Systemic inflammation is related to coronary microvascular dysfunction in obese patients without obstructive coronary disease.

BACKGROUND AND AIMS: Obesity, systemic inflammation and changes in the heart functions are associated with increased cardiovascular risk. This study aimed to investigate coronary microvascular dysfunction as an early marker of atherosclerosis in obese patients without any evidence of cardiovascular disease. METHODS AND RESULTS: 86 obese subjects (aged 44 ± 12 years, body mass index (BMI) 41 ± 8 kg m(-2)), without evidence of heart disease, and 48 lean controls were studied using transthoracic Doppler echocardiography for detecting coronary flow reserve (CFR). A value of CFR ≤ 2.5 was considered abnormal. We measured interleukin-6 (IL-6), tumour necrosis factor-α (TNF-α) and adiponectin in all patients. Patients with abnormal CFR underwent coronary multislice computed tomography (MSCT) in order to exclude an epicardial stenosis. CFR in obese subjects was lower than in lean subjects (3.2 ± 0.8 vs. 3.7 ± 0.7, p = 0.02) and was abnormal in 27 (31%) obese patients and in one (2%) control (p < 0.0001). All subjects with abnormal CFR showed no coronary stenosis at MSCT. At multivariable analysis, IL-6 and TNF-α were the only determinants of CFR (p < 0.02 and p < 0.02, respectively). At multivariable logistic regression analysis, IL-6 and TNF-α were the only determinants of CFR ≤ 2.5 (p < 0.03 and p < 0.03, respectively). CONCLUSIONS: CFR is often reduced in obese subjects without clinical evidence of heart disease, suggesting a coronary microvascular impairment. This microvascular dysfunction seems to be related to a chronic inflammation mediated by adipocytokines. Our findings may explain the increased cardiovascular risk in obesity, independently of BMI.

Status of the circle of Willis and intolerance to carotid cross-clamping during carotid endarterectomy.

PURPOSE: During carotid endarterectomy (CEA), an intolerance to the cross-clamping (CC) can occur. The purpose of this study was to evaluate whether preoperative magnetic resonance angiography (MRA) can predict CC intolerance. MATERIAL AND METHODS: Seventy-one patients (57 males, 14 females, mean age 71.8 years, age range 46-86 years) underwent 71 CEA procedures under local anaesthesia. Before CEA, patients underwent an MRA of the Circle of Willis (CoW) and were then classified into three groups: group A consisted of patients with a complete CoW, group B included patients with one agenesia/obstruction in the CoW and group C comprised patients with two or more agenesiae/obstructions in the CoW. The association between the number of anatomical variants in the CoW, corrected for the status of the contralateral carotid artery, and the onset of CC intolerance was evaluated. RESULTS: The prevalence of intolerance to CC was 15.5% (11/71). The Fisher test and logistic regression analysis showed a statistically significant association between the intolerance to CC and two or more agenesiae/obstructions in the CoW (p value < 0.00001 and p < 0.001, respectively). No neurological complications were observed. CONCLUSION: The results of our study showed that two or more agenesiae/obstructions of the CoW identified by MRA were associated with a high risk of intolerance to CC during CEA.

Malpratice claims in cardiology and cardiac surgery: A medico-legal issue.

Medical liability has become a challenge in every physician's modern practice with the consequent loss of the physician's autonomy and an increase in "defensive medicine". From this perspective, the role of Legal Medicine in assessing medical liability has become increasingly specific and a homogenization of the methods of ascertainment is increasingly necessary, since such a process can contribute to strengthening the guarantees in professional liability procedures. Focusing on malpractice claims in the field of cardiology, the complexity of the management of cardiac pathologies and the frequency of severe adverse events implies the importance of a multi-disciplinary approach, together with the application of a shared ascertainment methodology. In particular, it is essential for the forensic pathologist to collaborate with experts in cardio-pathology, cardiology and/or cardiac surgery in cases of alleged medical liability in the cardiologic field and to follow the guidelines which have been produced to assist the expert dealing with deaths reflecting cardiac disease, in order to prevent criticism of case analysis in medico-legal environments and to promote the standardization of the structure of the juridical-legislative medical malpractice lawsuits.

