular Radiology (ESCR).

Transcatheter aortic valve replacement (TAVR) is a minimally invasive alternative to conventional aortic valve replacement in symptomatic patients with severe aortic stenosis and contraindications to surgery. The procedure has shown to improve patient's quality of life and prolong short- and mid-term survival in high-risk individuals, becoming a widely accepted therapeutic option which has been integrated into current clinical guidelines for the management of valvular heart disease. Nevertheless, not every patient at high-risk for surgery is a good candidate for TAVR. Besides clinical selection, which is usually established by the Heart Team, certain technical and anatomic criteria must be met as, unlike in surgical valve replacement, annular sizing is not performed under direct surgical evaluation but on the basis of non-invasive imaging findings. Present consensus document was outlined by a working group of researchers from the European Society of Cardiovascular Radiology (ESCR) and aims to provide guidance on the utilisation of CT and MR imaging prior to TAVR. Particular relevance is given to the technical requirements and standardisation of the scanning protocols which have to be tailored to the remarkable variability of the scanners currently utilised in clinical practice; recommendations regarding all required pre-procedural measurements and medical reporting standardisation have been also outlined, in order to ensure quality and consistency of reported data and terminology. KEY POINTS: • To provide a reference document for CT and MR acquisition techniques, taking into account the significant technological variation of available scanners. • To review all relevant measurements that are required and define a step-by-step guided approach for the measurements of different structures implicated in the procedure. • To propose a CT/MR reporting template to assist in consistent communication between various sites and specialists involved in the procedural planning.

Value of Relative Myocardial Perfusion at MRI for Fractional Flow Reserve-Defined Ischemia: A Pilot Study.

OBJECTIVE. Correcting the perfusion in areas distal to coronary stenosis (risk) according to that of normal (remote) areas defines the relative myocardial perfusion index, which is similar to the fractional flow reserve (FFR) concept. The aim of this study was to assess the value of relative myocardial perfusion by MRI in predicting lesion-specific inducible ischemia as defined by FFR. MATERIALS AND METHODS. Forty-six patients (33 men and 13 women; mean [± SD] age, 61 ± 9 years) who underwent adenosine perfusion MRI and FFR measurement distal to 49 coronary artery stenoses during coronary angiography were retrospectively evaluated. Subendocardial time-enhancement maximal upslopes, normalized by the respective left ventricle cavity upslopes, were obtained in risk and remote subendocardium during adenosine and rest MRI perfusion and were correlated to the FFR values. RESULTS. The mean FFR value was 0.84 ± 0.09 (range, 0.60-0.98) and was less than or equal to 0.80 in 31% of stenoses (n = 15). The relative subendocardial perfusion index (risk-to-remote upslopes) during hyperemia showed better correlations with the FFR value (r = 0.59) than the uncorrected risk perfusion parameters (i.e., both the upslope during hyperemia and the perfusion reserve index [stress-to-rest upslopes]; r = 0.27 and 0.29, respectively). A cutoff value of 0.84 of the relative subendocardial perfusion index had an ROC AUC of 0.88 to predict stenosis at an FFR of less than or equal to 0.80. CONCLUSION. Using adenosine perfusion MRI, the relative myocardial perfusion index enabled the best prediction of FFR-defined lesion-specific myocardial ischemia. This index could be used to noninvasively determine the need for revascularization of known coronary stenoses.

Axillary Sonography of the Shoulder: An Adjunctive Approach.

Sonography of the shoulder is widely used to assess various disorders, including tendinous diseases of the rotator cuff and the long head of the biceps brachii muscle. The shoulder is commonly explored through anterior, superior, and posterior approaches, but the inferior axillary approach is rarely considered in the literature. However, this technique allows the direct visualization of relevant anatomic structures. The aim of this pictorial essay is, first, to technically describe this approach and the normal musculoskeletal sonographic anatomy of the region and, second, to present the sonographic findings of shoulder disorders that may be helpfully explored this technique.

Diffusion tensor imaging in acute pyelonephritis in children.

BACKGROUND: Diffusion-weighted imaging plays a key role in the imaging of acute pyelonephritis by MRI. However the use of respiratory triggering is challenging and time-consuming in children. Diffusion tensor imaging without respiratory triggering might provide satisfying images of the moving kidneys. OBJECTIVE: To compare mean diffusivity diffusion tensor images obtained with free breathing with diffusion-weighted images obtained with respiratory triggering. MATERIALS AND METHODS: Thirty-one children with suspected acute pyelonephritis underwent axial diffusion tensor imaging acquisition with free breathing and axial and coronal diffusion-weighted imaging acquisitions with respiratory triggering. We compared image quality and detection of nephritis between the two sequences. RESULTS: Diffusion tensor imaging demonstrated agreement with diffusion-weighted imaging in all cases, with no difference in the detection of nephritis areas. The image quality was significantly better with diffusion tensor imaging (P<0.01). CONCLUSION: Diffusion tensor imaging could replace diffusion-weighted imaging for diagnosis of acute pyelonephritis.

