Right ventricular ejection fraction derived from intraoperative three-dimensional transesophageal echocardiography versus cardiac magnetic resonance imaging.

PURPOSE: Right ventricle (RV) assessment is critical during cardiac surgery. Traditional assessment consists of visual estimation and measurement of validated parameters. Cardiac magnetic resonance imaging (cMRI) is the gold standard for RV analysis, and transthoracic three-dimensional (3D) echocardiography is validated against this. We aimed to show that intraoperative 3D transesophageal echocardiography (TEE) RV assessment is feasible and can produce results that correlate with cMRI. METHODS: We recruited cardiac surgery patients who underwent cMRI within the preceding twelve preoperative months. An anesthetic protocol was followed pre-sternotomy and a 3D RV data set was acquired. We used TOMTEC 4D RV-Function to derive RV end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF). We compared these data with the corresponding MRI values. RESULTS: Twenty-five patients were included. Transesophageal echocardiography EDV and ESV differed from MRI measurements with a mean bias of -53 mL (95% confidence interval [CI], -80 to 26) and -21 mL (95% CI, -34 to -9). Transesophageal echocardiography EF did not differ significantly, with a mean bias of -4% (95% CI, -8 to 1). Results were unchanged after excluding MRIs older than 180 days. Correlation coefficients for EDV, ESV, and EF were r = 0.85, 0.91, and 0.80, respectively. Interclass correlation coefficients for EDV, ESV, and EF were 0.86, 0.89, and 0.96, respectively. CONCLUSIONS: Intraoperative TEE RV, EDV, and ESV are underestimated relative to cMRI because of analysis, anesthetic, and ventilation factors. The EF showed a low mean difference, and all values showed strong correlation with MRI. Reproducibility and feasibility were excellent and increased use in clinical practice should be considered.

RéSUMé: OBJECTIF: L'évaluation du ventricule droit (VD) est essentielle pendant la chirurgie cardiaque. L'évaluation traditionnelle consiste en une estimation visuelle et une mesure de paramètres validés. L'imagerie par résonance magnétique cardiaque (IRMc) est l'étalon-or pour l'analyse du VD, et l'échocardiographie transthoracique tridimensionnelle (3D) est validée par rapport cette modalité. Notre objectif était de démontrer que l'évaluation peropératoire du VD par l'échocardiographie transœsophagienne (ETO) était faisable et pouvait générer des résultats en corrélation avec l'IRMc. MéTHODE: Nous avons recruté des patient·es de chirurgie cardiaque ayant bénéficié d'une IRMc au cours des douze mois préopératoires précédents. Un protocole anesthésique a été suivi avant la sternotomie et un ensemble de données 3D sur le VD a été acquis. Nous avons utilisé le système TOMTEC 4D RV-Function pour calculer le volume télédiastolique (VTD), le volume télésystolique (VTS) et la fraction d'éjection (FE). Nous avons comparé ces données avec les valeurs correspondantes obtenues à l'IRM. RéSULTATS: Vingt-cinq personnes ont été incluses. Les valeurs de VTD et VTS obtenues à l'échocardiographie transœsophagienne différaient des mesures obtenues par IRM avec un biais moyen de ­53 mL (intervalle de confiance [IC] à 95 %, ­80 à 26) et ­21 mL (IC 95 %, ­34 à ­9). La FE obtenue par échocardiographie transœsophagienne ne différait pas significativement, avec un biais moyen de ­4 % (IC 95 %, ­8 à 1). Les résultats étaient inchangés après l'exclusion des IRM réalisés plus de 180 jours auparavant. Les coefficients de corrélation pour le VTD, le VTS et la FE étaient r = 0,85, 0,91 et 0,80, respectivement. Les coefficients de corrélation interclasse pour le VTD, le VTS et la FE étaient de 0,86, 0,89 et 0,96, respectivement. CONCLUSION: L'ETO peropératoire sous-estime les mesures du VD, du VTD et du VTS par rapport à l'IRMc en raison de facteurs d'analyse, d'anesthésie et de ventilation. La FE a montré une faible différence moyenne, et toutes les valeurs ont montré une forte corrélation avec l'IRM. La reproductibilité et la faisabilité étaient excellentes et une utilisation accrue dans la pratique clinique devrait être envisagée.

Effect of Active Cancer on the Cardiac Phenotype: A Cardiac Magnetic Resonance Imaging-Based Study of Myocardial Tissue Health and Deformation in Patients With Chemotherapy-Naïve Cancer.

