Vascular Plugs Improve Pulmonary Arteriovenous Malformation Occlusion over Coil Embolization Alone: A Proof-of-Concept Study using Dual Energy Computed Tomography.

PURPOSE: To evaluate efficacy of pulmonary arteriovenous malformation (PAVM) embolization using dual-energy computed tomography (DECT) and spectral curve analysis by characterizing contrast enhancement and vascular perfusion as a surrogate of the degree of vascular occlusion after embolotherapy. METHODS: Nine consecutive adult patients underwent embolization for 21 PAVMs (size range 0.4-2.0cm; 15/21 simple angioarchitecture) and subsequent post-embolization chest DECT angiography. Twelve PAVMS were treated with vascular plugs ± coils, whereas nine PAVMs were treated with coils-only. Virtual spectral curves (VSC) were generated using dual-energy image post-processing in order to measure embolization effectiveness. RESULTS: Complete occlusion of target PAVM was achieved in all cases on digital subtraction angiography at the end of the embolization procedure. With a median follow-up of 12.7 months, the vascular plug group demonstrated significantly less vascular opacification compared to the coils-only group, as measured by opacification between upstream feeding artery and and different downstream vasculature locations (Δslope1: median 79.1 versus 28.6, p=0.0030; Δslope2: 76.4 versus 28.6, p=0.0197; Δslope3: 78.9 versus 28.6, p=0.0041). Persistence occurred in three PAVMs based on size criteria, which demonstrated higher vascular vascular opacification by DECT (Δslope1: 72 versus 28.6, p=0.253; Δslope2: 65.1 versus 32.7, p=0.326; Δslope3: 72.9 versus 53.5, p=0.733), although statistical significance was not reached. CONCLUSION: Similar to emerging literature, DECT showed improved occlusion in PAVMs treated with vascular plugs compared to coils alone.

Myocardial Blood Flow Quantified Using Stress Cardiac Magnetic Resonance After Mild COVID-19 Infection.

BACKGROUND: Severe COVID-19 infection is known to alter myocardial perfusion through its effects on the endothelium and microvasculature. However, the majority of patients with COVID-19 infection experience only mild symptoms, and it is unknown if their myocardial perfusion is altered after infection. OBJECTIVES: The authors aimed to determine if there are abnormalities in myocardial blood flow (MBF), as measured by stress cardiac magnetic resonance (CMR), in individuals after a mild COVID-19 infection. METHODS: We conducted a prospective, comparative study of individuals who had a prior mild COVID-19 infection (n = 30) and matched controls (n = 26) using stress CMR. Stress and rest myocardial blood flow (sMBF, rMBF) were quantified using the dual sequence technique. Myocardial perfusion reserve was calculated as sMBF/rMBF. Unpaired t-tests were used to test differences between the groups. RESULTS: The median time interval between COVID-19 infection and CMR was 5.6 (IQR: 4-8) months. No patients with the COVID-19 infection required hospitalization. Symptoms including chest pain, shortness of breath, syncope, and palpitations were more commonly present in the group with prior COVID-19 infection than in the control group (57% vs 7%, P < 0.001). No significant differences in rMBF (1.08 ± 0.27 mL/g/min vs 0.97 ± 0.29 mL/g/min, P = 0.16), sMBF (3.08 ± 0.79 mL/g/min vs 3.06 ± 0.89 mL/g/min, P = 0.91), or myocardial perfusion reserve (2.95 ± 0.90 vs 3.39 ± 1.25, P = 0.13) were observed between the groups. CONCLUSIONS: This study suggests that there are no significant abnormalities in rest or stress myocardial perfusion, and thus microvascular function, in individuals after mild COVID-19 infection.

Fibrosing Mediastinitis Caused by Histoplasmosis in an Adolescent.