Coronary flow reserve by transthoracic echocardiography predicts epicardial intimal thickening in cardiac allograft vasculopathy.

Cardiac allograft vasculopathy (CAV) is the leading cause of morbidity and mortality in heart transplantation (HT). We sought to investigate the role of coronary flow reserve (CFR) by contrast-enhanced transthoracic echocardiography (CE-TTE) in CAV diagnosis. CAV was defined as maximal intimal thickness (MIT) assessed by intravascular ultrasound (IVUS) > or =0.5 mm. CFR was assessed in the left anterior descending coronary artery in 22 HT recipients at 6 +/- 4 years post-HT. CAV was diagnosed in 10 patients (group A), 12 had normal coronaries (group B). The mean MIT was 0.7 +/- 0.1 mm (range 0.03-1.8). MIT was higher in group A (1.16 +/- 0.3 mm vs. 0.34 +/- 0.07 mm, p < 0.0001). CFR was 3.1 +/- 0.8 in all patients and lower in group A (2.5 +/- 0.6 vs. 3.7 +/- 0.3, p < 0.0001). CFR was inversely related with MIT (r =-0.774, p < 0.0001). A cut point of < or =2.9, identified as optimal by receiver operating characteristics analysis was 100% specific and 80% sensitive (PPV = 100%, NPV = 89%, Accuracy = 91%). CFR assessment by CE-TTE is a novel noninvasive diagnostic tool in the detection of CAV defined as MIT > or =0.5 mm. CFR by CE-TTE may reduce the need for routine IVUS in HT.

Study of endoleaks after endovascular repair by using MDCTA.

PURPOSE: Our purpose was to investigate the multi-detector-row CT angiography (MDCTA) application in endoleak detection. METHODS: Fifty-nine patients that underwent endovascular aneurysm repair (EVAR) of an infrarenal abdominal aortic aneurysm with endoluminal stent graft were retrospectively studied. MDCTA scans were obtained after administration of 110-130 mL of contrast material using a 4-6 mL/sec flow rate. We made unenhanced, arterial (15-20 sec) and delayed (100 sec) acquisitions. For each patient four MDCTA datasets (pre-EVAR, 1, 6, and 12 months follow-up) were obtained. Each examination was studied by two observers. Kappa value was calculated in order to evaluate inter-observer agreement. RESULTS: Twenty-one endoleaks were detected in eighteen patients. Fifteen and eighteen endoleaks were detected by using biphasic arterial CT and biphasic delayed CT respectively (sensitivity of 71.4% and 85.7% respectively). We observed a positive correlation between the presence of endoleak and the increasement in aneurysm size. Interobserver agreement was 88.1% and kappa value was 0.685. CONCLUSIONS: Biphasic CT for endoleak detection is significantly superior to arterial and delayed phases respectively. We observed a good interobserver agreement.

Superior mesenteric artery spontaneous and isolated dissection diagnosed by using MDCTA.

We report the case of a 49-year-old man admitted to our Institute because he suffered acute abdominal pain induced by eating. Sonography don't revealed pathological findings. Then underwent a multi-detector row computed tomography angiography (MDCTA) that revealed an intimal flap separating true and false lumens that was located 2 cm from the origin of the superior mesenteric artery (SMA) and with an extension of 8 cm. Since the dissection was limited without occlusion of the SMA and the mesenteric marginal artery served as a collateral vessel on the distal side of the SMA, the treatment has been conservative. Improved CT technology facilitates the diagnosis of superior mesenteric artery dissection. Prompt diagnosis and treatment result in the lowest mortality rate and minimize the prevalence of intestinal infarction. Only 107 cases (including the present case) of isolated spontaneous SMA dissection without associated aortic dissection were identified from the literature.

Perivascular Fat Density and Contrast Plaque Enhancement: Does a Correlation Exist?

