Positron emission tomography/MRI for cardiac diseases assessment.

Functional imaging tools have emerged in the last few decades and are increasingly used to assess the function of the human heart in vivo. Positron emission tomography (PET) is used to evaluate myocardial metabolism and blood flow. Magnetic resonance imaging (MRI) is an essential tool for morphological and functional evaluation of the heart. In cardiology, PET is successfully combined with CT for hybrid cardiac imaging. The effective integration of two imaging modalities allows simultaneous data acquisition combining functional, structural and molecular imaging. After PET/CT has been successfully accepted for clinical practices, hybrid PET/MRI is launched. This review elaborates the current evidence of PET/MRI in cardiovascular imaging and its expected clinical applications for a comprehensive assessment of cardiovascular diseases while highlighting the advantages and limitations of this hybrid imaging approach.

Ultrasonographic assessment of right heart intracardiac mass in patients with hepatitis B virus infection.

OBJECTIVE: The characteristics of right heart intracardiac mass in hepatitis B virus infection patients are not well known. Our aim is to describe their ultrasonographic features and nature of such masses. METHODS: We retrospectively reviewed imaging reports of hepatitis B virus infection patients from January 2014 to December 2018. Patients with a confirmed finding of right heart intracardiac mass were included, whose pathology reports and contrast-enhanced images were analyzed. Various masses were compared to a general control group from a published study. RESULTS: Thirty-eight cases were finally included. Different types of masses presented with a variety of echocardiographic manifestations. Thirty-six cases had masses located in the right atrium, including five thrombus and 31 metastatic carcinoma. The later included one metastatic non-Hodgkin lymphoma and 30 metastatic hepatic carcinoma cases (27 of which had inferior vena cava tumor thrombus). Two cases presented with masses in the right ventricle that included one multiple myxoma and one tricuspid valve leaflet vegetation. Compared with the general population, no primary malignant tumor was found in our study (65% vs. 100%, P = 0.001), and hepatic metastasis was the most common type of malignant tumors (P < 0.001). CONCLUSION: The nature and ultrasonographic features of right heart intracardiac masses in hepatitis B virus infection patients are diverse, and the incidence of malignant tumors was similar to that seen in the general population. Hepatic metastasis, possibly extending via the inferior vena cava into the right atrium, was the most common type. Our study may improve understanding of the right heart intracardiac mass in hepatitis B virus infection patients.

The Assessment of Cardiac Masses by Cardiac CT and CMR Including Pre-op 3D Reconstruction and Planning.

PURPOSE OF REVIEW: The purpose of this review is to (1) review the recent evidence examining the use of CT and CMR in the assessment of a suspected cardiac mass, (2) summarize the typical imaging features of the most common cardiac masses, and (3) examine the latest developments in the use of three-dimensional reconstructions and models in the preoperative assessment of a cardiac mass. RECENT FINDINGS: CMR can distinguish between tumors and non-tumor masses and between benign and malignant mass with a high degree of accuracy. CT and CMR are complementary tools in the evaluation of cardiac masses. CMR is the preferred initial imaging modality due to its versatile imaging planes and superior tissue characterization. CT better depicts calcification and has a higher spatial resolution compared with CMR, which is of particular importance in preoperative planning. CT also offers a valuable alternative in those with contraindications to CMR. Three-dimensional reconstructions, particularly of CT datasets, are a valuable adjunct in the preoperative assessment of a cardiac mass and may allow a better appreciation of the margins of the mass and its relationship with surrounding structures. Three-dimensional printing is an emerging technology which may be of additional value in selected patients with a cardiac mass.

Multimodality Imaging for the Assessment of Pericardial Diseases.

PURPOSE OF REVIEW: The diagnosis of pericardial syndromes, while occasionally straightforward, includes a wide range of pathologies and is often a well-recognized clinical challenge. The aim of this review is to highlight the key role of the various imaging modalities for the diagnosis and management of the spectrum of pericardial diseases. RECENT FINDINGS: Cardiac imaging has become an integral part of the diagnostic process often beginning with echocardiography and supported by advanced imaging modalities including computed tomography, magnetic resonance imaging, and positive emission tomography. These modalities go beyond the simple identification of the pericardium, to identifying increased pericardial thickness, active pericardial edema and inflammation, and its effect on cardiac hemodynamics. Multimodality imaging has significantly facilitated the diagnosis and long-term management of patients with pericardial diseases. The role of these imaging modalities in overall prognosis and prevention remains to be investigated.