Fibrosing mediastinitis (FM) is a rare, potentially progressive disease resulting from an idiosyncratic immune response to a variety of stimuli that lead to fibrous infiltration of the mediastinum and possible narrowing of the bronchovascular structures. We report an unusual case of FM in a pediatric patient presenting as myopericarditis and progressing to pericardial thickening and encasement of the mediastinal vascular structures needing surgical intervention. Imaging, including transthoracic echocardiography, cardiac computed tomography, and cardiac magnetic resonance played a crucial role in the diagnosis, assessment, and follow-up. Contrast-enhanced computed tomography can be especially helpful to demonstrate potential findings associated with FM.

Pulmonary Alveolar Proteinosis-associated Pulmonary Fibrosis: Evolutional Changes and Radiologic-Pathologic Correlation.

Pulmonary alveolar proteinosis (PAP) is a rare disease with frequently favorable outcomes. In a minority of patients with primary or secondary PAP, the disease course may be complicated by pulmonary fibrosis (PF) despite appropriate management. Imaging and histopathologic manifestations of uncomplicated PAP are well-known. In contrast, radiologic-pathologic descriptions of PAP-associated PF (PAP-PF) are limited. The current manuscript presents three cases of PAP-PF, each with serial high-resolution CT imaging demonstrating the longitudinal progression of this unusual complication, with concordant pathologic findings in two patients. Much remains to be known regarding adverse prognostic factors contributing to PAP-PF. Early recognition of radiologic-pathologic manifestations would allow timely diagnosis and management optimization. Keywords: CT, Lung, Inflammation, Pathology © RSNA, 2023.

Anomalous right coronary artery from the main pulmonary artery (ARCAPA): Incidental finding in an asymptomatic septuagenarian.

Anomalous right coronary artery (RCA) from the main pulmonary artery (ARCAPA) is a rare finding. Clinical presentations range from asymptomatic to sudden death. We present the case of ARCAPA in a septuagenarian initially suspected on a screening chest computed tomography (CT) and later confirmed on cardiac CT. A summary of important points related to this entity is also discussed.

Cardiovascular computed tomography for the detection of quadricuspid aortic valve: A case report.

Aortic regurgitation (AR) represents a significant cause of morbidity and mortality. Due to its low cost and widespread availability, echocardiography remains the frontline for aortic valve (AV) assessment. However, poor sonographic windows may limit the assessment of valve morphology with this technique. Cardiovascular computed tomography (CCT) is increasingly utilized prior to structural AV interventions. Due to its excellent spatial resolution, CCT provides exceptional characterization of aortic leaflets. Accordingly, we present a case of a quadricuspid valve diagnosed by CCT. Here, CCT led to a new diagnosis of quadricuspid valve, highlighting the potential for CCT for the characterization of aortic leaflet morphology. CCT may be particularly useful in patients with contraindications to transesophageal echocardiography or those undergoing structural or robotic interventions.

Impact of wideband cardiac magnetic resonance on diagnosis, decision-making and outcomes in patients with implantable cardioverter defibrillators.

AIMS: Although myocardial scar assessment using late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) imaging is frequently indicated for patients with implantable cardioverter defibrillators (ICDs), metal artefact can degrade image quality. With the new wideband technique designed to mitigate device related artefact, CMR is increasingly used in this population. However, the common clinical indications for CMR referral and impact on clinical decision-making and prognosis are not well defined. Our study was designed to address these knowledge gaps. METHODS AND RESULTS: One hundred seventy-nine consecutive patients with an ICD (age 59 ± 13 years, 75% male) underwent CMR using cine and wideband pulse sequences for LGE imaging. Electronic medical records were reviewed to determine the reason for CMR referral, whether there was a change in clinical decision-making, and occurrence of major adverse cardiac events (MACEs). Referral indication was the most common evaluation of ventricular tachycardia (VT) substrate (n = 114, 64%), followed by cardiomyopathy (n = 53, 30%). Overall, CMR resulted in a new or changed diagnosis in 64 (36%) patients and impacted clinical management in 51 (28%). The effect on management change was highest in patients presenting with VT. A total of 77 patients (43%) experienced MACE during the follow-up period (median 1.7 years), including 65 in patients with evidence of LGE. Kaplan-Meier analysis showed that ICD patients with LGE had worse outcomes than those without LGE (P = 0.006). CONCLUSION: The clinical yield from LGE CMR is high and provides management changing and meaningful prognostic information in a significant proportion of patients with ICDs.

