Color doppler ultrasound for diagnosis of testicular carcinoma: A comparison with gold standard histopathology.

Introduction: Testicular carcinoma is the most common cancer among males aged 15-34 years. The known risk factors for testicular cancer include undescended testis (cryptorchidism), testicular dysfunction, perinatal factors and prior history of cancer in one testis. We aimed to determine the diagnostic accuracy of color doppler ultrasound in diagnosis of testicular carcinoma using histopathology as GOLD STANDARD. Method: ology: A cross sectional study was conducted from July 2015 to Feb 2016 at the Department of Radiology, Jinnah Post Graduate Medical Center, Karachi. 311 subjects were selected through inpatient/outpatient or emergency department. Patients were evaluated for testicular carcinoma by color doppler ultrasound on Toshiba nemio. Finding of color doppler ultrasound was compared with histopathology. True positive, true negative, false positive, false negative as per operational definition was determined. Results: Mean age of the patients of the study was 41.76 ± 8.11 (30-50) and mean and SD of Duration of symptoms was 5.5 ± 3.5 (4-15) months. Of 175(56.27%) subjects diagnosed as testicular carcinoma on CDUS, only 160(48.55%) were subsequently found to have testicular carcinoma. sensitivity of CDUS in diagnosing scrotal diseases was 88.8% while specificity was 78.1%. Conclusion: We conclude that CDUS is an excellent, safe, and reliable method for evaluating patients with testicular carcinoma. It helps to improve patient's management, especially by preventing unnecessary surgical exploration. It is also convenient and easy to perform. But it has its own limitations, and requires adequate expertise and experience. Its results are also equipment dependent.

To Determine the Diagnostic Accuracy of Diffusion-Weighted Imaging in the Diagnosis of Prostate Carcinoma Taking Histopathology As the Gold Standard.

Introduction Carcinoma of the prostate is the most common malignancy among males. Serum prostate-specific antigen (PSA) levels and digital rectal examination (DRE) are the initial investigations for the detection of prostate cancer. In recent years, some investigators have used color Doppler ultrasound and diffusion-weighted imaging (DWI) for the diagnosis of prostate cancer and avoided invasive and painful investigation, i.e., biopsy. The purpose of the study is to determine the validity of DWI in detecting prostatic cancer taking histopathology as the gold standard. Material and methods This cross-sectional study was conducted prospectively in the radiology department of a tertiary care hospital from January 1, 2019, to December 31, 2020. This study was approved by the Departmental Research Committee. A total of 272 male patients were included in our study who have elevated PSA levels (>4.0 ng/ml) with symptoms of hematuria and urinary retention. All included subjects were sent to the radiology department for DWI imaging. The DWI imaging was analyzed for prostate cancer and the results were correlated with histopathological diagnosis. Results The average age of patients was 50.28±9.93 years. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of DWI in the diagnoses of prostate cancer were 86.7%, 87.8%, 75.8%, 93.8%, and 87.5%, respectively. Conclusion DWI is an informative and non-invasive imaging modality with high diagnostic accuracy for the diagnosis of prostate carcinoma.

Clinical Utility and Prognostic Value of Right Atrial Function in Pulmonary Hypertension.

Background Although right atrial (RA) enlargement is an established marker for adverse outcomes, the prognostic importance of RA dysfunction independent of RA size in pulmonary arterial hypertension is not known. Methods and Results Study subjects with pulmonary arterial hypertension were prospectively enrolled from 2010 to 2014. RA function was measured using RA speckle-tracking longitudinal strain and strain rate (SR) during each phase of the cardiac cycle: (1) RA reservoir (peak longitudinal strain, peak systolic SR), (2) RA conduit (peak early diastolic SR), and (3) RA active contraction (peak active contraction strain, peak contraction SR). The primary outcome was a composite of time to hospitalization or death assessed on follow-up. A total of 63 subjects had complete echocardiographic data. Of these, 91% were females, and the mean age was 58±12 years. During the follow-up period (range: 1-58 months), 39 were hospitalized or had died. After multivariable adjustment for age, sex, and left atrial size, peak longitudinal strain, peak active contraction strain, and peak early diastolic SR were significantly associated with increased risk of the composite outcome ( P=0.0005, P=0.0167, and P=0.0054, respectively). Conclusions RA dysfunction independently predicts mortality and hospitalizations in patients with pulmonary arterial hypertension.