Assessment of Left Ventricular Myocardial Diseases with Cardiac Computed Tomography.

Rapid advances in cardiac computed tomography (CT) have enabled the characterization of left ventricular (LV) myocardial diseases based on LV anatomical morphology, function, density, and enhancement pattern. Global LV function and regional wall motion can be evaluated using multi-phasic cine CT images. CT myocardial perfusion imaging facilitates the identification of hemodynamically significant coronary artery disease. CT delayed-enhancement imaging is used to detect myocardial scar in myocardial infarction and to measure the extracellular volume fraction in non-ischemic cardiomyopathy. Multi-energy cardiac CT allows the mapping of iodine distribution in the myocardium. This review summarizes the current techniques of cardiac CT for LV myocardial assessment, highlights the key findings in various myocardial diseases, and presents future applications to complement echocardiography and cardiovascular magnetic resonance.

Role of Echocardiography in Assessment of Cardioembolic Sources: a Strong Diagnostic Resource in Patients with Ischemic Stroke.

PURPOSE OF REVIEW: This review will discuss the most frequent sources of cardiac embolism and the role of echocardiography in these different clinical settings, and, in addition, provide suggestions about the choice between transthoracic (TTE) and transesophageal echocardiography (TEE). RECENT FINDINGS: Stroke is the third leading cause of death in industrial countries, and 15-40% of all ischemic strokes are due to cardioembolism. TTE and TEE are cornerstones in the detection of cardioembolic sources and provide fundamental information about the embolic risk and most suitable treatment of these patients, improving long-term outcomes. Echocardiography is a widely available, inexpensive, and safe diagnostic tool that is almost free from contraindication, and these elements allow the common use of this technique in almost all the patients with ischemic stroke. The most common cardioembolic sources include left atrial appendage thrombosis during atrial fibrillation; vegetations in infective endocarditis; cardiac masses including left ventricular thrombosis, cardiac tumors, etc.; atherosclerotic plaques; and passageways within the heart serving as conduits for paradoxical embolization, e.g., patent foramen ovale.

INCA (Peru) Study: Impact of Non-Invasive Cardiac Magnetic Resonance Assessment in the Developing World.

Background Advanced cardiac imaging permits optimal targeting of cardiac treatment but needs to be faster, cheaper, and easier for global delivery. We aimed to pilot rapid cardiac magnetic resonance ( CMR ) with contrast in a developing nation, embedding it within clinical care along with training and mentoring. Methods and Results A cross-sectional study of CMR delivery and clinical impact assessment performed 2016-2017 in an upper middle-income country. An International partnership (clinicians in Peru and collaborators from the United Kingdom, United States, Brazil, and Colombia) developed and tested a 15-minute CMR protocol in the United Kingdom, for cardiac volumes, function and scar, and delivered it with reporting combined with training, education and mentoring in 2 centers in the capital city, Lima, Peru, 100 patients referred by local doctors from 6 centers. Management changes related to the CMR were reviewed at 12 months. One-hundred scans were conducted in 98 patients with no complications. Final diagnoses were cardiomyopathy (hypertrophic, 26%; dilated, 22%; ischemic, 15%) and 12 other pathologies including tumors, congenital heart disease, iron overload, amyloidosis, genetic syndromes, vasculitis, thrombi, and valve disease. Scan cost was $150 USD, and the average scan duration was 18±7 minutes. Findings impacted management in 56% of patients, including previously unsuspected diagnoses in 19% and therapeutic management changes in 37%. Conclusions Advanced cardiac diagnostics, here CMR with contrast, is possible using existing infrastructure in the developing world in 18 minutes for $150, resulting in important changes in patient care.

Assessment of left ventricular myocardial deformation by cardiac MRI strain imaging reveals myocardial dysfunction in patients with primary cardiac tumors.