Relation of Myocardial Perfusion Reserve and Left Ventricular Ejection Fraction in Ischemic and Nonischemic Cardiomyopathy.

Quantification of myocardial perfusion reserve (MPR) using vasodilator stress cardiac magnetic resonance is increasingly used to detect coronary artery disease. However, MPR can also be altered because of changes in microvascular function. We aimed to determine whether MPR can distinguish between ischemic cardiomyopathy (IC) secondary to coronary artery disease and non-IC (NIC) with microvascular dysfunction and no underlying epicardial coronary disease. A total of 60 patients (mean age 65 ± 14 years, 30% women), including 31 with IC and 29 with NIC, were identified from a pre-existing vasodilator stress cardiac magnetic resonance registry. Short-axis cine slices were used to measure left ventricular ejection fraction (LVEF) using the Simpson method of disks. MPR index (MPRi) was determined from first-pass myocardial perfusion images during stress and rest using the upslope ratio, normalized for the arterial input and corrected for rate pressure product. Patients in both groups were divided into subgroups of LVEF ≤35% and LVEF >35%. Differences in MPRi between the subgroups were examined. MPRi was moderately correlated with LVEF in patients with NIC (r = 0.53, p = 0.03), whereas the correlation in patients with IC was lower (r = 0.32, p = 0.22). Average LVEF in NIC and IC was 34% ± 8% and 35% ± 8%, respectively (p = 0.63). MPRi was not significantly different in IC compared with NIC (1.17 [0.88 to 1.61] vs 1.23 [1.07 to 1.66], p = 0.41), including the subgroups of LVEF (IC: 1.20 ± 0.56 vs NIC: 1.15 ± 0.24, p = 0.75 for LVEF ≤35% and IC: 1.35 ± 0.44 vs NIC: 1.58 ± 0.50, p = 0.19 for LVEF >35%). However, MPRi was significantly lower in patients with LVEF ≤35% compared with those with LVEF>35% (1.17 ± 0.40 vs 1.47 ± 0.47, p = 0.01). Similar difference between LVEF groups was noted in the patients with NIC (1.15 ± 0.24 vs 1.58 ± 0.50, p = 0.006) but not in the patients with IC (1.20 ± 0.56 vs 1.35 ± 0.44, p = 0.42). MPRi can be abnormal in the presence of left ventricular dysfunction with nonischemic etiology. This is a potential pitfall to consider when using this approach to detect ischemia because of epicardial coronary disease using myocardial perfusion imaging.

Assessment of right ventricular size and function from cardiovascular magnetic resonance images using artificial intelligence.

BACKGROUND: Theoretically, artificial intelligence can provide an accurate automatic solution to measure right ventricular (RV) ejection fraction (RVEF) from cardiovascular magnetic resonance (CMR) images, despite the complex RV geometry. However, in our recent study, commercially available deep learning (DL) algorithms for RVEF quantification performed poorly in some patients. The current study was designed to test the hypothesis that quantification of RV function could be improved in these patients by using more diverse CMR datasets in addition to domain-specific quantitative performance evaluation metrics during the cross-validation phase of DL algorithm development. METHODS: We identified 100 patients from our prior study who had the largest differences between manually measured and automated RVEF values. Automated RVEF measurements were performed using the original version of the algorithm (DL1), an updated version (DL2) developed from a dataset that included a wider range of RV pathology and validated using multiple domain-specific quantitative performance evaluation metrics, and conventional methodology performed by a core laboratory (CORE). Each of the DL-RVEF approaches was compared against CORE-RVEF reference values using linear regression and Bland-Altman analyses. Additionally, RVEF values were classified into 3 categories: ≤ 35%, 35-50%, and ≥ 50%. Agreement between RVEF classifications made by the DL approaches and the CORE measurements was tested. RESULTS: CORE-RVEF and DL-RVEFs were obtained in all patients (feasibility of 100%). DL2-RVEF correlated with CORE-RVEF better than DL1-RVEF (r = 0.87 vs. r = 0.42), with narrower limits of agreement. As a result, DL2 algorithm also showed increasing accuracy from 0.53 to 0.80 for categorizing RV function. CONCLUSIONS: The use of a new DL algorithm cross-validated on a dataset with a wide range of RV pathology using multiple domain-specific metrics resulted in a considerable improvement in the accuracy of automated RVEF measurements. This improvement was demonstrated in patients whose images were the most challenging and resulted in the largest RVEF errors. These findings underscore the critical importance of this strategy in the development of DL approaches for automated CMR measurements.