Clinical and Echocardiographic Predictors of Outcomes in Patients With Pulmonary Hypertension.

In pulmonary hypertension (PH), measurement of various echocardiographic parameters that assess right heart function is recommended by current clinical guidelines. Limited data exists on the combined value of clinical and echocardiographic parameters in precapillary PH in the modern era of therapy. We examined the association of clinical and echocardiographic parameters with surrogate outcomes (6-minute walk distance) and hard outcomes (hospitalization or death) in patients with precapillary PH. A cohort of patients with an established diagnosis of precapillary PH who underwent transthoracic echocardiography at the Duke Echo Lab were prospectively enrolled from 2010 to 2014. Univariable and multivariable models were constructed to examine the relation of clinical and echocardiographic parameters with surrogate and hard outcomes. Of the 98 patients with analyzable echocardiograms with good image quality, 85 were woman, mean age was 59.4 years, and 47% had ≥World Health Organization functional class III symptoms. The mean 6-minute walk distance was 354(±132) m, and 83% were on pulmonary arterial hypertension medications. At 24 months, the cumulative incidence rate for hospitalization or death was 47%. In univariable analyses, the REVEAL (Registry to Evaluate Early and Long-term PAH Disease Management) risk score (HR 1.72 per 1 SD (2.81) increment, 95% CI 1.34, 2.22; p=<0.001), RV global longitudinal strain (RVGLS) (HR 1.54 per 1 SD (5.31) worsening, 95% CI , 2.12; p=0.008) and log-2 NT proBNP (HR 1.43 per 1-fold increase, 95% CI 1.25, 1.63; p=<0.001) were significantly associated with hospitalization or death.

Elusive left ventricular thrombus: Diagnostic role of cardiac magnetic resonance imaging-A case report and review of the literature.

Identification of left ventricular mural thrombus (LVT) may be challenging depending on the imaging modality used. We present a case of LVT which was incidentally identified on cine cardiac magnetic resonance imaging (CMR). A sixty-four years old female presented with worsening dyspnea on exertion with troponin elevation. Transthoracic echocardiography (TTE) revealed a dilated left ventricle (LV) and ejection fraction (EF 30%) with thinning and akinesis of inferior/inferolateral wall was noted with basal and mid inferior wall aneurysm, and thrombus was not identified. CMR done to ascertain viability of myocardium revealed a mural thrombus within basal inferior aneurysm. This was not visualized on transthoracic echocardiography with and without use of contrast. She underwent coronary artery bypass grafting, bioprosthetic mitral valve replacement, resection and plication of posterior left ventricular aneurysm with removal of mural thrombus, and was started on anticoagulation with warfarin post-operatively for the apical thrombi. Cardiac magnetic resonance is a well suited imaging modality in detecting LVT due to its high resolution images and is more reproducible than TTE. In our patient, conventional TTE despite administration of echo-contrast agents failed to diagnose the presence of LVT in the basal inferior aneurysm as well as the apical thrombi. Delayed-enhancement CMR provides the greatest sensitivity for detection of left ventricular thrombus, superior to standard transthoracic and contrast-enhanced transthoracic echocardiography.

Dehiscence and embolization of CorMatrix tricuspid valve replacement in the setting of infective endocarditis: a case report.

