Cystic cardiac myxoma: a rare variant of cardiac myxoma in a woman with acute stroke.

BACKGROUND: Cardiac myxomas are the most common primary benign tumors of the heart usually presenting as an oval mass attached to the interatrial septum. Mild heterogenous enhancement is typically seen upon contrast administration. Myxomas are benign, however can present with embolic episodes necessitating prompt diagnosis and treatment. CASE PRESENTATION: A middle-aged woman presenting with acute ischemic stroke was detected to have a complex cystic mass in the left atrium on echocardiography. Further evaluation with cardiac magnetic resonance imaging narrowed a differential diagnosis to hemangioma, hemangioendothelioma, sarcoma, hydatid cysts, bronchogenic cysts, and cystic variant of cardiac myxoma. CTA demonstrated arterial supply from the left circumflex artery supplying the lesion. Following surgical excision, histopathology analysis suggested a cystic cardiac myxoma with secondary degeneration. CONCLUSION: Cystic masses in the heart are challenging to diagnose due to similar imaging characteristics, and misdiagnosis may lead to further major downstream complications such as stroke, hemorrhage, and hemodynamic alterations causing syncope. Therefore, surgical excision of a cystic cardiac mass is justified to establish a definitive histopathological diagnosis and prevent further downstream complications. We hereby report a rare case of cystic cardiac myxoma in the left atrium showing intense progressive enhancement in CMR and CTA in a middle-aged woman presenting with acute stroke. This case highlights an exceedingly rare variant of cystic cardiac myxoma.

Diagnostic Value of T1 Mapping in Detecting Iron Overload in Indian Patients with Thalassemia Major: A Comparison with T2* Mapping.

Purpose T2* is the gold standard for iron quantification in liver as well as myocardium. In this study, we evaluated the diagnostic accuracy of myocardial T1 mapping for the assessment of myocardial iron overload (MIO) as compared to the T2* mapping in patients with thalassemia major (TM). Methods Consecutive TM patients attending the thalassemia clinic were prospectively enrolled. Magnetic resonance imaging was performed on a 1.5 T scanner (Siemens Healthineers, Germany) using a gradient echo T2* as well as a T1 mapping (MOLLI) sequence done at a mid-ventricular short-axis single 8 mm slice of the left ventricle. Values were analyzed by manually drawing a region of interest in the mid-septum. T2*less than 20ms was used as the cutoff for significant MIO. Results One-hundred three patients (58 males, mean age: 17 ± 7.8 years, mean ferritin: 2009.5 µg/L) underwent cardiovascular magnetic resonance. Median T2* of myocardium was 33.45ms. Nineteen patients (18.4%) had T2*less than 20ms. T1 value was low (<850ms) in all the patients with T2* less than 20 ms. Receiver operating characteristic curve analysis revealed the best cutoff of native T1 mapping value as 850 ms which had high specificity (95.2%), sensitivity (94.2%) and negative predictive value (98.8%) for T2* less than 20ms. There was excellent agreement between T1 and T2* for diagnosis of MIO (Kappa-0.848, p <0.001). We did not find any patient who had normal T1 mapping values but had MIO on T2*. Conclusion T1 and T2* correlate well and normal T1 values may rule out presence of MIO. T1 mapping can act as additional imaging marker for MIO and may be helpful in centers with nonavailability or limited experience of T2*.

Role of Iron Therapy in Heart Failure: A Consensus Statement from India.

Iron deficiency (ID) with or without anemia is frequently observed in patients with heart failure (HF). Uncorrected ID is associated with higher hospitalization and mortality in patients with acute HF (AHF) and chronic HF (CHF). Hence, in addition to chronic renal insufficiency, anemia, and diabetes, ID appears as a novel comorbidity and a treatment target of CHF. Intravenous (IV) ferric carboxymaltose (FCM) reduces the hospitalization risk due to HF worsening and improves functional capacity and quality of life (QOL) in HF patients. The current consensus document provides criteria, an expert opinion on the diagnosis of ID in HF, patient profiles for IV FCM, and correct administration and monitoring of such patients.

Angiotensin Receptor-Neprilysin Inhibitor Therapy and Cardiac Remodeling in Heart Failure: Consensus Statement from India.

