Risk assessment of acute pulmonary embolism utilizing coronary artery calcifications in patients that have undergone CT pulmonary angiography and transthoracic echocardiography.

OBJECTIVE: To evaluate the relation of coronary artery calcifications (CAC) on non-ECG-gated CT pulmonary angiography (CTPA) with short-term mortality in patients with acute pulmonary embolism (PE). METHODS: We retrospectively included all in-patients between May 2007 and December 2014 with an ICD-9 code for acute PE and CTPA and transthoracic echocardiography available. CAC was qualitatively graded as absent, mild, moderate, or severe. Relations of CAC with overall and PE-related 30-day mortality were assessed using logistic regression analyses. The independence of those relations was assessed using a nested approach, first adjusting for age and gender, then for RV strain, peak troponin T, and cardiovascular risk factors for an overall model. RESULTS: Four hundred seventy-nine patients were included (63 ± 16 years, 52.8% women, 47.2% men). In total, 253 (52.8%) had CAC-mild: 143 (29.9%); moderate: 89 (18.6%); severe: 21 (4.4%). Overall mortality was 8.8% (n = 42) with higher mortality with any CAC (12.6% vs. 4.4% without; odds ratio [OR] 3.1 [95%CI 2.1-14.5]; p = 0.002). Mortality with severe (19.0%; OR 5.1 [95%CI 1.4-17.9]; p = 0.011), moderate (11.2%; OR 2.7 [95%CI 1.1-6.8]; p = 0.031), and mild CAC (12.6%; OR 3.1 [95%CI 1.4-6.9]; p = 0.006) was higher than without. OR adjusted for age and gender was 2.7 (95%CI 1.0-7.1; p = 0.050) and 2.6 (95%CI 0.9-7.1; p = 0.069) for the overall model. PE-related mortality was 4.0% (n = 19) with higher mortality with any CAC (5.9% vs. 1.8% without; OR 3.5 [95%CI 1.1-10.7]; p = 0.028). PE-related mortality with severe CAC was 9.5% (OR 5.8 [95%CI 1.0-34.0]; p = 0.049), with moderate CAC 6.7% (OR 4.0 [95%CI 1.1-14.6]; p = 0.033), and with mild 4.9% (OR 2.9 [95%CI 0.8-9.9]; p = 0.099). OR adjusted for age and gender was 4.2 (95%CI 0.9-20.7; p = 0.074) and 3.4 (95%CI 0.7-17.4; p = 0.141) for the overall model. Patients with sub-massive PE showed similar results. CONCLUSION: CAC is frequent in acute PE patients and associated with short-term mortality. Visual assessment of CAC may serve as an easy, readily available tool for early risk stratification in those patients. KEY POINTS: • Coronary artery calcification assessed on computed tomography pulmonary angiography is frequent in patients with acute pulmonary embolism. • Coronary artery calcification assessed on computed tomography pulmonary angiography is associated with 30-day overall and PE-related mortality in patients with acute pulmonary embolism. • Coronary artery calcification assessed on computed tomography pulmonary angiography may serve as an additional, easy readily available tool for early risk stratification in those patients.

Multimodality Assessment of Right Ventricular Strain in Patients With Acute Pulmonary Embolism.

Optimal risk stratification is essential in managing patients with an acute pulmonary embolism (PE). There are limited data evaluating the potential additive value of various methods of evaluation of right ventricular (RV) strain in PE. We retrospectively evaluated RV strain by computed tomography (CT), transthoracic echocardiography (TTE), electrocardiography (ECG), and troponin levels in consecutive hospitalized patients with acute PE (May 2007 to December 2014). Four-hundred and seventy-seven patients met inclusion criteria. RV strain on ECG (odds ratio [OR] 1.9, confidence interval [CI] 1.1 to 3.3; p = 0.03), CT (OR 2.7, CI 1.5 to 4.8, p <0.001), TTE (OR 2.8, CI 1.5 to 5.4, p <0.001), or a positive troponin (OR 2.7, CI 2.0 to 6.9, p <0.001) were associated with adverse events. In patients with ECG, CT, and TTE data, increased risk was only elevated with RV strain on all 3 parameters (OR 4.6, CI 1.8 to 11.3, p <0.001). In all patients with troponin measurements, risk was only elevated with RV strain on all 3 parameters plus a positive troponin (OR 8.8, CI 2.8 to 28.1, p <0.001) and was similar in intermediate-risk PE (OR 11.1, CI 1.2 to 103.8, p = 0.04). In conclusion, in patients with an acute PE and evaluation of RV strain by ECG, CT, and TTE, risk of adverse events is only elevated when RV strain is present on all 3 modalities. Troponin further aids in discriminating high-risk patients. Multimodality assessment of RV strain is identified as a superior approach to risk assessment.