BACKGROUND AND PURPOSE: Inflammatory changes in the fat tissue surrounding the coronary arteries have been associated with coronary artery disease and high-risk vulnerable plaques. Our aim was to investigate possible correlations between the presence and degree of perivascular fat density and a marker of vulnerable carotid plaque, namely contrast plaque enhancement on CTA. MATERIALS AND METHODS: One-hundred patients (76 men, 24 women; mean age, 69 years) who underwent CT angiography for investigation of carotid artery stenosis were retrospectively analyzed. Contrast plaque enhancement and perivascular fat density were measured in 100 carotid arteries, and values were stratified according to symptomatic (ipsilateral-to-cerebrovascular symptoms)/asymptomatic status (carotid artery with the most severe degree of stenosis). Correlation coefficients (Pearson ρ product moment) were calculated between the contrast plaque enhancement and perivascular fat density. The differences among the correlation ρ values were calculated using the Fisher r-to-z transformation. Mann-Whitney analysis was also calculated to test differences between the groups. RESULTS: There was a statistically significant positive correlation between contrast plaque enhancement and perivascular fat density (ρ value = 0.6582, P value = .001). The correlation was stronger for symptomatic rather than asymptomatic patients (ρ value = 0.7052, P value = .001 versus ρ value = 0.4092, P value = .001). CONCLUSIONS: There was a positive association between perivascular fat density and contrast plaque enhancement on CTA. This correlation was stronger for symptomatic rather than asymptomatic patients. Our results suggest that perivascular fat density could be used as an indirect marker of plaque instability.

Multidetector row CT of the brain and carotid artery: a correlative analysis.

AIM: To evaluate the association between types of carotid plaque, the presence of prior ischaemic events detectable with CT, and patient's symptoms. MATERIALS AND METHODS: Between January 2004 and May 2006, 112 patients were evaluated using multidetector row computed tomography angiography (MDCTA) of the carotid arteries and computed tomography (CT) of the brain. Carotid arteries were categorized by evaluating the degree of stenosis according to North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria, the type of plaque, and the presence of plaque ulceration. The brain was assessed via CT for the presence, type, and position of lesions. Chi-square tests, Student's t test, and simple logistic regression analysis were performed and the Cohen kappa test was applied for interobserver variability measurement. RESULTS: The Chi-square test indicated a statistically significant association between the presence of fatty plaques (p=0.005) and CT-detectable lesions in the brain (p=0.004). Moreover, the number of patients with CT-detectable brain lesions was greater in patients with >70% stenosis than in those with <70% stenosis (p=0.007). Logistic regression confirmed the association between fatty plaque and symptoms (p=0.001), between >70% stenosis and symptoms (p=0.041), and an inverse association between calcified plaque and symptoms (p=0.009). CONCLUSION: MDCTA allows adequate evaluation of the type of plaque. The results of the present study indicate that there is an association between cerebral lesions, symptoms, and fatty plaque in the carotid artery. The degree of stenosis also correlated with cerebral lesions and symptoms. According to the obtained data, the type of carotid plaque should be included among primary parameters in the classification of patients' risk class.

High angiotensin II state without cardiac remodeling (Bartter's and Gitelman's syndromes): are angiotensin II type 2 receptors involved?

BACKGROUND/AIMS: While Angiotensin II (Ang II) is a major factor in the development of cardiomyocyte hypertrophy and a pivotal role for Ang II signals via ERK1/2 has been identified, mechanism(s) responsible are still unclear. As Bartter's and Gitelman's syndrome patients (BS/GS) have increased Ang II, and yet normo/hypotension, hyporesponsiveness to pressors and blunted Ang II signaling via type 1 receptors (AT1R), this study assesses BS/GS's left ventricular (LV) mass and structure as well as Ang II induced ERK1/2 phosphorylation compared with essential hypertensive patients (EH) and normotensive healthy subjects (C) to gain insight into Ang II mediated processes. METHODS: Indices of cardiac hypertrophy were determined by M-mode, two-dimensional echo Doppler and ERK phosphorylation by Western blot. RESULTS: None of BS/GS exhibited LV remodelling; LV mass, LV end-diastolic volume and mass/volume ratio were unchanged vs C (60+/-14 g/m2 vs 64+/-12, 64+/-12 ml/m2 vs 60+/-8 and 0.95+/-0.2 vs 1.0+/-0.2, respectively) and reduced vs EH (119+/-15, p<0.001, 78+/-9, p<0.05 and 1.52+/-0.15, p<0.01). Despite BS/GS's higher plasma renin activity and aldosterone and unchanged level of AT1R, Ang II induced ERK1/2 phosphorylation was reduced vs both C and EH: 0.64 d.u.+/-0.08 vs 0.90+/-0.06 in C, p<0.006, and vs 1.45+/-0.07 in EH, p<0.001. CONCLUSION: The data point to a direct cardioremodeling role for Ang II and support a role of Ang II type 2 receptor (AT2R) signaling as involved in the lack of cardiovascular remodeling in BS/GS. However, further studies using more direct approaches to demonstrate the effects of AT2R signaling must be pursued.