BACKGROUND: Due to increased morbidity and mortality, prosthetic valve infective endocarditis (IE) with dehiscence requires urgent intervention. Early identification and therapy may prevent embolization. CASE SUMMARY: A 27-year-old Caucasian woman with a history of hepatitis C, intravenous drug abuse, and tricuspid valve (TV) replacement was admitted for recurrent IE. She was found to have bacteraemia and fungaemia, and empiric antibiotics were initiated. Transthoracic echocardiogram (TTE) revealed a mobile 'mass' on the TV and dehiscence. The patient developed cardiogenic shock and repeat TTE showed a ruptured TV and absence of the 'mass', suspicious of embolization. She underwent emergent surgery with TV replacement using a Biocor valve and retrieval of the old CorMatrix valve found in the right mid pulmonary artery (PA). The patient was successfully weaned off inotropic agents and completed a prolonged course of antibiotics and anti-fungals. DISCUSSION: The multi-disciplinary decision on timing of surgical intervention was challenging, especially due to ongoing mycobacterial infection that increased operative risk. With clinical deterioration, urgent surgery was performed revealing an embolized prosthetic valve in the PA. New surgical options for TV replacement in IE with extracellular-based material have shown promising outcomes with little reported data of long term complications. This case demonstrates a rare occurrence of embolized CorMatrix TV and highlights the challenge in timing of appropriate surgical intervention in a septic patient with thrombocytopenia.

Cardiomyopathy Related to a Weight Loss Supplement: A Case Report and Review of Literature.

There are various etiologies of dilated cardiomyopathy. However, in young patients without a strong family history of cardiovascular disease, alcohol or drug abuse, viral infections, and absence of endocrine and metabolic abnormalities, ischemia is an unlikely cause. We present an interesting case of a young female without traditional risk factors who developed dilated cardiomyopathy following administration of a weight loss supplement xenadrine and had resolution of symptoms after discontinuation of the supplement.

Clinical and echocardiographic predictors of mortality in acute pulmonary embolism.

PURPOSE: The aim of this study was to evaluate the utility of adding quantitative assessments of cardiac function from echocardiography to clinical factors in predicting the outcome of patients with acute pulmonary embolism (PE). METHODS: Patients with a diagnosis of acute PE, based on a positive ventilation perfusion scan or computed tomography (CT) chest angiogram, were identified using the Duke University Hospital Database. Of these, 69 had echocardiograms within 24-48 h of the diagnosis that were suitable for offline analysis. Clinical features that were analyzed included age, gender, body mass index, vital signs and comorbidities. Echocardiographic parameters that were analyzed included left ventricular (LV) ejection fraction (EF), regional, free wall and global RV speckle-tracking strain, RV fraction area change (RVFAC), Tricuspid Annular Plane Systolic Excursion (TAPSE), pulmonary artery acceleration time (PAAT) and RV myocardial performance (Tei) index. Univariable and multivariable regression statistical analysis models were used. RESULTS: Out of 69 patients with acute PE, the median age was 55 and 48 % were female. The median body mass index (BMI) was 27 kg/m2. Twenty-nine percent of the cohort had a history of cancer, with a significant increase in cancer prevalence in non-survivors (57 % vs 29 %, p = 0.02). Clinical parameters including heart rate, respiratory rate, troponin T level, active malignancy, hypertension and COPD were higher among non-survivors when compared to survivors (p ≤ 0.05). Using univariable analysis, NYHA class III symptoms, hypoxemia on presentation, tachycardia, tachypnea, elevation in Troponin T, absence of hypertension, active malignancy and chronic obstructive pulmonary disease (COPD) were increased in non-survivors compared to survivors (p ≤ 0.05). In multivariable models, RV Tei Index, global and free (lateral) wall RVLS were found to be negatively associated with survival probability after adjusting for age, gender and systolic blood pressure (p ≤ 0.05). CONCLUSION: The addition of echocardiographic assessment of RV function to clinical parameters improved the prediction of outcomes for patients with acute PE. Larger studies are needed to validate these findings.

Incidental finding of aberrant mitral valve chorda during a transesophageal echocardiography evaluation for suspected endocarditis.

Congenital defects involving anomalous chordae of the mitral valve with attachment in the left atrium are an extremely rare finding and may result in valvular insufficiency. Few cases have been reported in the literature with multiple variations in anatomical location and insertion of aberrant chordae within the left ventricle and left atrium. Reported cases have presented with cardiovascular symptoms leading to diagnosis of anomalous mitral valve chordae. We present a case of a young female in which an aberrant mitral valve chorda was an incidental finding on transesophageal echocardiography.