Validation of non-contrast multiple overlapping thin-slab 4D-flow cardiac magnetic resonance imaging.

BACKGROUND: Cardiac magnetic resonance (CMR) flow quantification is typically performed using 2D phase-contrast (PC) imaging of a plane perpendicular to flow. 3D-PC imaging (4D-flow) allows offline quantification anywhere in a thick slab, but is often limited by suboptimal signal, potentially alleviated by contrast enhancement. We developed a non-contrast 4D-flow sequence, which acquires multiple overlapping thin slabs (MOTS) to minimize signal loss, and hypothesized that it could improve image quality, diagnostic accuracy, and aortic flow measurements compared to non-contrast single-slab approach. METHODS: We prospectively studied 20 patients referred for transesophageal echocardiography (TEE), who underwent CMR (GE, 3 T). 2D-PC images of the aortic valve and three 4D-flow datasets covering the heart were acquired, including single-slab, pre- and post-contrast, and non-contrast MOTS. Each 4D-flow dataset was interpreted blindly for ≥moderate valve disease and compared to TEE. Flow visualization through each valve was scored (0 to 4), and aortic-valve flow measured on each 4D-flow dataset and compared to 2D-PC reference. RESULTS: Diagnostic quality visualization was achieved with the pre- and post-contrast 4D-flow acquisitions in 25% and 100% valves, respectively (scores 0.9 ± 1.1 and 3.8 ± 0.5), and in 58% with the non-contrast MOTS (1.6 ± 1.1). Accuracy of detection of valve disease was 75%, 92% and 82%, respectively. Aortic flow measurements were possible in 53%, 95% and in 89% patients, respectively. The correlation between pre-contrast single-slab measurements and 2D-PC reference was weak (r = 0.21), but improved with both contrast enhancement (r = 0.71) and with MOTS (r = 0.67). CONCLUSIONS: Although non-contrast MOTS 4D-flow improves valve function visualization and diagnostic accuracy, a significant proportion of valves cannot be accurately assessed. However, aortic flow measurements using non-contrast MOTS is feasible and reaches similar accuracy to that of contrast-enhanced 4D-flow.

CAD-RADS: Pushing the Limits.

Coronary CT angiography is now established as the first-line diagnostic imaging test to exclude coronary artery disease (CAD) in the population at low to intermediate risk. Wide variability exists in both the reporting of coronary CT angiography and the interpretation of these reports by referring physicians. The CAD Reporting and Data System (CAD-RADS) is sponsored by multiple societies and is a collaborative effort to provide standard classification of CAD, which is then integrated into patient clinical care. The main goals of the CAD-RADS are to decrease variability among readers; enhance communication between interpreting and referring clinicians, allowing collaborative determination of the best course of patient care; and generate consistent data for auditing, data mining, quality improvement, research, and education. There are several scenarios in which the CAD-RADS guidelines are ambiguous or do not provide definite recommendations for further management of CAD. The authors discuss the CAD-RADS categories and modifiers, highlight a variety of complex or ambiguous scenarios, and provide recommendations for managing these scenarios. Online supplemental material is available for this article. ©RSNA, 2020 See discussion on this article by Aviram and Wolak.

Novel Formula to Calculate Three-Dimensional Angle Between Inflow Cannula and Device Body of HeartMate II LVAD.

