On the quest for hidden ovarian teratomas in therapy-refractory anti-NMDA receptor encephalitis: a case report.

BACKGROUND: Anti-NMDA-receptor (anti-NMDAR) encephalitis is often associated with ovarian teratoma (OT). The best management of anti-NMDAR encephalitis patients with normal imaging studies (pelvic ultrasound/MRI) but clinically high risk of OT (e.g., female, adult, black) is unclear. We report on the surprising diagnostic quest in a young black woman with anti-NMDAR encephalitis, in whom invasive procedures could finally disclose two OTs that were hidden from the initial non-invasive diagnostics. CASE REPORT: The patient presented with a one-week history of psychotic symptoms, developing oro-facial dyskinesia, seizures and coma, eventually requiring mechanical ventilation. NMDA-receptor antibodies were positive in serum and cerebrospinal fluid. Pelvic MRI and transabdominal ultrasound were normal. Exploratory laparoscopy was also unremarkable at first, but due to a suspicious echogenic mass (15 mm) in the right ovary on perioperative transvaginal ultrasound, an ovarian incision was performed which led to the detection of a first OT and its removal via ovarian-preserving cystectomy. Following a severe therapy-refractory clinical course despite aggressive immunotherapy and tumor removal, 6 months later bilateral oophorectomy was performed as ultima ratio, disclosing a second micro-OT (6 mm) in the left ovary. Unfortunately, the patient has not improved clinically yet. CONCLUSIONS: In therapy-refractory anti-NMDAR encephalitis with high risk of OT, small and bilateral OTs hidden from primary non-invasive diagnostics should be considered, which may trigger further invasive diagnostic procedures.

Comprehensive analysis of haemodynamics in patients with physiologically curved prostheses of the ascending aorta.

OBJECTIVES: This is a comprehensive analysis of haemodynamics after valve-sparing aortic root replacement (VSARR) with anatomically curved prosthesis (CP) compared to straight prosthesis (SP) and age-matched volunteers (VOL) using 4D flow MRI (time-resolved three-dimensional magnetic resonance phase-contrast imaging). METHODS: Nine patients with 90° CP, nine patients with SP, and twelve VOL were examined with 4D flow MRI. Analyses included various characteristic anatomical, qualitative and quantitative haemodynamic parameters. RESULTS: Grading of secondary flow patterns was lower in CP patients than in SP patients (P = 0.09) and more comparable to VOL, albeit not reaching statistical significance. However, it was easy to differentiate between VSARR patients and healthy volunteers: Patients more often had angular aortic arches (CP: 89%, SP: 100%; VOL: 17%; P ≤ 0.002), increased average curvature (CP: 0.17/cm [0.15, 0.18]; SP: 0.15/cm [0.14, 0.16]; VOL: 0.14/cm [0.13, 0.16]; P ≤ 0.007; values given as median [interquartile range]), and more secondary flow patterns (CP: 3 [2, 4] SP: 3 [2, 3] VOL: 2 [1, 2]; P < 0.01). Maximum circulation (CP: 142.7 cm2/s [116.1, 187.3]; SP: 101.8 cm2/s [77.7, 132.5]; VOL: 42.8cm2/s [39.3, 65.6]; P ≤ 0.002), maximum helicity density (CP: 9.6 m/s2 [9.3, 23.9]; SP: 9.7 m/s2 [8.6, 12.5]; VOL 4.9 m/s2 [4.2, 7.7]; P ≤ 0.007), and wall shear stress gradient (e.g., proximal ascending aorta CP: 0.97 N/m2 [0.54, 1.07]; SP: 1.08 N/m2 [0.74, 1.24]; VOL: 0.41 N/m2 [0.32, 0.60]; P ≤ 0.01) were increased in patients. One CP patient had a round aortic arch with physiological haemodynamic parameters. CONCLUSIONS: The restoration of physiological aortic configuration and haemodynamics was not fully achieved with the curved prostheses in our study cohort. However, there was a tendency towards improved haemodynamic conditions in the patients with curved prostheses overall but without statistical significance. A single patient with a CP and near-physiological configuration of the thoracic aorta underlines the importance of optimizing postoperative geometric conditions for allowing for physiological haemodynamics and cardiovascular energetics after VSARR.