Imaging of the endoleak after endovascular aneurysm repair procedure by using multidetector computer tomography angiography.

Abdominal aortic aneurysms (AAA) are an important cause of death in elderly men. Most used treatment options are endovascular aneurysm repair (EVAR) and open surgical repair. After the endovascular stent graft placement, however, several complications may occur and an important complication of EVAR is endoleak formation which occurs in approximately one-fourth of patients. Endoleak represents a blood flow outside the stent graft lumen but within the aneurysm sac. For these reasons, unlike the minimal imaging follow-up that is typically performed after surgical repair, patients undergoing EVAR require a life-long postoperative surveillance imaging. In the last years, with the advent of multidetector-row CT (MDCT) scanners and the use of specific angiographic protocols (multidetector CT angiography, MDCTA), CT imaging became the most commonly used examination for endoleak detection. Moreover, the volume data obtained can be further rendered to generate high quality two-dimensional (2D) and three-dimensional (3D) images, that allow a better distinction between Endoleak type II, III and IV. Purpose of this study was to review and describe MDCTA potentialities in the detection of endoleak after EVAR procedures.

Carotid Plaque CTA Analysis in Symptomatic Subjects with Bilateral Intraparenchymal Hemorrhage: A Preliminary Analysis.

BACKGROUND AND PURPOSE: The presence of IPH is considered the most dangerous feature because it is significantly associated with clinical ipsilateral cerebrovascular events. Our aim was to explore the characterization of plaque with CT in symptomatic subjects with bilateral intraplaque hemorrhage. MATERIALS AND METHODS: Three-hundred-forty-three consecutive patients with recent anterior circulation ischemic events (<2 weeks) and CT of the carotid arteries (performed within 14 days of the cerebrovascular event) evaluated between June 2012 and September 2017 were analyzed for plaque volume composition to identify all subjects with bilateral intraplaque hemorrhage. Plaque volume was semiautomatically measured, and tissue components were classified according to the attenuation values such as the following: calcified (for values of ≥130 HU), mixed (for values of ≥60 and <130 HU), lipid (for values of ≥25 and <60 HU), and intraplaque hemorrhage (for values of <25 HU). Twenty-one subjects (15 men; mean age, 70 ± 11 years; range, 44-87 years) had bilateral intraplaque hemorrhage and were included in the analysis. RESULTS: Volume measurement revealed significantly larger plaques on the symptomatic side compared with the asymptomatic one (mean, 28 ± 9 versus 22 ± 8 mm, P = .007). Intraplaque hemorrhage volume and percentage were also significantly higher in the plaque ipsilateral to the cerebrovascular event (P < .001 and < .001, respectively). The volume of other plaque components did not show a statically significant association except for lipid and lipid + intraplaque hemorrhage percentages (23% versus 18% and 11% versus 15%), which were significantly different between the symptomatic and the asymptomatic sides (.016 and .011, respectively). The intraplaque hemorrhage/lipid ratio was higher on the symptomatic side (0.596 versus 0.171, P = .001). CONCLUSIONS: In patients with bilateral intraplaque hemorrhage and recent ischemic symptoms, the plaque ipsilateral to the symptomatic side has significantly larger volume and a higher percentage of intraplaque hemorrhage compared with the contralateral, asymptomatic side.

Carotid Intraplaque-Hemorrhage Volume and Its Association with Cerebrovascular Events.