Adverse cardiac remodeling refers to progressive structural and functional modifications in the heart because of increased wall stress in the myocardium, loss of viable myocardium, and neurohormonal stimulation. The guideline-directed medical therapy for Heart failure (HF) includes Angiotensin receptor-neprilysin inhibitor (ARNI) (sacubitril/valsartan), ß-blockers, sodium-glucose co-transporter 2 (SGLT2) inhibitors, and mineralocorticoid receptor antagonists (MRA). ARNI is under-prescribed in India despite its attractive safety and efficacy profile. Therefore, the consensus discusses objectives and topics related to ARNI in the management of cardiac remodeling, and experts shared their views on the early timely intervention of effective dosage of ARNI to improve the diagnosis and enhance mortality and morbidity benefits in cardiac reverse remodeling (CRR).

Inter-arterial course of the left coronary artery with a commissural origin in a 40-year-old patient with tricuspid atresia post Fontan shunt.

We report a case of an adult male with Tricuspid atresia post Fontan shunt in whom a rare coronary anomaly was demonstrated on Computed Tomography angiography using endoluminal views and volume rendering techniques.

A large cardiac tuberculoma masquerading a malignant mass in a 15-year-old boy.

We hereby present a case of large cardiac tuberculoma which was thought to be a malignant mass on cardiac magnetic resonance imaging (MRI). The present case highlights that high index of suspicion is necessary to diagnose this rare entity especially in tuberculosis-endemic areas, or in those who have relevant past history of this condition.

Low-dose ultra-high-pitch computed tomography coronary angiography: identifying the optimum combination of iteration strength and radiation dose reduction strategies to achieve true submillisievert scans

PURPOSE: To identify the optimum strength of advanced modeled iterative reconstruction (ADMIRE) to achieve the best subjective and objective image quality when combining three-dose reduction strategies, ultra-high-pitch computed tomography coronary angiography (FLASH CTCA; with single-dose ivabradine to lower heart rate), low tube voltage, and ADMIRE. METHODS: Sixty consecutive patients underwent FLASH CTCA at 100 kVp in this single-center prospective study. Single-dose ivabradine was administered to patients whose heart rate was above 75 bpm. Images were reconstructed using the three highest strengths of ADMIRE (A3, A4, and A5). Objective and subjective image quality (using a Likert scale) were evaluated in the three datasets. RESULTS: The signal strength remained unchanged but mean noise significantly reduced across the increasing strengths of ADMIRE [signal: 513.78 ± 101.7 Hounsfield units (HU) at A3, 515.6 ± 100.5 HU at A4, and 519.7 ± 107.9 HU at A5; noise: 23.4 ± 4.5 HU at A3, 20.2 ± 3.6 HU at A4, and 17.2 ± 3.3 HU at A5]. Signal-to-noise and contrast-to-noise ratios were the highest at A5, and A5 offered significantly higher Likert scores in image noise, vessel sharpness, and overall image quality than A3 or A4. Additionally, A5 did not interfere with image interpretation in any patient. CONCLUSION: Using all three dose reduction strategies during FLASH CTCA along with single-dose ivabradine administration ensures minimal radiation exposure in daily practice. In this study, A5 datasets had the best overall subjective and objective image quality despite their "plastic appearance". In the future, enhanced dose reduction can be obtained by further lowering tube voltages.

Origin of the left common carotid artery from ascending aorta in association with tetralogy of Fallot and hypoplastic right cervical aortic arch.

We present a case of a 6-year-old girl with tetralogy of Fallot (TOF) and hypoplastic aortic arch with anomalous origin of left common carotid artery from the ascending aorta. The case highlights the importance of screening for abnormalities of aortic arch and arch vessels in TOF patients for accurate presurgical planning and to predict the postoperative outcomes.

Evaluation of aortopulmonary window using virtual dissection of multidetector computed tomography angiography data sets.