Prognostic impact of nutritional and inflammation-based risk scores in follicular lymphoma in the era of anti-CD20 targeted treatment strategies.

BACKGROUND: The composition of the tumor microenvironment (TME) is conditioned by immunity and the inflammatory response. Nutritional and inflammation-based risk scores have emerged as relevant predictors of survival outcome across a variety of hematological malignancies. METHODS: In this retrospective multicenter trial, we ascertained the prognostic impact of established nutritional and inflammation-based risk scores [Glasgow Prognostic Score (GPS), C-reactive-protein/albumin ratio (CAR), neutrophil-lymphocyte ratio (NLR), prognostic nutritional index (PNI), and prognostic index (PI)] in 209 eligible patients with histologically confirmed CD20+ follicular lymphoma (FL) of WHO grade 1 (37.3%), 1-2 (16.3%), 2 (26.8%) or 3A (19.8%) admitted to the participating centers between January 2000 and December 2019. Characteristics significantly associated with overall or progression-free survival (OS, PFS) upon univariate analysis were subsequently included in a Cox proportional hazard model. RESULTS: In the study cohort, the median age was 63 (range 22-90 years). The median follow-up period covered 99 months. The GPS and the CAR were identified to predict survival in FL patients. The GPS was the only independent predictor of OS (p < 0.0001; HR 2.773; 95% CI 1.630-4.719) and PFS (p = 0.001; HR 1.995; 95% CI 1.352-2.944) upon multivariate analysis. Additionally, there was frequent occurrence of progression of disease within 24 months (POD24) in FL patients with a calculated GPS of 2. CONCLUSION: The current results indicate that the GPS predicts especially OS in FL patients. Moreover, GPS was found to display disease-specific effects in regard to FL progression. These findings and potential combinations with additional established prognosticators should be further validated within prospective clinical trials.

Serum Troponin T Concentrations Are Frequently Elevated in Advanced Skin Cancer Patients Prior to Immune Checkpoint Inhibitor Therapy: Experience From a Single Tertiary Referral Center.

Immune checkpoint inhibitor (ICI) therapy has revolutionized the treatment of several human malignancies, particularly metastatic skin cancer. However, immune-related myocarditis (irM), an immune-mediated adverse event (irAE), is often fatal. In the absence of a reliable biomarker, measurement of pre-ICI therapy serum troponin concentration has been proposed to identify patients at risk of developing irM, although real-world studies examining this strategy are lacking. Thus, we retrospectively analyzed the case records of all patients who commenced ICI therapy between January 2018 and December 2019 in a single university skin cancer center (n = 121) to (i) determine the incidence of irM, (ii) establish the frequency of pretreatment serum hsTnT elevations, and (iii) to establish whether this identified patients who subsequently developed irM. Only one patient developed irM, resulting in an overall incidence of 0.8%. Pretreatment hsTnT was measured in 47 patients and was elevated in 13 (28%). Elevated serum hsTnT concentrations were associated with chronic renal failure (p = 0.02) and diabetes (p < 0.0002). Pretreatment hsTnT was not elevated in the patient who developed fulminant irM. Pre-immunotherapy serum hsTnT concentrations were often asymptomatically elevated in patients with advanced skin cancer, none of whom subsequently developed irM during ICI therapy. However, large studies are required to assess the positive and negative predictive values of hsTnT for the development of irM. In the meantime, elevated hsTnT concentrations should be investigated before initiation of immunotherapy and closely monitored during early treatment cycles, where the risk of irM is greatest.

Magnetic resonance imaging and ultrasound for prediction of residual tumor size in early breast cancer within the ADAPT subtrials.