BACKGROUND AND PURPOSE: Our aim was to assess the relationship between volume and percentage of intraplaque hemorrhage measured using CT and the occurrence of cerebrovascular events at the time of CT. MATERIALS AND METHODS: One-hundred-twenty-three consecutive subjects (246 carotid arteries) with a mean age of 69 years who underwent CTA were included in this retrospective study. Plaque volume of components and subcomponents (including intraplaque hemorrhage volume) was quantified with dedicated software. RESULTS: Forty-six arteries were excluded because no plaque was identified. In the remaining 200 carotid arteries, a statistically significant difference was found between presentation with cerebrovascular events and lipid volume (P = .002), intraplaque hemorrhage volume (P = .002), percentage of lipid (P = .002), percentage of calcium (P = .001), percentage of intraplaque hemorrhage (P = .001), percentage of lipid-intraplaque hemorrhage (P = .001), and intraplaque hemorrhage/lipid ratio (P = .001). The highest receiver operating characteristic area under the curve was obtained with the intraplaque hemorrhage volume with a value of 0.793 (P = .001), percentage of intraplaque hemorrhage with an area under the curve of 0.812 (P = .001), and the intraplaque hemorrhage/lipid ratio with an area under the curve value of 0.811 (P = .001). CONCLUSIONS: Results of our study suggest that Hounsfield unit values <25 have a statistically significant association with the presence of cerebrovascular events and that the ratio intraplaque hemorrhage/lipid volume represents a strong parameter for the association of cerebrovascular events.

Accessory renal artery stenosis and hypertension: are these correlated? Evaluation using multidetector-row computed tomographic angiography.

BACKGROUND: Renal artery stenosis may produce hypertension, and this condition is referred to as renovascular hypertension (RVH). PURPOSE: To evaluate, by using multidetector-row spiral computed tomographic angiography (MDCTA), whether a relationship between accessory renal artery stenosis and hypertension may be hypothesized. MATERIAL AND METHODS: 214 patients (142 males, 72 females; mean age 66 years) who had previously undergone an MDCTA to study the abdominal vasculature were retrospectively studied. Patients with renal artery stenosis (RAS) were excluded from this analysis. The patients were studied by means of a four-detector-row CT, and scans were obtained after intravenous bolus administration of 110-140 ml of a nonionic contrast material with a 3-6 ml/s flow rate. As a second step, by means of statistical analysis, hypertension data were compared with findings of accessory artery stenosis. Two radiologists first independently reviewed the MDCTA images and then, in case of disagreement, in consensus. Interobserver agreement was calculated for all measurements. RESULTS: The overall number of detected accessory renal arteries was 74 in 56 of the 214 patients. Accessory renal artery stenosis was detected in 21 of the 56 patients. There was a difference in the prevalence of hypertension between patients with (n = 21) and without (n = 35) accessory renal artery stenosis (P = 0.0187). Interobserver agreement was good (kappa value 0.733). CONCLUSION: Any statistical association between the presence of accessory renal artery stenosis and hypertension could not be disclosed. However, accessory renal artery stenosis, detected by MDCTA, is an important pathological sign that the radiologist has to assess in the light of its possible association with hypertension.

Diagnostic sensitivity of multidetector-row spiral computed tomography angiography in the evaluation of type-II endoleaks and their source: comparison between axial scans and reformatting techniques.