AIM: The present study sought to evaluate the morphology and associated cardiovascular anomalies in patients with aortopulmonary window on virtual dissection of multidetector computed tomography (CT) angiography data sets. MATERIAL AND METHODS: We conducted a retrospective search of our departmental database from January 2014 to September 2021 to identify patients with aortopulmonary window and relevant information was extracted from the electronic case records and from routine examination as well as virtual dissection of CT data sets. RESULTS: An aortopulmonary window was observed in 26 patients (20 males; 6 females). Based on location of the defect, a distal aortopulmonary window was the most common subtype, seen in 13/26 (50%) patients followed by a proximal, complete and intermediate subtypes seen in 7/26 (27%), 5/26 (19%) and 1/26 (4%) patients respectively. Associated ventricular septal defect was observed in 9/26 (34.6%) patients while an interrupted aortic arch was present in 5/26 (19.2%) patients. Tetralogy of Fallot was seen in 5/26 (19.2%) patients. Anomalous origin of right pulmonary artery from ascending aorta and crossed pulmonary arteries were seen in 2/26 (7.6%) patients each. An isolated aortopulmonary window without any simple/complex congenital anomaly was seen in 10/26 (38.5%) patients. CONCLUSION: Aortopulmonary window is associated with a wide gamut of cardiovascular lesions, with ventricular septal defect being the commonest associated anomaly followed by tetralogy of Fallot and interrupted aortic arch respectively. Virtual dissection of multidetector CT angiography allows detailed anatomical evaluation of aortopulmonary window, allowing a clear visualization of the defect and associated cardiovascular anomalies.

Sporadic occurrence of multiple paragangliomas causing carotid and coronary arterial encasement.

We describe a case of a 32-year-old man with a paraganglioma causing encasement of ostioproximal segments of the left internal carotid artery and left external carotid artery with concurrent presence of bilobulated mediastinal paraganglioma, with similar imaging characteristics, causing encasement of the coronary arteries.

A rare pediatric case of pedunculated cardiac hemangioma of the left ventricle.

A 12-year-old male child with atypical chest pain and fatigue since past 3 months underwent cardiac magnetic resonance (CMR) imaging for suspicious globular mobile mass detected in the left ventricle on a transthoracic echocardiography. CMR revealed peripheral vascular blush on the first pass perfusion images with centripetal progressive intensely bright enhancement on late gadolinium-enhanced images. Further confirmation and histological diagnosis of the tumor was made through transaortic aortic resection of the mass.

Anomalous great cardiac vein draining into juxtaposed right atrial appendage.

We present a case of a 2-year-old boy with a double outlet right ventricle and juxtaposed atrial appendages with anomalous drainage of the great cardiac vein into the aneurysmally dilated juxtaposed right atrial appendage. The case highlights the role of computed tomography (CT) angiography in depicting anomalous coronary venous anatomy and guiding therapeutic interventions involving the coronary venous approach.

Imaging characteristics and associations of left atrioventricular valve atresia and patent aortic root with isometric atrial appendages on multidetector CT.

AIM: The present study sought to study the imaging associations of left atrioventricular valve (mitral) atresia and patent aortic root in patients with isomerism of atrial appendages as detected on multidetector computed tomography (CT) angiography MATERIALS AND METHODS: The CT angiography studies performed at a tertiary medical center from January 2014 to December 2021 were retrospectively evaluated to identify patients with left atrioventricular valve atresia and patent aortic root with isometric atrial chambers. The morphology of the atrial appendage and extent of pectinate muscles was used to identify the type of isomeric atrial chambers. A comprehensive assessment of discordant arrangement of organs and the variations in venoatrial connections was done. RESULTS: Left atrioventricular valve atresia in the presence of patent aortic root and isomeric atrial appendages was identified in eight patients (four males). The mean age at diagnosis was 7 years. Right isomerism of the atrial appendages was seen in five patients while three patients had left isomerism. Disharmonious patterns of abdominal visceral arrangement were seen in two patients. Atrial and ventricular septal defects were seen in all patients. The most common pattern of ventricular arterial connection was DORV (double outlet right ventricle) (n = 4). While five patients had normally related great arteries, three had aorta anterior to the pulmonary trunk. Right ventricular outflow obstruction was seen in seven patients. Right aortic arch with mirror image branching was seen in four patients. Coronary artery anomalies were seen in four patients. CONCLUSIONS: The presence of left atrioventricular valve atresia and patent aortic root with isomeric atrial appendages is a rare congenital anomaly frequently associated with anomalous systemic and pulmonary drainage, conotruncal anomalies, and right ventricular outflow obstruction. Hence, comprehensive CT-based evaluation is indispensable in providing detailed anatomy and aids in presurgical planning.

Meandering Retrosternal Course of Right Coronary Artery: Partially Empty Right Atrioventricular Groove.