BACKGROUND: Prediction of histological tumor size by post-neoadjuvant therapy (NAT) ultrasound and magnetic resonance imaging (MRI) was evaluated in different breast cancer subtypes. METHODS: Imaging was performed after 12-week NAT in patients enrolled into three neoadjuvant WSG ADAPT subtrials. Imaging performance was analyzed for prediction of residual tumor measuring ≤10 mm and summarized using positive (PPV) and negative (NPV) predictive values. RESULTS: A total of 248 and 588 patients had MRI and ultrasound, respectively. Tumor size was over- or underestimated by < 10 mm in 4.4% and 21.8% of patients by MRI and in 10.2% and 15.8% by ultrasound. Overall, NPV (proportion of correctly predicted tumor size ≤10 mm) of MRI and ultrasound was 0.92 and 0.83; PPV (correctly predicted tumor size > 10 mm) was 0.52 and 0.61. MRI demonstrated a higher NPV and lower PPV than ultrasound in hormone receptor (HR)-positive/human epidermal growth factor receptor 2 (HER2)-positive and in HR-/HER2+ tumors. Both methods had a comparable NPV and PPV in HR-/HER2- tumors. CONCLUSIONS: In HR+/HER2+ and HR-/HER2+ breast cancer, MRI is less likely than ultrasound to underestimate while ultrasound is associated with a lower risk to overestimate tumor size. These findings may help to select the most optimal imaging approach for planning surgery after NAT. TRIAL REGISTRATION: Clinicaltrials.gov , NCT01815242 (registered on March 21, 2013), NCT01817452 (registered on March 25, 2013), and NCT01779206 (registered on January 30, 2013).

Prognostic Value of Different CMR-Based Techniques to Assess Left Ventricular Myocardial Strain in Takotsubo Syndrome.

Cardiac magnetic resonance (CMR)-derived left ventricular (LV) global longitudinal strain (GLS) provides incremental prognostic information on various cardiovascular diseases but has not yet been investigated comprehensively in patients with Takotsubo syndrome (TS). This study evaluated the prognostic value of feature tracking (FT) GLS, tissue tracking (TT) GLS, and fast manual long axis strain (LAS) in 147 patients with TS, who underwent CMR at a median of 2 days after admission. Long-term mortality was assessed 3 years after the acute event. In contrast to LV ejection fraction and tissue characteristics, impaired FT-GLS, TT-GLS and fast manual LAS were associated with adverse outcome. The best cutoff points for the prediction of long-term mortality were similar with all three approaches: FT-GLS -11.28%, TT-GLS -11.45%, and fast manual LAS -10.86%. Long-term mortality rates were significantly higher in patients with FT-GLS > -11.28% (25.0% versus 9.8%; p = 0.029), TT-GLS > -11.45% (20.0% versus 5.4%; p = 0.016), and LAS > -10.86% (23.3% versus 6.6%; p = 0.014). However, in multivariable analysis, diabetes mellitus (p = 0.001), atrial fibrillation (p = 0.001), malignancy (p = 0.006), and physical triggers (p = 0.006) outperformed measures of myocardial strain and emerged as the strongest, independent predictors of long-term mortality in TS. In conclusion, CMR-based longitudinal strain provides valuable prognostic information in patients with TS, regardless of the utilized technique of assessment. Long-term mortality, however, is mainly determined by comorbidities.

Histomorphological analysis of false positive PI-RADS 4 and 5 lesions.