BACKGROUND: After endovascular stent-graft placement, several complications may occur. Retrograde filling of the aneurysm (type-II endoleak) is the most common. PURPOSE: To evaluate the accuracy, image quality, and interobserver agreement of multidetector-row spiral computed tomography angiography (MDCTA) in the diagnosis of type-II endoleak, by using various types of reformatting techniques in comparison to regular axial images. MATERIAL AND METHODS: Twenty-four patients who had had endovascular repair of an infrarenal abdominal aortic aneurysm with stent graft were retrospectively studied. In 12 of 24 patients, a type-II endoleak was found. CT scans were obtained after intravenous administration of 130 ml of nonionic contrast material using a 4-6-ml/s flow rate. All patients were investigated with axial scans, multiplanar reconstruction (MPR), maximum intensity projection (MIP), shaded-surface display (SSD), and volume-rendering (VR) techniques. For each patient and for each reconstruction method, the image quality of the scans was scored as 0 for bad quality, 1 for poor quality, 2 for good quality, and 3 for excellent quality images. Two radiologists reviewed the CT images independently. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each reconstruction method, with the axial images as the reference method. Interobserver agreement and kappa value were also recorded. RESULTS: MPR showed the highest sensitivity (83% and 67% for observers 1 and 2, respectively), PPV (91% and 80% for observers 1 and 2, respectively), and NPV (85% and 71% for observers 1 and 2, respectively), whereas VR showed the highest specificity (92% for both observer 1 and 2). CONCLUSION: Reformatting techniques provide good-quality images; nevertheless, their efficacy in the study of type-II endoleak was found to be suboptimal in comparison to regular axial images. The MPR technique is probably the best choice in conjunction with axial images.

CT Attenuation Analysis of Carotid Intraplaque Hemorrhage.

BACKGROUND AND PURPOSE: Intraplaque hemorrhage is considered a leading parameter of carotid plaque vulnerability. Our purpose was to assess the CT characteristics of intraplaque hemorrhage with histopathologic correlation to identify features that allow for confirming or ruling out the intraplaque hemorrhage. MATERIALS AND METHODS: This retrospective study included 91 patients (67 men; median age, 65 ± 7 years; age range, 41-83 years) who underwent CT angiography and carotid endarterectomy from March 2010 to May 2013. Histopathologic analysis was performed for the tissue characterization and identification of intraplaque hemorrhage. Two observers assessed the plaque's attenuation values by using an ROI (≥ 1 and ≤2 mm2). Receiver operating characteristic curve, Mann-Whitney, and Wilcoxon analyses were performed. RESULTS: A total of 169 slices were assessed (59 intraplaque hemorrhage, 63 lipid-rich necrotic core, and 47 fibrous); the average values of the intraplaque hemorrhage, lipid-rich necrotic core, and fibrous tissue were 17.475 Hounsfield units (HU) and 18.407 HU, 39.476 HU and 48.048 HU, and 91.66 HU and 93.128 HU, respectively, before and after the administration of contrast medium. The Mann-Whitney test showed a statistically significant difference of HU values both in basal and after the administration of contrast material phase. Receiver operating characteristic analysis showed a statistical association between intraplaque hemorrhage and low HU values, and a threshold of 25 HU demonstrated the presence of intraplaque hemorrhage with a sensitivity and specificity of 93.22% and 92.73%, respectively. The Wilcoxon test showed that the attenuation of the plaque before and after administration of contrast material is different (intraplaque hemorrhage, lipid-rich necrotic core, and fibrous tissue had P values of .006, .0001, and .018, respectively). CONCLUSIONS: The results of this preliminary study suggest that CT can be used to identify the presence of intraplaque hemorrhage according to the attenuation. A threshold of 25 HU in the volume acquired after the administration of contrast medium is associated with an optimal sensitivity and specificity. Special care should be given to the correct identification of the ROI.

Efficacy and sensitivity of axial scans and different reconstruction methods in the study of the ulcerated carotid plaque using multidetector-row CT angiography: comparison with surgical results.

BACKGROUND AND PURPOSE: Carotid plaque ulceration is an important risk factor for stroke, and its diagnosis may be very important to plan a correct therapeutic approach. We hypothesized that axial scans and various reconstruction methods could have different specificity and sensitivity in the study of plaque ulceration. The object of this study was to evaluate their role and diagnostic efficacy in patients with carotid plaque complicated by ulceration through the comparison with surgical results. MATERIALS AND METHODS: From January 2004 to November 2005, 109 patients who underwent a carotid endarterectomy were analyzed using CT angiography for a total of 218 carotid arteries. We assessed every carotid for the presence of ulcerations. For each patient axial image, maximum intensity projection (MIP), multiplanar reconstruction (MPR), shaded surface display (SSD), and volume rendering (VR) reconstructions were obtained. RESULTS: Multidetector row CT angiography (MDCT) found 32 ulcerations; surgical confirmation underlined an overall 93.9% sensitivity (95% confidence interval [CI] 0.858-1.021), and a 98.7% specificity (95% CI, 0.961-1.012). Axial scans and volume rendering images demonstrated the highest sensitivity (90.9% and 87.9%, respectively); SSD, on the contrary, showed the lowest sensitivity: 39.4% (95% CI sensitivity, 0.227-0.561). CONCLUSION: Axial scans plus VR reconstruction techniques offer superior depiction of carotid plaque ulceration compared with MIP, MPR, and SSD.