Computed Tomography Angiographic Assessment of Acute Chest Pain.

Acute chest pain is a leading cause of Emergency Department visits. Computed tomography angiography plays a vital diagnostic role in such cases, but there are several common challenges associated with the imaging of acute chest pain, which, if unrecognized, can lead to an inconclusive or incorrect diagnosis. These imaging challenges fall broadly into 3 categories: (1) image acquisition, (2) image interpretation (including physiological and pathologic mimics), and (3) result communication. The aims of this review are to describe and illustrate the most common challenges in the imaging of acute chest pain and to provide solutions that will facilitate accurate diagnosis of the causes of acute chest pain in the emergency setting.

Multidetector computed tomographic imaging in chronic obstructive pulmonary disease: emphysema and airways assessment.

Chronic obstructive pulmonary disease (COPD) is a complex syndrome encompassing potentially overlapping diseases such as pulmonary emphysema, chronic bronchitis, and small airways disease. The management of COPD relies on distribution and severity of those processes, which clinically can manifest similarly. Relative contribution and severity of each of those pathologic changes can be assessed using qualitative and quantitative analysis of computed tomographic imaging data. Studies are under way to establish potential links among the imaging, clinical, and genetic manifestations of COPD.

An evidence-based estimate on the size of the potential patient pool for lung volume reduction surgery.

BACKGROUND: Observational and randomized studies have demonstrated that lung volume reduction surgery (LVRS) improves symptoms, lung function, and survival in selected patients with emphysema. In spite of an approximately 3.8 million patient prevalence of the disease in the US, only 119 LVRS procedures were performed nationwide under Medicare during 2008. In order to obtain evidence-based estimate on the size of the patient pool potentially suitable for LVRS, we analyzed the database from our clinical practice that is representative of a substantial segment of the general emphysema population. METHODS: Our pulmonary function test laboratory database between 1996 and 2006 was searched for patients with stage III and IV global initiative for chronic obstructive lung disease (GOLD) who also had lung volumes and carbon monoxide diffusing capacity data. Patients without available chest computed tomographic scans (CT) or with primary diagnoses other than emphysema were excluded. The resultant emphysema cohort was screened using clinical inclusion and exclusion criteria adopted from the National Emphysema Treatment Trial. A suitable clinical profile combined with CT scan evidence of 40% or greater involvement of the lungs and predominantly upper lobe distribution of emphysema were regarded as favorable markers for LVRS. RESULTS: Pulmonary function test criteria were met by 959 patients and CT scans were available in 588 patients, but 175 patients were excluded because of primary diagnoses other than emphysema. In the remaining 413 patients, 61 or 15% exhibited favorable clinical profiles and anatomy for LVRS. CONCLUSIONS: In a subset of patients that resembles a substantial segment of the general population with advanced emphysema, up to 15% appeared potential candidates for LVRS. Formation of a task force by relevant medical specialty and patient advocate organizations to address the apparent underutilization of LVRS is recommended.

Bronchial collapsibility at forced expiration in healthy volunteers: assessment with multidetector CT.

PURPOSE: To assess forced-expiratory bronchial collapsibility in healthy volunteers by using multidetector computed tomography (CT) and to compare the results with the current diagnostic criterion for bronchomalacia. MATERIALS AND METHODS: The institutional review board approved this HIPAA-compliant study. Following informed consent, 51 healthy volunteers with normal pulmonary function and no history of smoking were imaged by using a 64-detector row scanner with spirometric monitoring at total lung capacity and during forced exhalation. The total study population (in whom both main bronchi were imaged) included 25 men and 26 women (mean age, 50 years). Each scan was analyzed at a workstation by a fellowship-trained thoracic radiologist. Cross-sectional area measurements were obtained from end-inspiratory and forced-expiratory CT images for the right main bronchus (RMB), left main bronchus, (LMB), and bronchus intermedius (BI), and the mean percentage of expiratory collapse was calculated for each bronchus. The number of participants who exceeded the current diagnostic threshold level (>50% expiratory reduction in cross-sectional area) for bronchomalacia was calculated. Comparisons of airway dimensions and airway collapse according to bronchial segment and sex were made by using repeated-measures analysis of variance. RESULTS: Mean percentage of expiratory collapse was 66.9% ± 19.0 (standard deviation) for the RMB and 61.4% ± 16.7 for the LMB. Thirty-seven (73%) of 51 participants exceeded the diagnostic threshold level for bronchomalacia. Significant differences were observed in mean percentage of expiratory collapse between the RMB (66.9% ± 19.0) and LMB (61.4% ± 16.7) (P = .0005). Among a subgroup of 37 participants in whom the BI was also imaged, the mean percentage of expiratory collapse was 61.8% ± 22.8, and 27 (73%) participants exceeded the diagnostic threshold level for bronchomalacia. CONCLUSION: Healthy volunteers demonstrate a wide range of forced-expiratory bronchial collapse, frequently exceeding the current diagnostic threshold level for bronchomalacia.