INTRODUCTION: Multiparametric magnetic resonance imaging (mpMRI)/ultrasound fusion-guided biopsy, in short "targeted biopsy (TB)", is becoming more attractive as it improves the detection of clinically significant prostate cancer (CaP). The accuracy of fusion-guided biopsies is limited due to false positive radiological findings as well as to histological evidence for cancer in radiologically inconspicuous regions of the prostate. We aimed to analyze histomorphological findings on mpMRI lesions highly suspicious for CaP classified as PI-RADS 4 or PI-RADS 5 (Prostate Imaging - Recording and Data System) but cancer-negative in the biopsy of this region of interest (ROI), and to compare them with findings in radiologically inconspicuous regions. MATERIALS AND METHODS: We re-evaluated prostate biopsies from 57 patients who underwent TB in combination with systematic standard biopsy (SB) from June 2017 to July 2018 at the University Hospital Schleswig Holstein Campus Luebeck. Out of 143 ROIs, 34 PI-RADS 4/5 cancer-negative lesions were identified and subjected to comprehensive histomorphological reevaluation. Contralateral cancer-negative SBs were used as control. Chi-square test was used for statistical analysis. RESULTS: The frequency of histomorphological alterations including stromal, glandular, vascular, and inflammatory alterations were 97% and 79.2% in prostatic tissues from cancer-negative TBs and SBs, respectively. Stromal, glandular, and inflammatory alterations were present in the majority of biopsies from both TBs and SBs. Statistical analysis revealed no significant difference between TBs and SBs with regard to stromal, glandular, and inflammatory alterations. However, vascular abnormalities were exclusively detected in TBs (18.2%). CONCLUSION: The frequency of histomorphological alterations is slightly higher in prostate tissues from TBs compared to SB. Only vascular alterations seem to be distinct for TBs. However, it has to be assumed that additional factors influence the false-negative rate of mpMRI/ultrasound fusion-guided TB.

Time-resolved 3-dimensional magnetic resonance phase contrast imaging (4D Flow MRI) reveals altered blood flow patterns in the ascending aorta of patients with valve-sparing aortic root replacement.

OBJECTIVE: The aim of this study was to compare aortic flow patterns in patients after David valve-sparing aortic root replacement with physiologically shaped sinus prostheses or conventional tube grafts in healthy volunteers. METHODS: Twelve patients with sinus prostheses (55 ± 15 years), 6 patients with tube grafts (58 ± 12 years), 12 age-matched, healthy volunteers (55 ± 6 years), and 6 young, healthy volunteers (25 ± 3 years) were examined with time-resolved 3-dimensional magnetic resonance phase contrast imaging (4D Flow MRI). Primary and secondary helical, as well as vortical flow patterns, were evaluated. Aortic arch anatomy as a flow influencing factor was determined. RESULTS: Compared with volunteers, both sinus prostheses and tube grafts developed more than 4 times as many secondary flow patterns in the ascending aorta (sinus prostheses n = 1.6 ± 0.8; tube grafts n = 1.3 ± 0.6; age-matched, healthy volunteers n = 0.3 ± 0.5; young, healthy volunteers n = 0; P ≤ .012) associated with a kinking of the prosthesis itself or at its distal anastomosis. As opposed to round aortic arches in volunteers (n = 16/18), cubic or gothic-shaped arches predominated in patients (n = 16/18, P < .001). In all but 3 volunteers, 2 counter-rotating helices were confirmed in the ascending aorta and were defined as a primary flow pattern. This primary flow pattern did not develop in patients who underwent valve-sparing aortic root replacement. CONCLUSIONS: In patients after valve-sparing aortic root replacement, there was an increased number of secondary flow patterns in the ascending aorta. This seems to be related to surgically altered aortic geometry with kinking. Because flow alterations are known to affect wall shear stress, there seems to be an increased risk for vessel wall remodeling. Compared with previous 4D Flow MRI studies, primary flow patterns in the ascending aorta in healthy subjects were confirmed to be more complex. This underlines the importance of thorough examination of 4D Flow MRI data.

In vitro 4D Flow MRI evaluation of aortic valve replacements reveals disturbed flow distal to biological but not to mechanical valves.