CT and ultrasound in the study of ulcerated carotid plaque compared with surgical results: potentialities and advantages of multidetector row CT angiography.

BACKGROUND AND PURPOSE: Ulceration is a severe complication of carotid plaque. The purpose of this study was to evaluate the role and the diagnostic efficacy of multidetector row CT angiography (MDCTA) and ultrasound (US) echo color Doppler (US-ECD) in the study of patients with carotid plaque complicated by ulceration through the comparison with the surgical observation. MATERIALS AND METHODS: From January 2004 to October 2005, 237 patients, for a total of 474 carotid arteries, studied at first with color Doppler US, were analyzed using CT angiography. A total of 103 patients underwent a carotid endarterectomy. We analyzed stenosis degree, plaque composition, and presence of ulcerations. In a second phase, the data were compared with the surgical results when the MDCTA indicated surgical intervention. RESULTS: MDCTA found 31 ulcerations; the surgical confirmation underlined a 93.75% sensitivity and a 98.59% specificity. US-ECD performances were 37.5% and 91.5% for sensitivity and specificity, respectively. The number of patients who showed plaque ulcerations increased with the severity of stenosis. Furthermore, ulcerations of the carotid plaque occurred more often proximal than distal to the point of maximum stenosis, and this trend increased with the severity of the stenosis. We also determined that fatty plaques were more likely to be affected by ulcerations. CONCLUSIONS: The results of our study suggest that MDCTA detects with higher sensitivity and specificity the presence of ulcerated plaque compared with US-ECD, which has been demonstrated to be less effective in this evaluation. Considering the high MDCTA sensitivity and specificity for detection of plaque ulceration, we therefore recommend MDCTA as a useful step for correct presurgical planning.

[Two-years therapy with bosentan of pulmonary arterial hypertension related to connective tissue diseases]. / Due anni di terapia con bosentan dell'ipertensione arteriosa polmonare associata a connettiviti sistemiche.

OBJECTIVE: Pulmonary arterial hypertension (PAH) is a rare but severe complication of connective tissue diseases (CTD), with a negative impact on patients survival. Bosentan, a receptor antagonist of endothelin, has been proved effective for the treatment of PAH. The aim of this study was to evaluate the effects and the safety of bosentan administered for 2 years in a group of patients with PAH related to CTD. METHODS: Twelve patients with PAH related to systemic sclerosis (8 cases), SLE (2 cases), mixed connective tissue disease (1 case) and polymyositis (1 case) attending the Rheumatology Unit of Padova University were treated with bosentan for two years. Distance walked in 6 minutes, right ventricular systolic pressure and mean pulmonary artery pressure estimated by doppler echocardiography were evaluated at baseline and after 6, 12, 18 and 24 months of treatment. Safety was assessed by laboratory tests performed every two months. RESULTS: During bosentan treatment, a significant decrease of right ventricular systolic pressure was observed after 6, 12, 18 and 24 months in comparison to baseline, whereas pulmonary artery mean pressure remained unchanged. Distance walked in 6 minutes slightly increased after 6 and 12 months, but significantly decreased after 18 and 24 months, mostly because complications of CTD which compromised the ability to walk arose in 4 patients. Adverse events related to bosentan were observed in 2 cases. CONCLUSIONS: Bosentan has been demonstrated effective in reducing pulmonary arterial pressure in a two-year period of treatment. Exercise capacity improved only in the first year of therapy and worsened thereafter, suggesting the opportunity of a combination therapy for a long-term treatment of PAH related to CTD.

Effects of acute myocardial ischemia on intramyocardial contraction heterogeneity: A study performed with ultrasound integrated backscatter during transesophageal atrial pacing.