Background The overlap between cancer and cardiovascular care continues to expand, with intersections emerging before, during, and following cancer therapies. To date, emphasis has been placed on how cancer therapeutics influence downstream cardiac health. However, whether active malignancy itself influences chamber volumes, function, or overall myocardial tissue health remains uncertain. We sought to perform a comprehensive cardiovascular magnetic resonance-based evaluation of cardiac health in patients with chemotherapy-naïve cancer with comparison with a healthy volunteer population. Methods and Results Three-hundred and eighty-one patients with active breast cancer or lymphoma before cardiotoxic chemotherapy exposure were recruited in addition to 102 healthy volunteers. Both cohorts underwent standardized cardiovascular magnetic resonance imaging with quantification of chamber volumes, ejection fraction, and native myocardial T1. Left ventricular mechanics were incrementally assessed using three-dimensional myocardial deformation analysis, providing global longitudinal, circumferential, radial, and principal peak-systolic strain amplitude and systolic strain rate. The mean age of patients with cancer was 53.8±13.4 years; 79% being women. Despite similar left ventricular ejection fraction, patients with cancer showed smaller chambers, increased strain amplitude, and systolic strain rate in both conventional and principal directions, and elevated native T1 versus sex-matched healthy volunteers. Adjusting for age, sex, hypertension, and diabetes mellitus, the presence of cancer remained associated with these cardiovascular magnetic resonance parameters. Conclusions The presence of cancer is independently associated with alterations in cardiac chamber size, function, and objective markers of tissue health. Dedicated research is warranted to elucidate pathophysiologic mechanisms underlying these findings and to explore their relevance to the management of patients with cancer referred for cardiotoxic therapies.

Hemodynamic Assessment in Bicuspid Aortic Valve Disease and Aortic Dilation: New Insights From Voxel-By-Voxel Analysis of Reverse Flow, Stasis, and Energetics.

Objectives: Clinical management decisions surrounding ascending aorta (AAo) dilation in bicuspid aortic valve (BAV) disease benefit from personalized predictive tools. 4D-flow MRI may provide patient-specific markers reflective of BAV-associated aortopathy. This study aims to explore novel 4D-flow MRI parametric voxel-by-voxel forward flow, reverse flow, kinetic energy and stasis in BAV disease. We hypothesize that novel parametric voxel-by-voxel markers will be associated with aortic dilation and referral for surgery and can enhance our understanding of BAV hemodynamics beyond standard metrics. Methods: A total of 96 subjects (73 BAV patients, 23 healthy controls) underwent MRI scan. Healthy controls had no known cardiovascular disease. Patients were clinically referred for AAo dilation assessment. Indexed diameters were obtained by dividing the aortic diameter by the patient's body surface area. Patients were followed for the occurrence of aortic surgery. 4D-flow analysis was performed by a single observer in five regions: left ventricular outflow tract (LVOT), AAo, arch, proximal descending aorta (PDAo), and distal descending aorta (DDAo). In each region peak velocity, kinetic energy (KE), forward flow (FF), reverse flow (RF), and stasis were measured on a voxel-by-voxel basis. T-tests (or non-parametric equivalent) compared flow parameters between cohorts. Univariate and multivariate analyses explored associations between diameter and parametric voxel-by-voxel parameters. Results: Compared to controls, BAV patients showed reduced stasis (p < 0.01) and increased RF and FF (p < 0.01) throughout the aorta, and KE remained similar. In the AAo, indexed diameter correlated with age (R = 0.326, p = 0.01), FF (R = -0.648, p < 0.001), RF (R = -0.441, p < 0.001), and stasis (R = -0.288, p < 0.05). In multivariate analysis, FF showed a significant inverse association with AAo indexed diameter, independent of age. During a median 179 ± 180 days of follow-up, 23 patients (32%) required aortic surgery. Compared to patients not requiring surgery, they showed increased KE and peak velocity in the proximal aorta (p < 0.01), accompanied by increased RF and reduced stasis throughout the entire aorta (p < 0.01). Conclusion: Novel voxel-by-voxel reverse flow and stasis were altered in BAV patients and are associated with aortic dilation and surgical treatment.

Neural-Network-Based Diagnosis Using 3-Dimensional Myocardial Architecture and Deformation: Demonstration for the Differentiation of Hypertrophic Cardiomyopathy.