BACKGROUND AND AIM OF THE STUDY: Aortic hemodynamics influence the integrity of the vessel wall and cardiac afterload. The aim of this study was to compare hemodynamics distal to biological (BV) and mechanical aortic valve (MV) replacements by in vitro 4D Flow MRI excluding confounding factors of in-vivo testing potentially influencing hemodynamics. METHODS: Two BV (Perimount MagnaEase [Carpentier-Edwards], Trifecta [Abbott]) and two MV (On-X [CryoLife], prototype trileaflet valve) were scanned in a flexible aortic phantom at 3T using a recommended 4D Flow MR sequence. A triphasic aortic flow profile with blood-mimicking fluid was established. Using GTFlow (Gyrotools), area and velocity of the ejection jet were measured. Presence and extent of sinus vortices and secondary flow patterns were graded on a 0 to 3 scale. RESULTS: A narrow, accelerated central ejection jet (Area = 27 ± 7% of vessel area, Velocity = 166 ± 13 cm/s; measured at sinotubular junction) was observed in BV as compared to MV (Area = 53 ± 13%, Velocity = 109 ± 21 cm/s). As opposed to MV, the jet distal to BV impacted the outer curvature of the ascending aorta and resulted in large secondary flow patterns (BV: n = 4, grades 3, 3, 2, 1; MV: n = 1, grade 1). Sinus vortices only formed distal to MV. Although physiologically configured, they were larger than normal (grade 3). CONCLUSIONS: In contrast to mechanical valves, biological valve replacements induced accelerated and increased flow patterns deviating from physiological ones. While it remains speculative whether this increases the risk of aneurysm formation through wall shear stress changes, findings are contrasted by almost no secondary flow patterns and typical, near-physiological sinus vortex formation distal to mechanical valves.

Anti-Amphiphysin-associated limbic encephalitis in a 72-year-old patient with aortic angiosarcoma.

Paraneoplastic autoimmune encephalopathic syndromes have been described most often in association with small cell lung cancer or breast cancer, tumours of the ovaries, testes, lymphoma and thymoma. Antibodies associated with paraneoplastic encephalopathies are, among others, anti-Hu, anti-Ma2 and, in part, anti-N-methyl-D-aspartate(NMDA)-receptor antibodies. Here, we present the case of a 72-year-old patient hospitalised due to progressive cognitive decline and disorientation. Diagnostic workup revealed paraneoplastic anti-amphiphysin associated limbic encephalitis on the basis of an aortic angiosarcoma with metastases to kidney, muscle and bones. Highly aggressive chemotherapy as well as immunosuppressive therapy and cytoreductive laparoscopic nephrectomy were initiated. However, follow-up revealed further tumour progress and a worsening of neurological symptoms.

HeartMate III Left Ventricular Assist Device Thrombosis Triggered by an Automatic Implantable Cardioverter-Defibrillator Shock.

We report the case of an HeartMate III left ventricular assist device (LVAD) thrombosis triggered by a shock from an automatic implantable cardioverter defibrillator, releasing a left ventricular thrombus sucked in the LVAD inflow cannula. With LVAD low flow only the increase in motor temperature gave a hint of the thrombosis and a computer tomography scan confirmed the diagnosis. Pump exchange was performed with an uneventful outcome.

Time-resolved 3-dimensional magnetic resonance phase contrast imaging (4D Flow MRI) analysis of hemodynamics in valve-sparing aortic root repair with an anatomically shaped sinus prosthesis.

OBJECTIVE: The anatomically shaped sinus prosthesis (Uni-Graft W SINUS; Braun, Melsungen, Germany) used in valve-sparing aortic root replacement promises physiological hemodynamics believed to grant physiologic valve function. Using time-resolved 3-dimensional magnetic resonance phase contrast imaging (4D Flow MRI), we analyzed sinus vortex formation and transvalvular pressure gradients in patients with sinus prosthesis compared with age-matched and young healthy volunteers. METHODS: Twelve patients with sinus prosthesis (55 ± 15 years), 12 age-matched and 6 young healthy volunteers (55 ± 6 years, 25 ± 3 years, respectively) were examined at 3T with a 4D flow magnetic resonance imaging sequence. Sinus vortices visualized by streamlines and time-resolved particle paths were graded on a 4-point Likert scale. Time resolved pressure differences of the left ventricular outflow tract and the ascending aorta to a reference point in the aortic bulb as well as the transvalvular pressure gradient were evaluated. RESULTS: 4D flow visualizations revealed a propensity of the sinus prosthesis toward intermediate (50%) and large (28%) vortices compared with age-matched volunteers with small (61%) and intermediate (36%) vortices. Vortices in sinus prostheses had a similar configuration compared with those in volunteers. The peak transvalvular pressure gradient did not vary significantly between patients and age-matched volunteers (4.0 ± 0.9 mm Hg, 3.8 ± 0.7 mm Hg, P = .373), its temporal evolution resembled that of volunteers with a prolonged positive phase in patients. CONCLUSIONS: Hemodynamics closely relating to those of volunteers were confirmed in sinus prostheses, believed to grant physiological valve function. Minor differences are presumably attributed to graft compliance and temporal resolution of the acquisition. Nevertheless, long-term deterioration of valve function as it was described for straight grafts could potentially be decelerated using sinus prostheses.