BACKGROUND: The acute angle between inflow cannula and device body of HeartMate II left ventricular assist device (LVAD) (Abbott, Pleasanton, California) is associated with device thrombosis. However, most studies utilized two-dimensional (2D) angle obtained from chest roentgenogram (CXR), which is unlikely accurate. We aimed to create and validate a formula to estimate actual three-dimensional (3D) angle. METHODS: We retrospectively reviewed the cohort undergoing HeartMate II LVAD implantation between 2008 and 2016. A formula for calculating 3D angles of the LVAD inflow cannula relative to the device body was mathematically derived, using simple 2D measurements from CXR. RESULTS: The cohort included consecutive 275 patients with HeartMate II (median age: 60 [25% quartile: 51, 75% quartile: 68] years). There was no significant difference between the calculated 3D angles (from formula) and actual 3D angles (from computed tomography) from the subset group with 3D computed tomography (n = 28) (71.7° ± 13.4° vs 71.1° ± 11.5°, P = .858). Among all participants, the calculated 3D angle (from formula) was 74.4° ± 14.2°, which was significantly larger than the 2D projected angle (from CXR) (65.2° ± 11.3°, P < .001). There was no statistical difference in the calculated 3D angles (from formula) between patients with/without device thrombosis, hemorrhagic stroke, ischemic stroke, or mortality (P > .05 for all). CONCLUSIONS: We established a novel formula to mathematically calculate actual 3D angles between inflow cannula and device body of HeartMate II. The formula would help investigators to validate their findings of the relationship between 2D projected angle (from CXR) and device thrombosis.

Cardiac Magnetic Resonance in Patients With Cardiac Implantable Electronic Devices: Challenges and Solutions.

Until recently, cardiac implantable electronic devices (CIEDs) were an absolute contraindication to magnetic resonance imaging (MRI), due to concerns about their adverse interaction in the MRI environment. The increasing clinical need to perform MRI examinations in these patients was an impetus to the development of MR-Conditional CIEDs. Secure performance of MRI in these patients requires scanning under specified MR conditions as well as operating the device in MR-scanning mode. This requires robust institutional protocols and a well-trained multidisciplinary team of radiologists, cardiologists, device applications specialists, physicists, nurses, and MRI technologists. MRI can also be performed in patients with non-MRI Conditional or "legacy" CIEDs by following safety precautions and continuous monitoring. Cardiac magnetic resonance (CMR) is additionally challenging due to expected susceptibility artifacts generated by the CIEDs, which are either near or in the heart. As the most common indication for CMR in these patients is the evaluation of myocardial scar/fibrosis, acquiring a high-quality late gadolinium enhancement image is of the utmost importance. This sequence is hampered by artifactual high signal due to inadequate myocardial nulling. Several solutions are available to reduce these artifacts, including reducing inhomogeneity, technical adjustments, and use of sequences that are more resilient to artifacts. In this article, we review the precautions for CMR in patients with CIEDs, provide guidelines for secure performance of CMR in these patients, and discuss techniques for obtaining high quality CMR images with minimized artifacts.

Ultra-low dose contrast CT pulmonary angiography in oncology patients using a high-pitch helical dual-source technology.

PURPOSE: We aimed to determine if the image quality and vascular enhancement are preserved in computed tomography pulmonary angiography (CTPA) studies performed with ultra-low contrast and optimized radiation dose using high-pitch helical mode of a second generation dual source scanner. METHODS: We retrospectively evaluated oncology patients who had CTPA on a 128-slice dual-source scanner, with a high-pitch helical mode (3.0), following injection of 30 mL of Ioversal at 4 mL/s with body mass index (BMI) dependent tube potential (80-120 kVp) and current (130-150 mAs). Attenuation, noise, and signal-to-noise ratio (SNR) were measured in multiple pulmonary arteries. Three independent readers graded the images on a 5-point Likert scale for central vascular enhancement (CVE), peripheral vascular enhancement (PVE), and overall quality. RESULTS: There were 50 males and 101 females in our study. BMI ranged from 13 to 38 kg/m2 (22.8±4.4 kg/m2). Pulmonary embolism was present in 29 patients (18.9%). Contrast enhancement and SNR were excellent in all the pulmonary arteries (395.3±131.1 and 18.3±5.7, respectively). Image quality was considered excellent by all the readers, with average reader scores near the highest possible score of 5.0 (CVE, 4.83±0.48; PVE, 4.68±0.65; noise/quality, 4.78±0.47). The average radiation dose length product (DLP) was 161±60 mGy.cm. CONCLUSION: Using a helical high-pitch acquisition technique, CTPA images of excellent diagnostic quality, including visualization of peripheral segmental/sub-segmental branches can be obtained using an ultra-low dose of iodinated contrast and low radiation dose.