BACKGROUND: To assess left ventricular myocardial deformation in patients with primary cardiac tumors. METHODS: MRI was retrospectively performed in 61 patients, including 31 patients with primary cardiac tumors and 30 matched normal controls. Left ventricular strain and function parameters were then assessed by MRI-tissue tracking. Differences between the tumor group and controls, left and right heart tumor groups, left ventricular wall tumor and non-left ventricular wall tumor groups, and tumors with and without LV enlargement groups were assessed. Finally, the correlations among tumor diameter, myocardial strain, and LV function were analyzed. RESULTS: Left ventricular myocardial strain was milder for tumor group than for normal group. Peak circumferential strain (PCS) and its diastolic strain rate, longitudinal strains (PLS) and its diastolic strain rates, and peak radial systolic and diastolic velocities of the right heart tumor group were lower than those of the left heart tumor group (all p<0.050), but the peak radial systolic strain rate of the former was higher than that of the latter (p=0.017). The corresponding strains were lower in the left ventricular wall tumor groups than in the non-left ventricular wall tumor group (p<0.050). Peak radial systolic velocities were generally higher for tumors with LV enlargement than for tumors without LV enlargement (p<0.050). Peak radial strain, PCS, and PLS showed important correlations with the left ventricular ejection fraction (all p<0.050). CONCLUSION: MRI-tissue tracking is capable of quantitatively assessing left ventricular myocardial strain to reveal sub-clinical abnormalities of myocardial contractile function.

The advantages of live/real-time three-dimensional echocardiograhy in the assessment of left ventricular myxoma, which causes partial left ventricular outflow tract obstruction.

Myxomas are the most common cardiac primary tumors; however, left ventricular myxomas are extremely rare. We describe a young female patient with a giant left ventricular myxoma causing partial obstruction of the left ventricular outflow tract, who underwent successful surgical resection. Real-time three-dimensional echocardiography yielded incremental value to two-dimensional echocardiography by allowing better assess of the true size, extent, attachment, and morphology of the tumor. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:273-277, 2018.

Intrapericardial paraganglioma: The role of integrated advanced multi-modality cardiac imaging for the assessment and management of rare primary cardiac tumors.

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Multi-modality Imaging Assessment of Pericardial Masses.

PURPOSE OF REVIEW: This review will discuss the application of various imaging modalities including their advantages and disadvantages in the evaluation of the most common pericardial masses with a focus on pericardial cysts, tumors, and hematomas. RECENT FINDINGS: Accurate identification of pericardial masses and assessment of potential hemodynamic compromise is imperative for management. Cardiac imaging plays a central role in tissue characterization as well as evaluation of extension into neighboring structures. Currently, echocardiography is the preferred modality for the initial evaluation due to its low cost and widespread availability. However, due to potential limitations with echocardiography, computed tomography (CT), and cardiac magnetic resonance (CMR) imaging have become robust complementary imaging tests. CT provides superior spatial resolution and is the ideal test for evaluation of calcified masses while CMR provides excellent tissue characterization through various CMR sequences. Finally, positron emission tomography (PET) imaging can provide additional unique information in the assessment of potentially malignant tumors. An integrated, multi-modality imaging approach is helpful to evaluate the pericardium and diagnose pericardial masses. Advancements in imaging technology have provided improved diagnostic accuracy, with CT and CMR currently serving as complementary imaging techniques to traditional echocardiography imaging. Because each imaging modality has its unique sets of advantages and disadvantages, the choice of modality must be individualized to each patient. Through careful consideration, an integrated imaging approach is crucial in noninvasively providing information on cardiac structure, morphology, function, and associated complications that are important to the diagnosis and management of a variety of pericardial masses.

Multimodal Imaging for the Assessment of a Cardiac Mass - A Case of Primary Cardiac Sarcoma.

We present a case of an 85-year-old patient who underwent clinical work-up for chronic heart failure, acute coronary syndrome, and pulmonary embolism, until she was diagnosed with a cardiac mass that was histologically identified as sarcoma. The aim of this educational case report is to raise awareness of cardiac masses and to point out diagnostic hints towards a cardiac tumor on chest X-ray, coronary angiography, echocardiography, and chest CT. Moreover, the vital role of cardiac magnetic resonance for the diagnosis of a cardiac mass is highlighted.

Cardiac Sarcoma Arising From Malignant Transformation of a Preexisting Atrial Myxoma.

A 49-year-old man presented with shortness of breath on exertion, orthopnea, and chest pain. On transthoracic echocardiography, a myxomatous mass was seen in the left atrium. A diagnosis of atrial myxoma was made and the patient underwent urgent surgical intervention. At operation, the mass, which extended into the anterior leaflet of the mitral valve, was excised. Histopathologic examination showed a primary cardiac sarcoma arising within a preexisting atrial myxoma. The patient received no further treatment and died 7 months postoperatively. We report the first case of a malignant transformation of an atrial myxoma to a cardiac sarcoma.