Proposing a novel technique to exclude the left ventricle with an assist device: insights from 4-dimensional flow magnetic resonance imaging.

OBJECTIVES: Left ventricular assist device (LVAD) implantation has become an effective treatment for end-stage heart failure patients. However, LVAD support disrupts the natural intracavitary blood flow path through the heart, introducing flow patterns potentially associated with thrombosis especially around the inflow cannula. We present initial insights into in vitro 4D flow magnetic resonance imaging (MRI)-based analysis of flow patterns and an enzyme-activated milk test in a porcine left ventricular (LV) model during LVAD support, in a standard implant technique and in combination with a novel cone-shaped LV sparing prosthesis. METHODS: 4D MRI of an LVAD-supported ex vivo porcine heart failure model was performed in a mock circulatory loop with an LVAD flow of 4.5 l/min. Two separate sets of hearts with an MR-compatible LVAD inflow cannula were used: one with a standard inflow via the pulmonary veins into the LV, one sparing the LV with the cone-shaped prosthesis sutured to the mitral annulus and the LVAD inflow cannula sparing the LV cavity. In correlation, an enzyme-activated milk test was performed to reveal locations of disturbed flows. Data were analysed visually and by performing a case-by-case analysis of flow patterns and enzyme activation locations. RESULTS: Using 4D flow MRI, the standard implant technique showed markedly altered flow patterns with flow velocity reduction in the LV cavity especially around the inflow conduit. The average flow velocity in the LV cavity was 12.8 ± 2.9 m/s. In contrast, the LV-sparing technique with a cone-shaped prosthesis showed faster and more organized flow of 36.3 ± 7.2 m/s on average to the LVAD inflow cannula. Compared with the standard technique, no recirculating blood flow components were detected. The enzyme-activated milk test confirmed the location and extent of helical and vertical flow patterns. CONCLUSIONS: For the first time, intracardiac flows in an LVAD setting have been shown in vitro based on a mock porcine ex vivo heart failure model by applying 4D flow MRI. Differences in flow characteristics of the same model using a prosthesis sparing the LV cavity are encouraging to further investigate their potential to reduce potential LVAD-associated side-effects, such as intracavitary clotting and its sequelae.

A novel technique to exclude the left ventricle with an assist device.

Left ventricular assist device implantation disrupts the natural intracavitary blood flow path through the heart, introducing flow patterns potentially associated with thrombosis, especially around the inflow cannula. We describe a novel technique for completely excluding the left ventricle with an assist device by using a cone shaped ring-reinforced prosthesis.

Non-invasive assessment of cardiac function and pulmonary vascular resistance in an canine model of acute thromboembolic pulmonary hypertension using 4D flow cardiovascular magnetic resonance.