The diagnosis of cardiomyopathy states may benefit from machine-learning (ML) based approaches, particularly to distinguish those states with similar phenotypic characteristics. Three-dimensional myocardial deformation analysis (3D-MDA) has been validated to provide standardized descriptors of myocardial architecture and deformation, and may therefore offer appropriate features for the training of ML-based diagnostic tools. We aimed to assess the feasibility of automated disease diagnosis using a neural network trained using 3D-MDA to discriminate hypertrophic cardiomyopathy (HCM) from its mimic states: cardiac amyloidosis (CA), Anderson-Fabry disease (AFD), and hypertensive cardiomyopathy (HTNcm). 3D-MDA data from 163 patients (mean age 53.1 ± 14.8 years; 68 females) with left ventricular hypertrophy (LVH) of known etiology was provided. Source imaging data was from cardiac magnetic resonance (CMR). Clinical diagnoses were as follows: 85 HCM, 30 HTNcm, 30 AFD, and 18 CA. A fully-connected-layer feed-forward neural was trained to distinguish HCM vs. other mimic states. Diagnostic performance was compared to threshold-based assessments of volumetric and strain-based CMR markers, in addition to baseline clinical patient characteristics. Threshold-based measures provided modest performance, the greatest area under the curve (AUC) being 0.70. Global strain parameters exhibited reduced performance, with AUC under 0.64. A neural network trained exclusively from 3D-MDA data achieved an AUC of 0.94 (sensitivity 0.92, specificity 0.90) when performing the same task. This study demonstrates that ML-based diagnosis of cardiomyopathy states performed exclusively from 3D-MDA is feasible and can distinguish HCM from mimic disease states. These findings suggest strong potential for computer-assisted diagnosis in clinical practice.

Application of Lung-Screening Reporting and Data System Versus Pan-Canadian Early Detection of Lung Cancer Nodule Risk Calculation in the Alberta Lung Cancer Screening Study.

BACKGROUND: False-positive scans and resultant needless early recalls can increase harms and reduce cost-effectiveness of low-dose CT (LDCT) lung cancer screening. How LDCT scans are interpreted and classified may impact these metrics. METHODS: The Pan-Canadian Early Detection of Lung Cancer risk calculator was used to determine nodule risk of malignancy on baseline screening LDCTs in the Alberta Lung Cancer Screening Study, which were then classified according to Nodule Risk Classification (NRC) categories and ACR Lung Screening Reporting and Data System (Lung-RADS). Test performance characteristics and early recall rates were compared for each approach. RESULTS: In all, 775 baseline screens were analyzed. After a mean of 763 days (±203) of follow-up, lung cancer was detected in 22 participants (2.8%). No statistically significant differences in sensitivity, specificity, or area under the receiver operator characteristic curve occurred between the NRC and Lung-RADS nodule management approaches. Early recall rates were 9.2% and 9.3% for NRC and Lung-RADS, with the NRC unnecessarily recalling some ground glass nodules, and the Lung-RADS recalling many smaller solid nodules with low risk of malignancy. CONCLUSION: Performances of both the NRC and Lung-RADS in this cohort were very good with a trend to higher sensitivity for the NRC. Early recall rates were less than 10% with each approach, significantly lower than rates using the National Lung Screening Trial cutoffs. Further reductions in early recall rates without compromising sensitivity could be achieved by increasing the NRC threshold to 20% for ground glass nodules or by applying the nodule risk calculator with a 5% threshold to 6- to 10-mm solid nodules under Lung-RADS.

Treatment Decisions in Geriatric Cardiac Lymphoma Facilitated by Serial Cardiac Magnetic Resonance Imaging and Positron Emission Tomography.

A tumour encasing the right coronary was identified on computed tomography pulmonary embolism protocol in an 81-year-old man. Concerns regarding tolerability of chemotherapy in an octogenarian were addressed using cardiac magnetic resonance imaging to monitor a trial of modified-chemotherapy for his primary cardiac B-cell lymphoma. Residual activity on positron emission tomography computed tomography mandated consolidation with radiotherapy to achieve a tumor-free return to health. Despite advanced age, successful therapy in this, the oldest case of primary cardiac lymphoma reported, was facilitated by monitoring treatment effectiveness with advanced cardiac imaging and the use of standardized frailty scores in communicating his appropriate level of robustness for tolerating chemotherapy.

Une tumeur enveloppant l'artère coronaire droite a été décelée lors du protocole de tomodensitométrie à la recherche d'une embolie pulmonaire chez un homme de 81 ans. Les préoccupations relatives à la tolérance à la chimiothérapie chez un octogénaire ont été prises en considération lors de l'imagerie cardiaque par résonance magnétique pour surveiller l'essai d'une chimiothérapie modifiée de son lymphome cardiaque primitif à cellules B. L'activité résiduelle à la tomographie par émission de positons associée à la tomodensitométrie a rendu nécessaire la consolidation par radiothérapie pour un retour à la santé sans tumeur. En dépit de son âge avancé, la réussite du traitement de cet homme, le cas signalé le plus ancien de lymphome cardiaque primitif, a été facilitée par la surveillance de l'efficacité du traitement par une technique avancée d'imagerie cardiaque et l'utilisation des scores de fragilité standardisés pour connaître son degré de robustesse approprié pour tolérer la chimiothérapie.

3D myocardial deformation analysis from cine MRI as a marker of amyloid protein burden in cardiac amyloidosis: validation versus T1 mapping.