Predictors and progression of aortic stenosis in patients with preserved left ventricular ejection fraction.

We aimed to characterize the hemodynamic progression of aortic stenosis (AS) in a contemporary unselected cohort of patients with preserved left ventricular ejection fraction. Current guidelines recommend echocardiographic surveillance of hemodynamic progression. However, limited data exist on the expected rate of progression and whether clinical variables are associated with accelerated progression in contemporarily managed patients with AS. We conducted a retrospective analysis of patients presenting with AS and explored the trajectory of AS mean gradient over time using generalized estimating equations and fit a longitudinal linear regression model with adjustment for baseline clinical variables. A total of 1,558 patients (median age 72; interquartile range 65 to 79) having mild (n = 982), moderate (n = 363), or severe AS (n = 213) were included. In patients with mild AS at baseline (n = 983), 303 (31%) had progressed to moderate/severe AS/AVR within 5 years of the index echo. In patients with moderate AS, 159 of 363 (44%) had progressed to severe AS/AVR within 2 years of the index echo. The annual change in mean gradient was dependent on baseline AS severity. Average annual increases in mean gradient were 6.8% (95% confidence interval 6.0 to 7.6) and 7.1% (95% confidence interval 4.8 to 9.3) in patients with mild and moderate AS, respectively. In the subset of patients with mild AS at baseline, age (p = 0.0310) and gender (p = 0.0270) had significant interaction with change in mean gradient over time. In patients with moderate AS, age (p <0.0001), gender (p = 0.0346), renal dysfunction (p = 0.0036), and hyperlipidemia (p = 0.0010) demonstrated significant interaction with change in mean gradient over time. In conclusion, although average disease progression was slower than previously reported, a significant proportion of patients with mild and moderate AS progressed to higher grades within the currently recommended time windows for echocardiographic follow-up.

Percutaneous patent foramen ovale closure using Helex and Amplatzer devices without intraprocedural echocardiographic guidance.

OBJECTIVES: We compared procedural outcomes of patients undergoing patent foramen ovale (PFO) closure using Helex (W.L. Gore & Assoc., Flagstaff, AZ, USA) and Amplatzer (AGA Medical Corp., Plymouth, MN, USA) devices using intracardiac echocardiographic (ICE) versus fluoroscopic-only guidance. BACKGROUND: Use of transesophageal or ICE to guide PFO closure is associated with patient discomfort and cost. While fluoroscopic guidance of septal closure using Amplatzer is well established, there is no published experience for Helex. METHODS: We performed a single-center, single-operator analysis of patients undergoing PFO closure using Helex or Amplatzer occluders. Device and guidance strategy was selected by the operator. RESULTS: Of the 132 PFO patients, 23 were closed with Helex, and 109 were closed with Amplatzer (103 Cribriforms, 4 PFO occluders, and 2 atrial septal occluders). Fluoroscopic guidance was used for 15 (65%) Helex and 102 (94%) Amplatzer cases. Successful device placement was achieved in all patients with a 1.5% complication rate (1 arrhythmia and 1 device embolization). Procedure time was shorter for fluoroscopic guidance of Amplatzer cases compared to ICE guidance (P = 0.023), and for Amplatzer versus Helex cases (P = 0.0004). Among the Helex cases, there were no differences in procedure or fluoroscopy time comparing ICE to fluoroscopic guidance. There was no residual shunting by transthoracic echocardiographic bubble study in 93% of Helex and 95% of Amplatzer cases at 6 months. CONCLUSIONS: Use of right atrial angiography and fluoroscopic-only guidance for PFO closure using Helex and Amplatzer devices provides an efficient alternative to ICE guidance. While procedure and fluoroscopy times were significantly shorter for Amplatzer versus Helex cases, these times were similar for Helex comparing fluoroscopy versus ICE guidance.