BACKGROUND: The purpose of this study was to quantify right (RV) and left (LV) ventricular function, pulmonary artery flow (QP), tricuspid valve regurgitation velocity (TRV), and aorta flow (QS) from a single 4D flow cardiovascular magnetic resonance (CMR) (time-resolved three-directionally motion encoded CMR) sequence in a canine model of acute thromboembolic pulmonary hypertension (PH). METHODS: Acute PH was induced in six female beagles by microbead injection into the right atrium. Pulmonary arterial (PAP) and pulmonary capillary wedge (PCWP) pressures and cardiac output (CO) were measured by right heart catheterization (RHC) at baseline and following induction of acute PH. Pulmonary vascular resistance (PVRRHC) was calculated from RHC values of PAP, PCWP and CO (PVRRHC = (PAP-PCWP)/CO). Cardiac magnetic resonance (CMR) was performed on a 3 T scanner at baseline and following induction of acute PH. RV and LV end-diastolic (EDV) and end-systolic (ESV) volumes were determined from both CINE balanced steady-state free precession (bSSFP) and 4D flow CMR magnitude images. QP, TRV, and QS were determined from manually placed cutplanes in the 4D flow CMR flow-sensitive images in the main (MPA), right (RPA), and left (LPA) pulmonary arteries, the tricuspid valve (TRV), and aorta respectively. MPA, RPA, and LPA flow was also measured using two-dimensional flow-sensitive (2D flow) CMR. RESULTS: Biases between 4D flow CMR and bSSFP were 0.8 mL and 1.6 mL for RV EDV and RV ESV, respectively, and 0.8 mL and 4 mL for LV EDV and LV ESV, respectively. Flow in the MPA, RPA, and LPA did not change after induction of acute PAH (p = 0.42-0.81). MPA, RPA, and LPA flow determined with 4D flow CMR was significantly lower than with 2D flow (p < 0.05). The correlation between QP/TRV and PVRRHC was 0.95. The average QP/QS was 0.96 ± 0.11. CONCLUSIONS: Using both magnitude and flow-sensitive data from a single 4D flow CMR acquisition permits simultaneous quantification of cardiac function and cardiopulmonary hemodynamic parameters important in the assessment of PH.

First clinical results with the new sinus prosthesis used for valve-sparing aortic root replacement.

OBJECTIVES: Sinuses of Valsalva are important in assuring the physiological function of the aortic valve. This study evaluates short-term clinical results of the reimplantation technique for aortic valve-sparing root replacement using a new prosthesis with three separate sinuses of Valsalva (sinus prosthesis). METHODS: Between February 2009 and February 2011, a total of 23 patients (20 m/3 f; mean age 52 ± 14.8 years; range 24-70 years) with aortic root aneurysm underwent aortic valve-sparing procedures according to the David reimplantation technique using the new sinus prosthesis. Eighteen patients had tricuspid and five patients bicuspid aortic valves. All patients received clinical as well as echocardiographic examinations postoperatively (mean 13 ± 9.3 months; 0.3-28 months). RESULTS: There was no death and no reoperation of the aortic valve. At latest follow-up, most patients were in New York Heart Association class I (n = 22; 95.7%). In 95.7% aortic valve regurgitation (AR) was 0 or 1+; one patient had AR 2+. Pressure gradients were between the normal range (mean pressure gradient 4.7 ± 1.9 mmHg). Echocardiographic images demonstrate physiological aortic root dimensions and configuration with three separate sinuses of Valsalva without systolic contact of leaflets to the wall. CONCLUSIONS: The new sinus prosthesis provides near normal root geometry and hemodynamics in valve-sparing aortic root replacement using the reimplantation technique, applicable for tricuspid and also bicuspid aortic valves.

Four-dimensional, flow-sensitive magnetic resonance imaging of blood flow patterns in thoracic aortic dissections.

OBJECTIVE: The purpose of this study was to evaluate alterations in flow patterns in thoracic aortic dissections using 4-dimensional, flow-sensitive magnetic resonance imaging. METHODS: This prospective study was conducted at 2 academic tertiary referral medical centers. Thirteen 4-dimensional flow magnetic resonance imaging studies were performed in 12 subjects (4 female, aged 25-71 years) with thoracic aortic dissection using 3.0T clinical scanners. Qualitative assessment of flow patterns in the true and false lumina was performed in consensus by 3 cardiovascular radiologists. Quantitative analysis included measurement of net flow, retrograde flow, peak flow, and time-to-peak flow in the true and false lumina in the ascending aorta, aortic arch, and descending aorta. Differences in flow through the true and false lumina at each analysis plane were compared with the 2-tailed, paired Student t test. RESULTS: Flow patterns were significantly altered in association with different extents of disease, vessel dilatation, and post-therapeutic anatomy. Total flow per cardiac cycle and peak flow were higher in the true lumen than in the false lumen (P < .01). Retrograde flow was less in the true lumen than in the false lumen (P ≤ .01). Time-to-peak flow in the true lumen occurred later than in the false lumen (P = .05-.08). CONCLUSIONS: Four-dimensional, flow-sensitive magnetic resonance imaging at 3.0T provided qualitative and quantitative information on alterations of aortic flow in patients with thoracic aortic dissection. Future application of this magnetic resonance flow methodology may help provide insights into the pathophysiology and effects of flow alterations and establish prognostic indicators for the development of complications or aneurysm growth in patients with aortic dissection.