Improved visualization of the coronary arteries using motion correction during vasodilator stress CT myocardial perfusion imaging.

BACKGROUND: Vasodilator stress computed tomography perfusion (sCTP) imaging is complementary to coronary CT angiography (CCTA), used to determine the hemodynamic significance of coronary artery disease. However, it requires a separate image acquisition due to motion artifacts caused by higher heart rates during stress, resulting in increased iodine contrast dose and radiation. We sought to determine whether a novel motion correction algorithm applied to stress images would improve the visualization of the coronary arteries to potentially allow CCTA + sCTP evaluation in a single scan. METHODS: 28 patients referred for clinically indicated CCTA (iCT, Philips) underwent sCTP imaging (retrospective-gating with dose modulation; 100 kVp and 250 mA; 5.2 ± 4.3 mSv) after regadenoson (0.4 mg, Astellas). Stress images were reconstructed using standard filtered back-projection (FBP) and also processed to generate interaction-free coronary motion-compensated back-projection reconstructions (MCR). Each coronary artery from standard FBP and MCR images was viewed side-by-side by a reader blinded to the reconstruction technique, who graded severity of motion artifact by segment (scale 0-5, with 3 as the threshold for diagnostic quality) and to measure signal-to-noise and contrast-to-noise ratios (SNR, CNR). RESULTS: Visualization scores were higher with MCR for all coronary segments, including 14/86 (16%) segments deemed as non-diagnostic on FBP images. SNR (7 ± 2) and CNR (15 ± 8) were unchanged by motion-correction (7 ± 3, p = 0.88 and 15 ± 5, p = 0.94, respectively). CONCLUSIONS: MCR improves the visualization of coronary anatomy on sCTP images without degrading image characteristics. This algorithm is an important step towards the combined assessment of coronary anatomy and myocardial perfusion in a single scan, which will reduce study time, radiation exposure and contrast dose.

Congenital Thoracic Aortic Disease.

Congenital abnormalities of the thoracic aorta encompass a variety of disorders with variable clinical manifestations ranging from asymptomatic to life threatening. A variety of imaging modalities are available for the evaluation of these anomalies with computed tomography (CT) commonly preferred due to its excellent spatial resolution and rapid acquisitions, avoiding the need of general anesthesia or even sedation. We review the embryology, imaging findings, and associations of multiple congenital thoracic aorta malformations with emphasis in the role of CT angiography in the evaluation of these pathologies.

Updated Fleischner Society Guidelines for Managing Incidental Pulmonary Nodules: Common Questions and Challenging Scenarios.

The new guidelines for managing incidental pulmonary nodules published by the Fleischner Society in 2017 reflect an improved understanding of the risk factors and biologic features of lung cancer. Specific topics emphasized in the updated guidelines include a new threshold size for follow-up, the importance of the morphologic features of nodules, accurate nodule measurements, recognition of subsolid components, understanding interval growth or change in nodule morphology, and knowledge of patient risk factors. The updated guidelines enable greater personal flexibility in the decision-making process and encourage individualized management of pulmonary nodules. These factors may introduce new challenges for radiologists, who previously used solely nodule size to make management recommendations. The authors describe eight scenarios that illustrate the challenges potentially encountered when applying the new guidelines to pulmonary nodule management. ©RSNA, 2018.