Cardiac amyloidosis (CA) is a significant contributor to heart failure with preserved ejection fraction and is appreciating expanding therapeutic options. Non-invasive tools aimed at accurate identification and surveillance of therapeutic response are of immediate and expanding need. While native and post-contrast T1 mapping quantify expansion of the extra-cellular compartment from amyloid protein deposition, 3D strain analysis of non-contrast cine images offers unique advantages relevant to high prevalence of renal insufficiency in this population and reduced dependency on field strength, pulse sequence, and vendor implementation. We aimed to evaluate global and segmental associations between 3D strain and T1 mapping in patients with cardiac amyloidosis. Twenty consecutive patients with confirmed CA were recruited and underwent a standardized cardiovascular magnetic resonance imaging protocol at 3 T including using multi-planar cine imaging and T1 mapping using a shortened modified look-locker inversion recovery sequence. T1 mapping was performed pre- and (when permitted by renal function) post-contrast and measured for segmental T1 values. Spatially-matched 3D strain-based measures were similarly calculated. Mean left ventricular ejection fraction was 61 ± 21% (range 30-73%). Mean global native T1 was 1308 ± 96 ms. Post-contrast T1 and partition coefficient were 558 ± 104 ms and 0.85 ± 0.31, respectively. Global myocardial strain values were 8.1 ± 2.9% in the longitudinal direction, - 9.2 ± 3.4% in the circumferential direction, and 41.7 ± 22.8% in the maximum principal direction. Segmental analyses confirmed relative worsening in T1 values and reductions in strain values in the basal myocardial segments with relative sparing of the apical segments. Significant associations between T1 and strain-based measures were observed globally and segmentally, with the strongest associations found both globally and segmentally in the circumferential and minimum principal directions of deformation. This study identifies strong associations between 3D myocardial strain and T1-mapping based markers of regional amyloid protein deposition. These findings support expanded investigation of myocardial strain as a surrogate marker of response to novel therapeutic strategies in patients with cardiac amyloidosis.

Gastroesophageal reflux therapy is associated with longer survival in patients with idiopathic pulmonary fibrosis.

RATIONALE: Gastroesophageal reflux (GER) is highly prevalent in patients with idiopathic pulmonary fibrosis (IPF). Chronic microaspiration secondary to GER may play a role in the pathogenesis and natural history of IPF. OBJECTIVES: To investigate the relationship between GER-related variables and survival time in patients with IPF. METHODS: Regression analysis was used to investigate the relationship between GER-related variables and survival time in a retrospectively identified cohort of patients with well-characterized IPF from two academic medical centers. MEASUREMENTS AND MAIN RESULTS: Two hundred four patients were identified for inclusion. GER-related variables were common in this cohort: reported symptoms of GER (34%), a history of GER disease (45%), reported use of GER medications (47%), and Nissen fundoplication (5%). These GER-related variables were significantly associated with longer survival time on unadjusted analysis. After adjustment, the use of GER medications was an independent predictor of longer survival time. In addition, the use of gastroesophageal reflux medications was associated with a lower radiologic fibrosis score. These findings were present regardless of center. CONCLUSIONS: The reported use of GER medications is associated with decreased radiologic fibrosis and is an independent predictor of longer survival time in patients with IPF. These findings further support the hypothesis that GER and chronic microaspiration may play important roles in the pathobiology of IPF.

Chest radiographic and CT manifestations of chronic granulomatous disease in adults.

OBJECTIVE: The purpose of this study was to describe the thoracic radiologic findings of chronic granulomatous disease in adults. MATERIALS AND METHODS: We retrospectively analyzed the chest radiographic and CT findings in four adults with chronic granulomatous disease during five episodes of lower respiratory tract infection. RESULTS: Chest radiographic findings included areas of consolidation (60%), diffuse reticulonodular opacities (40%), pleural effusion (20%), and pulmonary artery enlargement (20%). CT findings included areas of consolidation (60%), pulmonary nodules in a random distribution (60%), centrilobular nodules (60%), tree-in-bud opacities (40%), areas of scarring and traction bronchiectasis (100%), emphysematous changes (75%), areas of decreased attenuation and vascularity associated with air trapping on expiratory CT (50%), mediastinal and/or hilar lymphadenopathy (60%), pulmonary artery enlargement (50%), and pleural effusion (20%). Areas of consolidation and nodules were the most prominent findings and at histologic examination were found to be associated with infection or granulomatous inflammation. CONCLUSION: The pulmonary radiologic findings of chronic granulomatous disease include consolidation, nodules, areas of scarring, traction bronchiectasis, emphysema, air trapping, mediastinal and hilar lymphadenopathy, pulmonary artery enlargement, and pleural effusion.