BACKGROUND: [corrected] Subendocardial thickening is greater than subepicardial thickening and acute myocardial ischemia mainly impairs the former. Integrated backscatter cyclic variations (IBScv) reflect regional myocardial contractility and are blunted during myocardial ischemia. We hypothesized that stress-induced myocardial ischemia mainly affects subendocardial IBScv. METHODS AND RESULTS: Multiplane transesophageal echocardiography and simultaneous atrial pacing were performed in 12 patients without coronary artery disease (CAD) and in 25 with significant CAD. In a transgastric 2-chamber view, we calculated IBScv in subendocardium and subepicardium and a heterogeneity index, both at rest and at peak-pacing. In 27 myocardial segments of patients with normal coronary arteries, and in 16 myocardial segments supplied by coronary artery without significant stenosis in patients with CAD, there was a transmural gradient of IBScv at rest and the heterogeneity index did not change during all the protocol steps. In the 53 myocardial segments related to a significantly narrowed coronary artery, the transmural gradient of IBScv, present at rest, significantly decreased at peak-pacing because of subendocardial blunting, but promptly recovered 5 seconds after pacing interruption. Moreover, the myocardial thickening at rest and peak pacing correlated with the subendocardial IBScv behavior and not with the subepicardial one. CONCLUSIONS: IBScv are greater in the subendocardium than in the subepicardium. Atrial pacing stress test does not affect IBScv in segments supplied by nonstenotic coronary arteries, whereas it affects segments supplied by diseased coronary arteries, blunting exclusively subendocardial IBScv. Heterogeneity of IBScv intramyocardial changes caused by stress-induced ischemia must be taken into account when using IBScv for investigating myocardial ischemia.

Contrast-enhanced transthoracic second harmonic echo Doppler with adenosine: a noninvasive, rapid and effective method for coronary flow reserve assessment.

OBJECTIVES: The purpose of this study is to evaluate the feasibility in detecting blood flow in the left anterior descending coronary artery (LAD) using transthoracic color Doppler (CD) imaging (in both second harmonic and fundamental mode) along with contrast enhancement and to verify if this new noninvasive method along with adenosine is safe, rapid and effective in assessing coronary flow reserve (CFR). BACKGROUND: Feasibility of contrast-enhanced transthoracic Doppler recording (in both second harmonic and fundamental mode) of blood flow velocity in the LAD has not been assessed. Adenosine has a greater vasodilator potency and more favorable kinetics than dipyridamole and thus it can be more suitable for assessing CFR in conjunction with this method. METHODS: Sixty-one patients with angiographically patent LAD underwent CD (both in fundamental and harmonic mode) as well as color-guided pulsed wave (PW) Doppler recording of blood flow velocity in the distal LAD before and after intravenous contrast injection. A second group of patients (n = 77), undergoing coronary angiography, was submitted to transthoracic contrast-enhanced PW Doppler recording of blood flow velocity in the LAD using harmonic CD as a guide, at rest and during adenosine-induced hyperemia. RESULTS: Harmonic CD along with echo contrast consistently improved blood flow detection in the LAD; the success rate in detecting flow of optimal quality was 88% with this approach, whereas it was 11% and 16% with CD in fundamental mode, respectively, before and after contrast. Pulsed wave Doppler results paralleled those of harmonic CD (p < 0.001 contrast harmonic vs. fundamental). In the second group of patients coronary angiography revealed 0% to <40% stenosis in 24 patients (group I), > or =40% to < or =75% in 17 patients (group II) and >75% stenosis in 34 patients (group III). There was a significant difference in CFR among the three groups of patients; CFR for peak diastolic velocity was (mean +/- SD): 2.88+/-0.7 (group I), 2.09+/-0.5 (group II) and 1.51+/-0.5 cm/s (group II) (p < 0.05 group I vs. both group II and group III; p < 0.05 group II vs. group III). The whole examination took less than 10 min. CONCLUSIONS: Contrast-enhanced second harmonic Doppler recording of blood velocity in the LAD is highly feasible and in combination with adenosine it is a rapid, safe and effective method for assessing CFR ratio.