Computerized tomography angiography in preoperative assessment of intravenous leiomyomatosis extending to inferior vena cava and heart.

BACKGROUND: Intravenous leiomyomatosis (IVL) extending to inferior vena cava and heart is one of the most challenging conditions for surgical treatment. We explored the use of computerized tomography angiography (CTA) in preoperative assessment for this disease. METHODS: A cohort of 31 patients with IVL extending to inferior vena cava and heart were reviewed from the year 2002 to 2014, focusing on the preoperative CTA imaging characteristics and the surgical procedures in clinical treatment. RESULTS: All patients were diagnosed correctly combining the clinical medical history and CTA imaging. Thirteen patients had tumors confined within the inferior vena cava, and 18 patients had tumors intruding into the right heart. Furthermore, 15 tumors were located in the right atrium alone, and 3 tumors involved both the right atrium and the right ventricle. All patients had simple or multiple soft tissue masses from the pelvis, with 22 tumors extending into inferior vena cava through the iliac veins and 9 tumors through the ovarian veins. Three patients had tumors invading into lung and underwent tumor thrombus resection in the pulmonary artery. Patients received either one-stage surgery or two-stage surgery dependent on patient general condition and tumor status. All operations were successfully performed by multidisciplinary cooperation, including gynecology, cardiac surgery, and vascular surgery, without severe surgical-related complications or deaths. CONCLUSIONS: CTA imaging can present location, size, and full-scale extension pathway of IVL lesions, and can be used as first-line imaging technique in preoperative assessment, having great significance in making surgical plan and obtaining successful outcome.

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of primary cardiac malignant fibrous histiocytoma.

We describe a case of primary cardiac malignant fibrous histiocytoma where live/real time three-dimensional transesophageal echocardiography added incremental value to the two-dimensional modalities. Specifically, the three-dimensional technique allowed us to delineate the true extent and infiltration of the tumor, to identify characteristics of the tumor mass suggestive of its malignant nature, and to quantitatively assess the total tumor burden.

Integrated 18F-FDG PET/MR imaging in the assessment of cardiac masses: a pilot study.

UNLABELLED: The objective of the present study was to evaluate whether integrated (18)F-FDG PET/MR imaging could improve the diagnostic workup in patients with cardiac masses. METHODS: Twenty patients were prospectively assessed using integrated cardiac (18)F-FDG PET/MR imaging: 16 patients with cardiac masses of unknown identity and 4 patients with cardiac sarcoma after surgical therapy. All scans were obtained on an integrated 3-T PET/MR device. The MR protocol consisted of half Fourier acquisition single-shot turbo spin-echo sequence, cine, and T2-weighted images as well as T1-weighted images before and after injection of gadobutrol. PET data were acquired simultaneously with the MR scan after injection of 199 ± 58 MBq of (18)F-FDG. Patients were prepared with a high-fat, low-carbohydrate diet in a period of 24 h before the examination, and 50 IU/kg of unfractionated heparin were administered intravenously 15 min before (18)F-FDG injection. RESULTS: Cardiac masses were diagnosed as follows: metastases, 3; direct tumor infiltration via pulmonary vein, 1; local relapse of primary sarcoma after surgery, 2; Burkitt lymphoma, 1; scar/patch tissue after surgery of primary sarcoma, 2; myxoma, 4; fibroelastoma, 1; caseous calcification of mitral annulus, 3; and thrombus, 3. The maximum standardized uptake value (SUVmax) in malignant lesions was significantly higher than in nonmalignant cases (13.2 ± 6.2 vs. 2.3 ± 1.2, P = 0.0004). When a threshold of 5.2 or greater was used, SUVmax was found to yield 100% sensitivity and 92% specificity for the differentiation between malignant and nonmalignant cases. T2-weighted hyperintensity and contrast enhancement both yielded 100% sensitivity but a weak specificity of 54% and 46%, respectively. Morphologic tumor features as assessed by cine MR imaging yielded 86% sensitivity and 92% specificity. Consent interpretation using all available MR features yielded 100% sensitivity and 92% specificity. A Boolean 'AND' combination of an SUVmax of 5.2 or greater with consent MR image interpretation improved sensitivity and specificity to 100%. CONCLUSION: In selected patients, (18)F-FDG PET/MR imaging can improve the noninvasive diagnosis and follow-up of cardiac masses.