Sonographic detection of pneumothorax by radiology residents as part of extended focused assessment with sonography for trauma.

OBJECTIVE: The purpose of this study was to assess the accuracy of sonographic pneumothorax detection by radiology residents as a part of extended focused assessment with sonography for trauma (eFAST). METHODS: In a prospective study, a sonographic search for pneumothoraces was performed as part of a standard FAST examination by the on-call resident. Each lung field was scanned at the second to fourth anterior intercostal spaces and the sixth to eighth midaxillary line intercostal spaces. A normal pleural interface was identified by the presence of parietal-over-visceral pleural sliding with "comet tail" artifacts behind. Absence of these normal features indicated a pneumothorax. The sonographic diagnosis was correlated with supine chest radiography and chest computed tomography (CT). RESULTS: A total of 338 lung fields in 169 patients were included in the study. Patients underwent eFAST, chest radiography, and chest CT when clinically indicated. Chest CT was considered the reference standard examination. Computed tomography identified 43 pneumothoraces (13%): 34 small and 9 moderate. On chest radiography, 7 pneumothoraces (16%) were identified. Extended FAST identified 23 pneumothoraces (53%). Compared with CT, eFAST had sensitivity of 47%, specificity of 99%, a positive predictive value of 87%, and a negative predictive value of 93%. All of the moderate pneumothoraces were identified by eFAST. Twenty small pneumothoraces missed by eFAST did not require drainage during the hospitalization period. CONCLUSIONS: Extended FAST performed by residents is an accurate and efficient tool for early detection of clinically important pneumothoraces.

Integrated single-photon emission computed tomography and computed tomography coronary angiography for the assessment of hemodynamically significant coronary artery lesions.

OBJECTIVES: The purpose of this study was to assess the physiologic significance of coronary artery lesions with an integrated single-photon emission computed tomography (SPECT) and computed tomography coronary angiography (CTCA) device. BACKGROUND: Myocardial perfusion imaging (MPI) with SPECT is of value for assessing the physiologic significance of coronary lesions. Computed tomography coronary angiography is a new technique to noninvasively detect coronary stenosis, with high sensitivity and negative predictive value (NPV) but lower specificity and positive predictive value (PPV). The experimental SPECT/CTCA hybrid imaging device (Infinia gamma camera and LightSpeed16 CT, General Electric, Milwaukee, Wisconsin) enables concurrent assessment of coronary anatomy and myocardial perfusion. METHODS: Fifty-six patients with angina pectoris underwent single-session SPECT-MPI and CTCA with the hybrid device and coronary angiography (CA) within 4 weeks. The ability of fused SPECT/CTCA images to diagnose physiologically significant lesions showing >50% stenosis and reversible perfusion defects in the same territory was determined and compared with CTCA stand-alone. RESULTS: Of a total of 224 coronary segments in 56 patients, 12 patients and 54 segments (23%) were excluded from further analysis of CTCA. Overall, 170 coronary segments were evaluated. The sensitivity, specificity, PPV, and NPV of CTCA were 96%, 63%, 31%, and 99%, respectively, as compared with 96%, 95%, 77%, and 99%, respectively, for SPECT/CTCA. CONCLUSIONS: Hybrid SPECT/CTCA imaging results in improved specificity and PPV to detect hemodynamically significant coronary lesions in patients with chest pain. Single-photon emission computed tomography/CTCA might play a potentially important role in the noninvasive diagnosis of coronary artery disease and introduce an objective decision-making tool for assessing the need for interventions in each occluded vessel.

Comprehensive multidetector computed tomography assessment of severe cardiac contusion in a pediatric patient: correlation with echocardiography.

Multidetector computed tomography (MDCT) cardiac findings in an unconscious teenager after blunt chest trauma are presented. Multidetector computed tomography enabled accurate comprehensive evaluation of the coronary arteries, myocardial perfusion, and left ventricular function. This case illustrates the full capabilities of MDCT in the evaluation of cardiac contusion in a noncooperative pediatric patient.