Characterization of hepatic adenoma and focal nodular hyperplasia with gadoxetic acid.

PURPOSE: To characterize imaging features of histologically proven hepatic adenoma (HA) as well as histologically and/or radiologically proven focal nodular hyperplasia (FNH) using delayed hepatobiliary MR imaging with 0.05 mmol/kg gadoxetic acid. MATERIALS AND METHODS: Five patients with six HAs with histological correlation were retrospectively identified on liver MRI studies performed with gadoxetic acid, and T1-weighted imaging acquired during the delayed hepatobiliary phase. Additionally, 23 patients with 34 radiologically diagnosed FNH lesions (interpreted without consideration of delayed imaging) were identified, two of which also had histological confirmation. Signal intensity ratios relative to adjacent liver were measured on selected imaging sequences. RESULTS: All six hepatic adenomas (100%), which had histological confirmation, demonstrated hypointensity relative to adjacent liver on delayed imaging. Furthermore, all of the FNH (including 34 radiologically proven, 2 of which were also histologically proven) were either hyperintense (23/34, 68%) or isointense (11/34, 32%) relative to the adjacent liver on delayed imaging. None of the FNHs were hypointense relative to liver. CONCLUSION: Distinct imaging characteristics of HA versus FNH on delayed gadoxetic acid-enhanced MRI, with adenomas being hypointense and FNH being iso- or hyperintense on delayed imaging may improve specificity for characterization, and aid in the differentiation of these two lesions.

Time-resolved three-dimensional magnetic resonance velocity mapping of cardiovascular flow paths in volunteers and patients with Fontan circulation.

OBJECTIVE: To apply flow-sensitive magnetic resonance imaging for the evaluation of whole-heart flow characteristics in healthy volunteers and patients with Fontan circulation. METHODS: Time-resolved three-dimensional magnetic resonance velocity mapping (spatial resolution = 2.5 × 2.8 × 2.8mm(3), temporal resolution = 38.4 ms) was acquired in normal controls and in four Fontan patients with extracardiac total cavopulmonary connection. Data analysis included flow connectivity mapping and flow quantification of arterial and venous blood flow. Haemodynamics in four patients with Fontan circulation were individually evaluated in the aorta, caval veins and left and right pulmonary arteries. RESULTS: In four controls, nine distinct flow features were consistently identified with good feature clarity (median = 2 in 80.6% of readings) and image quality (median = 2 in 75.0% of readings). In patients, a marked variability of flow from the caval veins towards the left and right pulmonary arteries (flow ratio = 1.7 ± 0.6, range 1.2-2.6 vs 1.1 ± 0.1 in controls) was found. Increased offset of the caval venous connection resulted in enhanced pulmonary flow asymmetry. Compared with controls, reduced pulsatility in pulmonary arteries (1.4 ± 0.6 vs 4.1 ± 0.6 in controls) and caval veins (1.2 ± 0.4 vs 2.8 ± 1.1 in controls) were observed. Peak flow was reduced in both superior (22 ± 14 mls(-1) vs 76 ± 7 mls(-1) in controls) and inferior vena cava (61 ± 28 mls(-1) vs 187 ± 42 mls(-1) in controls). CONCLUSIONS: This feasibility study demonstrated the potential of whole-heart three-dimensional magnetic resonance velocity mapping to reveal overt haemodynamic differences in surgically palliated congenital heart with similar extracardiac cavopulmonary connection geometry. Future studies are warranted to evaluate its diagnostic impact for improved evaluation of the pre- and postoperative status in the individual patient.