We report a case of a 35-year-old man with a dilated ascending aorta and a unique meandering retrosternal course of the right coronary artery (RCA) resulting in a partially empty right atrioventricular groove. The aortic root showed an exaggerated clockwise rotation, resulting in an anteriorly directed RCA ostium and the RCA, instead of entering the right atrioventricular groove, traversed caudally in the subepicardial space over the anterior surface of the right ventricle directly posterior to the sternum.

Evaluation of Remodeling of Visceral Arteries and Impact on Renal Function Post-endovascular Repair of Type B Aortic Dissection Vis-A-Vis Baseline Visceral Artery Morphology.

PURPOSE: To evaluate the remodeling of visceral arteries post-endovascular repair (TEVAR) of type B aortic dissection and to investigate interval change in renal volume and estimated glomerular filtration rate (eGFR) vis-a-vis baseline visceral artery morphology. MATERIALS AND METHODS: All patients of type B aortic dissection who underwent TEVAR with a baseline and follow-up CT during the study period were included. Baseline morphology of visceral arteries (celiac, superior, and inferior mesenteric artery and bilateral renal artery) were classified into 7 patterns depending upon the origin of the artery (from true/false lumen) and the extension of dissection flap, while occluded vessels were categorized as pattern 8. RESULTS: One hundred and thirty-two branches were analyzed in 25 patients (23 males; mean age: 50.1 years) with a mean follow-up of 386 days. 51 visceral branches were arising from the true lumen without any stenosis. Of the remaining 81 branches, 48 showed favorable remodeling (P = .0001). The highest incidence of favorable remodeling was observed in arteries arising from the true lumen (pattern 2,3: 44/48; 91.6%) whereas only one thrombosed and artery arising from the false lumen each (pattern 5 and 8) showed favorable remodeling. Kidneys perfused by false lumen or occluded renal artery suffered statistically significant volume loss compared to kidneys perfused by true or both lumens (-16.5% vs .2%; P = .01); however, the change in eGFR failed to reach statistical significance. CONCLUSION: Visceral arteries arising from the true lumen are more likely to undergo favorable remodeling. The kidneys supplied by false lumen or by occluded renal artery suffer significantly more volume loss after TEVAR.

Imaging characteristics and associations of left atrioventricular valve atresia and patent aortic root with lateralized atrial chambers on multidetector CT.

AIM: To study the imaging characteristics and the associations of left atrioventricular valve atresia with patent aortic root and lateralized atrial chambers on multidetector computed tomography (CT) angiography. MATERIALS AND METHODS: We retrospectively evaluated all the CT angiography studies performed for the evaluation of various congenital heart diseases at our center from January 2014 to December 2021. Cases with left atrioventricular valve atresia and patent aortic root with lateralized atrial chambers were identified. The types of cardiovascular involvement as identifiable on CT angiography were studied and compiled. RESULTS: A total of 38 patients with left atrioventricular valve atresia and patent aortic root were included (median age: 5 months, males: 31). A total of 89.5% had usual atrial arrangement and 10.5% had mirror imagery of atria. Normal drainage of right and left superior caval veins and inferior caval vein into systemic venous atrium was seen in 77.8%, 61.5%, and 86.6%, respectively. Anomalous pulmonary venous drainage was seen in 3 (7.9%) patients. Atrial and ventricular septal defects were the most common associations. Imperforate left atrioventricular membrane was seen in 9 (23.7%) patients and absent left atrioventricular connection in 27 (71.1%). Discordant right atrioventricular connection was seen in 5 (13.1%) patients. While a double outlet right ventricle (76.3%) was the most common ventriculoarterial connection, discordant ventriculo-arterial connection (transposition) in 4 (10.5%). Most patients had good sized pulmonary arteries. Patent arterial duct and right aortic arch were seen in 29% and 21%, respectively. Aberrant right subclavian artery was the most common arch vessel anomaly. Coronary anomalies were seen in 7 patients (19%); single coronary artery being the most common. CONCLUSIONS: Majority of the patients with left atrioventricular valve atresia and patent aortic root with lateralized atrial chambers have usual atrial arrangement, normal right atrioventricular connections and a double outlet configuration of the right ventricle. Absent left atrioventricular connection is a more common than imperforate left atrioventricular valve membrane. Atrial and ventricular septal defects are the most common associations. Comprehensive CT based evaluation of vascular and nonvascular thoracic structures is imperative before surgery or interventions in patients with mitral atresia.