Morphological features in juvenile Huntington disease associated with cerebellar atrophy - magnetic resonance imaging morphometric analysis.

BACKGROUND: The imaging features of Huntington disease are well known in adults, unlike in juvenile-onset Huntington disease. OBJECTIVE: To conduct a morphometric magnetic resonance imaging (MRI) analysis in three juvenile Huntington disease patients (ages 2, 4 and 6 years old) to determine whether quantitative cerebral and cerebellar morphological metrics may provide diagnostically interesting patterns of cerebellar and cerebellar atrophy. MATERIALS AND METHODS: We report the cases of three siblings with extremely early presentations of juvenile Huntington disease associated with dramatic expansions of the morbid paternal allele from 43 to more than 100 CAG trinucleotide repeats. Automatic segmentation of MRI images of the cerebrum and cerebellum was performed and volumes of cerebral substructures and cerebellar lobules of juvenile Huntington disease patients were compared to those of 30 normal gender- and age-matched controls. Juvenile Huntington disease segmented volumes were compared to those of age-matched controls by using a z-score. RESULTS: Three cerebral substructures (caudate nucleus, putamen and globus pallidus) demonstrated a reduction in size of more than three standard deviations from the normal mean although it was not salient in one of them at clinical reading and was not diagnosed. The size of cerebellum lobules, cerebellum grey matter and cerebellum cortex was reduced by more than two standard deviations in the three patients. The cerebellar atrophy was predominant in the posterior lobe. CONCLUSION: Our study sheds light on atrophic cerebral and cerebellar structures in juvenile Huntington disease. Automatic segmentations of the cerebellum provide patterns that may be of diagnostic interest in this disease.

Ultrasound and anatomical assessment of the infraspinatus tendon through anterosuperolateral approach.

OBJECTIVES: In the literature, shoulder ultrasound (US) protocols rely on the widely accepted anatomical concept of the infraspinatus tendon (IST) running parallel and posterior to the supraspinatus tendon (SST). To assess the IST, authors currently recommend placing the transducer posteroinferior to the acromion; however the examination of the anterosuperior part of the IST remains problematic. The aim of our study was to apply recent anatomical knowledge to propose a simple protocol to assess the IST over its entire width including its anterosuperior margin. MATERIALS AND METHODS: Six non-diseased shoulders from four cadavers were assessed in hyperextended internal rotation (HIR) position with US anterosuperolateral approach followed by dissection. Twelve healthy volunteers underwent similar US examination of the shoulder. RESULTS: The IST is a thin, wide, strap-like tendon. The HIR position exposed the largest area of IST beyond the acromion; combined anterosuperolateral US approach enabled imaging of the IST over its entire width with transverse and longitudinal views. The anterosuperior margin of the IST was distinguishable from the SST. CONCLUSION: The anterosuperolateral US approach in HIR position enables an accurate assessment of the IST including the transverse plane. The limit between the SST and IST appears more clearly. KEY POINTS: • The hyperextended internal rotation of the shoulder brings the infraspinatus tendon forward. • The infraspinatus tendon is visible with anterosuperolateral ultrasound approach. • The anterosuperior margin of the infraspinatus tendon is visible with this technique.

Supranormal differential renal function in unilateral hydronephrotic kidney: insights from functional MR urography.

PURPOSE: To retrospectively assess supranormal differential renal function (DRF) in unilateral hydronephrotic kidney by functional MR urography (fMRU). MATERIALS AND METHODS: The ethics committees granted exempt status for this study and also waived the need for informed consent. A retrospective analysis was performed of all patients undergoing fMRU from January 2008 to November 2011. DRF was measured by both the area under the curve method and Rutland-Patlak plot. Glomerular DRF per unit of volume and kidney volumes were analyzed. Kidney volumes were compared with nomograms. RESULTS: Of 170 children, 3 patients (2, 12, and 14 years) with a left ureteropelvic junction obstruction were included. Glomerular DRF per unit of volume was slightly higher on the dilated side but remained within normal range (<55%). Dilated kidney volumes were higher on the dilated side (≥55%). The volumes of nondilated kidneys were within normal range. CONCLUSION: The data support the fact that the dilated kidney was not hyperfunctioning and that the nondilated kidney was not hypofunctioning. Based on these three patients, it could be assumed that supranormal DRF on the dilated side might be explained by a slight kidney volume asymmetry, in association with higher DRF per unit of volume, remaining within normal physiological range. J. Magn. Reson. Imaging 2014;40:577-582. © 2013 Wiley Periodicals, Inc.